Co-Kinetic Journal Issue 78 - October 2018 by Co-Kinetic

ISSUE 78 OCTOBER 2018 ISSN 2397-138X

Formerly published as....

medicine & dynamics

what’s inside PRACTICAL ADV ICE

HAN DOU

38-43 THE CO-KINETIC

MARKETING SYSTEM BLUEPRINT

Y ACL INJUR

higher to have a are known g in Female athletes while participatin ing ACL tear fibrous ely, understand risk of an band of tough of long, sports. Unfortunat to ACL injury is a short prone mainly competitive with A ligament are more connect s that it is problems tissue composed why women and suggestion . Ligaments related. connective limit There are molecules knee instability start joints and and hormonally is unclear. may stringy collagen in and around ical, strength all three. ‘giving way’ or prevent bones biomechan a factor of Stay disciplined in that joint, are bones to is probably or worsen. of mobility and exercises. ACL There In truth, it treatment the amount s altogether. that following with your INSIDE? anterior and extensive has shown certain movementligaments; the in your GOING ON within who have Research knee WHAT’S felt or heard a ‘pop’out from found deep four major surgery, patients their strength, ligaments have injury or collateral cruciate to rebuild You may usually gives and lateral fully functional posterior the knee physical therapyand agility can be outside of and the medial knee, and cause significant tion the joint known that around the clinical ACL tears risk of propriocep It is also pain. On wrapped under you. an ACL are all at to sport. for ligaments and severe to prevent and return r will look swelling These ligaments and the anterior can help knee joint. the n, your practitioneAn MRI scan may similar exercisesplace. during soccer, most commonly examinatio the instability. first an ACL being injured most (ACL) is ligament tear in the if you have ligament is also the signs of cruciate to determine any associated an ACL rupture AL also be used reveal signs of or injured. Sadly PHYSIC bruising the also injury. with will HOW bone knee bone tive tear. It CAN HELP such as debilitating the thigh occur to the knee, THERAPY to avoid ACL reconstrucsive connects injuries in function is that regularly The ACL way inside. Its damage, of the a comprehen Your best from the meniscus to undertake that involves leg shin bone forward movementto prevent e surgery is an ACL tear. of sports also excessive with level and programm high-level n your prevent and on critical tion and to the thigh rehabilitatio Depending joint. It is work demands ific agility ing, propriocep shin in relation the knee injury you n, lifestyle, soccer, strengthen rotation at following plus sport-spec participatio s used in excessive of your knee you will require Manoeuvre ent. turns, balance retraining, the stability enhancem tive for joint stability. pivoting and sudden surgery, but functional need and Reconstruc not n. may will aim to: such as cutting, on the ACL. and rehabilitatio success if followed demands treatment therapy specialist n has huge Many place high Your physical and inflammatio surgery, however,e rehabilitation protocol. pain of motion ■ reduce pivoting to the game HAPPENS by a progressiv joint range returned HOW IT ACL tears occur when knee season. als have ■ normalise your knee: especially and in the next profession onto a bent obliquus) Most often, surgery, albeit ■ strengthen (vastus medialis from a jump ding the knee, and following or landing quadriceps blow to over-exten hip and blunt force I DO? then twisting, ‘PRICE’ limb (calves, hamstrings CAN the from a direct tackle. The incident lower apply WHAT after injury your sometimes Rest, Ice, soccer ly ■ strengthen knee gives and core during a for Protect, Immediate alignment and your 24–72 the knee at speed pelvis muscles) which stands oral (kneecap) for the first your ACL. protocol, patellofem usually happens you once you tear lengths (flexibility) n can ion and Elevation, the use of ■ improve under Compress coordinatio your muscle tion, agility and may include out from or lack of not possible. ■ normalise a ligament hours. Protection is painful or at risk of your propriocep Muscle weakness if walking try anything ■ improve you are more eg. crutches just don’t mean that for 10–20 and function, relative – balance regularly tear. and Rest is all your technique ion, sprain or Ice the injury hopping ■ improve squatting, that is painful. times a day. Compress to running, walking, several will help minutes or a bandage, as well as of re-injury. landing using strapping and bleeding support. The your chance swelling ■ minimise some reduce the and tive the injury giving swelling by post-opera the pain is to reduce important, have surgery, of elevation If you do of the most purpose n is one of surgery. start to feel aspects rehabilitatio aid circulation. ACL tear you often neglected, outcomes You may an yet too often and quickest Following or weeks. again n. successful a few days is ‘normal’ rehabilitatio The most better within your knee supervised you are able as though result from medical even feel settles and individual planning the swelling this is when a basis for because However, upon as activities. relied be daily 2018 to do should not

The information

contained

only and and information in each individual guidance as general medical advice is intended for specialist in this article or as a substitute care

TIME -SAV

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FOR URCE S ING RESO APIST S THER

PHYS ICAL

UAL AND MAN journal

D PRODUCE BY:

ENTREPRENEUR THERAPIST

NEW CUSTOMERS ONLY, PLEASE? BY ANDREW BYRNE MCSP HCPC

ow annoying is it when companies focus so hard on getting new customers but neglect their existing customers, or worse still once they have them through the door, neglect those new patients and fail to give them the exceptional service that they deserve and need? Don’t get me wrong, for a therapy business to be successful, it needs new patients. It doesn’t matter how great the service is, if there’s nobody there to make use of it. However, new patients are only part of the picture.

and having spoken to hundreds of therapists, most manage to get about 70–75% of the patients who need to come back, to actually return for a second session. That results in another £3,150. The therapists who aren’t really focusing on retention are then likely to see someone, on average, one more time after that (three appointments in total), giving us a total income of £10,800. However, the very best therapists at retention generally get 95–98% of the patients who need to come back, to do just that. So let’s repeat the maths: £4,500 for the 100 initial appointments, but this time, they get 95 of those people back say, which is £4,275 from the second sessions. Good retention therapists will then see patients at least another two times giving us a total of £17,325, nearly £7,000 more than the other therapists. Yes, this assumes everyone needed to come back, but still, for the same number of new patients, the therapist who retains well would get an extra £7,000 in a year. And this doesn’t take into account the fact that the therapist who treats their patients a few more times, is likely to get better outcomes, and have built stronger relationships with their patients, which will mean more word of mouth referrals … and that of course means more new patients! I know the numbers above are a rough guide, and the retention rates may seem impossible to you, but believe me there are plenty of therapists I’ve worked with who manage to hit at least 95% retention at the first session. There are also plenty of good therapists who treat for more than four sessions per patient because they understand that you’re unlikely to have got the patient back to full health in any less time.

RETENTION OF PATIENTS IS NOT UNETHICAL! So just before I talk more about retention of patients, I want to make it quite clear that I’m not talking about over-treating patients. That is unethical, and will get you a very bad reputation very quickly. However, in my experience, most therapists go the other way, and under-treat to such an extent that that in itself almost becomes unethical. In order to reach the maximum benefit for your patients, you usually have to retain them past the first couple of sessions. In my mind, if you know you can help a patient, but you don’t retain them to such a time that you have given them maximum benefit, then that is unethical! And, as a therapy business owner, if you’re not working on retention of patients, you are doomed to failure. And even if you don’t own a business, without retention, you won’t keep your patients coming back to see you long enough to reach their maximum benefit. If you’re not doing that, then you will be failing as a therapist to get the best results. Your outcomes will suffer, your reputation will remain static, and you are unlikely to progress in your career.

LET’S DO THE MATHS As a business owner, say you have 100 new patients in a year and you charge £45 per session, that’s £4,500. From experience of managing 15 clinics

SO WHAT DO I DO ABOUT IT?

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Don’t Waste Your Marketing: How to Ethically Boost Patient Retention [Article] http://spxj.nl/2C1UANl How to Grow Your Business By Making Your Customers Want to Come Back [Video presentation] https://spxj.nl/2J91Wlk THE AUTHOR Andy Byrne MCSP HCPC has over 10 years’ experience in private practice, the last 4 of which were spent as area manager for one of the largest physiotherapy providers in the UK. He managed 15 clinics simultaneously with over 100 staff. He launched Triad Health in September 2017 to help therapists from around the world to learn and help them get great results for their patients and themselves. He has mentored hundreds of therapists particularly in the nonclinical skills that create exceptional patient experiences and allow for rapid, sustainable and ethical business growth within therapy businesses. Email: info@triadhealth.co.uk Twitter: https://twitter.com/AndyThePhysio Website: https://www.triadhealth.co.uk/

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MANUAL THERAPY FOR THE HIP Manual therapy (MT) encompasses hands-on techniques for both joints and soft tissues. In this article we will focus on joint procedures and look briefly at how clinical effects may be achieved. Using the hip as an example we will examine several clinically effective MT techniques for this region. This will allow you to understand when and how to use joint-based MT and so to tailor a care package to the specific needs of your patients for the optimum results. Read this article online https://spxj.nl/2LWMwku BY DR CHRISTOPHER NORRIS PHD

DEFINITIONS Joint-based manual therapy (MT) may be applied to both the spinal and peripheral joints. Manipulation (thrust) techniques are generally passive (the patient does not move; the therapist applies the force) and applied rapidly (high velocity) to achieve very small movements (low amplitude). Mobilisations are non-thrust techniques that may be applied at a variety of speeds and amplitudes, with or without patient movement. The aim in each case is to reduce pain and improve motion, and several variables are involved in the application of joint-based MT (Table 1). The description of a joint-based MT technique may also be improved using grading systems, and several systems have been used in the past. In general, higher grade movements involve greater force and are applied at or close to end range of a joint’s motion. Maitland described five MT grades, with grade I being a small amplitude oscillation early within a movement range, grades II and III larger amplitude actions further into range, and grade IV an oscillation at end range (2). These four grades represent mobilisation in that they are non-thrust techniques. The grade V action is a thrust technique (manipulation) at full end range. Kaltenborn described three techniques, again of increasing force with grade I taking up slack (neutralising joint pressure), grade II separating the joint surfaces, and grade III stretching the soft tissues of the joint (3). Within the Cyriax Orthopaedic Medicine approach, peripheral techniques are graded as: (A) a mobilisation within the

patient’s pain-free range; (B) a sustained stretch at the end of the available range; or (C) a small amplitude high velocity manipulation giving overpressure once the joint slack has been taken up (Table 2) (4).

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DEHYDRATION IMPAIRS COGNITIVE PERFORMANCE: A META-ANALYSIS

Medicine & Science in Sports & Exercise

EFFECTIVE MANUAL THERAPY FOR THE HIP

MEDIA CONTENTS Set of three videos demonstrating hip mobilisation techniques http://spxj.nl/2LWMwku

TABLE 1: MANUAL THERAPY APPLICATION FRAMEWORK [SOURCED MINTKEN ET AL. (1)] Variable

Meaning

Speed

Rate at which the MT force is applied – eg. high velocity

Location within ROM

Is the force applied at the start, middle or end of the motion range currently available to the subject – eg. at mid-range

Force direction

Anatomical and or biomechanical direction of the force – eg. lateral glide

Tissue target

Which joint or part of a joint is moving – eg. spinal level

Relative movement

Which region is moving and which remaining stable – eg. tibial glide on femur

Subject position

Gross body position of subject and limb position – eg. supine lying with femur flexed, abducted & externally rotated

MT, manual therapy; ROM, range of motion

TABLE 2: CLASSICAL MANUAL THERAPY GRADING SYSTEMS Maitland

Kaltenborn

Cyriax

Grade I – Small amplitude rhythmic oscillating at beginning of ROM

Grade 1 – neutralise joint pressure without separating joint surfaces

Grade A – mobilisation within pain-free range

Grade II – Large amplitude rhythmic oscillating in midrange

Grade 2 – separate joint surfaces

Grade B – sustained stretch at EOR

Grade III – Large amplitude rhythmic oscillating to point of limitation in ROM

Grade 3 – stretch soft tissue

Grade C – high velocity/low amplitude manipulation at EOR

Grade IV – Small amplitude rhythmic oscillation at EOR Grade V – high velocity/low amplitude manipulation at EOR EOR, end of range

09-11 MANUAL THERAPY

BRAIN, PAIN AND SPORTS PERFORMANCE

JOURNAL WATCH

British Journal of Sports Medicine

MUSCULAR WEAKNESS IN ADOLESCENCE IS ASSOCIATED WITH DISABILITY 30 YEARS LATER: A POPULATION-BASED COHORT STUDY OF 1.2 MILLION MEN

British Journal of Sports Medicine

STICKS AND STONES: THE IMPACT OF LANGUAGE IN MUSCULOSKELETAL REHABILITATION

Journal of Orthopaedic & Sports Physical Therapy

2018 CONSENSUS STATEMENT ON EXERCISE THERAPY AND PHYSICAL INTERVENTIONS TO TREAT PATELLOFEMORAL PAIN: RECOMMENDATIONS FROM THE 5TH INTERNATIONAL PATELLOFEMORAL PAIN RESEARCH RETREAT, AUSTRALIA, 2017

Sleep is the foundation of good health, yet we seem to take it for granted, and some may even consider sleep an annoying necessity. We couldn’t be further from the truth. We’ve all heard the phrase, “I’ll sleep when I’m dead” … I’d like to think that this article will propel you and your athletes into developing some great habits when it comes to sleep, so that we can all benefit from its amazingly restorative effects. There’s an abundance of research telling us about the importance of nutrition and physical activity for our health and longevity, along with the dangerous effects of alcohol and smoking (1), and how diet and physical activity can help to tackle cancer, obesity and type 2 diabetes (2). Without question diet and exercise are incredibly important, but surely sleep is the preeminent force in this health trinity (3)? The physical and mental impairments caused by one night of bad sleep dwarf those caused by an equivalent absence of food or exercise (3):

News stories

British Journal of Sports Medicine

EFFECTS OF PHYSICAL ACTIVITY INTERVENTIONS ON COGNITIVE AND ACADEMIC PERFORMANCE IN CHILDREN 2018 CONSENSUS AND ADOLESCENTS: A NOVEL COMBINATION STATEMENT ON EXERCISE A SYSTEMATIC REVIEW AND THERAPY ANDOFPHYSICAL RECOMMENDATIONS FROM INTERVENTIONS TO AN EXPERT PANEL

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INSERTIONAL AND MID-SUBSTANCE ACHILLES TENDINOPATHIES: ECCENTRIC TRAINING IS NOT FOR EVERYONE – UPDATED EVIDENCE OF NONSURGICAL MANAGEMENT

Journal of Manual & Manipulative Therapy

BRAIN MECHANISMS OF ANTICIPATED PAINFUL MOVEMENTS AND THEIR MODULATION BY MANUAL THERAPY IN CHRONIC LOW BACK PAIN

TIME-SAVING RESOURCES FOR PHYSICAL AND MANUAL THERAPISTS

Journal of Physiotherapy (Australian Physiotherapy Association)

Journal of Pain

57 5

128 0

TRIAL PROTOCOL: COGNITIVE FUNCTIONAL THERAPY COMPARED WITH COMBINED MANUAL THERAPY AND MOTOR CONTROL EXERCISE FOR PEOPLE WITH NONSPECIFIC CHRONIC LOW BACK PAIN: PROTOCOL FOR A RANDOMISED, CONTROLLED TRIAL

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Journal of Sports Medicine TREATBritish PATELLOFEMORAL PAIN: RECOMMENDATIONS FROM THE 5TH INTERNATIONAL PATELLOFEMORAL PAIN

RESEARCH RETREAT,ACTIVITY: AUSTRALIA, 2017 LEADERSHIP IN PHYSICAL IS THIS British Journal of Sports THE CURRENCY OF CHANGE IN THE Medicine STUDENT HEALTHCARE CURRICULUM? British Journal of Sports Medicine

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CREDIBILITY OF MANUAL THERAPY IS AT STAKE ‘WHERE DO WE GO FROM HERE?’

Chiropractic & Manual Therapies

Physiotherapy

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ACL INJURY:

Patient Advice Leaflet Preventing and Managing ACL Injury https://spxj.nl/2NfBJ9Q

Sleep is an internally and externally controlled process structured by an interaction of our body

* All references marked with an asterisk are open access and links are provided in the reference list. BY KATHRYN THOMAS BSC MPHIL

BACKGROUND Return to sports! Isn’t that your ultimate end goal with anterior cruciate ligament (ACL) injury or really, any musculoskeletal injury? Where patients are fully functional, back to their ‘preinjury life’; when you can proudly pat them on the back and confidently discharge them from your clinic. With some it’s a bitter sweet time to say goodbye, whereas with others it’s a silent sigh of relief and post-work visit to your local. But ever too often there is a small niggle in your gut wondering, (knowing) how soon you will see them again! Also, you may be questioning the success of the above: How did we get there? How long did it take? Will it last? So too are these questions echoed through the evidence and clinical trials of managing ACL reconstruction (ACLR); starting as early on as: Should they have reconstructive surgery or not? Besides its mechanical function in maintaining knee stability, the ACL contains mechanoreceptors (2.5%) and therefore directly influences the neuromuscular control of the knee (1*). ACL deficiency causes partial deafferentiation and alters spinal and

Management of anterior cruciate ligament injury is complex and is affected by physiological, psychological and sociological factors. Hence, it is important to tailor the injury management in partnership with each individual patient according to their beliefs and outcome expectations. This article highlights the need for good preoperative and postoperative rehabilitation and lays out the latest evidence on what tests and exercises to use to guide your patient through rehabilitation. This knowledge will allow you to create a personalised rehabilitation pathway for your patient that will provide the greatest chance of a successful return to sport. Read this article online https://spxj.nl/2LTrTG3 supraspinal motor control. The changes in motor control strategy can reveal changes in proprioception, postural control, muscle strength, movement and recruitment patterns (1*). An ACL injury might therefore be regarded as a neurophysiological dysfunction and not a simple peripheral musculoskeletal injury. It is also not self-evident that ACLR will automatically lead to a return to pre-injury activity level (1*). Complex factors influence the likelihood of success with ACLinjured athletes to return to sports (RTS). Higher quadriceps strength, less effusion, less pain, greater tibial rotation, higher Marx Activity score, higher athletic confidence, higher

AN ACL INJURY COULD BE REGARDED AS A NEUROPHYSIOLOGICAL DYSFUNCTION AND NOT A SIMPLE PERIPHERAL MUSCULOSKELETAL INJURY

The PDF version of this infographic includes hyperlinks to the individual pieces of research. Click here to access https://spxj.nl/2PB0Rpd

SHORT

MEDIA CONTENTS

Briefly Into the Science

European Journal of Pain

TIME-SAVING RESOURCES FOR PHYSICAL AND MANUAL THERAPISTS

Supporting the Shocking Statements Our bodies are amazing at going about their business without us having to do a thing! I’ve said it before and I’ll say it again, we often live in our heads with no consideration or concern about what our body is doing while we live our lives – until it goes wrong! Then we become injured, ill or are in pain and we wonder what happened … “it came from nowhere!”

Sleep is no exception and is possibly the most important thing we must do to survive, repair, recover and retain skills. It enriches a diversity of functions, including our ability to learn, memorise, and make logical decisions and choices. It recalibrates our emotional brain circuits and down in the body it restocks the immune system: fighting malignancy, preventing infection and protecting from illness, etc. The list is so long that I highly recommend reading Why We Sleep by Mathew Walker PhD (3).

SEEING THE SITE OF TREATMENT IMPROVES HABITUAL PAIN BUT NOT CERVICAL JOINT POSITION SENSE IMMEDIATELY AFTER MANUAL THERAPY IN CHRONIC NECK PAIN PATIENTS

Archives of Physical Medicine & Rehabilitation

29 0

TRIGGER POINT MANUAL THERAPY FOR THE TREATMENT OF CHRONIC NONCANCER PAIN IN ADULTS: A SYSTEMATIC REVIEW AND META-ANALYSIS

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28 0

SURVEY OF CHIROPRACTIC CLINICIANS ON SELF-REPORTED KNOWLEDGE AND RECOGNITION OF CONCUSSION INJURIES

INDIVIDUALISED MANUAL THERAPY PLUS GUIDELINE-BASED ADVICE VERSUS ADVICE ALONE FOR PEOPLE WITH CLINICAL FEATURES OF LUMBAR ZYGAPOPHYSEAL JOINT PAIN: A RANDOMISED CONTROLLED TRIAL

– Good sleep can improve performance speed by 20% and accuracy by 35% (see more about the impact on athletes later).

25-32 I'LL SLEEP WHEN I'M DEAD

Physiotherapy

36 0

BY PAULA CLAYTON MSC FA. DIP. MAST. STT, MSMA (L5) MCSP HCPC

Co-Kinetic.com

EFFECTS OF ORTHOPAEDIC MANUAL THERAPY IN KNEE OSTEOARTHRITIS: A SYSTEMATIC REVIEW AND META-ANALYSIS

Journal of Manual & Manipulative Therapy

IF THE LACK OF IT DOESN’T KILL ME FIRST! We all know how much better we feel after a good night’s sleep. However, do you know just how much harm, both physically and mentally, the lack of sleep causes? This article describes what can cause poor sleep and spells out the wide-ranging detrimental effects of it. Additionally, instructions for good sleep hygiene are provided, which will allow you to maximise your training and performance potential. Read this article online https://spxj.nl/2LTIGbV

n Less than 6–7h of sleep per night severely compromises our immune system, more than doubling the risk of cancer! n Insufficient sleep is a key factor which determines whether or not you will develop Alzheimer’s disease. n Reduced sleep, including moderate reductions even for one week, impacts blood sugar levels so profoundly that you would be classified as pre-diabetic! n Reduced sleep also: – increases the chances of developing coronary heart disease – increases the chances of developing a stroke – increases the chances of developing congestive heart failure – contributes to all major psychiatric conditions, including depression, anxiety and suicidality – increases concentrations of a hormone that makes you feel hungry and supresses the hormone that tells you that you’re satisfied – affects physical performance – can reduce an athletes time to physical exhaustion by 30%.

British Journal of Sports Medicine

THE ADDUCTOR STRENGTHENING PROGRAMME PREVENTS GROIN PROBLEMS AMONG MALE FOOTBALL PLAYERS: A CLUSTERRANDOMISED CONTROLLED TRIAL

I’LL SLEEP WHEN I’M DEAD,

INTRODUCTION

MANUAL THERAPY & PHYSICAL THERAPY INFOGRAPHICS

IS IT TIME TO REFRAME HOW WE CARE FOR PEOPLE WITH NON-TRAUMATIC MUSCULOSKELETAL PAIN?

HIP | 18-10-COKINETIC FORMATS WEB MOBILE

MARKETING CAMPAIGN CASE STUDY

33-36 CLINICALLY

MANUAL THERAPY

CLINICALLY EFFECTIVE

Co-Kinetic.com

12-13

Mendely readers

The PDF version of this infographic includes hyperlinks to the individual pieces of research. Click here to access: https://spxj.nl/2PCD9cf

PHYSICAL THERAPY JOURNAL WATCH

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THE 8 MOST DISCUSSED PIECES OF RESEARCH IN PHYSICAL THERAPY (JUL-SEPT 2018)

NEW CUSTOMERS ONLY, PLEASE?

18-10-COKINETIC FORMATS WEB MOBILE PRINT

There are so many techniques for getting better retention, I created a course for exactly this. It teaches you easy-to-use techniques for getting great buy-in and engagement from your patients, which does wonders for retention! Take action and make some changes to give your patients a better service. For more information on “Why Don’t My Patients Listen?” visit https://spxj.nl/ triadhealth

Co-Kinetic.com

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44-47

CLIENT RESOURCES

case. ©Co-Kinetic

preoperative knee self-efficacy, lower kinesiophobia and higher preoperative self-motivation have been associated with returning to sport after ACLR (2*). Other studies have found that hopping performance, younger age (less than 30), male gender, participation in elite sport, reconstruction within 3 months, high baseline activity level and having a positive psychological response favoured returning to the pre-injury level of sport (3*,4). Outcome after rehabilitation is negatively affected by smoking, high body mass index, low quadriceps strength and range-ofmotion (ROM) deficits (5). It is, however, still unclear if and in what way these factors influence the athlete’s ability and/or decision to RTS, and it is likely that many factors interact in a complex manner. So, physiological, psychological and sociological factors all play a role in managing an ACL injury. This article will endeavour to answer some of

14-24

ACL INJURY: RUPTURE, RECONSTRUCT, REHAB, REFURB AND REINSTATE THE ACL

Co-Kinetic Journal 2018;78(Oct):14-24

TECHNICAL

LONG OCTOBER 2018 ISSUE 78 ISSN 2397-138X

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

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

ISSUE 78 OCTOBER 2018 ISSN 2397-138X

Formerly published as....

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is published by Centor Publishing Ltd 88 Nelson Road Wimbledon, SW19 1HX, UK https://Co-Kinetic.com

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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 BIOMECHANICAL CORRELATES OF RUNNING PERFORMANCE IN ACTIVE CHILDREN. Williams S, Netto K, Kennedy R et al. Journal of Science and Medicine in Sport 2018;doi:10.1016/ j.jsams.2018.05.025

CONCURRENT VALIDITY AND RELIABILITY OF AN IPHONE APP FOR THE MEASUREMENT OF ANKLE DORSIFLEXION AND INTER-LIMB ASYMMETRIES. Balsalobre-Fernández C, Romero-Franco N, Jiménez-Reyes P. Journal of Sports Sciences 2018;doi:10.1080/02640414.2018.1494908

Fifteen children (age 9 years, ± 11 months) completed a 1km time trial before undergoing three-dimensional running motion analysis. There was a strong positive correlation between the biomechanical variables of stride length, contact time and ankle dorsiflexion angle with time trial performance. Between variable analyses revealed a strong positive correlation between peak angles of hip adduction and knee flexion. There was no correlation between hip adduction and knee flexion peak angles or the vertical displacement of centre of mass with trial performance.

Twelve healthy participants (age, 28.6 ± 2.3 years) performed a weightbearing lunge test with each leg on five separate occasions while dorsiflexion angle was simultaneously registered using a professional digital inclinometer and the Dorsiflex iPhone app, which was specifically developed for this study. A total of 120 angles measured both with the digital inclinometer and the app were then compared for validity, reliability and accuracy purposes using several

Co-Kinetic comment Always nice to have ‘scientific’ proof but isn’t it a bit obvious? A longer stride length and shorter contact time make you faster.

Apparently shoulder pain affects between 7 and 26% of the population with most describing it as ‘troublesome pain’. A large number of diagnostic categories have been developed: they are based on patho-anatomical classifications, such as tendinopathies, bursitis, labral tears, tendon tears, impingement, etc. However, this system has been described as, “a Babylonian confusion of tongues and seem to be of little benefit”. One problem is that clinical tests appear unable to clearly identify the structures that generated pain; additionally, interpretation of diagnostic imaging is still controversial. This paper moves away from all of this to create a framework for assessment 4

statistical tests. There was an almost perfect correlation between the digital inclinometer and the Dorsiflex app for the measurement of ankle dorsiflexion.

Co-Kinetic comment This one seems to work. Your friendly neighbourhood app store has loads of them ranging from free to £12. Do you know that the mark-one eyeball is as accurate as you will ever need?

NOT ALL ANKLE INJURIES ARE ANKLE SPRAINS - CASE OF AN ISOLATED CUBOID STRESS FRACTURE. Unnithan S, Thomas J. Clinics and Practice 2018;8(3):doi:https://doi.org/10.4081/cp.2018.1093 A 22-year-old lady had a twisting injury to her left ankle followed by pain on prolonged weight-bearing and walking. Magnetic resonance imaging with computed tomography correlation was done which showed an isolated cuboid stress fracture. Isolated cuboid

stress fractures are very rare and are usually misdiagnosed as ankle sprains.

Co-Kinetic comment Rare does not mean never. As it says on the tin. Not all ankle sprains are ankle sprains.

TOWARDS AN INTEGRATED CLINICAL FRAMEWORK FOR PATIENT WITH SHOULDER PAIN. Ristori D, Miele S, Rossettini G et al. Archives of Physiotherapy 2018;8:7 and treatment of shoulder pain that integrates and includes a bio-psychosocial perspective using anamnesis, physical assessment, triage and treatment. What this boils down to is the adoption of something similar to the way many therapists treat the lumbar spine with an emphasis on red flags by excluding them first, then specific pain that can be identified, then categorise what’s left as non-

specific pain. Then treat it with education, desensitisation and load management.

OPEN

Co-Kinetic comment On the plus side this gets close to admitting that the shoulder, like the back, is an emotional joint, meaning that psychological and emotional issues can manifest as pain. Also, although the presenting pain may be at the shoulder, good therapists don’t assume that that is where it is coming from. People carry the weight of the world on their shoulders. The downside is that non-specific back pain is a lazy diagnosis. It would be a pity if we started applying that nonsense to other areas. All pain has a source, even if that source is not mechanical. Co-Kinetic Journal 2018;78(October):4-8

RESEARCH INTO PRACTICE

Physical Therapy

Journal Watch This was a secondary analysis of data collected during the Rugby Injury in Ulster Schools survey that was published in 2017. In total, 825 male rugby players (aged 15–18 years old) from 27 school first teams were included. Subsequent injuries were classified as: new, local or recurrent (same site and type as the first index injury). All recurrent injuries were subgrouped by body part and diagnosis. Burden was based on frequency, days lost and injury proportion ratios. Over a single season 426 injuries were eligible for analysis, of which, 121 were subsequent injuries. The majority of subsequent injuries involved a different body part than their index injury. There were n = 23 cases of within-season recurrence. Seventyeight percent of recurrences occurred

This was a retrospective study of 357 multiligament knee injuries (MLKIs). Inclusion involved patients with two or more knee ligaments requiring surgical reconstruction. Mean follow-up time was 35 months. Incidence of concurrent peroneal nerve injury was noted and patients with and without nerve injury were evaluated for outcomes. Concurrent peroneal nerve injury occurred in 68 patients (19%). In patients with nerve injury, 45 (73%) returned to full duty at work; 193 (81%) patients without nerve injury returned to full

This is a report on the dissection of a 45-year-old male. The origin of biceps brachii muscle was normal, but its insertion was by two separate tendons: one by the common tendon and the other by a musculotendinous slip which arises from short head of biceps brachii muscle inserting on the medial epicondyle of humerus. This particular variation is important from Co-Kinetic.com

RECURRENT INJURY PATTERNS IN ADOLESCENT RUGBY. Archbold HAP, Rankin AT, Webb M et al. Physical Therapy in Sport 2018;33:12–17 within 2 months of return to play. Recurrent injuries comprised 5% of all injuries and their cumulative time loss was 1073 days. Recurrent injury to the ankle ligaments, lumbar muscles and concussions carried the greatest burden.

Co-Kinetic comment This is a much more unusual reporting of injury data than the ones that just quote the number of injured body parts. It looks at patterns and shows that there is a problem with reinjury following return to play and the majority happen within the first 2 months of the return. The authors speculate about why this is. Clinical criteria and psychological readiness

before making a return to play decision, the fact that adolescents may be more likely to engage in risky behaviour, incorrect diagnosis and lack of access to qualified physicians or physiotherapists. As to physios, according to the ‘Which University Guide’ there are well over a 100 higher education establishments offering degree level courses in physiotherapy or variations on sports therapy, so where are all those graduates going? Maybe sports clubs should start encouraging them!

INCIDENCE OF CONCURRENT PERONEAL NERVE INJURY IN MULTILIGAMENT KNEE INJURIES AND OUTCOMES AFTER KNEE RECONSTRUCTION. Worley JR, Brimmo O, Nuelle CW et al. The Journal of Knee Surgery 2018;doi:10.1055/s-0038-1660512 duty. In patients with nerve injury, 37 (60%) returned to their previous level of activity; 148 (62%) patients without nerve injury returned to their previous level of activity. At final follow-up, there were no significant differences in level of pain, Lysholm score, or International Knee Documentation Committee score for patients with or without peroneal nerve injury, respectively. Postoperative range of motion (ROM) (mean 121°)

was significantly lower for patients with nerve injury compared with patients without nerve injury (mean 127°).

Co-Kinetic comment The most useful practical statistic in this is the last one: ROM was less in the nerve injury patients. Maybe worth looking out for this if your patient is not getting the range you expect.

A VARIATION WITH AN EXTRA MUSCULO TENDINEOUS SLIP OF INSERTION FROM BICEPS BRACHII MUSCLE. Yadav S, Kumar S, Joshi A et al. International Ayurvedic Medical Journal 2018;2(4) a clinical perspective as this extra musculotendinous slip may cause entrapment syndrome of the median nerve and hypo-perfusion of the upper limbs owing to compression of the brachial artery.

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Co-Kinetic comment Don’t assume we are all like the illustrations in Gray’s Anatomy. Previous studies tell us that a third head of biceps brachii is seen in about 8% of Chinese, 10% of Europeans, 12% of Black Africans, 18% of Japanese and 2% of the Indian population. 5

IS INJURY PART OF SPORTS? A CHILDREN’S RIGHTS PERSPECTIVE. Turkeri-Bozkurt H, Bulgu N. International Review for the Sociology of Sport 2018;doi:10.1177/1012690218778536 The purpose of this research was to examine the injury experiences of children involved in volleyball and determine the violation of their rights and the link with injury. Research data was collected via in-depth interviews with 13 male and 8 female players aged between 13 and 18 years. Data analysis was conducted using the interpretative phenomenological analysis method in interviews lasting between 23 and 60 minutes. The research was conducted in the context of the ‘Bill of Rights for Young Athletes’ (Martens and Seefeldt, 1979) which states that children have the right to: n participate in sports (which includes an equal amount of game time); n participate at a level commensurate with maturity and ability (age groups); n have qualified adult leadership (coaches working with children should have special education); n play as a child, not as an adult (level of physical and emotional maturity); n share in the leadership decisionmaking of sports participation (an opportunity to make decisions); n participate in safe and healthy environments (physical and psychological health); n proper preparation for participation in sport (basic skills before being competitive);

Eighteen studies were included in the meta-analyses, with a total of 27,231 participants, 347 sustaining an anterior cruciate ligament (ACL) injury. Injury prevention neuromuscular training (NMT) programmes reduced the risk for ACL injury from 1 in 54 to 1 in 111. The overall mean training volume was 18.17 hours for the entire NMT (24.1 minutes per session, 2.51 times per week). Interventions targeting middleschool- or high-school-aged athletes reduced injury risk to a greater degree than did interventions for collegeor professional-aged athletes. All interventions included some form of implementer training. Increased landing

n an equal opportunity to strive for success (effort and development before winning); n be treated with dignity (insensitive adults have no place in children’s sports); n have fun in sport (this will spontaneously occur if the other nine rights are realised). The findings revealed that a significant proportion of the athletes stated that they did not think much about injuries, thought injuries were normal, and continued to play despite being injured. Others said they felt sad when they were first injured and had experienced intense fear of another injury. A telling phrase from one participant was, “there were times when I did not tell anyone about my pain”. One of the main themes that emerged was a violation of the ‘rights’ that included the lack of qualified leadership, especially in relation to playing through injury. This is also tied in with the right to a safe and healthy environment with coaches encouraging children to play through injury and the right to play as a child, especially involving playing in specialised positions. However, on the positive side the participants felt that there were major benefits in participating in sports. They felt that thanks to sport they, ‘learn to behave’, ‘expand their social circles’, ‘see different places’, ‘acquire social status’,

‘stay away from bad habits’ and ‘acquire leadership skills’. They also felt that sport helped them to deal with the challenges of life by making them ‘psychologically stronger ’, instilling in them ‘the ability to look at events differently’, they ‘learn to compete’, their ‘self-confidence increases’, they ‘develop the skills for self-expression’, they ‘develop problemsolving skills’, ‘learn discipline and tolerance’, ‘develop thinking skills’ and learn to ‘stand on their own feet’.

Co-Kinetic comment Let’s not get too carried away. This was a small study conducted in Turkey but the kids were extremely positive about the benefits of sport. Those of you who work in sport will be nodding at the negatives. This was volleyball but they happen in all sports. The ‘run it off, son’ mentality is all too prevalent. It is up to medical staff to educate coaches into thinking that missing a game or a training session now may save the loss of a season. It is up to everyone involved to keep the injured kids involved in the club so that they don’t feel that injury deprives them of the reasons they think sport is great. This is nothing new by the way. A declaration of children’s rights was first adopted by the League of Nations in 1924 and is now enshrined in the 1989 United Nations Convention on the Rights of the Child.

EVIDENCE-BASED BEST-PRACTICE GUIDELINES FOR PREVENTING ANTERIOR CRUCIATE LIGAMENT INJURIES IN YOUNG FEMALE ATHLETES: A SYSTEMATIC REVIEW AND METAANALYSIS. Petushek EJ, Sugimoto D, Stoolmiller M et al. The American Journal of Sports Medicine 2018;doi:https://doi.org/10.1177%2F0363546518782460 stabilisation and lower body strength exercises during each session improved prophylactic benefits. A meta-regression model and simple checklist based on the aforementioned effective components were developed to allow practitioners to evaluate the potential efficacy of their ACL NMT and optimise injury prevention effects.

Co-Kinetic comment According to papers cited in this piece, women’s basketball, soccer, gymnastics and lacrosse are the highest-risk sports for ACL injury. They all involve jumping and landing so it seems a no brainer. If you want to add a bit of lower limb strength training to young athletes’ programmes, they give an example of Nordic hamstrings, lunges and heel-calf raises with a specific focus on landing stabilisation, ie. jump/hop and hold. If you want another reason to prevent the injury, they add that the current cost in the USA of repairing an ACL injury is $38,000.

Co-Kinetic Journal 2018;78(October):4-8

RESEARCH INTO PRACTICE

RECREATIONAL SOCCER AS SPORT MEDICINE FOR MIDDLEAGED AND OLDER ADULTS: A SYSTEMATIC REVIEW. Luo H, Newton RU, Ma’ayah F et al. BMJ Open Sport & Exercise Medicine 2018;4(1):e000336

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The objective of this work was to examine the health benefits of recreational soccer in middle-aged and older adults. The usual databases were searched up to June 2017 for randomised trials with or without a control group and nonrandomised controlled trials that used recreational soccer, which includes smallsided soccer games, as the sole or principal intervention, and reported relevant effects in untrained/sedentary, healthy or unhealthy adults aged 40 years. Five trials described in 13 articles were included, which scored 6–9 out of 12 points on the modified Delphi quality rating scale. The duration was from 12 to 52 weeks, with various frequencies, volumes and game formats performed both outdoors and indoors with men and women. The trials indicate that recreational soccer may result in improvement in cardiovascular function, body composition and functional ability, although no significant changes were observed in postural balance.

Co-Kinetic comment Every therapy practice in the world should give out copies of this report. It actually concludes that football (we refuse to call it soccer) is an alternative exercise modality for untrained and unhealthy middle-aged and older athletes of both sexes. It will be torn-hamstring and twisted-ankle central. Physical therapists will be kept in work for ever!

AB0060 MECHANISMS OF ACTION OF CHONDROITIN SULFATE AND GLUCOSAMINE IN MUSCLE TISSUE: IN VITRO AND IN VIVO RESULTS. A NEW POTENTIAL TREATMENT FOR MUSCLE INJURIES? Montell E, Contreras-Muñoz P, Torrent A et al. Annals of the Rheumatic Diseases 2018;77:1228–1229 This is a pre-clinical study of the impact of chondroitin sulphate (CS) and glucosamine (GLU) combination on muscle healing and force recovery. The rationale behind the study was the stated fact that “Musculoskeletal injures are the most common cause for severe, chronic pain and physical disability affecting hundreds of millions of people around the world and represent a major concern also in sports medicine.” Basically the CS/GLU combination did have some effect on muscle cell proliferation and NF-κB signalling pathway. (NF-κB is a protein complex that controls transcription of DNA, cytokine production and cell survival.)

Co-Kinetic comment Usually we give you the gist of the experiment or the study but this paper is a detailed description of various scientific procedures done to human muscle tissue. The bottom line is that the substances they were testing (both of which are used in the treatment of osteoarthritis) seem to have an effect on skeletal muscle injury. This is a long way from taking a pill to heal your hamstring strain but it’s a start.

MECHANISMS OF ACUTE ADDUCTOR LONGUS INJURIES IN MALE FOOTBALL PLAYERS: A SYSTEMATIC VISUAL VIDEO ANALYSIS. Serner A, Mosler AB, Tol JL et al. British Journal of Sports Medicine 2018;doi:10.1136/bjsports-2018-099246 Working on the theory that change of direction and kicking are the main actions resulting in adductor longus injury, this work set out to perform a standardised visual video analysis of a series of acute adductor longus injuries in football. Video footage was reviewed by players, and assessed independently by five sports medicine professionals. Inciting events were described and categorised using standardised scoring, including playing situation, player/opponent behaviour, movement and body positions. Videos of acute adductor longus injuries in 17 professional male football players were analysed. Most injuries occurred in noncontact situations (71%), following a quick reaction to a change in play (53%). Injury actions were: change of direction (35%), kicking (29%),

Co-Kinetic.com

reaching (24%) and jumping (12%). Change of direction and reaching injuries were categorised as closed chain movements (59%), characterised by hip extension and abduction with external rotation. Kicking and jumping injuries were categorised as open chain (41%), characterised by a change from hip extension to hip flexion, and hip abduction to adduction, with external rotation. A rapid muscle activation during a rapid muscle lengthening appears to be the fundamental injury mechanism for acute adductor longus injuries.

Co-Kinetic comment How about someone combines this study with the injury prevention one on neuromuscular therapy we are also reporting in this edition (See Petushek et al. Evidence-based best-practice guidelines for preventing anterior cruciate ligament injuries in young female athletes: a systematic review and meta-analysis) and comes up with an injury reduction programme for adductor strains?

DOES MY PATIENT WITH SHOULDER PAIN HAVE A ROTATOR CUFF TEAR? A PREDICTIVE MODEL FROM THE ROW COHORT. Jain NB, Fan R, Higgins LD et al. Orthopaedic Journal of Sports Medicine 2018;6(7):2325967118784897 The purpose of this was to model patient characteristics, symptoms and physical examination findings that predict a rotator cuff tear. A total of 301 patients from outpatient clinics who were up to 45 years of age and who had shoulder pain and reduced ROM of at least 4 weeks’ duration were recruited. A rotator cuff tear was diagnosed based on expert clinical impression and the presence/ absence of a tear on a blinded review of MRI. The patients completed a structured shoulder and general health questionnaire, the Shoulder Pain and Disability Index (SPADI), had 13 special tests administered and their strength was assessed using a hand-held dynamometer in abduction, external rotation and internal rotation. Using a variety of statistical tools they compared the data from the subjective This study collected data from patients undergoing surgical reattachment of proximal adductor avulsion injuries from December 2012 to May 2015 by a single surgeon. Six athletes presented after a traumatic sports-related injury with disabling groin pain, adductor weakness, and magnetic resonance imaging confirmation of fibrocartilage avulsion of the proximal adductor with retraction. Surgical reattachment was by a multiple suture anchor technique. Patient-reported outcomes (Hip

and objective assessment to conclude that pooling external rotation strength ratio (affected vs contra), sex (it’s more likely in males), lift-off test, and Jobe’s test were significant predictors of the diagnosis of a rotator cuff tear.

Co-Kinetic comment This is not a bad piece of work but you can simplify things even further. There will be trauma somewhere in the past (sudden or the repeated trauma of overuse) or your patient is getting on a bit and thus subject to atraumatic degeneration. Night pain and difficulty lying on it is a big clue, and a simple isometric resisted test of abduction and lateral rotation and the lift-off tests with comparison of both limbs removes the need for the dynamometer.

FOREFOOT TRANSVERSE ARCH HEIGHT ASYMMETRY IS ASSOCIATED WITH FOOT INJURIES IN ATHLETES PARTICIPATING IN COLLEGE TRACK EVENTS. Bito T, Tashiro Y, Suzuki Y et al. Journal of Physical Therapy Science 2018;30(8):978–983 This was a study of 55 male athletes participating in a college track and field club. Data including demographic information and the incidence of foot injuries within a year before participation in this study were obtained via questionnaires. Transverse arch height (TAH) and the medial longitudinal arch height during 10 and 90% loading, leg-heel alignment, and the heel angle were measured before calculating the asymmetry of each alignment parameter was measured. Participants were categorised into an injury or a normal group. TAH asymmetry during 10 and 90% loading was significantly greater in the injury group. Further logistic regression analysis performed showed that only TAH asymmetry during 90% loading was significantly associated with foot injuries after adjustment for demographic data.

Co-Kinetic comment Could this be useful as a screening test for potential injury? It would nice to follow this by prescribing them all with orthotics and seeing if that reduced the injuries.

PROXIMAL ADDUCTOR AVULSION INJURIES: OUTCOMES OF SURGICAL REATTACHMENT IN ATHLETES. Bharam S, Feghhi DP, Porter DA et al. Orthopaedic Journal of Sports Medicine 2018;6(7):2325967118784898 Outcome Score – Activities of Daily Living and Hip Outcome Score – Sport Specific subscales, modified Harris Hip Score, and visual analogue scale for pain) were collected preoperatively. The latest follow-up of each patient averaged 33.4 months postoperatively (range, 25–42.5 months). All patients returned to sporting activities, with

This study involved 25 university students (13 male, 12 female) with a mean age of 20.16 years (SD = 1.48) and a mean body mass index of 22.76 (SD =3.54). Using a counterbalanced design, they completed two 50-minute experimental manipulations (high vs low cognitive control exertion) before exercising at a self-selected intensity for 30 minutes. At visit 1, participants performed a graded exercise task to gain familiarity with a range of exercise intensities and rating of perceived exertion (RPE) while exercising. At visits 2 and 3, participants rated their intended RPE for the exercise session, performed the experimental manipulations, re-rated their intended RPE, and then completed 30 minutes of exercise on a cycle ergometer. Total work performed while exercising was recorded for each session. Compared with the low cognitive control condition, the high cognitive control manipulation resulted in significantly greater mental

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one minor wound complication that resolved. Postoperative scores for all patients were significantly better than their mean preoperative scores.

Co-Kinetic comment It’s only one surgeon but good for him. We are assuming it’s a him as all the authors are male. The most important fact is that they all returned to sport.

EFFECTS OF MENTAL FATIGUE ON EXERCISE INTENTIONS AND BEHAVIOUR. Brown DMY, Bray SR. Annals of Behavioral Medicine 2018;https://doi.org/10.1093/abm/kay052 fatigue, significantly greater reductions in intended RPE (mean difference, −0.62), and significantly less total work (−12.7kJ) performed during the exercise session.

Co-Kinetic comment So if you are mentally knackered, you don’t want to do as much work. Employers please note.

Co-Kinetic Journal 2018;78(October):4-8

RESEARCH INTO PRACTICE

Manual Therapy

Journal Watch

CLICK ON RESEARCH TITLES TO GO TO ABSTRACT THE EFFECTS OF CORE STABILITY TRAINING ON THE SPEED OF RUNNING IN MALE CRICKET PLAYERS. RAMACHANDRAN S, PAUL J, CYRUS BE et al. International OPEN Journal of Medical and Exercise Science 2018;4(2):464–468

WORDS AND PERCEPTIONS: THERAPY OR THREAT? Johnston KN, Williams MT. Journal of Physiotherapy 2018;64(3):137–139

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This is an editorial that explores the use of language. It suggests that the language we use presents the outward face of our thoughts, beliefs and perceptions and that the words we use can have unintended consequences for patients and their families. One theory that was discussed, the Common Sense Model of Self-Regulation, proposes that the patient’s perception of the threat posed by illness guides their initiation of beneficial or maladaptive coping strategies to deal with those threats. The medical practitioners words if perceived as a threat may have unexpected consequences, especially if those words are misunderstood when technical language or jargon is used or there is a vagueness about the problem and its treatment or a sense of urgency increases anxiety.

Co-Kinetic comment In another study reported in this issue the word ‘lunacy’ is used. Would that be acceptable when talking to a patient? You can get a bit bogged down in this stuff. This article is a thought-provoking work. It’s open access so it’s worth a look, but it’s more of an academic read than a practical guide. How about, keep it simple and honest and even if you think someone understands you, check they have? EFFECTIVENESS OF MOBILIZATION WITH MOVEMENT (MULLIGAN CONCEPT TECHNIQUES) ON LOW BACK PAIN: A SYSTEMATIC REVIEW. Pourahmadi MR, Mohsenifar H, Dariush M et al. Clinical rehabilitation 2018;doi:10.1177/026921 5518778321

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The usual databases were searched up to 31 March 2018 for randomised clinical trials reporting outcomes of pain or disability in adult patients (≥18 years) with low back pain, which resulted in 20 studies with 693 patients being included. Nine trials focused on sustained natural apophyseal glide, three on spinal mobilisation with limb movement and seven on bent leg raise. The results showed that Mulligan techniques can decrease pain and disability and increase range of motion in patients with low back pain; however, the strength of conclusion for pain and disability was moderate. Furthermore, inconclusive results were observed for the effectiveness of Mulligan techniques on movement speed. In this review, eight studies were categorised

Ten male volunteers were given a 6-week programme of core stability training exercises with bridging, curl-up, side push-up (both sides) to strengthen the core muscles. The speed was measured by a 4 × 10m shuttle run test. After the 6 weeks participants had significant positive differences in effect in the shuttle test.

Co-Kinetic comment The Australian cricketer of the sixties and seventies Doug Walters believed that it was his late-night socialising over a beer or two, not training too hard and enjoying a card game and a smoke that enabled him to average 48.26 in Test cricket. How times have changed.

as low risk of bias, while 12 studies had high risk of bias. The overall conclusion was that current evidence is insufficient in supporting the benefits of Mulligan techniques on pain, disability and range of motion in low back pain patients.

Co-Kinetic comment Hang on. The overall conclusion quoted above is taken from the article’s abstract yet in the discussion it says, “From the results of this review, the Mulligan techniques can decrease pain and improve disability in patients with low back pain (moderate strength of conclusion).” The overall conclusion about the jury being out comes from the fact that eight papers with positive outcomes had a low risk of bias and 12 didn’t. Part of the bias criteria involves blinding. How can you really blind subjects or therapists to manual therapy? It is time that we shouted from the rooftops that hands-on therapy works but the gold standard of the double-blind randomised trial just does not work in the this context. 9

THE ADDUCTOR STRENGTHENING PROGRAMME PREVENTS GROIN PROBLEMS AMONG MALE FOOTBALL PLAYERS: A CLUSTER-RANDOMISED CONTROLLED TRIAL. Harøy J, Clarsen B, Wiger EG et al. British Journal of Sports Medicine 2018;doi:10.1136/bjsports-2017-098937 Thirty-five semi-professional Norwegian football teams were cluster-randomised into an intervention group (18 teams, 339 players) and a control group (17 teams, 313 players). The intervention group performed an adductor strengthening programme as part of their warm-up using the Copenhagen Adduction exercise, three times per week during the preseason (6–8 weeks), and once per week during the competitive season (28 weeks). The control group were instructed to train

as normal. The prevalence of groin problems was measured weekly in both groups during the competitive season using the Oslo Sports Trauma Research Centre Overuse Injury Questionnaire. The average prevalence of groin problems during the season was 13.5% in the intervention group Co-Kinetic comment and 21.3% in the control group. The Hey – you ask for an adductor injury reduction programme risk of reporting groin problems and lo and behold one comes along. Adding this exercise to the was 41% lower in the intervention warm-up takes only a few minutes but it group. seems to have an effect on the injury figures.

THE EFFECTS OF SCAPULAR MOBILISATION ON UPPER LIMB NEURODYNAMIC TEST 1: A RANDOMISED, PLACEBOCONTROLLED CROSSOVER STUDY. Milne K. Journal of Musculoskeletal Disorders and Treatment 2018;4(2):051 OPEN

Twelve young healthy individuals (10 men and 2 women; age 21.1 ± 0.3 years; body mass index 20.4 ± 1.9) received randomly assigned interventions. These were large-amplitude end-range scapular mobilisations involving elevation and depression at a rate of once every 4 seconds towards each direction for 40 seconds repeated three times with 10 second intervals between each set, or placebo intervention during which the therapists hands were placed on the scapula for the same time frame but there was no movement. Range of motion in elbow extension and pain during upper limb neurodynamic test 1 (ULNT1) were assessed before and after each intervention. There was a statistically significant

LUNACY REVISITED – THE MYTH OF THE FULL MOON: ARE FOOTBALL INJURIES RELATED TO THE LUNAR CYCLE? Yousfi N Rekik RN, Eirale C et al. Chronobiology International 2018;DOI:10.1080/07420528.2018.1483943 This paper analysed injuries of professional footballers over four seasons in the Qatar Premier league to ascertain the association between the lunar cycle and injury risk. Injuries (1184) were tested for correlation with moon illumination, lunar distance from earth and tidal coefficient, the data for which was acquired from the lunar calendar and tide tables. There was no link so the authors conclude that event organisers need not consult moon or tide tables when planning future event schedules.

Co-Kinetic comment Sometimes research is so wonderful it has to be shared. Was this part of the successful bid for the next world cup then?

improvement in ULNT1 only after scapular mobilisation. The scapular mobilisation group displayed large or moderate effect sizes to improve ULNT1 and pain, whereas effect sizes of placebo intervention were small.

Co-Kinetic comment This paper is suggesting that scapula mobs might affect the sensitivity of the nervous system. The bottom line is that if you have a patient presenting with peripheral neuropathy and you are getting nowhere using the upper limb tension test or cervical mobs as a treatment, scapular mobs is worth a try. The trouble with it, as in so many manual therapy papers, is that it studied a healthy population. Can we have a case study from someone on patients with symptoms, please?

EFFECTIVENESS OF MUSCLE ENERGY TECHNIQUE ON CERVICAL RANGE OF MOTION AND PAIN. Jalal Y, Ahmad A, Rahman AU et al. The OPEN Journal of the Pakistan Medical Association 2018;68(5):811–813 This case series study was conducted at the physical therapy department of the North West General Hospital, Peshawar, Pakistan, from August 2015 to January 2016. A total of 20 patients (male and female aged 25–50 years old) who were suffering neck pain, cervical range of motion (ROM) limitation and muscle spasm were included in the study. Patients were treated by muscle energy technique (MET). The patient outcome measures were Inclinometer and visual analogue scale (VAS). The patients treated with MET showed clinical improvement in ROM and pain. Results showed that pre- and post-treatment differences were statistically significant for cervical flexion, cervical extension, cervical right side rotation, cervical left side rotation, cervical

right side bending, and cervical left side bending. Paired t-test finding for the pain showed statistically significant difference.

Co-Kinetic comment Forget the actual article. That just supports earlier work that proves that MET increases ROM although it was using patients with actual neck problems rather than the more usual asymptomatic ones. What is great about this is that when you find it online there is a full audio file reading and a translation facility into the major tongues of the world. It’s the future. Mind you some of the stuff we read is as dry as dust so maybe there should be a health warning about listening while driving or operating heavy machinery. Co-Kinetic Journal 2018;78(October):09-11

RESEARCH INTO PRACTICE

EFFECT OF SOFT TISSUE MOBILIZATION TECHNIQUES ON ADHESION-RELATED PAIN AND FUNCTION IN THE ABDOMEN: A SYSTEMATIC REVIEW. Wasserman JB, Copeland M, Upp M et al. Journal of Bodywork and Movement Therapies 2018;doi:https://doi. org/10.1016/j.jbmt.2018.06.004 PubMed, Cochrane, Google Scholar, OVID, and EBSCO were searched and the quality of the studies was assessed using the MINORS scale. This turned up nine studies on the effects of soft tissue mobilisation (STM) on both surgical and non-surgical abdominal adhesion-related symptoms. The total number of subjects within these studies included 220 humans and 70 rats. The population age (of the humans) ranged from 10.7 to 89.4 years. Four articles were non-randomised and had scores ranging from 3 to 14 out of 16 total on the MINORS scale. Five articles were randomised controlled trials or comparative studies and scores ranged from 16 to 23 out of 24 total on the MINORS scale. There were five articles that used pain as an objective measure and all of them reported a decrease in pain after treatment. Two studies looked at quality of life and function and both saw objective improvements following abdominal adhesion treatment. Collectively, there

THE EFFECTIVENESS OF MANUAL THERAPY AND PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION (PNF) COMPARED WITH TRADITIONAL KINESIOTHERAPY IN THE TREATMENT OF NON-SPECIFIC LOW BACK PAIN. Zaworski K, Latosiewicz R. Annals of Physical and Rehabilitation Medicine 2018;61(Suppl):e15

were also improvements seen in scar mobility, infertility, posture, a reduction in medication, increased pressure tolerance and decreased postoperative ileus.

Co-Kinetic comment We will take the positive message of ‘hands-on therapy works on scar tissue’. The authors say there is, ”strong evidence for the benefits of STM.” However, one of the major difficulties is highlighted, which is the terminology used for such treatment. The interventions here are described as, “visceral massage, myofascial induction therapy, hot pack combined with STM (superficial and deep), mechanical abdominal massage, as well as pelvic and abdominal diaphragm myofascial release or direct scar release”. Without going to the source papers it is not possible to tell exactly what has been going on and it’s not always possible when you do track down the originals.

This was a single-blinded randomised controlled trial and conducted on a group of 200 patients of the Rehabilitation Ward of Hospital in Parczew, Poland. The patients were randomly divided into four 50-person groups: group A used manual therapy, group B PNF, group C manual therapy and PNF, and group D traditional kinesiotherapy. Pain intensity was measured using the visual analogue pain scale (VAS) and modified Laitinen’s pain questionnaire. The evaluation was carried out four times: before, in the middle of, immediately after, and 2 weeks after completion of therapy. Functional disability was assessed using Oswestry Disability Index (ODI) and Back Pain Functional Scale (BPFS). Assessments were done twice – before and after the treatment. The reduction of pain intensity was statistically significant in all groups at each stage of the study. However, the differences between the groups were not statistically significant. In all groups the change in the degree of disability measured by the ODI was statistically significant. The improvement in functional ability in patients as measured on the BPFS was statistically significant in all groups. Statistically significant differences were noticed between group C and group D.

Co-Kinetic comment It all worked and did so for at least 4 weeks. The best improvement in the functional capability of patients was caused by the combined therapy. This consisted of manual therapy and PNF, so do them both. Unfortunately, we can’t tell you exactly what the manual therapy was because it is not reported in the paper.

HIP AND GROIN INJURY IS THE MOST COMMON NON-TIME-LOSS INJURY IN FEMALE AMATEUR FOOTBALL. Langhout R, Weir A, Litjes W et al. Knee Surgery, Sports Traumatology, Arthroscopy 2018;doi:10.1007/s00167-018-4996-1 The data were collected during the 2015–16 preseason. An online questionnaire based on the previous season and current preseason was submitted by 434 Dutch female amateur football players. The Hip and Groin Outcome Score (HAGOS) was used to assess the severity of hip and groin injuries. The hip/groin (17%), knee (14%), and ankle (12%) were the most frequent non-time-loss injury locations. The ankle (22%), knee (18%), hamstring (11%), thigh (10%), and hip/groin (9%) were the most common time-loss injury locations.

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The previous season prevalence of total injury was 93%, of which nontime-loss injury was 63% and time-loss injury was 37%. The prevalence of hip/ groin injury was 40%, non-time-loss hip/groin injury was 36%, and time-loss hip/groin injury was 11%. The preseason prevalence of hip/groin injury was 27%, non-time-loss hip/groin injury was 25%, and time-loss hip/groin injury was 4%. Players with longstanding hip/ groin injury (>28 days) in the previous season had lower HAGOS scores at the next preseason than players with short-term (1–7 days) or no hip/ groin injury (P <0.001). From all players

with hip/groin injury from the previous season, 52% also sustained hip/groin injury in the following preseason, of which 73% were recurrent and 27% were chronic hip/groin injuries.

Co-Kinetic comment Injury statistic papers like this are very interesting but they are a bit pointless on their own. Yes, there are a lot of injuries in competitive sports but is there a plan to do anything about it? Maybe take these players and add an injury prevention programme to their training and see what happens.

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ACL INJURY:

MEDIA CONTENTS Patient Advice Leaflet Preventing and Managing ACL Injury https://spxj.nl/2NfBJ9Q

* All references marked with an asterisk are open access and links are provided in the reference list. BY KATHRYN THOMAS BSC MPHIL

AN ACL INJURY COULD BE REGARDED AS A NEUROPHYSIOLOGICAL DYSFUNCTION AND NOT A SIMPLE PERIPHERAL MUSCULOSKELETAL INJURY 14

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the questions above and provide an update on the latest evidence available to guide your clinical decision-making on when to progress patients through rehabilitation and which tests or exercises to use when aiming for that ultimate goal of a successful RTS.

WHO GETS INJURED? The incidence of non-contact ACL injuries appears to be the greatest in athletes who are between 15 and 40 years of age and participate in pivoting sports such as soccer, handball, volleyball and alpine skiing. Every year, about 3% of amateur athletes injure their ACL; for elite athletes, this percentage could be as high as 15%. Females are 2 to 8 times more likely to sustain an ACL injury than their male counterparts, probably because male and female neuromuscular patterns diverge during and following puberty (1*). Research from six cohorts (including countries from Europe, UK and the USA) showed that the majority of patients having primary ACLR were male (range, 56.8–72.4%) and younger

than 30 years of age [See Table 1 of Prentice HA et al. (6) for the complete data). The most common age group at the time of surgery was 15–19 years in all countries except the UK where 25– 29 years was more common. Almost 20% of knees in Norway had had a previous procedure to the index knee; however, <5% were previously operated on in the US. Most reconstructions occurred within at least 6 months following the injury. Delay in surgery could be due to a misdiagnosis or that patients in Scandinavian countries are recommended to complete 3–6 months of physical therapy before ACLR (6).

WHAT ARE YOU DOING WHEN YOU GET INJURED? Soccer is the most commonly reported activity at the time of injury in primary ACLR, followed by winter sports (skiing and snowboarding), handball, American football/rugby and basketball/netball (Table 1) (6). The incidence proportion (IP) and incidence rate (IR) of ACL injury in female football players was 2.0%

and 2.0/10,000 athlete exposures (AEs) over a period of one season to 4 years. The IP and IR of ACL injury in male players were 3.5% and 0.9/10 000 AEs (7). Simply stated, more men sustained ACL injury in football. However, women have 2.2 times greater incidence of ACL injury compared with men (7). Confused? It comes down to the statistics. IR is the rate of new injuries, and IP is the number of newly injured individuals. If the rate at which ACL injury occurs is more than twice as high in women, it seems reasonable to expect that a higher proportion of women would sustain this injury than men. However, this assumes that exposure is similar between men and women. The higher IR of ACL injury among female athletes associated with the absence of sex effects on IP suggests that men have greater exposure than women (ie. men participate in more training sessions and games). Given that the number of female sports teams is increasing, the difference in participation rates between men and women might be

TABLE 1: ACTIVITY AT THE TIME OF INJURY/AETIOLOGY FOR PRIMARY ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTIONS Characteristic, n (%) Total N American football/rugby Basketball/netball

Denmark* Luxembourg† Norway‡

Sweden§

UK¶

US**

21 820

300

17 556

30 422

2972

28 055

–

9 (3.1)

–

244 (0.8)

147 (14.5)

2348 (11.9)

240 (1.2)

28 (9.6)

230 (1.3)

622 (2.1)

40 (3.9)

3525 (17.9)

Fall

–

5 (1.7)

–

268 (0.9)

34 (3.4)

1098 (5.6)

Floor ball

–

1 (0.3)

–

2641 (8.7)

–

0 (0.0)

Football

8946 (43.2)

124 (42.6)

7045 (40.5)

12 876 (42.6)

419 (41.4)

5262 (26.7)

Handball

3513 (17.0)

28 (9.6)

2505 (14.4)

1632 (5.4)

0 (0.0)

2 (0.0)

–

1 (0.3)

1185 (6.8)

31 (0.1)

8 (0.8)

321 (1.6)

196 (0.9)

5 (1.7)

330 (1.9)

840 (2.8)

17 (1.7)

671 (3.4)

Hiking/jogging/running/walking Martial arts/wrestling Motorsports/motor vehicle accident Winter sports (skiing/snowboard) Work injury Other Other sport

–

3 (1.0)

184 (1.1)

1330 (4.4)

13 (1.3)

824 (4.2)

2740 (13.2)

44 (15.1)

3033 (17.4)

4236 (14.0)

142 (14.0)

1509 (7.6)

1266 (6.1)

9 (3.1)

437 (2.5)

512 (1.7)

9 (0.9)

320 (1.6)

1811 (8.7)

14 (4.8)

1595 (9.2)

1824 (6.0)

41 (4.0)

599 (3.0)

1997 (9.6)

20 (6.9)

864 (5.0)

3162 (10.5)

143 (14.1)

3261 (16.5)

*Missing data: 1111 (5.1). †Missing data: 9 (3.0%). ‡Missing data: 148 (0.8%). §Missing data: 204 (0.7%). ¶Missing data: 1959 (65.9%). **Missing data: 8315 (29.6%). – , not reported. Table: Activity at the time of injury/aetiology for primary anterior cruciate ligament reconstructions. Reproduced with permission from Prentice HA et al. Patient demographic and surgical characteristics in anterior cruciate ligament reconstruction: a description of registries from six countries. British Journal of Sports Medicine 2018;52:716–722 (6). https://spxj.nl/2MEEDER

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ATHLETES MAY BE OVERTREATED WITH ACLR SURGERY, BUT UNDERTREATED WHEN IT COMES TO REHABILITATION expected to reduce (7). An increase in the number of championships, games per championship and training sessions played by women is also likely. Therefore, an increase in IP among female football players may follow.

WHEN THE ACL GOES, WHAT GOES WITH IT? When the ACL ruptures, depending on the mechanism of injury or the force through the joint, other surrounding soft tissue structures can be simultaneously damaged. Medial meniscal tears are more frequent than, or of similar frequency to, lateral meniscal tears. Articular cartilage lesions range from a 27.6% incidence to as low as the 3.6% in some reports (6). Both menisci can be torn (15.7%) and more often (20.6%) both meniscal and cartilage injuries occur concurrently with ACL rupture (6). Posterior cruciate ligament (PCL) tears with an ACL rupture are very infrequent (<2%) (6). The addition of any of the above with an ACLR can impact on the speed of progression and therefore rehabilitation goals as well of the long-term prognosis and possible development of osteoarthritis in years to come.

WHERE DOES SURGERY LEAVE YOU? ACL tears are a common orthopaedic injury and to date the ideal treatment protocol is yet to reach consensus. Some studies suggest that only 65% of patients who undergo surgical reconstruction return to the same level of activity, and yet the incidence of ACLR continues to increase (6). Evidence in many areas is insufficient to guide clinical practice, particularly for multi-ligament injuries, graft selection and fixation method (6). There are still many questions to be answered on who will benefit from surgery and who will not. Before

deciding on the management plan it is important to understand the patient’s beliefs around the management of their injury. If someone has a strong belief that they need surgery, then it is unlikely they will do well with conservative management. If someone is open minded, does not want to pursue surgical management or has lower demands, conservative management might be appropriate. Explore the individual’s understanding of the outcomes following an ACL injury, specifically the risk of osteoarthritis, probability of returning to same level of sport and risk of reinjury or contralateral injury. We have a duty of care to the patient, so we need to be honest about the risks associated with this injury. Historically, it has been thought that all ACL injuries need to be managed surgically. In lower demand athletes outcomes are identical following conservative and surgical management, with similar risks associated with developing osteoarthritis, reinjury and not returning to sport (8*,9*). Frobell et al. in a randomised controlled trial (RCT) comparing outcomes after early ACLR plus rehabilitation with rehabilitation alone could not demonstrate differences between groups in terms of symptoms, function in sports, knee-related quality of life and muscle function 1–5 years after injury (8*,9*). Still, many would argue that reconstruction is the only option for an athlete desiring to return to pivoting sports at a high level. Unquestionably, there is a need for more comprehensive studies evaluating athletes’ ability to RTS without surgery

after ACL injury, as well as the shortterm and long-term outcomes. Currently, autografts are used the most in European countries (range, 93.7–99.7%); whereas allografts are more common in the US (39.9%) (6). For femoral fixation the interference screw is the most frequently used technique over the suspensory fixation technique. These current surgical methods result in a 3-year revision probability (range, 2.8–3.7%) (6). Of the popular autografts, the quadriceps tendon (QT) autografts are used far less commonly than hamstring (HS) tendon and bonepatella tendon-bone (BPTB) grafts in ACLR. Historically the QT autograft had inferior biomechanical properties and unacceptably high rates of residual rotatory knee laxity and persistent quadriceps weakness, especially in women (10). Traditional BPTB and HS tendon ACL grafts are also not without limitations (10). However, modern QT autograft harvest techniques reliably yield a robust volume of soft tissue, possessing superior biomechanical characteristics when compared while other autografts, mitigating the likelihood of variably sized grafts and obviating the necessity of allograft augmentation. This new harvest technique is minimally invasive offering the advantages of low rates of donor site morbidity and residual extensor mechanism strength deficits (10). After ACLR, the typical goal is RTS as quickly as possible, preferably performing at the same level as preinjury yet protected from re-rupture. Ardern et al. reported that, after an ACLR, 81% of patients return to any kind of sport, 65% return to their pre-injury level of sports participation and only 55% return to competitive sports (3*). Also, after RTS the risk of reinjury (graft rupture) ranges from 6% to 25% (11*), whereas the risk of contralateral ACL

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PHYSICAL THERAPY

injury ranges from 2% to 20.5% (11*). Potential risk factors for ACL reinjury/re-rupture, have been identified but are largely non-modifiable factors, such as gender, age, pre-injury activity level and anatomical characteristics (11*). Only one study has addressed neuromuscular control and coordination, of which poor neuromuscular control was a risk factor for ACL graft rupture (12*). Younger athletes have a higher chance of graft rupture, a 10-year difference in age is associated with a 2.6 times greater chance of ACL graft rupture (11*). However, compliance with rehabilitation programmes are substantially lower among younger athletes, which might also contribute to the higher ACL reinjury risk (11*). Quadriceps and hamstring strength contribute to a successful RTS (11*). However, it is not clear whether strength is a risk factor for an ACL graft rupture. Factors such as poor knee alignment or poor neuromuscular control are often described as predisposing factors for ACL reinjuries (11*), but only one study has reported data. Paterno et al. showed transverse plane net moment impulse at the hip, dynamic frontal plane knee ROM, side-to-side differences in sagittal plane, knee moment at initial contact and deficits in postural stability were associated with a 3 times greater risk of ACL graft rupture (12*).

HOW CAN WE REHABILITATE SAFELY BUT EFFECTIVELY? A recent study has highlighted the alarming underutilisation of rehabilitation after ACLR (13). An emerging realisation is evident that athletes may be overtreated with ACLR surgery, but undertreated when it comes to rehabilitation. ‘Undertreated’ may describe insufficient rehabilitation – either where athletes are discharged too quickly or because the rehabilitation content is inadequate (14). Among non-elite athletes with ACLR, only 5% received rehabilitation (13) that followed evidence-based guidelines (1*), which involve ≥6 months’ rehabilitation, including agility and landing exercises and a structured RTS. Most athletes were undertreated:

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45% never saw a clinician after the third postoperative month and 70% never did agility or landing exercises (13). The risk of clinical practice not following evidence-based guidelines is that we are not offering the best to our patients (14). Is it surprising then to see that 35% of athletes after ACLR do not return to pre-injury sport level within 2 years (1*,15)? Half of these athletes report their ACL injury as the primary reason for a lower activity level. Psychological response (eg. fear of reinjury), apart from physical recovery after ACLR has an influence on whether an athlete chooses to return to play. Return to play is defined as the ability to play a competitive match at the preinjury level, or in non-elite individuals to be able to participate in their sport or activity at the level equivalent to pre-injury. Recent research also shows that 3–22% of athletes re-rupture the reconstructed ligament and that 3–24% rupture the contralateral ACL in the first 5 years after ACLR (1*). There is often a misconception that surgery will get me back on the field. No, surgery will fix the anatomical structural damage but it is the rehab afterwards that will get you back on the field. So, the rehabilitation phase is crucial to success. The rehabilitation of ACL deficient and ACL reconstructed knees should be the same. The challenge is, it seems, that some individuals with ACL deficiency do not put the same level of effort or commitment into rehabilitation as they would following a reconstruction. If an individual with an ACL deficient knee is consistently showing signs of instability, then they may need to explore surgical management to achieve their goals. Management of all ACL injuries should involve criteria-based, not time-based, rehabilitation, where the individual has to achieve certain markers before progressing onto the next stage. Historically, timebased markers determined when the patient could move onto the next phase; however, owing to variables in everyone’s ability, their level of dedication to rehabilitation, their progress will vary and may not be

time dependent. However, time does need to be considered with regards to physiological healing processes, tissues repair and strength, ossification postsurgery, etc.

Criteria-Based not TimeBased Progression Through Rehabilitation The poor postoperative outcomes highlight concerns over the criteria used to define readiness to return to the pre-injury activity level and further point to the absence of a consensual, comprehensive set of return-to-activity criteria (RTAC). Multiple factors have been reported to be associated with the low rate of return to pre-injury activities; however, some of them are non-modifiable by rehabilitation. Other factors are modifiable (ie. quadriceps strength deficit, knee ROM limitation, psychological unreadiness, neuromuscular dysfunction and aberrant biomechanical patterns) and can promote patients’ functional recovery and maximise their functional capacities. This, in turn, may allow patients to meet the physical demands of their high-level physical activities. A comprehensive battery of RTAC that include both performance-based and patient-reported measures has been instituted to determine a patient’s readiness to return to multidirectional activities. Patients who had RTAC scores of >90% on all the criteria at 6 months were categorised as the PASS group and those who scored <90% on any of the criteria were categorised as the FAIL group. Patients who did not complete the hop tests because of quadriceps weakness (quadriceps LSI <80%) or pain or who reported having instability or were apprehensive to hop were also classified as FAIL. Studies have shown that: n T he rates of return to participation in the same pre-injury activity level at both 12 and 24 months after ACLR were higher among patients who passed the RTAC than those who failed at 6 months after ACLR (16*,17). n F our out of five patients who passed

the criteria returned to the preinjury activity level at both 12 and 24 months after ACLR compared with only one out of two of those who failed the criteria (16*,17). n Participants who returned to participate in the same pre-injury activity level at both 12 and 24 months after ACLR were almost 3 times more likely to pass the criteria at 6 months after ACLR than those who did not return, whereas participants who did not return at 12 and 24 months after ACLR were at or over 2 times more likely to fail the criteria, respectively, at 6 months after ACLR than those who did return (16*,17). Kyritsis et al. reported that athletes who returned to professional sports without meeting the discharge criteria had a 4 times greater risk for ACL graft rupture compared with those who met the criteria (11*). Another study that used the same RTAC of this study reported that 38% of the athletes who returned to level I sport activities without passing the criteria sustained a knee injury compared with only 5.6% who passed the criteria (17). So, what are the RTAC that are being used with such positive outcomes? For full details on the RTAC,

Crossover Hop

Distance measured

Distance measured Single Hop

Triple Hop

6-m Timed Hop

Figure 1: Hop tests (© Elizabeth Wellsandt 2013, reproduced under the Creative Commons license BY 3.0)

see Link 1. The measures include: 1. quadriceps strength testing 2. four single-legged hop tests (Fig. 1) n straight-line single hop for distance n cross over hop for distance n 6m timed hop n triple hop for distance 3. two patient-reported outcome questionnaires n Knee Outcome Survey–activities of daily living subscale (KOSADLS) (Link 2) n global rating scale of perceived function (GRS). The GRS asks participants to rate their current knee function on a scale from 0 to 100, with 0 being the inability to perform any activity and 100 being the level of knee function before the injury, including sports (18*). These RTAC emphasise good knee function and normal limb-to-limb movement symmetry and achieving them may aid in preventing graft rupture in the future (See Further Resource 1) (11*). Additionally, the majority of these RTAC are sensitive to knee functional changes over time and have the potential to provide therapists with clinically relevant information, including patients’ functional deficits and responses to different therapeutic interventions, so as to provide appropriate rehabilitation training (16*,17). So, with the RTAC explained and ready to guide your progression through rehabilitation ultimately to RTS, what does ACL rehabilitation entail? The aim is to build physical qualities such as strength, global fitness, local muscle fitness, static and dynamic stability through a series of stages (strength and movement control) ultimately to running and RTS. Start by identifying the individual’s goal and understanding what they need to be able to do to achieve this. For an individual to return to football, for example, they need to be able to run, jump, land on one leg, rapidly plant the leg and change direction at high speed and resist perturbation while stood on the leg. Studies have shown that short-

term (5 weeks) progressive exercise therapy programmes are well tolerated and should be incorporated in earlystage ACL rehabilitation (details at Link 3), either to improve knee function before ACLR or as a first step in further conservative management (19*). Clinicians and patients can be more confident in a non-surgical treatment choice (active rehabilitation alone) in athletes who are female, are older in age, and have good knee function, as measured by single-leg hop tests and patient-reported outcome measures, early after an ACL injury. Prediction models that include measures of knee function, assessed either before or after rehabilitation, can estimate 2-year prognoses for non-surgical treatment and thereby assist shared treatment decision-making (Link 4) (20*,21*,22*). In Scandinavia everyone goes through conservative management first. Then if they want to have surgery or fail conservative management, surgery is considered. This may delay the time to RTS for some, but is a sensible approach, as even if the individual goes on to have surgery, improved preoperative physical function is associated with improved postoperative outcome: 1. Studies [using the 5-week rehab programme by Eitzen et al. (19*)] have shown that intensive preoperative rehabilitation protocol including heavy resistance strength training and plyometrics should be considered beneficial, and not harmful, as long as functional criteria for initiation of exercises are met (20*). 2. ACLR patients who underwent progressive preoperative and postoperative active rehabilitation showed superior 2-year patientreported outcomes compared with usual care (20*). 3. 86–94% of the ACLR patients who underwent progressive preoperative and postoperative rehabilitation had 2-year postoperative patientreported outcomes comparable to the general population (21*). 4. After an acute ACL tear, the majority of young active adults regain physical performance and muscle

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strength after a structured exercise programme (mean 37 weeks), with or without surgical reconstruction. Poor physical performance at the end of rehabilitation predicted worse patientreported outcomes at 2 and 5 years, regardless of treatment (22*). Based on the latest (2016) systematic review and multidisciplinary consensus (1*), rehabilitation after ACL injury should include a prehabilitation phase and three criteria-based postoperative phases: (1) impairment-based, (2) sportspecific training and (3) return to play. A battery of strength and hop tests, quality of movement and psychological tests should be used to guide progression from one rehabilitation stage to the next. Postoperative rehabilitation should continue for 9–12 months. The key areas of rehabilitation are discussed below incorporating new research since this review; however, you can follow Link 5 to the full text review and see the summary of the different phases of rehabilitation (See Appendix 2 in the article at Link 5). 1. Movement Control Post-ACLR rehabilitation too often focuses only on the restoration of limb-to-limb symmetry for strength and function. Although symmetry is one potential important goal, regaining symmetry alone will not prevent athletes returning to play with the same underlying deficits that likely contributed to the primary ACL injury. Rehabilitation after ACLR should focus on addressing the underlying neuromuscular control deficits that led to the initial injury and that may be amplified subsequent to ACL injury and reconstruction (23). Following an ACL injury, excessive transverse and frontal plan motion will increase the shear force on the articular surfaces. ACL rehabilitation should aim to regain symmetrical motion and appropriate movement strategies to reduce risk of reinjury and improve function. Movement control training can start with a single-leg squat (supported initially if necessary and for balance) and provide the patient with verbal and visual feedback

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THE UNINJURED LIMB MAY NOT PROVIDE AN APPROPRIATE ‘GOLD STANDARD’ BENCHMARK FOR REHABILITATION COMPARISON to help improve movement control (Link 6) (1*). It would be suboptimal to instruct the athlete to control the knee of the injured leg with a unilateral cueing such as ‘don’t let your knee roll inward when landing or squatting down’ (internal focus). The emphasis should rather be on cueing on an external goal; for example, ‘reach your knees towards the cones when landing’ (external focus). This is a more central approach, aimed at reducing the increased reliance on conscious (internal) control during movement frequently seen after initial ACL injury. Adoption of this approach during rehabilitation can potentially better address the neurological deficits in motor planning, sensory processing and visual motor control seen after ACLR and even return to play (23). Another open access paper that provides good examples of feedback techniques is “Optimization of the anterior cruciate ligament injury prevention paradigm: novel feedback techniques to enhance motor learning and reduce injury risk” by Benjaminse et al. (Further Resource 2). Movement control can be scored using the Qualitative Analysis of Single Leg Loading tool (QASLS) (Link 7) (24*,25*). Scoring is defined as zero for the appropriate strategy and 1 for inappropriate strategy, with the best overall score being 0 and worst 10. This scoring system can be taught to patients so they understand what we are looking for with movement tasks. Once a patient has good singleleg movement, control and strength, then they can progress onto load acceptance. This involves tasks such as: n step-ups n forward step-lowers n forward stepping and stepping down. These tasks can be progressed using directional challenges such as: n oblique stepping

n side stepping n stepping off a step with rotation. Once the patient can maintain good alignment during these tasks, the load can be altered by: n increasing the height of the step n increasing the step distance n introducing unstable surfaces n using a hop instead of step. These exercises are a closed skill and require block practice to master. Once the closed-skill tasks have been mastered, open-skill elements should be gradually incorporated in a more and more random fashion while performing tasks of progressively increasing complexity. This can be achieved by providing the patient with a verbal cue to step forwards/ sideways or using different height boxes so the patient has to adjust their landing strategy, making a circuit of different steps, height and surface changes. Complexity can be added by introducing perturbation by nudging them, attaching bungee cords, following a partner around or introducing a skill such as catching or kicking while stepping. Adding perturbation to a standard training programme has been proven to be effective to reduce the risk of continued episodes of giving way of the knee during athletic participation, and it allows subjects to maintain their functional status for longer periods (Link 8) (26*). Movement control is a learning process for the patient and they will go into valgus with some landings. This can be a positive as it puts altered directional stress on the knee and increases the patient’s confidence that the knee can cope with landing in this position. However, the number of landings into valgus should be limited. If the patient is consistently going into valgus, then the task is too challenging and should be regressed.

MANAGEMENT OF ALL ACL INJURIES SHOULD INVOLVE CRITERIA-BASED, NOT TIME-BASED, REHABILITATION 2. Strength Training Seventy five percent of individuals who sustained a secondary ACL injury had ‘passed’ their limb symmetry indices (LSI) with >90% (23). Therefore, contemporary rehabilitation approaches should focus on a broad spectrum of individual sensorimotor and biomechanical outcomes within a biopsychosocial framework. What does this mean? 1. Strength alone, be it isometric or isokinetic, is not an absolute sign of recovery There is more to it, possibly involving movement patterns, central control, psychological element, trunk and lower limb motor control. 2. Strength testing alone (LSI) and using that as a bench mark for progression or RTS is based on comparison with the ‘good’ leg Is that uninjured leg really that good, what is the bench mark? The contralateral (uninjured) limb may not provide an appropriate ‘gold standard’ benchmark for rehabilitation comparison, particularly considering the neurological changes that occur after injury. If the primary risk factors are not addressed during rehabilitation, asymmetries that magnify initial injury risk factors likely underlie the ‘healthy’ limb injury risk after a primary ACL injury. As the uninjured leg is affected too after ACL injury, rehabilitation should not only focus on regaining strength and function of the injured leg matching the uninjured leg but a more global picture of symmetry and motor control from the trunk down (23). Therefore LSIs should still be used in assessing strength and function (such as a hop test) but can be compared to other normative data of controls and/ or be included in a larger test battery (as discussed earlier under RTAC) to give a fuller picture of the patient’s

capacity(27*). Movement control rehabilitation should be combined with a strengthening programme. n Open kinetic chain (OKC) and closed kinetic chain (CKC) quadriceps exercises are a good way to strengthen the quadriceps in isolation (1*). n After ACLR, OKC exercises can be performed from week 4 after surgery in a restricted ROM of 90– 45° (1*). This range of movement limits anterior tibial translation while still allowing isolation of the quadriceps (28*). n Owing to the different fixations used, full range knee extension exercises should not be used before 12–14 weeks for bone patellar bone grafts and before 14–16 weeks for hamstring grafts. n Starting eccentric quadriceps training (in CKC) from 3 weeks after ACLR is safe and contributes to a bigger improvement in quadriceps strength than concentric training (1*). n Isometric quadriceps exercises are safe from the first postoperative week (1*). n Immediate weight-bearing does not affect knee laxity and results in decreased incidence of anterior knee pain (1*). In the event of harvest site morbidity in the rehabilitation period, an approach Video 1: Improve jumping & sprinting performance. Front squat vs hip thrust (Courtesy of YouTube user Physiotutors) (https://spxj.nl/2OUf8Nb)

similar to that taken for quadriceps tendinopathy may be used. This involves preferential stretching of the rectus femoris and systematic loading of the quadriceps to increase tolerance to load (10). To improve strength, perform 3–5 sets of 8–12 repetitions using maximal loads. Open chain exercises can be combined with leg-press or squat depending on the technical ability of the patient (Video 1). Following a hamstring graft, combine open chain hamstring exercises with Romanian deadlifts to ensure the patient is tolerant of both hip and knee dominant exercises. A strengthening programme should also include exercises for the calf complex and gluteal muscles. Hang cleans or mid-thigh pulls can be used to improve concentric force generation. 3. Return to Running An important milestone is returning to running (RTR). The RTR is key to the participation element of the RTS continuum (Fig. 2) (29). Running places relatively low demands on the knee. However, RTR marks the beginning of the transition from impairment-focused tasks in early rehabilitation (eg. knee ROM exercises, isometric quadriceps strengthening) to the functional, sport-specific tasks that characterise more advanced rehabilitation (eg. sprinting, pivoting, cutting) (29). Patients often fear running so it is important to introduce it as early as possible. The clinician needs to be mindful that introducing running may reduce compliance in other areas of rehabilitation, maintaining focus on specific strength training is essential. Running may be used as a warmup and cool-down for the exercise component of rehabilitation. There is a lack of information regarding when the patient can RTR following ACLR. Steady progress through high-quality rehabilitation influences functional outcomes, and premature RTS increases the risk for reinjury. Conversely, delayed progress may hinder motivation and psychological readiness to RTS (29). Studies show the median time from which RTR was permitted was

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12 postoperative weeks, with a range of 5–39 weeks, depending on open or arthroscopic surgery and protected or contemporary rehabilitation (29). Arbitrary time points might reflect different rehabilitation goals: n Early RTR (ie. around 8 postoperative weeks) might reflect a focus on early RTS. n Late RTR (ie. around 16 postoperative weeks) might reflect a focus on protecting the healing ACL graft. The understanding of graft healing timelines in humans is limited. The ACL graft may undergo substantial change in mechanical properties during the period from 8 to 16 postoperative weeks, with ossification of the insertion sights (29). Healing times can vary across individuals and reinforces the fact that time may not be an ideal guide for RTR alone and no ‘one-size-fits-all’ timeline to recovery will work. Clinical criteria for RTR may vary from: n full ROM knee flexion or at least 95% to that of uninjured side; n full extension; n no effusion; and n pain, visual analogue scale (VAS) less than 2 (29). The most common objective measure is isometric quadriceps strength, a limb symmetry index (LSI: calculated by dividing the operated limb score by the non-operated limb score) >80% and isokinetic quadriceps and hamstrings LSI>70% (29). Other studies advocate a performancebased criteria including: n balance criteria; and n normal gait pattern during walking or jog-in-place or functional tests. The objective criteria used were proprioception LSI of 100%, composite score on Y-balance test >90%, functional test LSI >70%, hop test LSI >85%, and two combined tests as 10 consecutive single-leg squats to 45° knee flexion without loss of balance, and 30 step-up-and-holds without loss of balance or excessive motion outside of the sagittal plane (29).

Co-Kinetic.com

After ACL reconstruction

Return to participation

Return to sport

Return to performance

e.g. Return to running

e.g. Available for selection in first team

e.g. Score matchwinning goal

Figure 2: Return to Sport Continuum.pdf. Title Return-to-sport continuum [Reproduced with permission from Rambaud AJM et al. Criteria for return to running after anterior cruciate ligament reconstruction: a scoping review. British Journal of Sports Medicine 2018;doi:10.1136/bjsports-2017-098602 (29)]

Straight-line running can be introduced as long as the patient has a good gait pattern, avoids sudden stops or starts, and has appropriate levels of strength to absorb force. The patient should be able to single-leg press/ squat 1.5× body weight for 10 repetitions before starting running. This may seem excessive but following weeks of strength training in earlier rehabilitation phases they should be able to cope with this; bearing in mind that running has impact loads often more than 3× the body weight. Straight-line running can progress by increasing speed and introducing deceleration. The patient needs to be able to stop suddenly before the introduction of change-in-direction running. Progress changes of direction from 45° to 90° through to 180° while increasing speed and adding complexity. 4. Return to Sport What is really meant by return to sport (RTS)? The return should be safe and successful, meaning, no reinjury or other subsequent injury, and no exacerbations of knee pain and swelling, in the short term; as well as no negative long-term consequences, such as osteoarthritis. When (weeks, months, years) can a reinjury occur in order for us to say that the return was safe and successful? Likewise, the type and level of sport has to be specified when we discuss RTS. Is it an elite, competitive or recreational level of sport? Is it return to pre-injury sport at the same, or lower level, or to another sport? Is it return to contact, cutting and pivoting sports? Various aspects of performance when returning to sports, for example, athlete-perceived level of performance or match statistics, may

also need to be considered (5). Often the criteria for returning to sport is set too low: equal hop symmetry does not guarantee a safe RTS. As discussed above there should be a battery of tests/criteria looking at both strength, motor control, functional ability and then advanced sports-specific drills. The patient is ready to return to training when they have progressed through the taskbased rehabilitation programme. From the point of introducing sports-specific training, RTS can take a further 2 months. The athlete should be introduced to restricted team training which may involve only playing in certain areas of the field or for a set time period. Clearly define what restricted team training involves to both the athlete and coach (30*). The athlete needs to be confident in the chaotic scenarios of training before returning to sport. Aim to build up chronic exposure before returning an athlete to competition (30*). 5. Pain During Rehabilitation Intense pain during rehabilitation should result in an immediate cessation of a task. Use daily monitoring tools such as stiffness and swelling to monitor the knee’s response to loading. An increased circumferential measurement of the knee during the day combined with the knee being more stiff the next morning, suggests a degree of inflammation is present and the knee has not tolerated the rehabilitation load. Using monitoring tools can help to improve the patient’s confidence and empower them to push on with their rehabilitation knowing their knee is not ‘flaring’.

Questions to use for monitoring the response to load include: n How did it feel after the rehab sessions? n How did it feel that evening? n How did it feel the next morning? n How do the scores compare with your normal scores? If the knee is not flaring, it’s a great indication to you that you can push/ progress the patient further or harder. It gives the patient confidence that they are coping with rehabilitation, and confidence in your care and compassion should you require a few stalling sessions if the knee does flare up.

HOW CAN WE PREVENT AN ACL INJURY? Prevention of injury is always the ideal; however, so many of the risk factors identified are non-modifiable including age, gender and history of previous injury. Effective prevention programmes require substantial resources and time commitments. The programmes need intervention providers to supervise athletes to ensure correct technique and can be perceived as timeconsuming. Therefore implementing and encouraging adherence to prevention programmes to ensure efficacy is needed, and everyone involved needs to ‘buy into the idea’. Even where these factors are taken into consideration, the most effective prevention programmes are associated with a high number needed to treat. Optimistic estimates suggest that 108 athletes have to be treated to prevent one ACL injury. Therefore, these programmes may have greatest value when a large population, large team sports, or sports academies are considered (31). In clinical practice research shows that: n FIFA 11+ warm-up programme resulted in fewer lower limb, including ACL, injuries when followed through a season (32). n RTS is a continuum, not a single time point. To prevent reinjury or subsequent injury to the other limb following ACLR clinicians need to continue working with patients and continue specific strength and motor

control exercises beyond the RTS date (32). n The ACL-SPORTS programme (21*) may be a beneficial secondary prevention programme for men who wish to RTS after ACLR. The programme seems to be valuable for men and women, but during the RTS phase of rehabilitation when many clinicians shift their focus to sport-related activities, women may need a continued focus on strengthening, especially given the implications of quadriceps asymmetry on reinjury risk (21*).

WHAT ABOUT CHILDREN AND ACL INJURIES? Going into a full discussion about the specifics of paediatric ACL injury is outside the realm of this article. However, there seems to be an increasing incidence and concern for the number of ACL injuries in adolescents and the concern about their successful return to full function (See Further Resource 3). Some present with OA in the ACL-injured knee as early as aged 20 (33). There is reason to be concerned. If you treat a lot of children or are involved with sports teams and schools where you have exposure to this injury, please follow Link 9 to the most recent consensus statement (2018) regarding paediatric ACL injury (34*).

WHAT’S THE LONG-TERM OUTCOME FOLLOWING ACLR? The pathogenesis of the posttraumatic degenerative disease process is unclear, with many factors likely to contribute immediately after the ACL tear. Intra-articular damage to the cartilage, menisci and subchondral bone, and inflammatory responses following a high-impact knee injury, may initiate a degenerative process (35). The association between RTS following ACL tear and knee osteoarthritis (OA) is unknown. The ACL tears often occur during participation in pivoting sports, such as soccer. Pivoting sports cause high-impact loading on the knees, and a higher prevalence of knee OA has

been reported in uninjured soccer players compared with a matched group of military personnel (35). Returning to pivoting sport following an ACL tear with poor knee function may predispose for future knee OA. High rates of degenerative changes occur in the first 5 years following ACLR, particularly the development and progression of patellofemoral cartilage defects. Older individuals with a higher BMI appear to be at particular risk, and should be educated about this risk (36): n Worsening of cartilage defects in the patellofemoral, medial and lateral tibiofemoral compartments was present in 44%, 10% and 13% of ACLR patients respectively (36). n Overweight (BMI >25kg/m2) was consistently associated with elevated odds (between 2–5-fold) of worsening patellofemoral and tibiofemoral osteoarthritis features (36). n Older age (>26 years at surgery) was associated with 3-fold greater odds of worsening patellofemoral and tibiofemoral cartilage defects (36). A 10-year risk factor analysis identified several factors that can affect long-term knee function after ACLR. Most of the risk factors were surgery-related and unfortunately non-modifiable. Nevertheless, this information can be helpful to physicians counselling patients’ expectations of outcome after ACLR (37). At a 15-year follow-up in individuals post-ACLR, of those who had returned to pivoting sports 5.5% had symptomatic OA and 18.5% had radiographic OA. However, of those who did not return to pivoting sport 25% had symptomatic OA and 42% radiographic OA (35). The causal factors for this are unknown, but the data seem to contradict what is suspected to occur to the knee following ACL injury. Patients who returned to pivoting sports were younger, had better ADL ratings and better overall knee function. Current studies therefore, may indicate that

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returning to pivoting sports with good self-reported knee function does not increase the long-term development of knee OA (35). Possibly the patients who returned to pivoting sport (Level 1 sport) may have had a less serious injury with less intra-articular damage than the participants who did not return to pivoting sport (35). Those who returned to pivoting sport may also have had a combination of beneficial factors making them well prepared to return to pivoting sport. However, 30% of those who did not return to pivoting sport returned to alpine skiing, considered as a level II sport, but still extremely kneedemanding (35). So is it the type or classification of the sport that is limiting the understanding of longterm progress outcomes?

WHERE DOES THIS LEAVE YOU? There is no doubt that physical therapy and rehabilitation is a crucial, probably vital part of any ACL deficient or ACLR patients probability of successful long-term recovery. Discussions with patients about surgery pros and cons, outcomes after surgery and dedication to rehabilitation need to be encouraged. The belief that surgery is the only solution or at least the fastest solution to returning to sport is not always the case; conservative management may be a viable option for many patients especially non-elite or recreational athletes. Rehabilitation, be it before or after surgery needs to be criteria-based using a battery of RTAC. Similarly, the rehabilitation needs to be considered not simply as a single peripheral joint injury but rather as a complex dysfunction of strength, function, motor control, neuromuscular pathophysiology from the trunk (or even the central cortex) down. Progression to running and ultimately RTS needs to be criteria- not time-based, and requires not only strength, motor control and sports-specific functionality but also a psychological readiness and confidence in their knees ability.

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LINKS Link 1: For full details of the of return-to-activity criteria (RTAC), see “Do patients failing return-to-activity criteria at 6 months after anterior cruciate ligament reconstruction continue demonstrating deficits at 2 years?” by Nawasreh Z et al. The American Journal of Sports Medicine 2017;45(5):1037–1048. (https://spxj.nl/2whusvJ) Link 2: Knee Outcome Survey (KOS): Activities of Daily Living Scale; Sports Activity Scale. From Irrgang JJ et al. Development of a patient-reported measure of function of the knee. Journal of Bone & Joint Surgery (Am) 1998:80-A(8):1132–1145. (https://spxj.nl/2Mt0DmL) Link 3: A full description of the 5-week rehab/exercise programme and the exercises used is given in: “A progressive 5-week exercise therapy program leads to significant improvement in knee function early after anterior cruciate ligament injury” by Eitzen I et al. The Journal of Orthopaedic and Sports Physical Therapy 2010;40(11):705–721. (https://spxj.nl/2OSvgic) Link 4: Two papers that provide rehab exercise ideas: a. “Anterior cruciate ligament injury—who succeeds without reconstructive surgery? The Delaware-Oslo ACL cohort study” by Grindem H et al. Orthopaedic Journal of Sports Medicine 2018;6(5):2325967118774255. (https://spxj.nl/2PvzsWu) b. “Anterior cruciate ligament – specialized post-operative return-to-sports (ACL-SPORTS) training: a randomized control trial” by White K et al. BMC Musculoskeletal Disorders 2013;14:108 (https://spxj.nl/2Mr4X6d) Link 5: “Evidence-based clinical practice update: practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensus” by van Melick N et al. British Journal of Sports Medicine 2016;50:1506–1515. (https://spxj.nl/2OUYH3r) Link 6: See Figure 1 of “Examples of how to give verbal and visual feedback to improve your patient’s motor control” by Benjaminse A et al. British Journal of Sports Medicine 2018;doi:10.1136/bjsports-2017-098502 (23). (https://spxj.nl/2MDPgrs) Link 7: A scoring sheet and explanation for the Qualitative Analysis of Single Leg Loading tool (QASLS) is given in: “Task based rehabilitation protocol for elite athletes following anterior cruciate ligament reconstruction: a clinical commentary” by Herrington L et al. Physical Therapy in Sport 2013;14:188e198. (https://spxj.nl/2N8znpU) Link 8: Different ways to include perturbation in your rehab programme. “The efficacy of perturbation training in nonoperative anterior cruciate ligament rehabilitation programs for physically active individuals” by Fitzgerald GK et al. Physical Therapy 2000;80(2):128–140. (https://spxj.nl/2w0Zc4V) Link 9: “2018 International Olympic Committee consensus statement on prevention, diagnosis and management of paediatric anterior cruciate ligament (ACL) injuries” by Ardern CL et al. British Journal of Sports Medicine 2018;52(7):422–438 (34). (https://spxj.nl/2PoxyGV)

FURTHER RESOURCES 1. Kyritsis P, Bahr R, Landreau P et al. Infographic. Avoid ACL graft rupture. Meet discharge criteria. British Journal of Sports Medicine 2016;50:952 2. Benjaminse A, Gokeler A, Dowling AV et al. Optimization of the anterior cruciate ligament injury prevention paradigm: novel feedback techniques to enhance motor learning and reduce injury risk. Journal of Orthopaedic Sports Physical Therapy 2015;45(3):170–182 [Open access](https://spxj.nl/2LHjVzv) 3. Shaw L, Finch CF, Bekker S. Infographic: Trends in paediatric and adolescent ACL injuries. British Journal of Sports Medicine 2018;doi:10.1136/ bjsports-2017-098504. 23

KEY POINTS nA n ACL injury should be regarded as a neurophysiological dysfunction and not a simple peripheral musculoskeletal injury. n Higher quadriceps strength, less effusion, less pain, greater tibial rotation, higher Marx Activity score, higher athletic confidence, higher preoperative knee self-efficacy, lower kinesiophobia and higher preoperative selfmotivation have been associated with better outcomes in returning to sport after ACL reconstruction. n Only 65% of patients who undergo surgical reconstruction return to the same level of activity. There is an emerging realisation that athletes may be overtreated with ACLR surgery, but undertreated when it comes to rehabilitation. n Reconstruction has traditionally been the only option for an athlete desiring to return to pivoting sports at a high level. There is a need for more comprehensive studies evaluating athletes’ ability to return to sports without surgery after ACL injury, but preliminary research is showing good outcomes. n Criteria-based rather than time-based return to activity is crucial. Passing a testing battery of performance-based and patient-reported measures is associated with a higher rate of return to participation at the same pre-injury activity levels after reconstruction. n Return-to-activity criteria variables, individually and in combination, can help predict return to participation in the same pre-injury activity level at 12 and 24 months after ACLR. n Utilising return-to-activity criteria may help in identifying those patients with poor knee functional performance and limb-tolimb asymmetry and help in modifying the rehabilitation protocol by providing additional training sessions to address their functional deficits and limb-to-limb asymmetry after ACLR. n Limb symmetry index, used in many test batteries, may require further consideration as the ‘uninjured’ limb is often not of optimal motor function, control or strength for comparison and normative date from healthy individuals should be the bench mark for rehabilitation goals. n Return-to-sports criteria needs to include not only strength, motor control and sports-specific functionality but also psychological readiness and patient confidence in their knees ability. n ACLR rehabilitation needs to be considered not simply as a single peripheral joint injury but rather a complex dysfunction of strength, function, motor control, neuromuscular pathophysiology from the trunk, or even the central cortex, down.

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 https://spxj.nl/2NErLfn

RELATED CONTENT reventing and Managing ACL P Injury - http://spxj.nl/2EwFwMC

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

DISCUSSIONS aving reviewed this paper, what are your thoughts H on using a conservative rehabilitation approach on all patients as a first-line option before considering surgery, as practised in Scandinavian countries? What key tests, questionnaires or outcome measures would you include in your test battery for patients following ACL reconstruction? Before returning to sports, what are your fundamental rehabilitation goals, your nonnegotiables for an athlete to achieve to ensure confidence and reduce reinjury risk?

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: The rehabilitation of ACL deficient and ACL reconstructed knees should be the same https://spxj.nl/2LTrTG3 Tweet this: Management of all ACL injuries should involve criteria-based, not time-based, rehabilitation https://spxj.nl/2LTrTG3 Tweet this: Rehab after ACL injury should include a prehabilitation phase and 3 criteria-based postop phases https://spxj.nl/2LTrTG3

Co-Kinetic Journal 2018;78(Oct):14-24

BRAIN, PAIN AND SPORTS PERFORMANCE

INTRODUCTION Sleep is the foundation of good health, yet we seem to take it for granted, and some may even consider sleep an annoying necessity. We couldn’t be further from the truth. We’ve all heard the phrase, “I’ll sleep when I’m dead” … I’d like to think that this article will propel you and your athletes into developing some great habits when it comes to sleep, so that we can all benefit from its amazingly restorative effects. There’s an abundance of research telling us about the importance of nutrition and physical activity for our health and longevity, along with the dangerous effects of alcohol and smoking (1), and how diet and physical activity can help to tackle cancer, obesity and type 2 diabetes (2). Without question diet and exercise are incredibly important, but surely sleep is the preeminent force in this health trinity (3)? The physical and mental impairments caused by one night of bad sleep dwarf those caused by an equivalent absence of food or exercise (3): n L ess than 6–7h of sleep per night severely compromises our immune system, more than doubling the risk of cancer! n Insufficient sleep is a key factor which determines whether or not you will develop Alzheimer’s disease. n Reduced sleep, including moderate reductions even for one week, impacts blood sugar levels so profoundly that you would be classified as pre-diabetic! n Reduced sleep also: – increases the chances of developing coronary heart disease – increases the chances of developing a stroke – increases the chances of developing congestive heart failure – contributes to all major psychiatric conditions, including depression, anxiety and suicidality – increases concentrations of a hormone that makes you feel hungry and supresses the hormone that tells you that you’re satisfied – affects physical performance – can reduce an athletes time to physical exhaustion by 30%. Co-Kinetic.com

I’LL SLEEP WHEN I’M DEAD, IF THE LACK OF IT DOESN’T KILL ME FIRST! We all know how much better we feel after a good night’s sleep. However, do you know just how much harm, both physically and mentally, the lack of sleep causes? This article describes what can cause poor sleep and spells out the wide-ranging detrimental effects of it. Additionally, instructions for good sleep hygiene are provided, which will allow you to maximise your training and performance potential. Read this article online https://spxj.nl/2LTIGbV BY PAULA CLAYTON MSC FA. DIP. MAST. STT, MSMA (L5) MCSP HCPC – Good sleep can improve performance speed by 20% and accuracy by 35% (see more about the impact on athletes later).

“We are the supremely arrogant species; we feel we can abandon 4 billion years of evolution and ignore the fact that we have evolved under a light–dark cycle. What we do with the species, perhaps uniquely, is override the clock. And long term acting against the clock can lead to serious health problems.” (4) Supporting the Shocking Statements Our bodies are amazing at going about their business without us having to do a thing! I’ve said it before and I’ll say it again, we often live in our heads with no consideration or concern about what our body is doing while we live our lives – until it goes wrong! Then we become injured, ill or are in pain and we wonder what happened … “it came from nowhere!”

18-10-COKINETIC FORMATS WEB MOBILE PRINT

Briefly Into the Science Sleep is an internally and externally controlled process structured by an interaction of our body

THE PHYSICAL AND MENTAL IMPAIRMENTS CAUSED BY ONE NIGHT OF BAD SLEEP DWARF THOSE CAUSED BY AN EQUIVALENT ABSENCE OF FOOD OR EXERCISE clock (circadian clock) and homeostatic mechanisms. It is a glycogenic process that replenishes glucose stores in neurons, whereas the wake cycle is designed for repetitive glycogen breakdown (4). Don’t worry this will make sense in a minute! Although the evidence supporting the fact that sufficient sleep and adequate exercise are pivotal in maintaining health is overwhelming, these behaviours remain deprioritised with an estimated third of adults sleeping less than the recommended 7h a night needed to maintain optimal health (5), with teenagers demonstrating an even larger sleep deficit: almost two-thirds of high school students sleep less than the advised 8–10h on school nights. All this is interesting, but why is this relevant to sports injury? Keep reading, it will open your eyes!

TABLE 1: CURRENT SLEEP DURATION RECOMMENDATIONS, WHICH TEND TO CHANGE OVER TIME Recommended Stage of life Age amount of sleep (h) Newborns

0–3 months

14–17

Infants

4–11 months

12–15

Toddlers

1–2 years

11–14

Preschoolers

3–5 years

10–13

School-age children

6–13 years

9–11

Teenagers

14–17 years

8–10

Young adults

18–25 years

7–9

Adults

26–64 years

7–9

65+ years

7–8

Older adults

[Data sourced from Hirshkowitz et al. National Sleep Foundation’s updated sleep duration recommendations: final report. Sleep Health 2015;1(4):233–243, (7); available at the National Sleep Foundation website (https://spxj.nl/2LgTOiX)

In Britain, the average person sleeps for a little more than 6.5h a night. More worryingly, over one-third of the population sleeps for as little as 5–6h a night, 7% more of us than just 3 years before (6). The rest of the world is no exception; 20% of the population in the USA admit to sleeping less than 6h a night on workdays; Canada, Japan and Germany report similar statistics, with people admitting they catch up on their sleep at the weekends (6). This means we are fighting against our body’s circadian urge to be up with the sun. If we are sleeping optimally throughout the week, then waking up at the same time everyday should be achievable. Current sleep duration recommendations are shown in Table 1 and tend to change with age (7). You are probably aware that our brains are incredibly active while we’re awake (learning, developing, and helping you to be amazing), but did you know that during rapid eye movement (REM) sleep parts of our brains are 30% more active than when we are awake? You are also probably aware that we have a cellular waste management system responsible for eliminating metabolic waste and toxins (lymphatic system), but did you know that the brain has its own waste disposal system, removing and recycling dead cells and toxins making room for new growth and development? This is called the ‘glymphatic system’, which is easy to remember – the added ‘g’ represents the glial cells in the brain that control it. During sleep, the glymphatic system becomes 10 times more active than during wakefulness. Simultaneously, our brain cells are reduced in size by about 60% while we’re asleep to make waste removal even more efficient (8).

Circadian Rhythms – The Solar Powered Human! Interestingly our great night’s sleep begins the moment we wake up in the morning. Our sleep cycle or ‘circadian rhythm’ (Fig. 1) is heavily impacted by the amount of daylight we receive during our waking hours. Get outside with your cup of coffee or walk the dog! Did you know that sunlight in the morning actually signals your hypothalamus and all

corresponding organs and glands to be alert and wake up? Not only that, it also triggers our body to produce optimal levels of daytime hormones and neurotransmitters that regulate our internal clocks (functions that work deep within our brains and are a part of the fabric of our very being) regulating our internal patterns (sleep, alertness, eating, digestion, hormone production, mood and temperature). It is also a master regulator (9), which synchronises numerous physiological and biochemical processes, including the daily rhythm of sleep, along with the scheduled release of hormones, and it also helps to control your digestion, immune system, blood pressure, fat utilisation, appetite and mental energy … among other things. I know it sounds counterintuitive to get more sunlight during the day in order to get better sleep at night, but science has proven that this is precisely the case. Whereas our body clock controls our urge to sleep our homeostatic sleep pressure controls our need to sleep. From the second we awake, our body is already preparing for sleep (see the information on adenosine in the section ‘How Caffeine Affects our Sleep’). Daylight initiates our brain’s production of serotonin (the neurotransmitter from which melatonin is derived), so the longer we are awake the greater the need for sleep becomes. Unfortunately, however, we are able to override this urge (the second wind) – something that is definitely not advisable if you are suffering from chronic stress or fatigue, or overtraining syndrome.

STAGES OF HEALTHY SLEEP When we are asleep, REM and nonREM (NREM) sleep battle through the night, a battle that is won and lost every 90min, ruled at first by NREM sleep. NREM sleep is subdivided into four stages: shallow sleep stages 1–2 and deep sleep stages 3–4. REM sleep is our dreaming state, in which some parts of the brain are 30% more active than when we are awake! REM has important metabolic consequences owing to the reported increase in metabolic rate and glucose utilisation (10). Co-Kinetic Journal 2018;78(Oct):25-32

BRAIN, PAIN AND SPORTS PERFORMANCE

12.00 midnight

21.00 Melatonin secretion starts

02.00 Deepest sleep

19.00 Highest body temperature 18.30 Highest blood pressure

04.00 Lowest body temperature

Circadian rhythms

18.00 17.00 Greatest cardiovascular efficiency and muscle strength

06.45 Sharpest blood pressure rise 07.30 Melatonin secretion stops

15.30 Fastest reaction time

14.30 Best coordination

06.00

12.00 noon

10.00 Highest alertness

Figure 1: Circadian rhythms (Oras E. Are your sleeping habits ruining your recovery? How to fix your circadian rhythm? Follow the Intuition 2017; https://spxj.nl/2w611gT)

NREM Sleep

Deep Sleep

In shallow stages 1–2, we are still close to the surface (using a scuba diving analogy, as I am an avid diver). This is in the first few minutes when we slowly begin our descent, where we are somewhere between being awake and being asleep. This is the place we may experience the sensation of falling, if we should wake at this stage, we would begin our descent again. From here it is very easy to reach the surface. A door banging, a phone ringing can pull us back up, but once we manage to negotiate this stage successfully, we make our way down to the next stage.

Deep sleep is like diving into the deep. At this depth, in deep sleep, we begin to produce delta waves (the slowest frequency brainwaves). This is the most wonderful place to be and we ideally want to stay here for as long as possible (20% of our sleep). We spend most of the earlier part of our sleep cycles in this state and the benefits are incredible: n We weed out and remove unnecessary neural connections. n It is a state of vivid reflection, fostering information transfer and the distillation of memories. n We store and strengthen the raw ingredients of new facts and skills. n Missing out on this stage by going to bed late, reducing your total sleep time will cause brain impairment.

Light Sleep We have now descended but we are diving in the shallows, where we can still see colour. In light sleep the heart rate and body temperature decreases. It is still possible to be pulled back to the surface by the noise of your baby crying or someone shouting your name. When we are asleep we spend the largest percentage of our time in this state. Information consolidation and improved motor skill performance are linked to this stage (11), and as we go deeper we begin to reap even more benefits.

Co-Kinetic.com

REM Sleep We often return to the shallows for a while before we reach the REM stage (ideally around 20% of our sleep time), where we are temporarily paralysed and dreaming. It is believed that REM sleep is related to creativity. We spend a higher proportion of the later part of our sleep cycles in this state and the benefits are directly related to the quality of NREM sleep. REM sleep: n involves ‘paralysis’ or no tone (atonia) in the voluntary muscles;

n p revails later in the night, etching the detail of learned skills, strengthening the neural connections once NREM has removed the unnecessary neural connections; and n interconnects the raw ingredients with each other, building a more accurate model of how the world works, including innovative insights and problem solving abilities. Going to sleep late and waking early may lead to the loss of up to 25% of total sleep time, which could mean losing up to 90% of REM sleep, reducing your ability to consolidate learning from the previous day. Both types of sleep restore the brain’s capacity for learning. Sleeping before learning increases the capacity to learn and store information (eg. after a nap) and sleeping after learning effectively clicks the ‘save’ button leading to consolidation. Win–win!

ATHLETES AND SLEEP “Practice does NOT make perfect, but practice ‘with’ sleep does!” (3) The research surrounding sleep and its effect on athletic performance is astounding. So, much so, that athletes, coaches and performance directors need to take note – if, of course, they are not already!

“If you don’t snooze … you lose (skill memory)!” (3) Poor sleep can quickly affect physical and sports performance and sleep quality is a significant factor in the achievement of peak athletic performance. Accumulated sleep debt has been found to affect cognitive function, mood, daytime sleepiness and traditional performance indices such as reaction time and learning and memory tasks (12).

The Human Performance Project advises many Olympic, NCAA and Professional Teams. The sleep recommendation for athletes training at this level is 9h 15min every night. In 2015 the International Olympic Committee published a consensus statement highlighting the critical importance of, and the essential need for, sleep in athletic development across all sports for men and women (13).

Sleep Deprivation in Athletes Sleep deprivation in athletes is not an uncommon occurrence. If you consider their demanding training schedules, pre-competition anxiety and often extensive travel, you can see why loss of sleep can regularly lead to hindered performances (14). Gupta et al. agree with this finding (15), going on to say that the timing of competitive events has a significant impact, particularly if sleep is pushed later. Being ‘half asleep’ where half of the brain will resist going to sleep in an unfamiliar place (innate protection mechanism), should be taken into consideration when planning when the athlete and support staff arrive at the competition venue. The following examples demonstrate clearly how as little as one night’s loss of sleep can affect the athlete: n Chronic lack of sleep across a season predicts a considerably higher risk of injury (16). n One night of sleep deprivation can result in metabolic irregularities, causing: – increased plasma lactate concentration (17)

n n

– increased creatine phosphokinase and myoglobin levels (17). Elite athletes’ training intensity is typically near their maximum capacity. – DO NOT increase training to help aid sleep. – Increased intensity, such as altering periodisation has proven to be significantly (progressively) detrimental to sleep quality (18) and simply subjects the athlete to a higher risk of fatigue and overuse injury. Diet can also significantly impact on sleep quality (19). – Positive outcome: high protein diets can improve sleep quality. – Positive outcome: tryptophan, which may be consumed from turkey or pumpkin seeds, can improve sleep onset latency (the time take to fall asleep) and sleep quality. – Negative outcome: high fat diets can negatively affect total sleep time – Negative outcome: total caloric intake reduction may disrupt sleep quality. Physical performance has been shown to be affected by lack of sleep, including weight-lifting, cardiorespiratory functioning and psychomotor tasks that require accuracy and consistent performance (20). Lack of sleep reduces accuracy during skill testing (21). Less than 8h sleep (and particularly less than 6h) reduces your time to physical exhaustion by up to 30%, and aerobic output is reduced (3). In addition, the following are also seen: – reduced limb extension force – reduced vertical jump height – reduced peak and sustained muscle strength – reduced cardiovascular capacity – reduced metabolic and respiratory capability – increased rates of lactic acid build-up – reduced blood oxygen saturation – increased blood carbon dioxide – a reduction in self-cooling ability. There is evidence of impaired immunity and a decline in function,

n n n

which affect the recovery process and adaptations to training (19). Lack of sleep has been seen to reduce cognitive function, increase pain perception, cause mood changes, alter metabolism and cause changes in inflammatory markers (19). Important relationships may suffer (family, friends) and work productivity is likely to decline. Fatigue and tiredness are present (22). Poor sleep quality is experienced (23). Endurance exercise was more affected than single maximal efforts following partial sleep deprivation (24). Longer submaximal exercise tasks such as long distance running maybe affected. As with most sports, an athlete’s mental approach is crucial for both training and competition. – Despite athletes thinking they are performing optimally on less sleep, athletes who slept for longer (10h+) experienced improvements in physical performance and mood (24). – Athletes acknowledged that they had previously misperceived the amount of sleep required to perform at their peak both physically and mentally (25). Extending total sleep time may therefore have the most potential for positive impact on athletic performance.

The Amazing Power of a Full Night’s Sleep for Athletes: n Training followed by a full night’s sleep increases skilled performance by 20–30% when compared to the previous day (3). n Automaticity is accomplished by sleep. – The act of visualisation is approximately 50% as effective at changing the plastic connections in the brain as performing a skill. – The brain has the capability of dividing long motor sequences into bite sized chunks. Before you sleep there are gaps in your motor learning; however, sleep enables the brain to find the Co-Kinetic Journal 2018;78(Oct):25-32

BRAIN, PAIN AND SPORTS PERFORMANCE

problem points in the motor skill and smooth it out – the next day the sequence you were attempting to learn is smooth and achievable. – Muscle memory is a misnomer – muscle memory is in fact brain memory! – The brain will continue to improve skill memories in the absence of any further practice. n The increases in speed and accuracy, underpinned by efficient automaticity, are directly related to the amount of stage 2 NREM, especially in the last 2h of an 8h night of sleep n Post-performance sleep accelerates physical recovery from common inflammation, stimulates muscle repair and helps restock cellular energy in the form of glucose and glycogen (13). Interestingly, coaches who keep athletes late training and have them return early the following morning may be innocently but effectively affecting their performances (denying an important phase of motor memory development in the brain, one that fine tunes skilled athletic performances).

Sleep Interventions Sleep interventions have been shown to increase the quality and extend the duration of an athlete’s sleep (25). n Two mechanisms in particular are associated with sport-related insomnia symptoms, therefore offering potential targets for intervention (14): – pre-sleep cognitive/ psychophysiological arousal – sleep restriction. – Daytime napping appears to be a common compensatory strategy used by athletes. n It is now fairly common for elite sports teams to utilise activity monitors to measure sleep (26). n Athletes should now be consistently employing sleep hygiene strategies to improve sleep quality the night before and after a competition, such as: limiting exposure to electronic devices before bed; going to sleep in darkness; and waking up in natural light (27). Co-Kinetic.com

SLEEP IS POSSIBLY THE MOST IMPORTANT THING WE MUST DO TO SURVIVE, REPAIR, RECOVER AND RETAIN SKILLS Sleep Deficiency in the General Public Sleep deficiency in the general public affects: n all efforts to improve body composition n strength and fitness n long-term health contributing to: – increased blood pressure – impaired appetite control – over eating, weight gain and obesity – carbohydrate metabolism/blood sugar control introducing a state similar to diabetes – inflammation – lowered immune function – heart disease – loss of muscle mass – reduced muscle recovery – lower levels of anabolic hormones, including growth hormone and testosterone – stroke, depression and increased risk of death (28–30). Additionally, less than 6h sleep or more than 10h sleep is associated with a greater risk of obesity, heart disease and diabetes.

UNDERSTAND THE POWER OF CAFFEINE AND HOW IT AFFECTS YOU “Caffeine is the world’s most popular performance-enhancing drug/neurostimulant with psychoactive properties which fight off fatigue and has proven beneficial effects on alertness, reaction times, concentration and endurance” How Caffeine Affects our Sleep Caffeine DOES NOT give you energy in the way that you might believe. During our waking hours our nervous system is constantly monitoring adenosine (a by-product produced by neurons firing in our brains). When the adenosine levels rise (scientists think that the chemical begins to inhibit the brain cells that promote alertness), our brain and spinal cord take it as a signal to relax and prepare for sleep (32). Caffeine is an adenosine-receptor antagonist, which means that it binds to the adenosine receptors but without reducing neural activity and so blocks the effects of adenosine.

Caffeine Has a Half-Life Consequences of Sleep Deficiency and Circadian Rhythm Disruption Sleep deficiency and disruption of circadian rhythms can have the following consequences (31): n changes in mood patterns n anxiety and depression n decreased motor performance n decreased cognitive performance n impairment of memory and concentration n poorer communication and decisionmaking n increased irritability n increased risk-taking n weight gain n increased risk of metabolic disorders and diabetes n increased risk of hypertension, and heart-attack n increased risk of some cancers n impaired immune response.

Take note if you want to sleep tonight! Caffeine has been found to have a halflife of around 5–8h (depending on a person’s unique biochemical make-up), therefore forget worrying about the late

NO CAFFEINE 107 MINS REM

1 CUPS

2 CUPS

3+ CUPS

86 MINS REM 72 MINS REM 66 MINS REM

Figure 2: Caffeine intake affects the amount of time spent in REM sleep (Curran T. How does caffeine affect the body? Penn State University SC200 course blog 2015)

afternoon coffee, if you have already had two cups of coffee at home, a Starbucks on your break, and a can of coke with your lunch. There’s also the sneaky caffeine contributions from any pain killers you have taken, decaf tea or chocolate you have consumed. If you have just had 1–2 standard cups of coffee (200mg of caffeine), the effect of the half-life of caffeine means that: n after 8h you would still have half the caffeine (or 100mg) active in your system n after 16h you would have a quarter of the caffeine (50mg) active in your system n after another 8 hours you would have 25mg of caffeine in your system, etc. Therefore, drinking a cup of coffee as close to 6h before bedtime can still cause sleep disturbances (Fig. 2). Ending your caffeine intake before 2.00pm would be advisable and perhaps even earlier, or not consuming it at all, if you have a caffeine sensitivity.

Exercise and Sleep It goes without saying that physical activity during the day, especially vigorous exercise tires you out and contributes to a great night’s sleep, particularly when compared to people who do not exercise at all (83% vs 65%). Exercise also: n aids sleep by increasing melatonin levels (33) n affects temperature regulation n is advocated for a number of conditions where sleep is affected (34), such as: – cardiovascular disease – type 2 diabetes – depression – some cancers – arthritis – obesity. The timing of exercise is important (35): n Exercising earlier in the day may improve the quality of nocturnal sleep. n Exercising earlier in the day was also linked to a reduction in how often athletes woke during the 30

night (36), with morning resistance exercise significantly improving the time required to fall asleep. n Evening exercise was found to significantly reduce wake time after sleep onset (37).

Chronotype Chronotype is an important consideration for coaches of athletes, managers of companies and heads of education. n Our wakefulness arrives at different times – we are not all programmed the same way for many reasons (such as, somebody needed to be awake to protect the rest of the group). Where we sit is strongly determined by our genetics. n4 0% of us are morning ‘larks’, we wake early and go to sleep early. n3 0% of us are night ‘owls’, we wake late and go to bed late, who often: – are chronically sleep deprived – are expected to wake up early to train, work, go to school – cannot go to sleep early, no matter how hard they try have higher rates of depression, cancer, heart attacks and stroke. n 30% of us are a combination of both. It is likely, therefore, that chronotype will have an effect on an athlete’s training and competition abilities.

Tiredness Kills If the above information hasn’t convinced you enough, it has been estimated that a quarter of accidents on major roads in the UK are sleep related, and in the USA they have found a high correlation of accidents are not only sleep related but time of day related (between 2.00am and 6.00am; and 2.00pm and 4.00pm). Tiredness not only kills, it kills performance too. Each of the Real Madrid football team players have been provided with an apartment in a luxury accommodation block at their training facility. These rooms can only be unlocked by the individual player’s fingerprints, and are kitted out with high spec bathrooms, beds and televisions. Manchester City football team adopted a similar approach with a new £200 million training complex, with rooms for the players (38).

Nightworkers and Shift Workers “Shift work that involves circadian disruption is probably carcinogenic to humans (group 2A)” (39) When you sleep during the day, it’s important to utilise power naps. Shift workers are more likely to be at risk of obesity (40), so diet and exercise are important too. Constantly changing sleep patterns have been shown to have an impact on health, eg. early death and increased chance of developing cancer (41). Again, there is much more to this than we have time for in this chapter, please read further (3).

WHAT CAN WE DO TO HELP US SLEEP AT NIGHT? Reduce Your Blue-Light Exposure We need blue light (a wavelength that is highly concentrated in sunlight) during the day. In fact, it is absolutely crucial for many of our body’s processes including setting the body clock, supressing melatonin production during the day but increasing it at night, increasing serotonin production and improving alertness and performance (28). However, it is also emitted from the screens of electronic devices and so the use of these devices after dark impacts the human circadian clock and therefore contributes to sleep deficiency (42) and next-morning alertness, in addition to: n prolonging the time it takes to fall asleep n d ecreasing subjective sleepiness n d ecreasing EEG delta/theta activity n s uppressing levels of the sleeppromoting hormone melatonin n reducing the amount and delaying the timing of REM sleep n increasing alertness at the wrong time (bed time), leading to delayed bed time (43) n impacting on performance, health and safety. Melatonin, dubbed ‘the vampire hormone’ because it’s released at night, is our biological command to sleep. However, it does not ‘contribute’ to sleep and is why melatonin is not an effective sleep aid, at least not for healthy, non-jet-lagged people. This powerful hormone diminishes Co-Kinetic Journal 2018;78(Oct):25-32

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throughout the night and the brakes are applied to the pineal gland (which secretes melatonin) when dawn arrives (when sunlight enters the brain), arresting the release of melatonin. We really are solar powered! Chronic suppression of melatonin secretion by nocturnal light exposure contributes to (44): n an increased risk of breast cancer n an increased risk of colorectal cancer n an increased risk of advanced prostate cancer associated with night-shift work n a likely increase in the risk of delayed sleep-phase disorder and sleep onset insomnia. The evidence of is such that nocturnal light exposure has been classified as a probable carcinogen by the World Health Organization (67). The World Health Organization has now classified mobile phone radiation as a possible group 2B carcinogen.

Maximising Your Daylight Exposure As soon as you wake, open your curtains/blinds and let the natural light flood in: n Spend some time outside early in the morning (I get up and immediately take my dog Ebby out every morning before 8am). This could also be standing on the patio drinking a cup of coffee. n Maximise your time outside during day light (get out of the office and simply take a 10min walk during your breaks and at lunch time, especially if you don’t work near a window). – Poor sleep has been linked to working in windowless environments. – If taking a break outside or moving your desk next to a window is not feasible, you may want to invest in some bright light therapy (ideally, 10,000 lux of light, which can be equivalent to full daylight), these have been linked with improved alertness, cognitive and physical performance, mood and well-being.

Add a Pre-Sleep Routine of Winding Down Avoid using electronic devices 2h Co-Kinetic.com

EXTENDING TOTAL SLEEP TIME MAY HAVE THE MOST POTENTIAL FOR POSITIVE IMPACT ON ATHLETIC PERFORMANCE before going to bed: n LEAVE YOUR MOBILE PHONE IN ANOTHER ROOM, if you use it as your alarm clock, make plans to change this. – This not only reduces too much blue light entering your eyes after dark, but prevents unnecessary thought stimulation just before you sleep (social media, emails, etc). n Turn down the lights in the evening or use lower wattage lamps. n Download free blue-light filter software for your phone and computer screens (I use F.lux for my laptop). n Blue-light blocking sunglasses may be useful for watching TV. n Get rid of any alarm clocks that have a bright display (I use the alarm setting on my Garmin, but you could just as easily buy a cheap oldfashioned alarm clock. n Keep all EMF devices out of your room. n Invest in blackout curtains, I cannot tell you how much of a difference this makes. n If you have to get up in the night, use low-level lighting (I use a battery-operated camping lamp). Avoid switching on the main light, at all cost. n Check your room temperature, being too hot or too cold can affect sleep. The optimum temperature may be around 18 to 22°C (it must feel comfortable to you). n Address noise levels, noisy environments are one of the most common factors causing sleep disturbances: – block out the noise with earplugs, or white noise. n Put your thoughts down onto paper (see below). n Begin your pre-sleep routine 90min before you plan to go to bed: – eat a light snack if you are hungry – take on your last fluids now, so you do not need to wake in the night thirsty – empty your bladder. n Wear a nasal strip or ‘turbine’ to

keep your nasal passages open and encourage nasal breathing at night. n Have a 400g Epsom salts/magnesium sulphate bath for 20-40 mins, magnesium is one of the cofactors for serotonin production from tryptophan. n Wake up at the same time every day. n Take power naps.

Put Your Thoughts Onto Paper Going to bed only to struggle to fall asleep because you are ruminating about your day/week isn’t ideal. A huge 82% of people in Britain struggle with this exact issue (45). I was given this advice many years ago and continue to do it to this day, but I’ve added Post-it notes to the initial pad

Figure 3: How sleep affects your performance (YLMSportScience 2014; follow this link to see the image on their Twitter feed https://twitter.com/YLMSportScience/ status/540768390991069185/photo/1)

of paper, just in case I wake up in the night with a thought or plan (I can then write that down on the Post-it, in the dark, and stick that note to the edge of my bedside table). I give this advice to all of my athletes and patients who struggle to fall asleep and it has helped numerous business owners and CEOs who I treat, towards not only a faster ‘falling asleep’ time, but a less disturbed sleep pattern. To begin this process and to develop that all important ‘positive’ habit, please leave your phone downstairs, or in another room, so that you are not adding further input just before you go to sleep. Simply climb into bed, close your eyes and think about the day or week you have just had. On a pad of paper write down anything that pops into your head as a concern or you deem as unfinished. Don’t confuse this with your to-do list, which for me is on my

phone. When you are finished put this list somewhere that you won’t forget it (I have just developed the habit of picking it up off the bedside table in the morning and taking it with me). Putting it all down on paper means that I go to bed feeling I have consciously addressed the issue for now, and I can trust the work that goes on in my sleeping brain to take care of it overnight. One of the key reasons we sleep is to process our experiences into memories and to consolidate new learning skills (Fig. 3). 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 https://spxj.nl/2PpF0B4

KEY POINTS n Sleeping less than 6–7h per night severely compromises our immune system. n The physical and mental impairments caused by one night of bad sleep dwarfs those caused by and equivalent absence of food or exercise. n Sleep is possibly the most important thing we must do to, survive, repair, recover and retain skills. n “If you don’t snooze … you lose (skill memory)!” n Chronic lack of sleep across a season predicts a considerably higher risk of injury. n Training followed by a full night’s sleep increases skilled performance by 20–30% when compared to the previous day. n The increases in speed and accuracy, underpinned by efficient automaticity, are directly related to the amount of stage 2 NREM, especially in the last 2h of an 8h night of sleep. n Post-performance sleep accelerates physical recovery from common inflammation, stimulates muscle repair and helps restock cellular energy in the form of glucose and glycogen.

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: Good sleep can improve performance speed by 20% and accuracy by 35% https://spxj.nl/2LTIGbV Tweet this: During REM sleep, parts of our brains are 30% more active than when we are awake https://spxj.nl/2LTIGbV Tweet this: Getting more sunlight during the day results in better sleep at night https://spxj.nl/2LTIGbV Tweet this: The sleep recommendation for athletes training at the top level is 9h 15min every night https://spxj.nl/2LTIGbV Tweet this: Nocturnal light exposure from mobile phone screens suppresses melatonin secretion and delays sleep https://spxj.nl/2LTIGbV

RELATED CONTENT It’s Time to Redefine Sleep: Applied SWR Techniques Developed for Elite Olympic Athletes https://spxj.nl/2PvwfWU Low Back Pain and Sleep: A Content Marketing Campaign for Therapists http://spxj.nl/2ludLuL

THE AUTHOR Paula Clayton MSc Physiotherapy, MSc Sports Injury Management, FA. Dip. Mast. STT, MSMA (L5), MCSP, HCPC is a triple Olympic therapist who worked as a senior performance therapist for the English Institute of Sport and British Athletics between 2003 and 2014. She has travelled extensively to Olympic Games (Athens, Beijing and London), Commonwealth Games, World and European Championships with GB track and field (British Athletics) as part of the medical team during this time. She is a member of the Health Care Professions Council (HCPC), Chartered Society of Physiotherapy MCSP), Sports Massage Association (Director; SMA), and the Association of Chartered Physiotherapists in Sports and Exercise Medicine. Before 2003 Paula worked in Premiership and Championship football for 4 years. She has taught on two sports therapy degree programmes, delivered sessions to MSc students and sports medicine students, written a number of articles and has an MSc in Physiotherapy and an MSc in Sports Injury Management. Paula also delivers soft tissue masterclasses to senior physiotherapists and soft tissue therapists within premiership and championship football clubs, National Governing Bodies and to soft tissue therapists nationally and internationally. Paula is the author of a book entitled Sacroiliac Joint Dysfunction and Piriformis Syndrome: The Complete Guide for Physical Therapists (Print £26.02 Kindle £11.27) Buy from Amazon. https://amzn.to/2Q6QZnZ). Paula also runs very successful sports injury clinics in Shropshire (established in 1994) and Worcestershire with her husband Rick. Email: office@stt4performance.com Twitter: https://twitter.com/PaulaClaytonSTT LinkedIn: https://www.linkedin.com/in/paulaclayton/ Facebook: https://www.facebook.com/ STT4Performance-179905718757270/

DISCUSSIONS hat will you do today to educate your athletes/ W patients/clients about the importance of their sleep? What have you learned about caffeine and its effect on our sleep? What can we do to help aid a restful night’s sleep?

Co-Kinetic Journal 2018;78(Oct):25-32

MANUAL THERAPY

CLINICALLY EFFECTIVE

HIP | 18-10-COKINETIC FORMATS WEB MOBILE

MEDIA CONTENTS Set of three videos demonstrating hip mobilisation techniques http://spxj.nl/2LWMwku

TABLE 1: MANUAL THERAPY APPLICATION FRAMEWORK [SOURCED MINTKEN ET AL. (1)] Variable

Meaning

Speed

Rate at which the MT force is applied – eg. high velocity

Location within ROM Is the force applied at the start, middle or end of the motion range currently available to the subject – eg. at mid-range Force direction

Anatomical and or biomechanical direction of the force – eg. lateral glide

Tissue target

Which joint or part of a joint is moving – eg. spinal level

Relative movement

Which region is moving and which remaining stable – eg. tibial glide on femur

Subject position

Gross body position of subject and limb position – eg. supine lying with femur flexed, abducted & externally rotated

MT, manual therapy; ROM, range of motion

TABLE 2: CLASSICAL MANUAL THERAPY GRADING SYSTEMS Maitland

Kaltenborn

Cyriax

Grade I – Small amplitude rhythmic oscillating at beginning of ROM

Grade 1 – neutralise joint pressure without separating joint surfaces

Grade A – mobilisation within pain-free range

Grade II – Large amplitude rhythmic oscillating in midrange

Grade 2 – separate joint surfaces

Grade B – sustained stretch at EOR

Grade III – Large amplitude rhythmic oscillating to point of limitation in ROM

Grade 3 – stretch soft tissue

Grade C – high velocity/low amplitude manipulation at EOR

Grade IV – Small amplitude rhythmic oscillation at EOR Grade V – high velocity/low amplitude manipulation at EOR EOR, end of range

THE EFFECT OF THE JOINT-BASED MANUAL THERAPY IS TO ENHANCE PROPRIOCEPTION AND INCREASE THE PATIENT’S BODY AWARENESS EFFECTS When originally described, MT techniques were often claimed to apply various forces and potential movements upon the joint, using a standard biomechanical model. However, scientific studies have often disproved many of these original claims, and our understanding of the method by which clinical effects Video 1: Longitudinal glide mobilisation for the hip

Video 2: Lateral glide mobilisation for the hip

Video 3: Lateral glide MWM for the hip

are achieved has progressed. Many spinal manipulations for example are performed with the joint in close pack position where the joint capsule and collateral ligaments tend to draw the joint surfaces together, so greater movement is unlikely. Cavitation (formation and collapse of bubbles within the synovial fluid) has been demonstrated in both spinal and peripheral joints. However, it occurs both at the level of the manipulation and above or below this point, so is non-specific (5). Alteration in muscle stiffness through a short-term reduction in tone occurs with a rapidly applied force, but no change has been found between different grades of technique (6). The scientific literature in general does not support a biomechanical explanation for MT (7), leading to the development of a neurophysiological model (8). The mechanical force imposed through MT can be seen as a noxious stimulus which initiates a cascade of neurophysiological reactions invoking analgesia (pain relief) at local, spinal, brainstem and higher centre levels. Subjects receiving MT have reduced cytokine levels (blood and serum) and pain biomarkers compared to controls. In addition, temporal summation (a measurement of pain sensitivity) is lessened. A laboratory-induced stretch reflex (H reflex) is decreased following MT suggesting a brief inhibition of the motoneuron pool. Changes in cortical excitability have been observed (9), as has alteration in cerebral blood flow (10). The effects described above point to a reduction in pain (pain modulation) and muscle spasm. In addition, where MT is applied with movement (mobilisation with movement, or MWM techniques), non-associative learning may occur. Here, the response to a stimulus is changed by altering the movement pattern – for example, allowing a greater motion range in the presence of pain. The effect of the MT is to enhance proprioception and increase the patient’s body awareness. Although research shows that these effects are statistically significant, the therapist must determine whether they are clinically relevant, and superior to other treatment modalities that

could be used. A continual process of clinical reasoning is therefore essential (11). The barrier to recovery must be identified, and treatment aimed at this. Initially the patient may simply require reassurance that their condition will progress along a standard healing timescale for example. They may require neuroscience education to dispel myths about ‘hurt and harm’ – the belief that the amount of pain experienced is directed related to the degree of tissue damage. Where deconditioning has occurred, strength or mobility training may be required. Where the barrier to recovery is biomechanical, pain, or reduced body awareness, a MT method may help but not usually in isolation. The approach is to use sound clinical reasoning to apply an escalation of care.

APPLICATION When originally described, MT was often used as a single blanket approach to treatment, taking a biomechanical model of effect (joints moved, tissue stretched for example). As our understanding of therapeutic effect has changed from a classical mechanistic model to a biopsychosocial model of healthcare (considering psychological and social influences interacting with biological factors), MT is seen as part of a total care package that emphasises rehabilitation and patient-led management. Using the hip (coxa-femoral) joint as an example, three techniques will be considered to illustrate the breadth and effectiveness of MT in the hip region.

Technique One: Longitudinal Mobilisation/Distraction The longitudinal glide or distraction mobilisation (caudal glide) is best used when the patient describes their symptoms increasing with prolonged standing or full weight-bearing activities (Video 1). Often during subjective examination (questioning), patients will say that they ‘want someone to pull their leg’. The patient lies on their back in a relaxed position (support under the head if required). An open or loose pack position is chosen for the hip (open pack occurs when the joint surfaces are naturally apart as the soft tissues surrounding the joint are Co-Kinetic Journal 2018;78(Oct):33-36

MANUAL THERAPY

relaxed). The leg is positioned in slight flexion (30–40°), abduction, and lateral rotation and a caudal glide is imposed by gripping the leg as the therapist leans backwards. There are two considerations to this technique. Firstly, if the grip is on the shin, although this is easier for the therapist as the hands surround the limb, glide will also be imposed on the knee joint in addition to the hip. Where a patient has a knee problem as well (co-morbidity) this may be unsuitable. Gripping above the knee eliminates the knee effect but is more difficult for the therapist as their hands do not surround the limb. Further, there is a tendency to increase grip power by digging the fingertips into the patient’s muscle bulk, which is obviously painful for them. An alternative is to use a figure four grip. For this, the therapist stands facing the patient’s head, and when treating the left leg places their left arm beneath the patient’s thigh, to grip the leg beneath their axilla. They hook their left hand over their right forearm and press down on the top of the patient’s thigh with their right hand, locking the leg. The lock is maintained as the therapist leans back to apply a distraction to the hip joint (Fig.1). The figure four grip is often more comfortable for the patient as the surface area of contact is greater. The grip is also better for the therapist, as less hand strength is required.

Technique Two: Lateral Glide Using Seatbelt This lateral distraction technique begins with the patient’s hip flexed to 90° and abducted slightly (maximum 30°). The therapist stands facing the patient’s greater trochanter and grasps their hands over the upper thigh close to the joint line. A lateral glide is imposed by pulling the thigh towards the therapist using a force perpendicular to the greater trochanter. Larger distraction forces are imposed using a seatbelt technique (Video 2). A webbing belt (5–7cm width) is used, with the belt wrapped in a towel

for padding. The belt is placed into the patient’s groin crease close to the hip joint line. The belt passes behind the therapist in a long loop, going below their buttocks to avoid slipping. The action is to create the distraction (lateral glide) force by leaning backwards and pulling through the belt while guiding and refining the movement using the hands placed over the belt. An oscillation may be performed early within the range (grade I or II) to target pain or at end range (grade IV) to emphasise mobility. In addition, the lateral glide may be used as part of an MWM technique described below.

Technique Three: MWM The lateral glide technique may also be used with a hip flexion movement aiming to increase pain-free range. The action is a MWM, a technique originally pioneered by Mulligan (12). Initially the therapist assesses the patient’s quality and range of motion into hip flexion. Where pain occurs, or movement is limited (compared to the non-symptomatic side) a lateral glide is applied using a seatbelt as above, and the hip is once again moved into flexion (Video 3). Where the motion range increases and/or pain reduces the MWM technique is appropriate. The action is performed to repetition (5–10 times) and the original movement reassessed. The technique may be repeated two or three times providing symptoms continue to change. An MWM may also be applied using rotation at the hip (Fig. 2). The start position is with the hip and knee at 90° flexion, with the therapist gripping the tibial to impose a rotation movement. A lateral glide is imposed using the seatbelt technique above. The hip is passively moved into medial rotation (foot outwards) and lateral rotation (foot inwards), again aiming for symptom modification to re-test.

THE BARRIER TO RECOVERY MUST BE IDENTIFIED, AND TREATMENT AIMED AT THIS Co-Kinetic.com

Figure 1: Figure four grip for longitudinal distraction of the hip

Figure 2: MWM for hip rotation

References 1. Mintken PE, DeRosa C, Little T et al. A model for standardizing manipulation terminology in physical therapy practice. The Journal of Orthopaedic and Sports Physical Therapy 2008;38(3):A1–A6 2. Maitland GD. Peripheral manipulation, 3rd edn. Butterworth Heinemann 1991. ASIN B00RWM5BZS (£113.01) Buy from Amazon https://amzn.to/2BQfeDO 3. Kaltenborn FM. Manual mobilization of the joints Vol 1: The extremities, 7th edn. Orthopedic Physical Therapy & Rehabilitation 2011. ISBN 9788270540709 (£88.04). Buy from Amazon https://amzn.to/2NsNHK2 4. Atkins E, Kerr J, Goodland E. A practical approach to orthopaedic medicine, 3rd edn. Churchill Livingstone 2010. ISBN 9780702031748 (Kindle £38.97 Print £133.81) Buy from Amazon https://amzn.to/2PJtNfq 5. Ross JK, Bereznick DE, McGill SM. Determining cavitation location during lumbar and thoracic spinal manipulation: is

spinal manipulation accurate and specific? Spine 2004;29(13):1452–1457 6. Dishman JD, Bulbulian R. Comparison of effects of spinal manipulation and massage on motoneuron excitability. Electromyography and Clinical Neurophysiology 2001;41(2):97–106 7. McCarthy C, Bialosky J, Rivett D. Spinal Manipulation. In: Jull G, Moorse A, Falla D et al. (eds) Grieve’s Modern Musculoskeletal Physiotherapy, 4th edn. Elsevier 2015. ISBN 978-0702051524 (Kindle £74.68 Print £78.61) Buy from Amazon https://amzn.to/2wsNsaB 8. Bialosky JE, Bishop MD, Price DD et al. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Manual Therapy 2009;14:531–538 9. Fryer G, Pearce AJ. The effect of lumbosacral manipulation of corticospinal and spinal reflex excitability on asymptomatic participants. Journal of Manipulative and Physiological

KEY POINTS nM anipulation (thrust) techniques are applied rapidly to achieve very small movements. n Mobilisation (non-thrust) techniques can be applied at different speeds and amplitudes. n The aim of both manipulation and mobilisation techniques is to reduce pain and improve movement. n Grading systems are also used to improve the description of joint-based manual therapy (MT) techniques. n The effect of the MT can be to enhance proprioception and increase the patient’s body awareness. n The therapist must continually use clinical reasoning to decide on the best treatment approach. n Longitudinal distraction is often used when the patient notices that their symptoms increase with full weight-bearing. n A figure four grip is useful for longitudinal mobilisation at the hip to eliminate any unwanted effects at the knee. n The lateral glide technique is used when the patient describes a snagging in the hip, particularly with prolonged sitting. n The use of a seatbelt makes the lateral glide technique more effective and reduces the use of the therapist’s hands.

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: The aim of manipulation and mobilisation techniques is to reduce pain and improve motion https://spxj.nl/2LWMwku Tweet this: Manual therapy enhances proprioception and increases the patient’s body awareness https://spxj.nl/2LWMwku Tweet this: Manual therapists must continually use clinical reasoning to decide on the best treatment approach https://spxj.nl/2LWMwku Tweet this: Manual therapy is part of a total care package based on rehabilitation and patient-led management https://spxj.nl/2LWMwku

Therapeutics 2012;35(2):86–93 10. Daligadu J, Haavik H, Yielder PC et al. Alteration in cortical and cerebellar motor processing in subclinical neck pain patients following spinal manipulation. Journal of Manipulative and Physiological Therapeutics 2013;36(8):527–537 11. Norris CM. Sports and soft tissue injuries (5th edition) Routledge 2018. ISBN 978-1138106598 (£49.99). Buy from Amazon https://amzn.to/2NqxOUm 12. Mulligan BR. Manual therapy: nags, snags, MWM, 6th edn. Orthopedic Physical Therapy & Rehabilitation 2010. ISBN 9781877520037 (£49.99) Buy from Amazon https://amzn.to/2PKbmXW.

RELATED CONTENT rticles and patient handouts related to the hip joint A https://www.co-kinetic.com/tag/hip rticles by the same author A https://www.co-kinetic.com/profile/14

DISCUSSIONS hat is the aim of using manual therapy (MT) W mobilisation and manipulation techniques? Thinking about the ‘total care package’ for the patient. How would you decide when and when not to use MT? With regards to the three techniques described, how would you perform them (a) for the maximum benefit of the patient and (b) for the least detriment to your own health?

THE AUTHOR Dr Chris Norris PhD, MCSP is a physiotherapist with over 35 years’ experience. He has an MSc in Exercise Science and a PhD in Backpain Rehabilitation, together with clinical qualifications in manual therapy, orthopaedic medicine, acupuncture, and medical education. Chris is the author of 12 books on physiotherapy, exercise, and acupuncture and lectures widely in the UK and abroad. He is a visiting lecturer and external examiner to several universities at postgraduate level. He runs a private clinic in Cheshire and his postgraduate courses for therapists are on his website: http://www.norrishealth.co.uk/. Email: cmn@norrishealth.co.uk Twitter: https://twitter.com/NorrisHealth LinkedIn: https://uk.linkedin.com/in/dr-christopher-norrisaa366115 Facebook: https://www.facebook.com/NorrisAssociates

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NEW CUSTOMERS ONLY, PLEASE? BY ANDREW BYRNE MCSP HCPC

LET’S DO THE MATHS As a business owner, say you have 100 new patients in a year and you charge £45 per session, that’s £4,500. From experience of managing 15 clinics Co-Kinetic.com

Ethically retaining more customers can have a major impact on not only your business, but your effectiveness as a therapist. This article explains why it’s so key both personally and professionally. Read this article online https://spxj.nl/2LR0m7X and having spoken to hundreds of therapists, most manage to get about 70–75% of the patients who need to come back, to actually return for a second session. That results in another £3,150. The therapists who aren’t really focusing on retention are then likely to see someone, on average, one more time after that (three appointments in total), giving us a total income of £10,800. However, the very best therapists at retention generally get 95–98% of the patients who need to come back, to do just that. So let’s repeat the maths: £4,500 for the 100 initial appointments, but this time, they get 95 of those people back say, which is £4,275 from the second sessions. Good retention therapists will then see patients at least another two times giving us a total of £17,325, nearly £7,000 more than the other therapists. Yes, this assumes everyone needed to come back, but still, for the same number of new patients, the therapist who retains well would get an extra £7,000 in a year. And this doesn’t take into account the fact that the therapist who treats their patients a few more times, is likely to get better outcomes, and have built stronger relationships with their patients, which will mean more word of mouth referrals … and that of course means more new patients! I know the numbers above are a rough guide, and the retention rates may seem impossible to you, but believe me there are plenty of therapists I’ve worked with who manage to hit at least 95% retention at the first session. There are also plenty of good therapists who treat for more than four sessions per patient because they understand that you’re unlikely to have got the patient back to full health in any less time.

SO WHAT DO I DO ABOUT IT? There are so many techniques for getting better retention, I created a course for exactly this. It teaches you easy-to-use techniques for getting great buy-in and engagement from your patients, which does wonders for retention! Take action and make some changes to give your patients a better service. For more information on “Why Don’t My Patients Listen?” visit https://spxj.nl/ triadhealth

18-10-COKINETIC FORMATS WEB MOBILE PRINT

RELATED CONTENT on’t Waste Your Marketing: How to Ethically Boost D Patient Retention [Article] http://spxj.nl/2C1UANl ow to Grow Your Business By Making Your Customers H Want to Come Back [Video presentation] https://spxj.nl/2J91Wlk THE AUTHOR Andy Byrne MCSP HCPC has over 10 years’ experience in private practice, the last 4 of which were spent as area manager for one of the largest physiotherapy providers in the UK. He managed 15 clinics simultaneously with over 100 staff. He launched Triad Health in September 2017 to help therapists from around the world to learn and help them get great results for their patients and themselves. He has mentored hundreds of therapists particularly in the nonclinical skills that create exceptional patient experiences and allow for rapid, sustainable and ethical business growth within therapy businesses. Email: info@triadhealth.co.uk Twitter: https://twitter.com/AndyThePhysio Website: https://www.triadhealth.co.uk/

The Co-Kinetic Marketing System Blueprint for Physical Therapists The Co-Kinetic Marketing System: is a package of content and technology, built on a proven marketing strategy, which is specifically designed to help physical therapists attract more clients, and grow their businesses. It is a bit like a fajita kit with all the ingredients, cooking utensils and the oven included too! The Blueprint: has been put together to support subscribers using the Co-Kinetic Marketing System. However, it also outlines a proven marketing strategy that can be used by anyone to win new clients, and it explains in practical terms how to implement this strategy, step-bystep.

Full interactive version at https://co-kinetic.com/blueprint Interactive pop-up menu Click the video icon to play the relevant video Guidance on the number of minutes that specific task will take (overestimated for safety!)

Indicates where Co-Kinetic content is provided – click on the icon for more details More information icon – click for details Link to supporting information or help Link to further reading or helpful resources

Step 1: How Hungry are You For New Clients?

Purpose: The degree of your need/hunger for new clients will determine which pathway you take. Which description fits you best? Click the i icon for more info.

HIGH

I need them SOON ie. next 30 days

HIGH/MEDIUM

I want to start building my customer base strongly as soon as possible

Decide on your Conversion Event

MEDIUM

I’d like to add a few more new clients to my monthly schedule

LOW

The status quo is fine but I’d like to be able to ramp things up when needed

Are you going to run a Conversion Event?

i YES

The desire to grow your business is important. If you’re not invested and committed in growing your business, then your commitment to promoting it won’t be there either. One of the most common reasons people subscribe to our marketing system is because they have reached a point where they are ready to take on a new therapist. People often have enough business for themselves, sometimes too much, and the only way they can progress, be it to buy themselves some more time or freedom, or make a bit more money, is by taking on an additional therapist. However, they need to feel confident that they can generate that extra business, to be confident of making it work.

Skip to Step 2

And this is where a system like this is perfect, because it can do just that. It is a fully flexible system that means you can turn it on when you need to, and turn it off when you’ve got more than you can cope with. And it can work for anyone at any level or size of business, from a one-man/woman band to big teams. But I get the greatest professional satisfaction in working with individuals or small teams, because you are the ones that this system can have the greatest life-changing effect on. You have the greatest pressure to get a bigger bang for your buck. Everything you do, has to count. I know, because I’ve been there! So let’s get stuck in…

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Step 2: Set Up and Send Your Emails Purpose: Nurturing Existing Email Contacts, Developing Relationships, Building Authority Do you have a Mailchimp account?

YES

Have you connected your Mailchimp account to Co-Kinetic?

Connect Mailchimp to Co-Kinetic

i Did you set up a Mailchimp account?

Import the Pre-Written Mailchimp email into your account

Download the Email Text and Images.zip file and create your email in your email software

Are you running a Conversion Event?

YES Write a short paragraph of text in the email explaining about your conversion event: n what it is n when it’s happening n where it’s taking place n how to sign up (with a link to the sign-up page)

NO Edit the email text provided to suit your brand/personality and: Step 1. Send (or schedule) the value-added email to go out to your existing email database Step 2. Set up an automated autoresponder for new lead generation sign-ups

TIME SAVER: We have no affiliation with Mailchimp but we are committed to saving you time. Setting up a free Mailchimp account and using our templates is likely to save you at least 30 minutes a month. The email nurture activity is one of the most neglected, but arguably the most powerful tools in your non-salesy marketing armoury. I’m constantly gob-smacked at how few people ever bother with this, and yet it’s your bread and butter activity. I’d probably go as far as to say that it’s the single most important thing you can do each month. According to the results from my Marketing Grader Email Course (which you can access here), only 16% of practitioners bother to send their customers non-salesy (ie. informative emails) every 4–6 weeks. People, this is SOOOOO important. We know first hand

as therapists that it can take weeks, maybe even months, before a patient is ready to book an appointment with us because they just haven’t reached their ‘clinical tipping point’ yet. Which is exactly why gentle, value-added resources and helpful information that can improve the quality of their lives, delivered to them via email, can be such a powerful relationship and trust builder. EVERYONE, with no exception, should be doing this one piece of marketing, over and above EVERYTHING else.

Full interactive version at https://co-kinetic.com/blueprint Co-Kinetic.com

Step 3: Post the Social Media Purpose: Bring new leads into your business and begin the process of developing these relationships [this is the lifeblood (at this stage) of growing your business] Are you using Co-Kinetic to post your social media?

YES

Are you using the Co-Kinetic Lead Collection Pages?

Schedule your social media campaign for posting

YES

Include your Personal Campaign URL with every social media post in which you offer the lead magnet in exchange for collecting email addresses

1. Set up your own email lead collection page 2. Set up your own lead magnet delivery mechanism

1. Download the social media from the Social Media.zip file in the Campaign Content 2. Post your social media posts manually using your own scheduling tool

TIME SAVER: If you choose to create your own lead collection pages and schedule your own social media, it’s Iikely to take you more than 90 minutes longer than using the Co-Kinetic platform. This is at least two patient appointments. Be mindful of your time and just make sure this extra time delivers a return on investment. Unsurprisingly, the ready-made social media campaigns is the section of our System that new subscribers make a beeline for when they first sign up. After all it’s the sexy aspect of marketing. All they want to do is schedule their first campaign and get those posts pumping out onto their social networks. Unfortunately, too many people believe that marketing starts and ends with social media and there is this sort of blind faith that social media is the marketing cure-all. The trouble is that there is rarely any strategy behind this frenzied social media activity. Fortunately, my system forces some strategy into the equation, because nearly all of our social media posts that are posted from within the Co-Kinetic system, link back to a high-value piece of content (lead magnet) which can only be accessed in exchange for an email address through a landing page, which we host for our subscribers. Which means the

social media is being used to build that customer’s email list ready for nurturing (see Step 2) towards a paying client. In other words, it’s part of a bigger picture strategy. But how many of you reading this article, are spending precious time posting to your social networks in the hope that you’ll pick up a few more page followers or fans, or attract a bit more engagement on your posts, with little or no additional strategy to your social media activities? And even worse, if you’re paying to boost these posts, with the same desired outcome, STOP NOW, PLEASE!!! There are so many better ways to spend your money. That said, social media, particularly if supplemented with some paid Facebook advertising, CAN have meaningful effects on your business, if done as part of a strategy. Check out the link to the Facebook Ads mini video course in the Helpful Links, Resources and Articles box on the last page.

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Step 4: PromoteYour Activities Purpose: In addition to the digital marketing content we create on your behalf, we also create print-ready content for you to print yourself or have professionally printed for local distribution Are you running a Conversion Event?

NO Focus on generating new email leads using the “Lead Generation” Promotional Content

YES Within 30 days or less?

YES

Step 1: Generate sign-ups directly to the Conversion Event itself using the relevant Promotional Content Theme, ie. Education Seminar or Workshop/Practical Assessment

Campaigns Include Promotional Content for Three Themes 1. Lead Generation (ie. growing your email list) 2. Running an Educational Presentation/Seminar 3. Running a Workshop/Practical Assessment

For each of those “themes” we create the following print-ready artwork: 1. Posters (sizes A1, A3, A4) 2. Leaflets (A5) 3. Postcards for people you may have postal addresses for but no email address (A6) 4. Facebook ads 5. Web banner for an email, website or blog

NO Ideally start a campaign between 30–45 days before running the Conversion Event: Step 1: Generate new email leads using the Lead Generation Promotional Material (approx 10–14 days) Step 2: Generate sign-ups to the actual Conversion Event using the relevant Promotional Content Theme, ie. Education Seminar or Workshop/ Practical Assessment (approx day 14 onwards)

Does your Conversion Event involve a Presentation?

YES Download the off-the-shelf PowerPoint Presentation provided as part of the campaign and edit to suit your needs

Remember that ‘marketing’ is just another word for ‘relationships’. It’s about building trust and utilising your skills to increase the quality of life of the people you serve. The Co-Kinetic Marketing System aims to give you all the tools and resources you need in order to achieve this. GIVE YOUR CLIENTS A CUSTOMER JOURNEY THEY’LL NEVER FORGET

Full interactive version at https://co-kinetic.com/blueprint Co-Kinetic.com

Step 5: Power Strategies Purpose: To amplify all the previous activities Are you able to add blog posts to your website?

YES

There are two big benefits to including blog posts on your website: 1. If you include links to your lead magnets in your blog posts, you turn your website into a 24/7 lead generation tool 2. SEO (search engine optimisation) benefits – Google loves good content and will reward you by making your website more findable if you feature it. This should be one of your next top marketing priorities if you aren’t currently able to add new blog posts quickly and easily to your site.

Facebook Advertising

YES

As many of you will know by now, very few of your Facebook Page followers will see anything you post on Facebook. I’ve written two articles of relevance on this topic: 1. Is Your Facebook Page Officially Dead? 2. Why it’s Impossible to Bombard Your Facebook Followers with Too Many Posts By utilising the targeting offered by Facebook ads, you can literally super-charge your marketing efforts.

Do you have a video channel, ie. YouTube?

YES

Video is the darling of the internet right now. Google and Facebook are in a turf war to dominate it, so this is a great visibility opportunity. 1. If you don’t already have a YouTube channel, it’s easy to start one and then keep it fresh by adding our new monthly videos. 2. Embed these videos and playlists on your website to get extra visibility through Google.

Have the campaign newsletter printed professionally, add your branding and distribute it locally

For more information Request more info by email More information (web page) Check if there’s a licence available in my area

Hopefully I’ve demonstrated that marketing doesn’t have to be a black art, or even hard for that matter. And even if you don’t have a subscription to our service, anyone can still follow this same strategy. But if you would like more info about how the Co-Kinetic Marketing System can help you grow your business, we’d love to help. Just use the buttons above.

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Helpful Links, Resources and Articles Part 1: How to Set Up and Use the Co-Kinetic Marketing System and Where to Find Your Marketing Content [Article] Part 2: What’s Included in a Co-Kinetic Marketing Campaign and How to Use It to Grow Your Business [Article] Part 3: Step by Step Guide to Using Our Marketing Content and Publishing Tools [How to Guide] How to Run Facebook Ads to Supplement the Co-Kinetic Marketing Campaigns

A “Ready-To-Go” Marketing Strategy for Therapists [Article] Why nobody ever engages with your Facebook posts and why it’s impossible to ‘bombard’ your page followers The 10 Biggest Marketing Mistakes and How to Avoid Them [Article] Five Go On a Patient Journey: Practical Lessons from the Co-Kinetic Business Growth Day at COPA 2018 [Presentation Recordings] Is Your Facebook Page Officially Dead? [Article]

The Co-Kinetic Marketing System in Pictures

Every therapist in business should be doing, at the very least, these two levels of activity, regardless of their hunger for new clients But this is where the magic happens – and it’s a perfect strategy for those with a healthy hunger to grow their business

Full interactive version at https://co-kinetic.com/blueprint Co-Kinetic.com

CASE STUDY

DON’T RUN INTO TROUBLE

Marketing Campaign

Blizard Physiotherapy Running MOT The team at Blizard Physiotherapy, in Doncaster, UK, used the Don’t Run into Trouble Content Marketing campaign included in the Co-Kinetic Marketing System, to run a customer ‘sales funnel’ designed to generate revenue, and introduce new people to their business. Here’s what we did, how we did it, what we achieved and how we’ll do it even better next time…..Read this article online METHOD

The first stage was to generate new email leads using the ready-made social media posts, lead magnet and lead collection form included in the Co-Kinetic system. The goal was grow Blizard Physio’s email list, warm up these leads with useful value-added information and offer these new leads a priority access invitation to a Running MOT event (conversion event). The existing email list was sent the straightforward nurture email included in the Co-Kinetic kit, which included a link to the running injury leaflets. The social media generated leads were given 3 days to claim their spot on the Running MOT event, before the second email went out to the existing email list offering the remaining places. After sending out the second email, the event was fully booked within 48 hours, with a further 16 people on the waiting list. The conversion event consisted of 36 appointment slots available between 4pm-8pm on one evening in August. There were three appointment types: free physio advice, gait analysis and taster massages (12 slots for each appointment type). The staff required to run the actual event on the night was two physios and one member of the reception team, who was vital for keeping the event running smoothly and making sure all the necessary forms had been filled in.

DISCUSSION

Following the social media lead collection and the email to existing contacts, all 36 slots were booked within 5 days, with a further 16 people on a waiting list. Due to a last minute discovery that the massage therapist’s insurance had lapsed, the massage slots had to 44

£££££££££££££££££££££££££££££££

THE SCORES ON THE DOORS Despite the missed sales opportunities discussed, this event still generated £910 in profit on the night, an average of £53.50 per person attending. Taking into account the estimated post-event profit, it results in an average profit per attendee of £118 (after direct costs).

£910 £53.50 £118 PROFIT

RSON

PER PE

RSON

PER PE

£££££££££££££££££££££££££££££££ be cancelled (although all were rebooked for a later date), but this did result in a decrease from 20, to 17 individuals who attended the sessions.

OPTIMISE FOR YOUR UPSELL OPPORTUNITIES

It became clear very early on in the event, that the gait assessment and free physio advice appointments were too similar and if people were booked on both sessions, which many were, it made offering an ‘upsell’ or recommending a paid appointment difficult, because if they discovered they had an issue in the first appointment, they would use the second appointment to answer all their queries. It also made it difficult for each clinician to know what the previous clinician had recommended, and neither wanted to contradict the other, which resulted in a significant loss of upsell opportunity. Co-Kinetic Journal 2018;78(Oct):44-47

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The team decided that for future events, they would only offer one session per person, and to make sure these sessions were sufficiently different. If they had done this, there would not only have been places for 36 individuals, as opposed to the 17 who actually attended, but the upsell opportunity would also have been much greater.

WARM LEADS ARE BETTER THAN COLD ONES

Jenny Blizard, the business owner and one of the physios who delivered the sessions on the night, made a couple of specific observations regarding the sequence of steps she took for this event, compared with events she’d run previously. Firstly, the take-up to the event was substantially better (and the places went more quickly) because the people being contacted, were already warm before the event was offered. This applied to both the social media leads, who’d benefited from the patient advice leaflet

RESULTS PHASE 1: PROMOTION PHASE Step 1: Generation of new warm email leads through social media using a lead magnet and lead collection form n 75 unique downloads of the lead magnets from the social media posts (new email leads) n Received a follow up email offering priority access to the conversion event n From these 75 new leads, 9 people (12%) booked places on the MOT event Step 2: Email 1 was sent to existing email database (nurture email only with link to injury leaflets and no specific mention of the MOT event) n 2449 emails sent in total n 27.5% open rate and 3.7% click rate Step 3: Email 2 was sent to the existing email database – specifically about the Running MOT event – asking people to call to book onto the event n 2419 emails sent n 40.7% open rate PHASE 2: CONVERSION PHASE n 36 slots booked within 5 days n 17 unique people (would have been 20 if the massage slots hadn’t been cancelled at the last minute – see Discussion for more details) n An additional 16 people on a waiting list, 12 of whom were brand new people who had never previously visited the clinic n 100% attendance rate n Emailed attendees to remind them 2 days before the event n Total event sales (excluding direct costs ie. shoes) = £910 nE stimated lifetime sales (minimum) = £2,010 n Testimonials/reviews – 6 Facebook reviews – 4 Google reviews n 5 x increase in web traffic in the run up to, and following, the event

Co-Kinetic.com

downloads which they’d already signed up to, before they were offered the priority access to the event. And, also to the existing email list, who received the nurture email giving access to the patient advice downloads, BEFORE they received the event invite. This also reinforces the importance of regular nurture emails, which Jenny has decided to prioritise going forward. Secondly the people booking were required to call by phone to book their place which required a greater level of effort, and perceived commitment, compared with signing up by email to book their space. As a result, they had only one cancellation before the event, which was immediately filled from the waiting list, and 100% turn out on the night (Jenny sent a reminder email 2 days before the event to all those booked on).

SOCIAL MEDIA WORKS IF THERE’S A STRATEGY

The team had run several promotional events like this

CAMPAIGN SALES Sales made at the event n Physio new bookings = 2 – Cost per appointment £37 – Total = £74 n Lactate tests = 1 – Total = £120 n Shoe purchases = 5 – Costs range between £115-£170 with 50% profit (average of £142 with profit of £71 per purchase) – Total = £355 (net profit) Sales made from bookings of new leads collected via the lead magnet (but who did not attend the Running MOT on the night) n Physio bookings = 4 – Total = £148 n Shoe purchases = 3 – Total = £213 (net profit) Profit after direct costs at the time of the event (but not including salaries) = £910

£910

Estimated additional physio appointments n Average customer episode of 5 appointments = £185 per client x 6 clients – Total = £1110 TOTAL ESTIMATED POST-EVENT PROFIT

£2,010 45

before but hadn’t used social media as the starting point, so they were particularly encouraged and excited by the potential this offered for attracting new warm leads of people who hadn’t attended the clinic before. And Jenny also felt that being able to do it in a much more nurturing, and less salesy, way by using the value-add lead magnet and lead signup as the first step in the process, was a significant improvement on previous events. She also said that in the past, people would often attend several promotional events without converting to becoming a paying client, but then all of a sudden they would book several different ‘paid’ services in quick succession. She felt this was down to the opportunity the events gave, to build trust, and once those people hit their trust tipping point, there was almost no holding them back, and for that reason she’s big advocate of the promotional event strategy. In terms of time taken to run and coordinate the event, Jenny did the admin herself and calculated that she spent about 60 minutes setting up or sending out the various emails, which she knew would be quicker next time, now she knew what she was doing. And a further 60 minutes putting together and organising the forms for the evening. After that, it was the time for reception staff, to take the phone call bookings, plus the 4 hours of the event itself. For the next event, she’s keen to try running some Facebook ads to encourage more sign ups to the lead magnets first, particularly from new people who haven’t already had contact with the clinic. And she’s already started posting blogs on her website, and flagging these up in Facebook which has resulted in a 5 times increase in her web traffic since the beginning of the campaign.

THE POST-MATCH ANALYSIS FROM TOR

Firstly, I’m really excited about this campaign, and also about the way Blizard Physio are using the Co-Kinetic resources. It’s a great example of what can be achieved, and how much more revenue could be generated in future campaigns, off the back of the experience from this campaign.

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Here are some key points: The team has been really good at measuring everything – which is fundamental for tracking and proving success but more importantly for identifying ways of improving the process next time. Blizard Physio have made excellent use of the Co-Kinetic resources featuring them not only on their Facebook page and on Twitter to collect leads, but to feature all the lead magnets, linked to a lead collection page under their Information Guides section on their website – which has turned their website into a powerful 24/7 lead collector for them. Combining regular lead-generating social media posts with blog posts promoted via Facebook, results in more websites visits, which ultimately means more leads collected, as more people explore the website. This also has a knock on effect on search engine optimisation benefits. The team have made great use of their Twitter feed by using the embedded Twitter widget on several main pages of their website (including the home page) meaning these pages stay fresh and visually impactful while also continuing to encourage lead sign up opportunities through the resources included in the feed. Simple but really effective. They’ve also embraced exactly what a social media feed should be, which is a combination of things that are personal to the clinic ie. blog posts from team members and involving the sporting activities of their staff and their clients, combined with educational, valueadded resources provided through Co-Kinetic, for specific lead generation purposes. This keeps their social media feed helpful, educational, varied and personal, all at the same time. By using the social media post scheduling functionality of the Co-Kinetic system, they’re running several campaigns on different topics simultaneously which also keeps their social media feeds varied and interesting and means that when the team does post their own unique clinic content, the posts tend to get great engagement. As this case study demonstrates, social media is an excellent way of not only collecting new prospective customer leads, but also warming them up so that they are receptive to your follow-up offer. Despite the missed upsell opportunities we’ve outlined, the event still generated £910 in profit on the night, an average of £53.50 per person attending. If you take into account the estimated post-event profit, it results in an average profit per attendee of £118 (after direct costs).

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7 8

During the campaign, Jenny reported that she would have liked to have focused on generating more lead magnet sign ups (and subsequent conversion event attendances) through Facebook, so that she could target more new customers, specifically. At the time she mentioned this, I thought this was her first ‘funnel’ and promotion event, so my resulting comments to her were a bit like teaching her to ‘suck eggs’! However, there are still some relevant learning points here, particularly for people starting this process from scratch, which are still worth mentioning here. Co-Kinetic Journal 2018;78(Oct):44-47

ENTREPRENEUR THERAPIST

For your first experience of doing this, it’s likely to be beneficial that 70+% of your attendees are existing clients, for at least three reasons: It’s the first time you’ve done it, there are likely to one or two hiccups/learning points and much better you do this with people who already know you and are really comfortable with your business You and your colleagues as the hosts of the session will feel more comfortable because many of the attendees are familiar already to you Existing customers offer great ‘social proof’. They are most likely advocates of your business which is great for new prospective clients to see. They are very often your best and strongest assets for new client conversion.

1 2 3

So, while they may not represent “new” business, they definitely do still have value. Also, are they actually active customers ie. in a current treatment programme? If so, why not find something additional you can offer them to purchase? Like an upgrade or a special deal on a separate treatment package they might not have otherwise purchased. If they’re recent again, can you get them onto an additional package of some sort? And at the very least, it’s definitely worth asking them to write a review for you on Facebook or Google before they leave that evening. Just saying something like “if you’ve enjoyed this evening and you’ve found it beneficial, we’d be really grateful if you could share this by giving us a review on FB or Google” can have great outcomes. A handful of new, up-to-date reviews, has real business value. What it does raise is how important it is to be able to extract a csv file or excel spreadsheet of ideally each of the following groups: n active/live customers n recent past customers n old past customers or never been a customer You can then use those lists when you run Facebook ads, to make sure to NOT target active customers in future. There’s nothing wrong with inviting a few active customers for all the reasons I’ve mentioned above, but you can start to move your focus to attracting new people specifically Also bear in mind, you’ve only just started collecting new leads from your website and social media pages. The more lead collecting you do, and for longer, the bigger your database of prospective new clients will become and the more you’ll be able to focus on marketing your live events to these people in the future. This is one of the biggest benefits of regular email list building. You’re effectively future-proofing yourself against incoming competitors and seasonal or market fluctuations. Co-Kinetic.com

RECOMMENDATIONS FOR THE NEXT CAMPAIGN

Get the Facebook Pixel installed on your website so that you can set up custom audiences based on the activities people take on your lead pages, website and Facebook page, and target or omit to target them accordingly. This is probably the single most important thing you can do at this stage. It’s definitely worth using Facebook ads in future to promote sign ups to your lead magnets but these should be run as ads (even if you’re using an existing social media post from our campaign) rather than using the ‘boost post’ function, because you have much less targeting options with boosted posts (see Resources at the end of the article for more details). a. Create Custom audiences of people who take actions relevant to your campaign so you can retarget them with an offer to attend your conversion events b. You should also upload your existing customer email list to Facebook and save it as a Custom Audience so you can exclude (or include) them in your ad campaigns You could also consider using Facebook ads to promote the conversion event as well, but it’s likely to be much more effective if you promote this to customers who have already had some sort of contact with your business ie. downloaded lead magnets, liked your Facebook page, visited your website etc. Divide your Mailchimp customer list into current customers and non-current customers so you can split who the email goes to offering your promotional events. You should 100% still send the nurture email to your existing customers with the value-added information, but you can leave out any mention of the ‘conversion event/promotion’. However, be ready with your policy should an existing customer come across the free event and ask to sign up. I would recommend letting them attend for all the reasons above, just perhaps set a ratio of new customers to existing customers, for example 80:20, and be strict about maintaining that ratio. There’s nothing wrong with explaining totally transparently that you have X number of slots for existing customers and Y for new customers.

FURTHER RESOURCES

n If you’re interested in using the Co-Kinetic marketing resources then it’s a good idea to check if your geographical territory is available first by clicking here https://co-kinetic.com/licence-check n For a short free course on running Facebook ads, installing the Facebook Pixel, creating custom audiences (and much more) click here https://spxj.nl/2PtI3YG n For more information on the Co-Kinetic Marketing System and content visit https://co-kinetic.com/marketing

CHILD’S POSE

Stretch Routine for Back Pain

10 11

LUMBAR MOBILISATION LYING

SUPINE LUMBAR TWIST STRETCH

SINGLE LEG BACK STRETCH

stop and move onto the next exercise

FLOOR SUPERMAN TWO LEGS TWO ARMS

6 7 5 4 Morning 8

INTERNAL ROTATION LYING DOUBLE LEG

l If an exercise causes pain,

exercises on both legs

l Perform single leg

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

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THE CAT

TOE TOUCH

HIP FLEXOR STRETCH

SEATED SIDE REACH

SITTING BOW AND ARROW

times holding each one for 5-10 seconds

l Repeat each exercise 3-5

Bed Time

STRETCHES

1. Shell Stretch

2. Pelvic Tilt Lying

3. Supine Lumbar Twist Stretch

4. Double Leg Back Stretch

5. G lute Stretch Supine

6 Single Leg Back Stretch l Repeat each exercise

7. External Rotation Lying Bilateral

8. Internal Rotation Lying Double Leg

l l

3-5 times holding each stretch for 10 seconds erform single leg P exercises on both legs

I f a stretch causes pain (instead of feeling like a stretch) stop and move onto the next exercise

ADVICE HANDOUT

ACL INJURY A ligament is a short band of tough fibrous connective tissue composed mainly of long, stringy collagen molecules. Ligaments connect bones to bones in and around joints and limit the amount of mobility in that joint, or prevent certain movements altogether. There are four major knee ligaments; the anterior and posterior cruciate ligaments found deep within the joint and the medial and lateral collateral ligaments wrapped around the outside of the joint. These ligaments are all at risk of being injured during soccer, and the anterior cruciate ligament (ACL) is the most commonly injured. Sadly an ACL rupture is also the most debilitating knee injury. The ACL connects the thigh bone with the shin bone from the inside. Its function is to prevent excessive forward movement of the shin in relation to the thigh and also to prevent excessive rotation at the knee joint. It is critical for joint stability. Manoeuvres used in soccer, such as cutting, pivoting and sudden turns, place high demands on the ACL.

HOW IT HAPPENS Most often, ACL tears occur when pivoting or landing from a jump onto a bent knee then twisting, over-extending the knee, and sometimes from a direct blunt force blow to the knee during a soccer tackle. The incident usually happens at speed and your knee gives out from under you once you tear your ACL. Muscle weakness or lack of coordination can mean that you are more at risk of a ligament sprain or tear.

Female athletes are known to have a higher risk of an ACL tear while participating in competitive sports. Unfortunately, understanding why women are more prone to ACL injury is unclear. There are suggestions that it is biomechanical, strength and hormonally related. In truth, it is probably a factor of all three.

WHAT’S GOING ON INSIDE? You may have felt or heard a ‘pop’ in your knee, and the knee usually gives out from under you. ACL tears cause significant knee swelling and severe pain. On clinical examination, your practitioner will look for signs of ligament instability. An MRI scan may also be used to determine if you have an ACL tear. It will also reveal signs of any associated injuries in the knee, such as bone bruising or meniscus damage, that regularly occur with an ACL tear. Depending on your level of sports participation, lifestyle, work demands and the stability of your knee following injury you may not need surgery, but you will require treatment and rehabilitation. Reconstructive surgery, however, has huge success if followed by a progressive rehabilitation protocol. Many professionals have returned to the game following surgery, albeit in the next season.

WHAT CAN I DO? Immediately after injury apply the ‘PRICE’ protocol, which stands for Protect, Rest, Ice, Compression and Elevation, for the first 24–72 hours. Protection may include the use of crutches if walking is painful or not possible. Rest is all relative – just don’t try anything that is painful. Ice the injury regularly for 10–20 minutes several times a day. Compression, using strapping or a bandage, will help to reduce the swelling and bleeding as well as the pain by giving the injury some support. The purpose of elevation is to reduce swelling and aid circulation. Following an ACL tear you often start to feel better within a few days or weeks. You may even feel as though your knee is ‘normal’ again because the swelling settles and you are able to do daily activities. However, this is when

problems with knee instability and ‘giving way’ may start or worsen. Stay disciplined with your treatment and exercises. Research has shown that following ACL injury or surgery, patients who have extensive physical therapy to rebuild their strength, proprioception and agility can be fully functional and return to sport. It is also known that similar exercises can help to prevent an ACL tear in the first place.

HOW PHYSICAL THERAPY CAN HELP Your best way to avoid ACL reconstructive surgery is to undertake a comprehensive rehabilitation programme that involves leg strengthening, proprioception and high-level balance retraining, plus sport-specific agility and functional enhancement. Your physical therapy specialist will aim to: n reduce pain and inflammation n normalise joint range of motion n strengthen your knee: especially quadriceps (vastus medialis obliquus) and hamstrings n strengthen your lower limb (calves, hip and pelvis muscles) and core n improve patellofemoral (kneecap) alignment n normalise your muscle lengths (flexibility) n improve your proprioception, agility and balance n improve your technique and function, eg. walking, running, squatting, hopping and landing n minimise your chance of re-injury. If you do have surgery, post-operative rehabilitation is one of the most important, yet too often neglected, aspects of surgery. The most successful and quickest outcomes result from supervised rehabilitation.

The information contained in this article is intended as general guidance and information only and should not be relied upon as a basis for planning individual medical care or as a substitute for specialist medical advice in each individual case. ©Co-Kinetic 2018

PRODUCED BY:

TIME-SAVING RESOURCES FOR PHYSICAL journal AND MANUAL THERAPISTS