Co-Kinetic Journal Issue 79 - January 2019 by Co-Kinetic

ISSUE 79 JANUARY 2019 ISSN 2397-138X

Formerly published as....

medicine & dynamics

what’s inside PRACTICAL Under Pressure : Strategies for Red ucing and Preventing Stre ss Incontinence M Building Bone Strength and Preventing Bone Loss in Later Life

any people, particularly women, and increasingly case a small (or sometimes larger) with age, experience amount of urine is leaked. urinary stress There are two incontinence. types of Kegel As many as 1 Exercises, in 5 women over slow (endurance) the age of 40 and fast: CAUSES OF MUSCLE will experience Slow it. However, it is also happens WEAKNESS to younger, active l Tighten, pulling women. Studies have reported up and in l Childbirth, that up to 47% a vaginal delivery l Hold tight physically active of for as long as can cause trauma to the women experience you can (up to pelvic floor muscles seconds) ten this problem at some or the nerves supplying time. In this article, l Rest for four the muscles going to look we’re seconds l Lack of exercise, at why it happens l Repeat the poor muscle tone and what you can do to exercise, up to l Changing stop it happening. ten times hormone levels Fast There is also an associated in pregnancy and menopause steoporosis is often referred to as exercise leaflet. l Tighten as Stress incontinence before, as quickly l Long a ‘silent disease’ because there is term history of as you can, is the leakage hold for 1 second constipation urine during of Quick physically l Chronic cough and relax very often little sign of it existing. stressful activities. l Repeat the or chest problems bone These activities exercise up to l Being overweight, However, osteoporosis is a condition that 10 times formation could be as simple as l Use this exercise obese, high BMI coughing, l Certain sports, lifting, or carrying to tighten your speeds up the loss of bone strength, the Balance allows pelvic for parcels floor muscle prior example, running and even laughing between bones to or sneezing. to coughing or jogging and word literally means ‘porous bones’. Despite sneezing It is also or bending over rate of grow in common New Rate of in sports that l Performing involve jogging, new bone popular belief, it’s not confined to elderly frail density bone bone abdominal exercises jumping, running, lifting incorrectly l Incorrect weights, aerobicsformation ladies or post-menopausal women either. and strength. forms resorption lifting techniques Repeat both exercises and abdominal during old Peak bone quickly exceeds exercises. at least 4 times People of any age, particularly if your mobility Common orand This sounds like a day. not, it bone mass is as you formation doesn’t make a lot but if you For a woman it any less comfortable is restricted due to spending a lot of time in consciously resorption reached grow and resulting in who a plan to build the doesn’t have other embarrassing sets into your significant andto studies have plateauorin wheelchairs or bed-bound, can suffer from in mid bones loss of factors bone that daily routine it can be done shown may cause stress women will change that easily – for example mass late lengthen mass incontinence, it. Other causes can include poor nutrition, their physicalbone such as nerve do a set each time you activity or sport, or even 20’s dysfunction or are standing waiting bladder infection, stop exercising eating disorders, over-training in a particular for the kettle to boil, research has shown all together. brushing pelvic floor exercises that sport, or chronic steroid use. Men can suffer the bus stop, sitting your teeth, waiting at are very effective WHY DOES IT treating stress on the train or in from osteoporosis to. Approximately 1 in 3 HAPPEN? incontinence. at a red traffic light. These exercises include “Kegel women and 1 in 12 men have osteoporosis. Exercises.” The pelvic floor muscles are the A simple fracture, especially when you’re EXERCISE THERAPY firm, supportive muscles KEGEL EXERCISES younger, may seem a minor consequence that stretch from pubic bone at your the front of your of the disease but this can impact your Kegel exercises pelvis, CHILDHOOD ADOLESCENTS & MID 20sto- APPROX 40 40s ONWARDS base of your the alone are not The best way spine at the personal, social and sports life as well as work enough. to experience Working the muscles floor muscles EARLY 20s back. The pelvic what this exercise should around the entire work as a sling commitments. In older patients however, feel like is to stop pelvic area and or hammock, and help to hold core, including THE BONE CYCLE the flow of urine while urinating. the more common hip fracture can have your bladder, your transversus uterus That bowel in place. and benefits that come from will contract the abdominus, have Those muscles lose the protectivemuscles much more serious outcomes. The estimated that you should shown to aid the contraction also be exercising. close the hormone, oestrogen. is bladdermainly Bone is made up your of minerals, of the pelvic floor musclesOestrogen The outlet calcium mortality rate following a hip fracture within around your vagina and rectal passage. muscles. can trip So, strengthening Whenbyyour responsible for facilitating the uptake and and anus should salts, bound together strong collagen those muscles be contracted pelvic the first month is 10%, and 21% in the first floor muscles that anyonefalling may also withthe help improve the feeling that well- of calcium toned retention in bone. Hence fibres. Bones have a thick, hard, shell feet are your symptoms. they they are being stopouter e all know the risk of year. Many patients do not recover full So leakage lifted “up and Your health your of urineaccelerated practitioner can but in”. Once older. from your decline in bone mass g in bladder following called cortical bone. Inside is aaccidental softer mesh g help with these and or fall, you have we get mobility or independence following a hip a silly or tinglin exercises. passing of wind. Other treatments es as essbone, it was dy walkin When you the menopause. that sensation, ed of bone, called trabecular has or dizzy increas by health practitioners go numbn towhich unstea saying the toilet, ‘bump fracture, which for some results in admission practice the g or Bone also include the can people the mat’, or l Feeling muscles structure. is a nted living, pelvic floor use of relax, ,once disorie the contractions lty walkin to a care facility. Damage to your spine due to a honeycomb-like empty on you hear poor they RISK FACTORS FOR when electrical stimulation vaginal cones and eadedrenewing been l Difficu OSTEOPOROSIS often restore active tissue thattoislight-h constantly itself. tighten tripped control. you’re not to improve muscle and having These muscles nt – ‘I has always lying on the ‘crumbling’ vertebra can result in chronic pain urinating. in the pelvic floor. rated tone actively l Feeling accide squeeze which Old bone is broken down by cells when Pilates is another Exercising your dehyd stool youcalled my dog laugh or ntal falls, and impact on your abdominal organs and excellent exercise therapy l Being into my ‘I didn’t see l to Early menopause, agepelvic of 45 accide avoid osteoclasts andleaking. is n replaced by new bone cough, that will work your can lung capacity. floor before should or older, nutritio core or walkercells. abdominal muscles, sion there,’ for them, , which l Hysterectomyatand removalnot of show one or both we get material producedaStress by osteoblast The cane incontinence pelvis, lower back all ‘on the outside.’ The good news is that there are But as or depres happens when uences the reason pelvic floor and and l Using floor’. ovaries is sudden there(loss of balance between theanxiety breakdown of old improve bladder extraption It isoestrogen) er stupid serious conseq that risk oftreatments available to reduce the amount important that pressure, control. with l Having howev fall, Don’t let this be ely lpelvic Family history of osteoporosis floor muscles consum bone and formation new bone, changes weak lof you a sensitive or you that can’t of bone loss resulting from both age and should extrem how to reduce if you do Alcoho ation withstand embarrassing have in g l BMI of 18.5 or less, if younot arepull underweight added pain can make le:this medic to cope through life.l pressure, health issue, affecting or your learnin maintain osteoporosis. The very best thing you can do how tummy, ations g Taking bladder l tighten your ing. social and personal is why g this disorder, anorexia,or l Eating medic a degree for examp In Everybody will experience of closure. or knowin ially life-sav we’ll only your buttocks.bulimia life, as well as is to achieve the best peak bone mass when – Some or dizzy, es, sleepin your ability falling, to participate fall, l Amenorrhea - your periods have stopped stamin loss in bone massfeel andsleepy density anti-hi as they age. in sports. The es potent when we you’re young, through good nutrition and an but even sooner you act, becom the better the lucky a cut, or cs are irregular for 6 months to a year prior older, nts, seizure The amount of bone lossation, can vary across outcome. medic However, many of us are past If we’re diureti pressa y or maybe when we’reactive lifestyle. and antide the age of menopause es, to fragilit age, sex, race, health, and a bruise pills,activity level to heal stage in our lives, and need to maximise tion,that laxativ or or carer suffer edtaken can ation, It is the l Have or are taking chronic steroid conditions. rate be chang take longer blood circula which and prevent bone loss through underlying medical medic your doctor es these rates bone strength can risk of withfactors medication diabet weight bearing activities. The ironic your the poorer healing of loss, accelerated– by certain (like ation Check skin es likeregular medic due to reduce of the what etc) red l Smoker skin and d by diseas But one menopause in women, thatto seesmoking, thing is that the thought of participating in of our ly monito affecte sleepyintake of more than 4 units per day ations. and lyou Alcohol ultimately results in osteoporosis. When a careful exercise be further some medic make or rm health resor sport may be frightening, because latLack as nightcalcium and/or vitamin D, poor diet bonetions is ‘weakened’ byfalling osteoporosis, is the Fractu thatit does es.you may worry about suffering a bone fracture precau as well threats to long-te avoid ation be taken andtolittle exposure to sunlight avoid st ing your in the spongy– honeycomb that grow Medic from fractur should resting with impact, butsome the simple g“holes” greate you to impact a fall. ble, loading or falling,with bed or land ing, comesarm, while Notrisk very mobile, wheelchair, confined to helpin larger and more numerous, or drowsy makingare theinbone resolva has proven the benefits ted of exercise, wellbe ation lly beresearchlike you preven around chair or bed prepar wrist and first place. when hopefu more fragile. g joints some to move to the safely, FAR outweigh es, will lf in the the uences andand E -bearin if done correctly l Underlying the need Women risk HOM D medical condition: conseq daily activities to weight seriousrisks NG? are at the greatest ofof osteoporosis.injuring yourse R AT hyperthyroidism, coeliac disease, Cushing’s ENTE following the menopause because theyOCCU PREV OF FALLI ity, loss but fractur have very FALLS can BE disabil AT RISK death. age of MOST the hip, permanent Y CAN ly even can over the ARE YOU safe: ng possib to injury BUT MAN includi e and walk year of people often your home not lead ndenc you can than 1/3 one fall each muscle indepe falls that do on older adults, older for making re so that More your l g ties, least tips fall, at Even can furnitu Some ve effect ce. 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ENTREPRENEUR THERAPIST

ul to akness e Fall Fo Don’t or Bone Wr Reducing ll le gies fo ffering a Fa Musc Strate W

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OVERVIEW In 2016, I ran our first Open Clinic event. I had absolutely no experience of running an Open Clinic before and had never even attended one before, and naturally instead of going small, and starting with an evening or relatively simple one day option, I decided to run an entire Open Clinic Week. Needless to say, it was a big learning curve and one I’m going to share with you over the next few articles. Three years down the line it’s the biggest event of our calendar, we gather 100s of email addresses from prospective new customers, have over 100 new clients visit the clinic during the week and deliver around 400 free appointments. Most therapy businesses are constantly looking for new or innovative ways to promote their business, and running an Open Clinic event is an AMAZING way to do it. There are lots of different ways of doing it, and the key is to test and see what works best for you, but typically it involves a 1- or 2-day event where current and potential clients can come and visit your premises, try out some taster sessions, meet the practitioners and access some exclusive offers. It boosts morale within the clinic, brings practitioners together with clients who need their help and is a great opportunity to help answer any of those questions that are holding potential clients back from booking that first appointment with you. Open Clinic events can come in any shape and size; it could be just you, opening the doors to your home practice, inviting clients to a free talk, all

of Su

the way up to collaborating with other practitioners in your area, making it a real Health & Wellness event, reaching as many new clients as possible. No matter what type of event you decide to run there is a very simple blueprint for ensuring success. In this series of articles, I’ll talk you through the 6 Step Blueprint for creating a winning Open Clinic event so that by next year you too will be getting over 100 new clients booking in a single day.

PART 1: CONCEPT & PLANNING This is THE most important phase of this process. Defining the goal of the event drives all your other decisionmaking, helps guide you in your planning and guarantees the results you’re looking for.

48-50 46-47 THE OVERWHELMING CASE CLIENT FOR "TRY BEFORE YOU BUY"

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RESOURCES

BY VICKI MARSH, MASSAGE THERAPIST, OWNER OF THE HEADSTART CLINICS

43-45

THE BLUEPRINT FOR RUNNING A SUCCESFUL OPEN CLINIC EVENT

CONVERSION EVENTS

MANUAL THERAPY

ROLE OF THE THORAX IN TREATMENT OF RECURRENT HAMSTRING INJURY It is now understood that that poor thorax biomechanics can play a role in multiple conditions and at regions far removed from it. This article describes the Integrated Systems Model approach for holistic assessment and treatment of your patients and a case study demonstrates how it can be used to identify the previously unsuspected (and, therefore, untreated) involvement of the thorax in a recurrent hamstring injury. Understanding and applying this biopsychosocial approach will enable you to find all the drivers of your patient’s injury and treat them in a meaningful way, so allowing your patient to get back to doing what they love. This article has been extracted from the author’s book The Thorax – An Integrated Approach. Read this article online https://spxj.nl/2Qwjxu8

32-38 ROLE OF THE

THORAX IN TREATMENT OF RECURRENT HAMSTRING INJURY

BY DIANE LEE BSR, FCAMT, CGIMS

Figure 1: The Clinical Puzzle is a reflection tool to help organise the assessment findings

HAMSTRING | THORAX | 19-01-COKINETIC FORMATS WEB MOBILE PRINT

MEDIA CONTENTS Downloadable template of the Clinical Puzzle reflection tool https://spxj.nl/2QshUO4

BACKGROUND The Interconnectedness of the Thorax In the past, the thorax has sometimes been depicted – and perhaps thought of – as an isolated box or cage. Current anatomical analysis, however, has demonstrated how connections from the thorax are made to the skull, scapula and pelvis, demonstrating that the thorax plays a critical role in multiple conditions as it is part of many integrated, and interdependent, systems including the musculoskeletal, respiratory, cardiovascular, digestive, and urogynaecological systems. As a result of this interconnectedness of the thorax, poor biomechanics of the thorax are often implicated in multiple conditions across a wide variety of populations and optimal thoracic function is paramount for good health. Therefore, the thorax can no longer be considered in isolation from the rest of the body, but in relation to it.

Assessment of the Thorax and the Integrated Systems Model It is now accepted that the best resolution of physical complaints comes from the assessment and treatment of the patient as a whole (body, mind and spirit), ie. a biopsychosocial approach. This requires an understanding of

the relationship between, and the contribution of, various body regions, systems, thoughts, beliefs, and social behaviours or contexts that are ultimately manifesting as cognitive, emotional or sensorial dissonance or altered performance. The broad understanding of the whole person’s experience, or the biopsychosocial components that collectively constitute their reality, can either overwhelm both the individual and the clinician, or highlight a path to change. The path is clearer when the patient’s information is organised, prioritised, and the clinical relevance of each component and finding determined. This requires a theoretical framework, or model, for both assessment and treatment of the individual patient. The Integrated Systems Model (ISM) has been developed to aid the biopsychosocial assessment and treatment of the patient. The ISM helps to identify the: ■ patient’s meaningful complaints ■ patient’s cognitive beliefs ■ patient’s emotional status ■ patient’s meaningful tasks as well as strategy analysis of the screening tasks that pertain to the meaningful task ■ drivers for the loss of function (alignment, biomechanics and/or control) Co-Kinetic Journal 2019;79(Jan):32-38

■ the underlying system impairment that is related to the loss of function of the driver.

1. Prone hip extension task Pelvis: Loss of control RSIJ (PD) Thorax: 4th and 6th thoracic rings translated left and rotated right, 5th thoracic ring translated right and rotated left. 2. R sacrotuberous ligament tender to palpation but not to nutation of the sacrum 3. 1. Delayed recruitment of the RTrA 2. Early recruitment of the right biceps femoris 3. Late recruitment of the right gluteus maximus 4. MC: Right PGP, loss of speed and agility, verge of hamstring grabbing CB: Hamstring will tear if he ‘goes hard,’ right hamstring is weak

ISM treatment includes: 1. releasing the barriers (cognitive, emotional and physical) and align; tools to improve**alignment**; followed by 2. teaching optimal strategies for function that relate to the patient’s goals and meaningful tasks (connect, control and move). To aid this, the information gathered from the patient can be organised with the help of a reflection tool, the ‘Clinical Puzzle’ (Fig. 1). The outer circle of the puzzle represents the strategies for function and performance that the patient currently uses for the screening tasks that relate to their meaningful task. The centre circle of the puzzle represents several systems that relate to the person and the sensorial, cognitive and emotional components of their current experience. It is the place where the meaningful complaint, and goals and barriers to recovery are noted. The four other pieces of the puzzle represent the various systems in which impairments are assessed and noted during the clinical examination. A downloadable template of the Clinical Puzzle is available to help you organise your assessment findings (See Media contents). Further information on these ideas and concepts is available in the author’s book The Thorax – An Integrated Approach. The next section, ‘Steve’s Story’, is a case study from this book demonstrating how these ideas and concepts can be applied to an individual.

STEVE’S STORY At the time of his initial assessment, Steve was a 26-year-old premier league elite soccer player who 2.5–3 years ago had suffered an acute tear of the right proximal biceps femoris. His meaningful complaints were: ■ a feeling of weakness in the right leg, ■ feeling ‘heavy on the field’, and ■ reduced agility and speed since the hamstring injury. He had received traditional soft tissue rehabilitation coupled with stretching

1 3 2

EB: Anxiety re ability to continue to be on the team MT: Vertical loading in a variety of directions

CB, cognitive belief; EB, emotional belief; MC, meaningful complaint; MT, meaningful task; PD, primary driver; PGP, pelvic girdle pain, RTrA, right transversus abdominis; RSIJ, right sacroiliac joint. Figure 2: Steve’s completed Clinical Puzzle from the initial assessment

and strengthening exercises for his right biceps femoris for 6 to 8 weeks after the initial injury but still experienced frequent episodes of ‘pulling pains’ in his right upper thigh and lower buttock. He felt he could only exert himself to 80% and that the upper hamstrings were always on the ‘verge of grabbing’. Subsequent local treatment beyond the 8-week period had not restored his function, nor relieved his persistent symptoms.

goals. Although he had tried, he could not seem to improve the strength of his right leg. His exercises were not improving his speed and agility on the field.

Steve’s Emotional Status For Steve to maintain his position on both his team and in the league he felt his performance needed to improve substantially. This fear of losing ‘his spot’ on the team was creating some anxiety for him.

Steve’s Current Meaningful Complaints

Meaningful Tasks and Screening Tasks Chosen for Strategy Analysis

Of primary concern for Steve was his loss of performance on the soccer field (agility and speed) and his ‘fear’ that the hamstring would tear again if he ‘goes as hard as he wants.’

Steve’s meaningful tasks were to be able to run forwards, backwards, and sideways, manipulate the soccer ball with either foot, and do all this with speed and agility. Multiple screening tasks could be chosen for this sport, including: ■ double leg loading (squat); ■ weight shift to single leg standing,

Steve’s Cognitive Beliefs Steve believed that his right proximal hamstring was still weak and felt that more strengthening exercises were needed to help him reach his athletic

THE INTERCONNECTEDNESS OF THE THORAX MEANS THAT IT CAN NO LONGER BE CONSIDERED IN ISOLATION FROM THE REST OF THE BODY

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MANUAL THERAPY PHYSICAL THERAPY

CLINICALLY EFFECTIVE

THE 10 MOST DISCUSSED PIECES OF RESEARCH IN PHYSICAL THERAPY (OCT-DEC 2018)

News stories

IS IT TIME TO REFRAME HOW WE CARE FOR PEOPLE WITH NON-TRAUMATIC MUSCULOSKELETAL PAIN? British Journal of Sports Medicine

5 1873 55

STICKS AND STONES: THE IMPACT OF LANGUAGE IN MUSCULOSKELETAL REHABILITATION

Journal of Orthopaedic & Sports Physical Therapy

805 14

STRENGTH TRAINING AS SUPERIOR, DOSE-DEPENDENT AND SAFE PREVENTION OF ACUTE AND OVERUSE SPORTS INJURIES: A SYSTEMATIC REVIEW, QUALITATIVE ANALYSIS AND META-ANALYSIS British Journal of Sports Medicine

British Journal of Sports Medicine

3 5

723 12

COMMUNICATION QUALITY BETWEEN THE MEDICAL TEAM AND THE HEAD COACH/MANAGER IS ASSOCIATED WITH INJURY BURDEN AND PLAYER AVAILABILITY IN ELITE FOOTBALL CLUBS

578 6

Mendely readers

The PDF version of this infographic includes hyperlinks to the individual pieces of research. Click here to access: https://spxj.nl/2E6HQJk

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American Journal of Sports Medicine

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ASSOCIATIONS OF RESISTANCE EXERCISE WITH CARDIOVASCULAR DISEASE MORBIDITY AND MORTALITY Medicine & Science in Sports & Exercise

Medicine & Science in Sports & Exercise

255 4

211 6

EFFECT OF EARLY SURGERY VS PHYSICAL THERAPY ON KNEE FUNCTION AMONG PATIENTS WITH NONOBSTRUCTIVE MENISCAL TEARS

JAMA: Journal of the American Medical Association

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ALTERED BRAIN MICROSTRUCTURE IN ASSOCIATION WITH REPETITIVE SUBCONCUSSIVE HEAD IMPACTS AND THE POTENTIAL PROTECTIVE EFFECT OF JUGULAR VEIN COMPRESSION: A LONGITUDINAL STUDY OF FEMALE SOCCER ATHLETES British Journal of Sports Medicine

0 4

EMPOWERING OR DISEMPOWERING THE PATIENT?

DEHYDRATION IMPAIRS COGNITIVE PERFORMANCE

57 45 1

THE INFLUENCE OF GRAFT TENSIONING SEQUENCE ON TIBIOFEMORAL ORIENTATION DURING BICRUCIATE AND POSTEROLATERAL CORNER KNEE LIGAMENT RECONSTRUCTION: A BIOMECHANICAL STUDY

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DEBUNKING THE MYTHS ABOUT TRAINING LOAD, INJURY AND PERFORMANCE: EMPIRICAL EVIDENCE, HOT TOPICS AND RECOMMENDATIONS FOR PRACTITIONERS British Journal of Sports Medicine

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THE BENEFITS OF BLOOD FLOW RESTRICTION TRAINING FOR REHABILITATION

Manual therapy (MT) is a commonly used therapeutic technique, which may be applied to both joints and soft tissue. As we saw in the article ‘Clinically Effective Manual Therapy for the Hip’, MT has quantifiable effects on pain and movement, but its effects are likely to sit within a biopsychosocial rather than purely mechanistic model of healthcare. In this article we will use examples of MT on the knee to show how this technique may be used as a central part of a rehabilitation process. Read this article online https://spxj.nl/2PaI8QI

USING MANUAL THERAPY TO INSTIGATE REHABILITATION ENABLES THE PATIENT TO MANAGE THEIR OWN TREATMENT OUTCOME

One of the criticisms often waged against manual therapy (MT) is that it disempowers the patient, encouraging them to be dependent on their therapist and less reliant on themselves – effectively eroding selfefficacy. However, the technique itself is unlikely to instigate this but the way in which it is presented may do so (1). Giving the message that a patient’s pain results from a stiff joint which is ‘blocking a movement’ is likely to result in the patient coming back to see a therapist time and time again. Seeing pain and lack of movement as a temporary barrier to recovery and using MT to instigate rehabilitation enables the patient to manage their own treatment outcome. Using MT as part of a progressive rehabilitation programme can lead to increased patient self-efficacy enabling the patient to move further along the recovery timescale when previously their recovery has plateaued.

SPECIFIC OR NON-SPECIFIC? Although traditionally it was often claimed that in MT techniques spinal joints may be moved individually (for example L4 motion on L5), or gliding motions may be directionally specific (for example detecting rotation of a

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

WEB

MOBILE

MEDIA CONTENTS

Blood Flow Restriction Training Manual by Novo MG. Lifters Clinic 2016 https://spxj.nl/2S2JX47

MEDIA CONTENTS Set of six videos demonstrating knee mobilisation technique. check wording LINK Here

BY DR CHRISTOPHER NORRIS PHD spinous process) this has largely been disproved. The skin–fascia interface over the thoracic spine is essentially frictionless, meaning that any movement of a vertebra which creates a reactive force would not be felt in the overlying skin (2). Further, many MT techniques, while resulting in a change of movement, are unlikely to generate sufficient force to enable significant accessory joint movement or tissue changes directly. Neuromuscular factors occurring at the time of MT application are a more likely explanation for any motion change. In addition, as we saw in the article ‘Clinically Effective Manual Therapy for the Hip’, motion changes resulting from MT are usually only temporary resulting from a short-term reduction in muscle tone. For this to occur the MT technique only has to be applied close to the region of pathology for a patient’s symptoms to be modified. For example, treating the thoracic spine with MT has been shown to reduce symptoms in the cervical spine (3). 39

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03/12/2018 09:59

There are many situations when patients experience loss of muscle mass and function, for example, after a sports injury, surgery, fracture or joint degeneration. Resistance training is known to be effective for strength training but is often not advised for these patients because of the increased injury risk. Low-load blood flow restriction training, however, has been found to cause beneficial responses in skeletal muscle while avoiding heavy loads. This article reviews blood flow restriction training, the theories about how it works and how to use it so that your patients can get stronger quicker. It is useful in a wide range of clinical applications including prehabilitation, rehabilitation after injury or postoperatively, as well as for athletes looking for those elusive marginal gains when the benefits from their current training programme seem to have plateaued. Read this article online https://spxj.nl/2BHPLue

39-42 CLINICALLY

EFFECTIVE MANUAL THERAPY FOR THE KNEE

BACKGROUND In your everyday practice, and probably multiple times a day, you are faced with patients requiring some form of strength training. Be it following a sports injury, surgery, fracture, ageing or joint degeneration. Whatever the cause of the inactivity, pain, instability and/or immobilisation results in loss of muscle mass and function. As a result, both the risk of reinjury and overall recovery time are a prime concern for clinicians and therapists trying to minimise these adverse side effects. Although we know that resistance training has been demonstrated to be highly effective in combating loss of muscle mass and function, it is often not advised for postoperative or injured patients because of elevated risk of injury or exacerbating existing injury sites, by overloading healing tissues. So, what techniques can you use for patients who require strengthening, be it for prehabilitation or rehabilitation, that keeps the low-intensity exercises interesting, dynamic and most importantly effective? Low-intensity resistance exercise [<30% 1 repetitionmaximum (1RM)] performed with mild to moderate blood flow restriction (BFR) has been observed to elicit beneficial anabolic and functional responses in skeletal muscle, similar to the responses seen following high-intensity resistance exercise. Low-load (LL) BFR training could possibly find its niche in the patients mentioned above, but perhaps is even more useful in clinical settings (1*,2). BFR training is not essentially ’new’ – having been around since the 1970s – but didn’t thrive in the sports and rehabilitation world until around 2015. BFR training involves placing a pneumatic restriction cuff (similar to

a blood pressure cuff) proximal to the target muscle. During properly performed BFR, blood is able to enter the muscle via arterial flow; however, the veins are restricted so that blood is partially prevented from leaving the working muscle. The muscle is then trained at a low intensity (20–30% of maximum capacity or 1RM). The reason these recent findings are such a big deal is that, traditionally, increases in muscle size and strength were thought to only be achievable by lifting weights of at least 70% 1RM (3*). BFR training has been shown to increase muscular strength and hypertrophy using loads less than half of what’s recommended by the American College of Sports Medicine (>60% of 1RM). Increasing muscular strength and size would be advantageous for most, if not all, clinical population groups, especially when heavy lifting (>60% of 1RM) is contraindicated for most painful conditions, postoperatively or until the latter stages of rehabilitation (2,3*). BFR creates an anaerobic environment. At the lower oxygen tension level the body recruits muscle fibres normally reserved for more strenuous exercise. In return, the mechanical stress on the muscle fibres leads to upregulation of the muscle hypertrophy-signalling cascade (1*,3*). BFR has recently and quickly gained interest as an exercise technique that could be a revolutionary tool to decrease the time to return to sport post-injury/postoperatively, for general rehabilitation, strength training, prehabilitation, and as a treatment option in vulnerable populations such as the elderly, frail and patients with reduced mobility. This article will review BFR training, the theories and physiology behind it, clinical application Co-Kinetic Journal 2019;79(Jan):24-31

BLOOD FLOW RESTRICTION (BFR) TRAINING HAS BEEN SHOWN TO INCREASE MUSCULAR STRENGTH AND HYPERTROPHY USING LOADS LESS THAN HALF OF WHAT’S RECOMMENDED BY THE ACSM

and where the current research and clinical trials can guide your choice of BFR in your daily practice.

BFR TRAINING: IS IT RELEVANT? Physical therapists (PTs) are intricately involved in the recovery and rehabilitation of various ailments and injuries. Every day PTs treat individuals who are limited in their function of daily or recreational activities. Treatments target specific impairments through a variety of methods: therapeutic exercise, neuromuscular re-education, manual therapy and therapeutic modalities. Ultimately you want to maximise the patient’s potential for rehabilitation. Dysfunction of the musculoskeletal system, in particular, often provides challenges for the patient and rehabilitation professional alike. Pain and dysfunction present in damaged muscle or connective tissue may commonly affect range of motion, muscular strength and neuromuscular control, leading to continued impairment and deficiencies in functional ability. Muscle weakness is a large contributor to functional impairment and treatment aims to stimulate muscular hypertrophy and subsequent strength gains (1*). The American College of Sports Medicine recommends using 75–85% of 1RM for strength training to induce hypertrophy (4). Unfortunately, a highload (HL) strengthening programme may not always be feasible for the average individual rehabilitating an injury. Following muscle and/ or ligament tears, tendon strain or surgical procedures patients are typically limited in their ability to perform activities with high loads in an attempt to protect the tissues’ integrity.

The challenge is to mitigate muscle atrophy while promoting/protecting the healing process. PTs and other medical professional have begun implementing BFR in their strengthening protocols to improve function and reduce pain (1*). Recent systematic reviews (1*,2,3 *,5,6*,7,8,9*,10*,11*,12) of the growing body of evidence indicate that BFR can produce “positive training adaptations at intensities lower than previously believed.”(5). Another review indicated that “BFR alone can attenuate muscle atrophy during periods of disuse.” (3*). Therefore, individuals who are impaired by weakness and pain or those who are restricted from HL training owing to post-surgical precautions can experience a productive training response with LL-BFR protocols. Furthermore, individualised BFR training may provide a comparable surrogate for HL training while minimising pain during training (1*,3*). Within most clinical musculoskeletal (MSK) conditions is a high prevalence of muscle weakness. However, this is not just applicable to sports injuries. Loss of strength is a major risk factor for osteoarthritis (OA), the most common MSK disease responsible for reduced function and quality of life of sufferers. Muscle weakness is increasingly evident in non-injured populations and can be caused by, for example, poor postural adaptations as well as sarcopenia in older adults (3*).

There are many situations where high loading of a joint or muscle may not be feasible. Therefore, training with LL effectively may be useful, as the early addition of muscle mass and function in rehabilitation may be beneficial for individuals who have suffered from atrophy (3*).

BFR TRAINING: HOW IT WORKS Research has demonstrated that augmentation of LL resistance training with BFR to the active musculature can produce significant hypertrophy and strength gains using loads as low as 30% 1RM (3*). But how? Typically, as skeletal muscle fibres fatigue, additional fibres that require a higher stimulatory threshold are recruited to assist in the activity (3*). Because of oxygen restriction and intramuscular metabolite accumulation, it is thought that the resulting fatigue drives the recruitment of additional muscle fibres. Skeletal muscle hypertrophy is largely governed by the total volume of mechanical work performed (sets × repetitions × resistance) and the number of muscle fibres used to perform

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TIME-SAVING RESOURCES FOR PHYSICAL AND MANUAL THERAPISTS

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04-11

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MANUAL THERAPY & PHYSICAL THERAPY INFOGRAPHICS

PELVIC FLOOR TRAINING FOR STRESS URINARY INCONTINENCE: AN UPDATE 19-01-COKINETIC FORMATS WEB MOBILE

BY KATHRYN THOMAS BSC MPHIL

14-23

PELVIC FLOOR TRAINING FOR STRESS URINARY INCONTINENCE: AN UPDATE

Stress urinary incontinence (SUI) is a little-discussed but perhaps surprisingly common condition in elite athletes involved in high-impact sports. This article discusses the possible causes of SUI (which is more complex than simply weak pelvic floor muscles), methods of SUI assessment and the various options for therapy. This will enable you to tailor a training regimen to suit your patient and create the best chances of a successful outcome, allowing your client to continue their sport with confidence and dignity. Read this article online https://spxj.nl/2DStStK All references marked with an asterisk are open access and links are provided in the reference list.

BACKGROUND Most women will have had the experience of ‘wetting their pants’ at some stage in their life, be it when coughing or sneezing or laughing hysterically. For some this has only happened while they were pregnant or during a bout of bad bronchitis or pneumonia. But for others this is not something that was simply a phase in their life and can giggle about afterwards with friends! For many women (and a few men) this is a daily occurrence that can grossly affect their self-confidence and instil fear of having an ‘accident’ when out socialising or at work. Apart from coughing and sneezing other activities that increase abdominal pressure, such as lifting heavy objects or physical activities with impact, can result in the involuntary loss of urine resulting in embarrassment, often to the extent where the women changes the activity or sport or even stops all together. Although we sometimes laugh about it in an accepting way as something else women have to deal with, especially after childbirth and the menopause, it really is a condition that deserves greater focus and research from the medical field. Stress urinary incontinence (SUI) can have serious psychosocial effects on all women, affecting their level of intimacy, work, studies, personal hygiene and sports, not to mention the impact should women stop exercising because of the condition and the negative effect that has on their general health as well as bone health with ageing. SUI is a debilitating condition of the genitourinary tract afflicting as many as 1 in 4 women during their lifetime. Well-functioning pelvic floor muscles (PFM) with intact endopelvic fascia

are necessary for maintaining urinary continence by providing essential support for the bladder and urethra. Thus, weakness of the PFM is associated with SUI and, therefore, strengthening the PFM is recommended as a first-line treatment in managing female SUI. Surgery represents the most invasive option available but, although highly effective initially, the durability of the surgical procedure seems to diminish over time. The role of PFM training (PFMT) perioperatively may enhance the outcome of the surgical procedure and seems promising; however, strong research in this area is lacking at this time. This article reviews the importance of PFMT in the conservative management of SUI, looking at exercise physiology strength training, training protocols, correct techniques and devices, and any new, innovative methods of PFMT. Greater dialogue is needed within the medical field to enhance our management of these patients; but also greater public awareness to remove any stigma associated with SUI and encourage women to seek treatment without embarrassment.

sports involving high-impact activities, such as gymnastics and ball games (eg. volleyball, handball, basketball). The highest percentage of SUI is seen in athletics (23.8%), followed by volleyball players (19.6%) (4). Volleyball players have a 116% chance of getting SUI compared to women who play other types of sports (4). Regarding the prevalence of SUI in different sports, the rates vary between 0% in golf players and 88.9% in artistic gymnastics and trampoline athletes (Fig. 1) (2). Two opposing hypotheses have been suggested regarding the effect of exercise on the PFMs. One proposes that the increased impact of abdominal pressure and ground-reaction forces may lead to simultaneous or precontraction of the PFM, resulting in a training effect of the muscles. The other suggests that strenuous physical activity without simultaneous cocontraction of the PFM may overload, stretch and weaken the pelvic floor (2). During high-impact physical activity the intra-abdominal pressure can rise above intraurethral pressure and can overwhelm even the normal continence mechanism, causing urine leakage (3). Even nulliparous women engaged in high-impact exercises can experience SUI. High-impact physical activity may also damage the endopelvic fascia and be responsible for SUI (2). Studies have shown that in elite, highly trained athletes involved in high-impact sports SUI is common. For women, with an average age of 19 years, the prevalence of urinary incontinence (UI) in elite females (national representation) was 29.6% versus the age-matched non-athletic control of 13.4%. Within this UI, 19.6% was SUI (2). So the prevalence of SUI is three times higher in elite athletes than age-matched controls (2). In addition to this a history of constipation, family history of urinary incontinence and history of urinary tract infection are added risk factors for an athlete developing SUI (2). More than onethird of the elite athletes consider SUI to have implications on sports performance; however, less than 15% report using strategies to hide the leakage, and significantly fewer athletes than controls had told a physician about

STUDIES HAVE SHOWN THAT IN ELITE, HIGHLY TRAINED ATHLETES INVOLVED IN HIGH-IMPACT SPORTS, STRESS URINARY INCONTINENCE (SUI) IS COMMON the condition (2). Not telling healthcare professionals about SUI is a common occurrence. Interestingly, in one of the latest clinical trials, incontinent nulliparous female professional athletes had greater PFM strength than continent athletes. This suggests that UI in this population of professional athletes was not due to PFM weakness. There was, however, a positive association between abdominal and PFM strengths in incontinent athletes, which may result from frequent co-contraction between these muscle groups (5). This highlights the fact that there may be more complexity to the issue than simply PFM weakness and greater understanding of the interactions of the PFMs with the core and abdominal muscles as well as other pelvic girdle muscles may require further research. Irrespective of population group, it is clear that SUI is a prevalent condition affecting a substantial segment of our society as a whole. Whereas ageing, obesity and smoking are consistently shown to be risk factors for symptomatic SUI (1), the role of pregnancy and mode of delivery remains debatable. Although several studies report a moderate-to-significant increase in relative risk of SUI among parous versus nulliparous women, other studies show little-to-no increase in risk (1). Additional risk factors can include neuromuscular disorders, family history, hysterectomy and chronic constipation (1). The risk factors are not completely understood, and further research into the pathophysiological mechanisms of SUI is needed.

THE PATHOPHYSIOLOGY AND REVIEW OF GRAY’S ANATOMY No, not S10E13 a flashback to McDreamy, more of a flashback to your undergraduate anatomy class. Reviewing the exact anatomy, physiology and pathogenesis of the pelvic floor will aid in better visualisation

Trampolining (17)

82.4

Weightlifting (1) 0.0 Acrobatic/rhythmic gymnastics (9)

22.2 25.0

Judo/karate (24) 10.0

Roller hockey (10)

19.0

Tennis*/paddle (21)

16.2

Football/futsal (37)

12.2

Rugby (41)

23.3

Handball (30) 4.2

Volleyball (24)

24.1

Basketball (58) 16.1

Water polo (31) Swimming (9) 0.0

18.2

Synchonised swimming (11) Figure roller skating (5) 0.0

12.5

Rowing/canoeing (8)

18.2

Athletics (22) 7.1

Horse jumping (14) 0

20 30 40 50 60 70 80 90

Figure 1: Prevalence (%) of stress urinary incontinence within each sport. *Tennis/beach tennis/table tennis. [Carvalhais A, Natal Jorge R, Bø K. Performing high-level sport is strongly associated with urinary incontinence in elite athletes: a comparative study of 372 elite female athletes and 372 controls. British Journal of Sports Medicine 2017;doi:10.1136/ bjsports-2017-097587 (2). Reproduced with permission]

TABLE 1: PREVALENCE OF STRESS URINARY INCONTINENCE [Adapted from Lasak A et al. The role of pelvic floor muscle training in the conservative and surgical management of female stress urinary incontinence: does the strength of the pelvic floor muscles matter? PM&R 2018;doi:10.1016/j. pmrj.2018.03.023 (1).]

Specific group

Percentage (%) Odds ratio (OR)

Gender: Women Men Age (years): 20–29 >80

20.8 1.5 3.5 38

Bodyweight: Obese Overweight

2.3 1.4

Physical activity: High-impact exercise Low impact/no exercise

24.6 14.3

Obstetric history: Singleton (vaginal delivery) Caesarian section

40.3 28.8

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LONG JANUARY 2019 ISSUE 79 ISSN 2397-138X

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

CLICK ON RESEARCH TITLES TO GO TO ABSTRACT UNUSUAL CONCURRENCE OF INTERMEDIATE PECTORALIS MUSCLE AND VARIANT INSERTION OF PECTORALIS MINOR WITH ITS CLINICAL ASPECTS. Vani PC, Anbalagan J, Rajasekar SS. International Journal OPEN of Anatomical Variations 2018;11(3):81–83 This is a case report on the dissection of a 48-year-old female. She was found to have what is described as an intermediate pectoralis muscle. It originated at the 5th and 6th ribs and the aponeurosis of the external oblique. It ran deep to the pectoralis major and close to its insertion it blended with the pectoralis minor. The majority of the fibres inserted onto the capsule of glenohumeral joint. Some fibres inserted on the coracoid process and a few fibres fused with fascia over the coracobrachialis and the short head of biceps brachii. It was 19cm in length and 1.5cm in width at its midpoint. It was supplied by the branch from 3rd intercostal nerve. Additionally, a similar muscle was present on the contra side but with slightly different dimensions and anchor points. Just to add to the picture, pectoralis minor originated on ribs 2–4 on one side and 2–5 on the other.

Co-Kinetic comment We are always a bit sceptical of structures that don’t appear in Gray’s Anatomy but this paper quotes previous case reports on the presence of other accessory muscles in the region including a pectoralis minimus, a pectoralis tertius and a pectoralis quartus. The bottom line here is that these variations may have a clinical significance but we don’t know what they are. Could the fibre attachment into the glenohumeral joint capsule have an effect on joint mobility or conditions such as adhesive capsulitis?

OPEN

CASE STUDIES IN PHYSICAL THERAPY: TRANSITIONING A “HANDS-ON” APPROACH INTO A VIRTUAL PLATFORM. Turner A. International Journal of Telerehabilitation 2018;10(1):37–49

These case study reports are based on the premise that here in this busy world where patients value the speed and convenience of the internet there is an increasing demand for telemedicine. Apparently, at present, physical therapy requires ‘tedious intake paperwork, manual evaluations, and treatments’. The basis of the mechanical assessment in the case studies was observation of movement rather than palpation. In each case, the virtual mechanical assessment identified a specific sub-classification with a directional preference and the patients were sent a video of the prescribed exercise. All patients reported improvements in symptoms and function in less than four visits and all maintained a reduction in symptoms after 3 months. Given the ‘hands-off’ role of the evaluator, this approach can become an effective tool in the evolving healthcare platform of telerehabilitation.

Co-Kinetic comment A presentation at last year’s Chartered Society of Physiotherapy congress took this a stage further and suggested that if hands-on treatment was necessary it may be done by a robot in future. Apparently the medical insurance companies in the United States are embracing this because it’s cost effective. Will the last ‘real’ therapist please turn off the lights as they leave… SPORTS PHARMACOLOGY: A MEDICAL PHARMACOLOGIST’S PERSPECTIVE. Malve HO. Journal of Pharmacy & BioAllied Sciences 2018;10:126–136 This essay is about the use of performance-enhancing substances (PESs) to improve athletic performance. The anti-drug agency (WADA) was established to keep the playing field level. They have their work cut out. In 1997 a survey of 198 aspiring US Olympians were asked if they would take a prohibited PES if they were promised to win and not get caught, 98% said yes. Then, when asked, “Would you take the same undetectable substance if it would contribute to winning every competition for 5 years, then leading to death?” half of them still said yes. The report is a summary of what various substances do and how they are detected by WADA. Anabolic–

androgenic steroids have anabolic effects, which lead to its abuse for the enhancement of sport performance. Gonadal steroids (ie. androgens and oestrogens) play a role in bone metabolism, growth, development, maintenance of reproductive organs and promotion of protein synthesis. Glucocorticoids are natural and synthetic hormones, steroidal in nature with anti-inflammatory properties. They are responsible for anabolic actions, which include stimulation of gluconeogenesis and utilisation of amino acids and fatty acids, reduce tiredness, relieve fatigue and inflammation, act as mental stimulants, and increase pain tolerance. Beta agonists are

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RESEARCH INTO PRACTICE

Journal Watch COMPARISON OF SUSTAINED PRESSURE VS ISCHEMIC COMPRESSION ON TRIGGER POINTS IN CHRONIC MYOFASCIAL PAIN MANAGEMENT. Sharifullah M, Sajjad AG, Mobeen A et al. Khyber Medical University Journal 2018;10(2):66–70

OPEN

sessions over a 2-week period. Outcomes were ROM, a numeric pain rating scale and a chronic pain acceptance questionnaire. Improvement in pain relief was observed in both groups but there was no significant improvement in pain relief between them.

Patients complaining of chronic muscle pain were randomly assigned to either Group A or Group B. Group A (n=19) received sustained, progressive pressure to trigger points in the affected muscles that had been identified by palpation: hot pack (10–15min); stretching, 3 sets of 10 repetitions with 10s hold (of targeted muscles); and active range of motion exercises (3 sets of 10 repetitions). Group B (n=18) received ischemic compression and the other treatments that Group A received. All the patients were assessed at the base line before intervention and at the completion of eight treatment

Sadly this paper includes details of the heat and the stretching but not how long the sustained pressure and ischemic compression were applied for. Not that it really matters because the headline is that both worked.

phenylethanolamines with a stimulant and anabolic effect. In some medical circumstances they are not banned but only if pre-authorised. Salbutamol, is an example. Beta blockers reduce heart rate and muscle tremors. Stimulants have direct and peripheral effects on the nervous system. They increase alertness, reduce fatigue, and affect mood and cardiovascular activation. Peptide hormones, growth factors and related substances have a very short half-life and are, therefore, metabolised rapidly making detection difficult. Growth hormone actions include increasing lean body mass, energy, performance, muscle mass and strength, stroke volume and maximal oxygen uptake. Insulin can increase muscle bulk. Erythropoietin acts on bone marrow and stimulates red

blood cell production. It can increase VO2max by 20%. Human chorionic gonadotropin is used to raise gonadal testosterone synthesis during and after self-administration of testosterone or anabolic steroids. Blood doping increases oxygen delivery to muscles and the aerobic capacity of athletes. It may include autologous or homologous blood transfusions, administration of erythropoiesis-stimulating agents such as erythropoietin, or blood substitutes such as perfluorocarbons and haemoglobin-based oxygen carriers. Gene doping is the intentional use of gene therapy to enhance an athlete’s performance. Amphetamine derivatives, including cocaine, amphetamines, and hallucinogens, can modify mental alertness. They can increase cardiac output and blood flow to muscles.

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ENVIRONMENTAL CONTAMINATION BY BACTERIA IN HOSPITAL WASHROOMS ACCORDING TO HAND-DRYING METHOD: A MULTI-CENTRE OPEN STUDY. Best E, Parnell P, Couturier J et al. Journal of Hospital Infection 2018;100(4):469–475 A total of 120 sampling sessions occurred over 12 weeks at three hospitals in the UK, France and Italy. Bacteria were cultured from air, multiple surfaces and dust. Washroom footfall (patients/visitors/staff) was monitored externally. Footfall was nine times higher in UK washrooms. Multiple examples of significant differences in surface bacterial contamination, including by faecal and antibiotic-resistant bacteria (MRSA), were observed, with higher levels in washrooms with air dryers than paper towels.

Co-Kinetic comment No, this has nothing to do with Brexit although it does seem to highlight cultural differences between EU countries. What it does show is that air dryers are not very hygienic. The question is should we be disposing of the hand towels in the bio-waste bins?

Narcotic analgesics are used for pain control as they interact with specific receptors and manage the neural axis for pain. They mainly depress the nervous system to reduce fear, anxiety and pain sensations. Diuretics are often used to lose weight quickly to compete in lower weight category or as a masking agent.

Co-Kinetic comment This paper is a must read for therapists in the sports industry. Not only does it include much more detail on the drugs than we have space for, it is informative on testing procedures and the use of drugs during injury rehabilitation, especially pain management and the use of NSAIDs.

OPEN

Data for this study came from a search of the past 15 years of MEDLINE using the keywords, ‘NSAIDs’, ‘Athletes’ and ‘Sports’ which brought up 16 studies involving elite athletes at the Olympics and the FIFA World Cup, as well as recreational athletes. In addition there was a randomised controlled trial involving 2,378 recreational Dutch athletes in which 883 of the runners (37%) sustained an injury during follow-up. All the injured athletes were asked what medication they took (if any). The combined results showed that there is a great deal of NSAID use but, as is often the case with reviews, differences in reporting confuse

NSAIDS USE IN ATHLETES. Koes B, van Ochten J, van Middelkoop M et al. Dansk Sportsmedicin 2018;3(22):25–30 the results. It was clear that they were taken before, during and after competition in increasing amounts with 50% of athletes taking them, and on occasion 100% usage. The study goes on to discuss the effects of NSAIDs. Unfortunately, few studies are about the anti-inflammatory effects of the drugs but what is clear is that as a pain relief NSAIDs are better than placebo for tennis elbow and chronic and acute musculoskeletal pain but not significantly better than other oral analgesics including paracetamol in people with acute soft tissue injury.

Co-Kinetic comment This study had good intentions but overall the results are confused because you have to dig deep to discover if the NSAIDs are oral or topical and if they are mild or stronger ones, such as diclofenac. What is reported is that the quality of the evidence is generally low. It is clear that athletes seem to have a lot of faith in NSAIDs, which may have a strong psychological effect. There is also a mention that in the one study comparing NSAIDs with paracetamol the latter produced less adverse gastrointestinal side effects and that in the longer term there is an increased risk of cardiovascular and renal events when using NSAIDs. What is not considered – and should be in the future – is that the inflammatory response is vital to the healing process and if this is hampered by early use of NSAIDs as a pain killer.

A SYSTEMATIC SUMMARY OF SYSTEMATIC REVIEWS ON THE TOPIC OF THE ROTATOR CUFF. Jancuska J, Matthews J, Miller T et al. The Orthopaedic Journal of Sports Medicine 2018;6(9):2325967118797891

OPEN

The usual databases were searched from 2007 to 2017 for anything to do with the rotator cuff (RC). It produced 1,078 articles of which 96 met the inclusion criteria. Included articles were summarised and divided into 15 topics: anatomy and function, histology and genetics, diagnosis, epidemiology, athletes, non-operative versus operative treatment, surgical repair methods, concomitant conditions and surgical procedures, RC tears after total shoulder arthroplasty, biological augmentation, postoperative rehabilitation, outcomes and complications, patient-reported outcome measures, costeffectiveness of RC repair, and quality of randomised controlled trials. This is a very comprehensive paper so we only have space for a few highlights. The most reliable position for rotation strength testing was seated with 45° of abduction in the scapular plane. Muscle thickness may be a predictor

of muscle function. The initial response to tendon injury or degeneration involved neovascularisation and hyperaemia, whereas hypovascularity contributed to degenerative lesions and aging. Nutrition and genetics could also play a role in vascular changes. Predictors of a diagnosis of an RC tear included history of hypercholesterolemia, family history of RC disease, excessive lifting, above shoulder work, handheld vibration work, or age >60 years. The most accurate tests for diagnosing an RC tear are a positive painful arc test, a positive ER lag test, and possibly the lateral Jobe’s test. Early surgical management may be warranted for traumatic acute tears and in the presence of weakness and substantial functional disability, whereas non-operative management is often successful when symptom duration is <3 months but may be unsuccessful for symptoms that last >1 year. The epidemiology showed that patients were 55 years old on average (range, 34–61 years), primarily male (77%), and most often injured by a fall onto an outstretched arm. The most commonly torn tendon was the supraspinatus (84%), and most tears were <5 cm (58%). Smoking is associated with an increased prevalence

of larger RC tears. In athletes the rate of return to play (RTP) was 55–73% among Major League Baseball pitchers and that about 25% of players never pitched in the league again. However in one study, the rate of RTP was only 8%; 66% of players had concurrent procedures, such as SLAP repair, which may have affected RTP. One study with pooled data discovered that the rate of RTP was 91% for contact sports, 40% for professional overhead athletes (although RC debridement was more common than RC repair for this group), and 83% for recreational overhead athletes. In another study the prevalence of RC tears in rugby was 2.1–43%, and the most common mechanisms of injury included tackling and falling onto the arm. For rehabilitation, the American Society of Shoulder and Elbow Therapists recommend following arthroscopic RC repair with a 2-week period of immobilisation, followed by performance of protected passive ROM during weeks 2 to 6, re-establishment of active ROM after 6 weeks, progression to strengthening at week 12, and finally the return to sport or work when appropriate. One study reported better outcomes in supervised rather than unsupervised therapy.

Co-Kinetic comment There is loads more in this paper and for researchers a lot of issues to explore further, such as cholesterol levels as a predictor or what could be done to improve the RTP levels. 6

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RESEARCH INTO PRACTICE

STRENGTH TRAINING RECOMMENDATIONS TO IMPROVE SCRUM FORCE AND IMPULSE IN RUGBY UNION FORWARDS. Mills BS, Smith B, McMaster D. Strength and Conditioning Journal 2018;doi:10.1519/SSC.0000000000000420 Although a rugby forward needs aerobic capacity, repeated high intensity efforts, and sprint ability they also require strength to cope with the scrum. This involves a large sustained coordinated horizontal impulse but training for such a horizontal impulse and the force for scrummaging is not easily simulated with traditional resistance training exercises such as squats and deadlifts. The players impose the force on their opposite numbers during the initial impact phase and follow this with a coordinated sustained push which can last 5–20s, or sometimes longer if the pushers are successful. This can result

in peak compressive forces of between 8000 (high school forward packs) and 16500N (international forward packs). To put this into prospective it takes only 4000N of force to break a typical human femur. This study looks at the demands of the task, positional requirements and individual physical capabilities. The forward must develop large eccentric, isometric and concentric strength qualities of the extensor muscles of the neck, back, hips, knees and ankles (plantar flexion) with an emphasis on horizontal delivery. Hence, traditional vertical strength exercises need to be

supplemented with resisted horizontal movements, such as sled push and pulls and if possible the use of a scrummage simulator machine during a periodised regime incorporated into every training session.

Co-Kinetic comment This is a good read for people involved in Rugby Union who are not strength and conditioning experts, giving you an insight into the preparation needed for being part of the scrum. Alternatively, given that in professional English matches 31% of scrums collapse and that the injury rate is 8.6 per 1000 scrum events when they do, maybe following Rugby League and scrapping the contested scrum is a better idea.

EFFECT OF WOUND MASSAGE ON NECK DISCOMFORT AND VOICE CHANGES AFTER THYROIDECTOMY. Lee JS, Kim JP, Ryu JS et al. Surgery 2018;164(5):965–971

DOES THE PATIENTS’ EXPECTATIONS ON KINESIOTAPE AFFECT THE OUTCOMES OF PATIENTS WITH A ROTATOR CUFF TEAR? A RANDOMIZED CONTROLLED CLINICAL TRIAL. Analay Akbaba Y, Kaya Mutlu E, Altun S et al. Clinical Rehabilitation 2018;32(11):1509–1519 Patients with a confirmed rotator cuff tear had kinesiotape applied to their shoulder. They were randomised to either Group 1 who were told there is no evidence that kinesiotaping is effective (n =33); Group 2 who were told that there is limited evidence that kinesiotaping is effective (n =33); and Group 3 who were told that there is evidence that kinesiotaping has an excellent effect (n =33). Outcomes were resting pain, activity pain, and night pain assessed by visual analogue scale. Range of motion was assessed by a universal goniometer. Function was evaluated by the Disabilities of the Arm, Shoulder and Hand Questionnaire and the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form before and 24h after Co-Kinetic.com

kinesiotape application. Only resting pain and activity pain were assessed after 30min. There were no statistically significant differences between any groups at the three assessment points. The intragroup assessment showed that in Group 2, only resting pain after 30min improved. An improvement in resting pain both after 30min and after 24h was found in the third group. Activity pain and night pain were improved in all groups after 24h.

Co-Kinetic comment This should not surprise any therapist working in sport because 95% of what they do is messing with a player’s mind. The rest is in the player’s head!

This is about post-thyroidectomy. Massage was given because ‘wound massage can release the fibrous tension of surgical adhesions, release shortened fibres and adhesions in the muscle and subcutaneous tissue, increase the range of motion back to normal function, and provide symptom relief’. At 4 weeks postop when the wound was fully healed and there were no scabs or open areas the patients in the intervention group, (n=21) were taught a 10min selfmassage routine which was to be performed 3 times daily for between 4 and 12 weeks with the objective of improving neck ROM. This was measured by assessing the distance from the skin incision line to the hyoid bone during swallowing. The massage routine is well described and is basically small circular movements around the wound site and bigger circles moving the skin over the underlying tissue. There was also a non-massage control group (n=24). The experimental group had significantly better recovery from surgical adhesion and subjective visual analogue scale, voice impairment score, and swallowing impairment score compared with the control group.

Co-Kinetic comment Forget the thyroid bit, this paper is about post-surgical scar management and if it works for this group it is not a big leap to think that it will work for all surgical scars. A similar study on more sporty injuries would be nice, please. There was another lesson from this paper which was that patients made weekly hospital visits to check and encourage compliance, which was 88.8% for average massages per day and 80.9% for massage minutes, which is pretty good for any home exercise routine.

EFFECTIVENESS OF MULTICOMPONENT LOWER EXTREMITY INJURY PREVENTION PROGRAMMES IN TEAMSPORT ATHLETES: AN UMBRELLA REVIEW. Brunner R, Friesenbichler B, Casartelli NC et al. British Journal of Sports Medicine 2018;doi:10.1136/bjsports-2017-098944 [Epub ahead of print] This was a literature search looking for studies published between January 2000 and March 2017 that investigated the effectiveness of a combination of two or more exercise components regarding injury incidence/rate of lower extremity injuries in team-sport athletes. The components investigated were strength, agility, plyometrics, balance, stretching, technique, warm-up and functional

activity. Twenty-four systematic reviews met the inclusion criteria. Multicomponent exercise interventions were effective in reducing the injury incidence/rate of lower extremity, knee, ACL and ankle injuries, but not groin injuries. Strength and balance exercise components were included in 10 of 11 effective injury prevention programmes for the lower extremity, knee, ACL and ankle injuries.

Co-Kinetic comment What is the difference between an, ‘umbrella review’ and a ‘meta -analysis’? While you are pondering that, content yourself with the somewhat obvious knowledge that specific injury prevention programmes seem to be successful at reducing injuries.

THE PRESENCE OF CONCOMITANT INTRA-ARTICULAR INJURIES AND BONE BRUISE DOES NOT AFFECT PRE-OPERATIVE KNEE PAIN AND SYMPTOMS IN PATIENTS UNDERGOING ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION. Panjwani T, Mok YR, Wong KL et al. Knee Surgery, Sports Traumatology, Arthroscopy 2018;doi:10.1007/s00167-018-5168-z [Epub ahead of print] Data for this study was collected from 270 (211 male) patients at a Singapore hospital who underwent primary ACL reconstruction within 3 months of injury. Mean age was 25.4 years. Bone bruise was present in 243 patients (90%), meniscal injury in 165 (61%) patients and chondral injury in 40 (15%) patients. The presence of bone bruise, meniscal injury or chondral injury was not significantly associated with worse preoperative Knee injury and Osteoarthritis Outcome Score (KOOS) pain and symptoms and SF-36 bodily pain scores. Other factors that were not associated were demographic characteristics (age, BMI and sex) and mechanism of injury.

Co-Kinetic comment It would appear from this paper that having a concomitant injury does not affect the postop pain and symptom scores, which may be a comfort you can pass onto the poor athlete about to go under the knife.

STRENGTH TRAINING AS SUPERIOR, DOSE-DEPENDENT AND SAFE PREVENTION OF ACUTE AND OVERUSE SPORTS INJURIES: A SYSTEMATIC REVIEW, QUALITATIVE ANALYSIS AND META-ANALYSIS. Lauersen JB, Andersen TE, Andersen LB. British Journal of Sports Medicine 2018;52(24):1557–1563 A search of the usual databases for randomised controlled trials on strength-training exercises as a primary prevention of sports injuries came up with an original 1,559 studies. These were eventually whittled down to six relevant ones that analysed five different interventions with four distinct outcomes involving 7,738 participants aged 12–40 years who sustained 177 acute or overuse injuries. Studies were published in 2003–2016, five from Europe and one from Africa. The result was consistent across robustness tests and strength of evidence was high. The intervention time scale ranged from 10 weeks to a full season. The results showed that a strength-training programme reduced the risk of injury 8

by an average of 66%. A bonus was that there were no adverse events reported in any of the studies. It was hypothesised that indirect effect of acute injury prevention works through mechanisms of strengthtraining-related carry-over with improved coordination, enhanced technique in training/match situations, strengthening of adjacent tissues reducing critical joint loads and better psychological perception of highrisk situations. For overuse injury the suggestion is that besides simply evading pain triggers or reducing the amount of training/competition in burdened periods, preconditioning, tissue-relieving variation in exercises and loads, and carry-over of improved

OPEN

coordination/technique from a strengthtraining injury prevention programme is potentially beneficial by altering load distributions in the tissues and joints.

Co-Kinetic comment Another one that is good for therapists who want to whisper in coaches’ ears that their training programmes break their athletes but it need not be so. The issue of compliance (or lack of it) with the programme comes up. A solution suggested by the authors is to plug the fact that in addition to injury prevention it should be emphasised that adherence to strength training can also lead to improved performance. It’s a win–win. Co-Kinetic Journal 2019;79(January):4-11

RESEARCH INTO PRACTICE

THE EFFECTS OF AN ACUTE BOUT OF FOAM ROLLING ON HIP RANGE OF MOTION ON DIFFERENT TISSUES. Hall M, Chadwick Smith J. International Journal of Sports Physical Therapy 2018;13(4):652–650 Twenty-six (14 female, 12 male) healthy adults completed each of three sessions. During the control session, each participant performed a 5min warm-up on a cycle ergometer and immediately following this had their passive hip adduction ROM assessed bilaterally using the modified Ober’s test. They then sat in a chair for 3min before being retested. For the active foam rolling session (AFR) and passive foam rolling session (PFR) the procedure was the same with the exception of foam rolling being performed instead of resting for 3min. For the AFR session, participants foam rolled over the gluteal muscle group for the hip that had the least amount of flexibility as determined during their first session. Participants sat on a 36×6-

inch round, high-density ethylene vinyl acetate foam roller on the floor with their feet flat on the ground. Using a metronome to keep pace, participants foam rolled at a rate of 30 rolls per minute with rolling from the gluteal fold to the PSIS and back to the gluteal fold counting as one roll. Three sets of 30s of foam rolling were completed with 30s of rest between each set. For the PFR session, participants foam rolled over the ITB instead of the gluteal muscle group. Participants rolled in a caudal-to-cephalad direction from the greater trochanter to the lateral femoral condyle of the femur for the same number of sets. The postintervention Ober’s test was performed immediately after completing each

session. Results showed that the control group had decreased ROM by 2%. PFR increased ROM by 1.1% and AFR by 14%.

Co-Kinetic comment The terminology in this paper is a bit weird. Why an acute bout? The difference between what is described as active and passive is that the former is over the glutes and the latter over the ITB. Strange! Not that it really matters because what it does is show that foam rolling over the muscle increases its ROM.

UNRAVELLING WHY SOME KIDS ARE MORE AT RISK OF SPORTS INJURIES AND WHAT WE CAN DO ABOUT IT. Johnson A. Journal of Science and Medicine in Sport 2018;21(Suppl-1):S3 This was a summary of a presentation given to the 2018 Sports Medicine Australia Conference. It starts by stating that the literature regarding injuries in youth athletes can be described as sparse. The main bulk of the literature is for soccer and covers mainly the U16–U18 year age-groups, very little covers athletes younger than this. Injuries have been linked to the unpredictable nature of growth and development which affects all immature athletes on an individual basis. The problem is that there are a number of ways that biological maturity can be measured. One is ‘bio-banding’ which allows players to be grouped on their maturity and biological age rather than their chronological age. It is being used particularly in soccer, to guide coaches in their player selection to ensure that bigger, more developed players do not overwhelm or dominate the smaller less mature ones. Another issue is that training load on youth athletes is difficult to assess owing to activities that many of them do outside the specific training environment, such as school PE sessions and general Co-Kinetic.com

OPEN

recreational activity. Many sports use a register to account for the amount of training that is undertaken or take a sessional RPE (rate of perceived exertion) which is done on an individual basis but neither method gives a totally reliable reflection of the burden of the session to the individual.

Co-Kinetic comment So the answer to the question in the title is we are not really sure because its multifactorial. However, if we treat young athletes as individuals rather than shoe horning them into groups that don’t really fit them we will get closer to the answer. Do people still use shoe horns? If you do a Google search for ‘bio-banding’ you will find plenty of positive articles and even a free banding calculator. Sadly there are also a number of dissenting articles so you may end up as confused about what is good for the kids as you are now.

PASSIVE HALLUX ADDUCTION DECREASES BLOOD FLOW TO PLANTAR FASCIA. Dunbar JL. Brigham Young University ScholarsArchive 2018;ISSN:2572-4479 This is actually a Master’s Degree thesis. It set out to see what effect an adducted big toe can have on blood flow. It’s the sort of thing that happens with ill-fitting shoes and is often seen in sports with runners who have bought trainers from the internet. Forty-five healthy volunteers (20 female, 25 male; age, 24.8±6.8 years; height, 1.7±0.1m; weight, 73.4±13.5kg) had the blood velocity and the vessel diameter of their lateral planter artery deep to abductor hallux measured by ultrasound before and after passive adduction tension was applied to the muscle. Duration of the pressure was 120s followed by 60s at rest followed by 60s more of pressure. The volume of blood flow was 22.2% lower after application than before.

Co-Kinetic comment What a great piece of work. As the author says this was pressure applied only for a couple of minutes. What would be the effect on tissue health of running a 10k in ill-fitting shoes? OPEN Any volunteers? 9

THE EFFECT OF EXERCISE ON SYMPTOMS OF DEPRESSION IN ADULTS DIAGNOSED WITH CLINICAL DEPRESSION: AN INTEGRATIVE LITERATURE REVIEW. Felix T, Moxley E. The Grace Peterson Nursing Research Colloquium 2018 (Poster presentation) The initial search found 195 relevant papers in ProQuest, PubMed and CINHAL which were eventually cut down to 19 for this study. A summary of the findings showed that exercise helps to release endorphins and other neurotransmitters in the body, exercise acts as a distraction method to relieve an individual’s depressive state, and that exercise helps to improve an individual’s self-efficacy. It has a

This quotes a 2010 systematic review of randomised controlled trials (RCTs) (N=5,224) of high school and collegiate American Football athletes. For some reason ACL injuries were excluded from the data. One of the RCTs (N=1,396) suggested that prophylactic knee braces significantly reduced MCL injuries with 25 injuries in non-braced athletes and 12 in those with a brace. However, inconsistent results were found in cohort studies with three showing no reduction in injuries and one suggesting that there was actually an increase in injuries in the braced athletes.

significant impact on the mental state and symptoms of depression. There is no ideal exercise prescription but consistency in the exercise regime is the most important factor in decreasing symptoms of depression.

Co-Kinetic comment According to the statistics body NHS Digital, at any one time a sixth of the population in England aged 16 to 64 have a mental health problem.

OPEN

According to the Anxiety and Depression Association of America 40 million adults are affected. That’s 18.1% of the population. That means two things for our readers. The first is that with those numbers some of you will be suffering. The second is that there is a lot of potential work out there for the exercise and injury professionals.

DOES THE USE OF PROPHYLACTIC KNEE BRACES PREVENT KNEE INJURIES IN ATHLETES? Boyce BR, Weirath MD. Evidence-Based Practice 2018;21(8):39–40 Also quoted is a previous systematic review in 2008 of RCTs and cohort studies (N=22,522) which included some of the work in the 2010 study. This had similar mixed results with four studies suggesting an increase and three a decrease.

Co-Kinetic comment So the answer to the question, Does a knee brace reduce injuries? is ‘maybe’. The trouble with a statistical review like this is that it cannot take account of the variables such as how

well the brace fits and the amount of force in a tackle causing injury. There is also the issue of poor protective equipment leading to more injury because the wearer believes themselves to be invincible. Much though we would like to eliminate them, sport is a risky business and there will be injuries.

EFFECTS OF HULA HOOPING AND MINI HOOPING ON CORE MUSCLE ACTIVATION AND HIP MOVEMENT. Chen WH, Yang WW, Liu YC et al. Proceedings of the Institution of Mechanical Engineers, Part P: Journal of Sports Engineering and Technology 2018;https://doi.org/10.1177/1754337118807821 This study analysed muscle activation in the torso and hip during hula hooping. Because injury to the waist often occurs after prolonged, repeated impact between the waist and a hula hoop, this study developed a novel waist fitness hoop that eliminates impact, called the ‘mini hoop’, and determined the effects of mini hooping on hip movement and muscle activation. A total of 16 healthy females performed hula hooping and mini hooping at a self-selected pace. Results showed that hula hooping caused larger muscle activation, with 46–49% maximum voluntary isometric contraction for the external oblique, spinal erectors and gluteus medius, whereas

gluteus maximus and adductor longus muscle activation was at 22–29% maximum voluntary isometric contraction. Mini hooping required a smaller range of hip motion in flexion, extension, abduction/adduction, higher pelvic oscillation frequency, and lower muscle activation for the external oblique, spinal erectors, gluteus medius, gluteus maximus and adductor longus (13–33% maximum voluntary isometric contraction) compared with hula hooping.

Co-Kinetic comment We thought that hula hoops were one of the many pre-1950s’ toys that were once hugely popular but had subsequently disappeared. Not so. Apparently they are back in vogue as fitness aids. In fact a quick search on Google Scholar reveals that there is a huge amount of research on them. Given the amount of muscle activation reported here they provide a pretty good workout. It is a sign of the times, however, that there is an injury risk which needed to be minimised. Co-Kinetic Journal 2019;79(January):4-11

RESEARCH INTO PRACTICE

This was a cross-sectional analytical study. Eighty-seven male patients with an ACL injury and who had had an MRI scan of the knee within the last two years participated in this study. The mechanism of injury and the pathology seen on the MRI scan was noted and categorised into different groups of injuries and associated pathologies. Statistical analyses included summaries of the data and a test for the association between the mechanism of injury and the pathology. MRI scans of ACL injuries indicated that the mechanism of a solid foot plant with rotation of the knee has a greater

ANTERIOR CRUCIATE LIGAMENT INJURIES OF THE KNEE: PATTERNS OF ASSOCIATION BETWEEN THE MECHANISM OF INJURY AND PATHOLOGY VISUALISED ON MAGNETIC RESONANCE IMAGING. Strauss GL, OPEN Janse van Rensburg DC, Grant CC et al. The South African Journal of Sports Medicine 2018;30(1):1-6 tendency to be associated with medial meniscal injuries (77%). There was also a 54% possibility for it to be associated with lateral meniscal injuries. A solid foot plant with a valgus stress on the knee showed a higher incidence of associated medial collateral ligament (MCL) injuries (41%) and femoral bone bruising (62%). These two mechanisms of injury are the most common in ACL injuries.

Co-Kinetic comment This confirms what first-contact therapists know. Mechanism of injury is the main indicator of the pathology. The most common mechanism of injury noted in this study was a solid foot plant with either rotation of the knee or valgus stress on the knee.

SUPERIOR LABRAL ANTERIOR TO POSTERIOR TEAR MANAGEMENT IN ATHLETES. Mathew CJ, Lintner DM. The Open Orthopaedics Journal 2018;12(Suppl-1, M6):303–313 The data for this one came from an evaluation of the injury history of 1,750 high level collegiate and high school baseball players eligible for the Major League Baseball draft over a 3-year period. Fifty-two pitchers were signed, including free agents. Every pitcher underwent an in-person evaluation and MRI scan of the shoulder at intake. The MRI evidence of labral lesions and rotator cuff pathology was assessed. Of the 1,750, 17% had a history of a SLAP lesion and of the 52 who were signed none reported a new injury but one did require surgery for a previous failed procedure. The paper goes on to discuss clinical examination and suggests that because MRI should only be used for the most recalcitrant cases as they show up a lot of apparent injuries even though the patients are asymptomatic. What the authors do rely on is the location of pain during the throwers action. Posterior pain with late cocking usually indicates a posterior superior labral tear or hypertrophy with or without under surface tearing of the infraspinatus-supraspinatus junction. Anterior pain during cocking is typically associated with some degree of dynamic anterior instability which can be multifactorial (cuff weakness, scapular dyskinesia, capsular laxity, labral pathology, etc.). Posterior pain during release or follow-through is most Co-Kinetic.com

OPEN

commonly indicative of an eccentric failure of the posterior rotator cuff. Anterior pain with ‘finishing’ the throw or terminal stage of follow-through can indicate mechanical impingement of the bicep or lesser tuberosity on the coracoid. Sadly people with symptomatic SLAP lesions typically present with a history identical to those with overuse, inflammatory or rotator cuff pathologies and none of the physical diagnostic tests are particularly accurate. Hence, the more accurately the history is taken the more chance there is of distinguishing the injured structure. Treatment is then discussed with a strong emphasis on non-surgical rehabilitation. The authors report that 85% of their patients do well with conservative treatment. Consideration is given to capsular tightness, restoration of lost internal rotation and addressing general scapular dyskinesia.

Co-Kinetic comment This highlights a few issues. The first is that baseball shoulders can get knackered at an early age. One reason for this may be anatomical variance, especially in the location of the attachment of the long head of biceps. Another is that MRI has a tendency to show apparent problems that are asymptomatic so much so in fact that labrum tears in baseball pitchers may be considered as adapted changes. A couple of tests for labral pathology are mentioned (Jobe’s and O’Brien’s) but a positive test of both of these could also indicate pathology other than a SLAP lesion so they are not very accurate. Finally the rate of return to play at a previous level following surgery is less than 50% so it is worth trying the physical therapy route first. 11

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ASSOCIATIONS OF RESISTANCE EXERCISE WITH CARDIOVASCULAR DISEASE MORBIDITY AND MORTALITY

American Journal of Sports Medicine

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THE INFLUENCE OF GRAFT TENSIONING SEQUENCE ON TIBIOFEMORAL ORIENTATION DURING BICRUCIATE AND POSTEROLATERAL CORNER KNEE LIGAMENT RECONSTRUCTION: A BIOMECHANICAL STUDY

578 6

British Journal of Sports Medicine

723 12

COMMUNICATION QUALITY BETWEEN THE MEDICAL TEAM AND THE HEAD COACH/MANAGER IS ASSOCIATED WITH INJURY BURDEN AND PLAYER AVAILABILITY IN ELITE FOOTBALL CLUBS

British Journal of Sports Medicine

STRENGTH TRAINING AS SUPERIOR, DOSE-DEPENDENT AND SAFE PREVENTION OF ACUTE AND OVERUSE SPORTS INJURIES: A SYSTEMATIC REVIEW, QUALITATIVE ANALYSIS AND META-ANALYSIS

Journal of Orthopaedic & Sports Physical Therapy

5 1873 55

British Journal of Sports Medicine

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

STICKS AND STONES: THE IMPACT OF LANGUAGE IN MUSCULOSKELETAL REHABILITATION

THE 10 MOST DISCUSSED PIECES OF RESEARCH IN PHYSICAL THERAPY (OCT-DEC 2018)

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British Journal of Sports Medicine

DEBUNKING THE MYTHS ABOUT TRAINING LOAD, INJURY AND PERFORMANCE: EMPIRICAL EVIDENCE, HOT TOPICS AND RECOMMENDATIONS FOR PRACTITIONERS

British Journal of Sports Medicine

66 ALTERED BRAIN MICROSTRUCTURE IN ASSOCIATION WITH REPETITIVE SUBCONCUSSIVE HEAD IMPACTS AND THE POTENTIAL PROTECTIVE EFFECT OF JUGULAR VEIN COMPRESSION: A LONGITUDINAL STUDY OF FEMALE SOCCER ATHLETES

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FASCIAL TISSUE RESEARCH IN SPORTS MEDICINE: FROM MOLECULES TO TISSUE ADAPTATION, INJURY AND DIAGNOSTICS: CONSENSUS STATEMENT

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

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PELVIC FLOOR TRAINING FOR STRESS URINARY INCONTINENCE: AN UPDATE 19-01-COKINETIC FORMATS WEB MOBILE

BY KATHRYN THOMAS BSC MPHIL

BACKGROUND Most women will have had the experience of ‘wetting their pants’ at some stage in their life, be it when coughing, sneezing or laughing hard. For some, this has only happened while they were pregnant or during a bout of bad bronchitis or pneumonia. But for others this is not something that can be passed off as simply as a phase in their life. For many women (and a few men) this is a daily occurrence that can grossly affect self-confidence and instil fear of having an ‘accident’ when out socialising or at work. Apart from coughing and sneezing other activities that increase abdominal pressure, such as lifting heavy objects or physical activities with impact, can result in the involuntary loss of urine resulting in embarrassment, often to the extent that the sufferer changes the activity or sport, or even stops all together. Although we often accept it as something women have to deal with, especially after childbirth and the menopause, it really is a condition that deserves greater focus and research from the medical field. Stress urinary incontinence (SUI) can have serious psychosocial effects, which affect the sufferer’s level of intimacy, work, studies, personal hygiene and sports, not to mention the impact that stopping exercising has on their general health, as well as bone health with ageing. SUI is a debilitating condition of the genitourinary tract afflicting as many as 1 in 4 women during their lifetime. Well-functioning pelvic floor muscles (PFM) with intact endopelvic fascia are necessary for maintaining urinary continence by providing essential support for the bladder and urethra. Weakness of the PFM is associated with SUI and, therefore, strengthening

the PFM is recommended as a first-line treatment in managing female SUI. Surgery represents the most invasive option available but, although highly effective initially, the durability of the surgical procedure seems to diminish over time. The role of PFM training (PFMT) perioperatively may enhance the outcome of the surgical procedure and seems promising; however, strong research in this area is lacking at this time. This article reviews the importance of PFMT in the conservative management of SUI, looking at exercise physiology strength training, training protocols, correct techniques and devices, and new, innovative methods of PFMT. Greater dialogue is needed within the medical field to enhance our management of these patients; but also greater public awareness to remove any stigma associated with SUI and encourage women to seek treatment without embarrassment.

REVIEW OF THE STATISTICS Epidemiologic data of SUI varies significantly in the literature (often owing to a lack of consensus regarding the definition and diagnosis of SUI in clinical trials), with prevalence rates ranging from 29% to 75% (1). A quick summary of the basics are shown in Table 1. Although moderate physical activity has been reported to decrease the risk of developing SUI, strenuous work/ exercise has been listed as a possible risk factor for the condition (2,3). The highest prevalence of SUI occurs during sports involving high-impact activities, such as gymnastics and ball games (eg. volleyball, handball, basketball). The highest percentage of SUI is seen in athletics (23.8%), followed by volleyball players (19.6%) (4). Volleyball Co-Kinetic Journal 2019;79(January):14-23

PHYSICAL THERAPY

players have a 116% chance of getting SUI compared to women who play other types of sports (4). Regarding the prevalence of SUI in different sports, the rates vary between 0% in golf players and over 80% in artistic gymnastics and trampoline athletes (Fig. 1) (2). Two opposing hypotheses have been suggested regarding the effect of exercise on the PFMs. One proposes that the increased impact of abdominal pressure and ground-reaction forces may lead to simultaneous or precontraction of the PFM, resulting in a training effect of the muscles. The other suggests that strenuous physical activity without simultaneous cocontraction of the PFM may overload, stretch and weaken the pelvic floor (2). During high-impact physical activity the intra-abdominal pressure can rise above intraurethral pressure and can overwhelm even the normal continence mechanism, causing urine leakage (3). Even nulliparous women (those who have never given birth) engaged in high-impact exercises can experience SUI. High-impact physical activity may also damage the endopelvic fascia and be responsible for SUI (2). Studies have shown that in elite, highly-trained athletes involved in high-impact sports, SUI is common. For women with an average age of 19 years, the prevalence of urinary incontinence (UI) in elite females (national representation) was 29.6% versus the age-matched non-athletic control of 13.4%. Within this UI, 19.6% was SUI (2). So the prevalence of SUI is three times higher in elite athletes than age-matched controls (2). In addition to this a history of constipation, family history of urinary incontinence and history of urinary tract infection are added risk factors for an athlete developing SUI (2). More than onethird of the elite athletes consider SUI to have implications on sports performance; however, less than 15% report using strategies to hide the leakage, and significantly fewer athletes than controls had told a physician about the condition (2). Not telling healthcare professionals about SUI is a common occurrence. Interestingly, in one of the latest clinical trials, incontinent nulliparous Co-Kinetic.com

STUDIES HAVE SHOWN THAT IN ELITE, HIGHLY TRAINED ATHLETES INVOLVED IN HIGH-IMPACT SPORTS, STRESS URINARY INCONTINENCE (SUI) IS COMMON female professional athletes had greater PFM strength than continent athletes. This suggests that UI in this population of professional athletes was not due to PFM weakness. There was, however, a positive association between abdominal and PFM strengths in incontinent athletes, which may result from frequent co-contraction between these muscle groups (5). This highlights the fact that there may be more complexity to the issue than simply PFM weakness, and greater understanding of the interactions of the PFMs with the core and abdominal muscles, as well as the other pelvic girdle muscles is required. Irrespective of population group, it is clear that SUI is a prevalent condition affecting a substantial segment of our society as a whole. Whereas ageing, obesity and smoking are consistently shown to be risk factors for symptomatic SUI (1), the role of pregnancy and mode of delivery remains debatable. Although several studies report a moderate-to-significant increase in relative risk of SUI among parous versus nulliparous women, other studies show little-to-no increase in risk (1). Additional risk factors can include neuromuscular disorders, family history, hysterectomy and chronic constipation (1). The risk factors are not completely understood, and further research into the pathophysiological mechanisms of SUI is needed.

Trampolining (17)

82.4

Weightlifting (1) 0.0 Acrobatic/rhythmic gymnastics (9)

22.2

Judo/karate (24)

25.0

Roller hockey (10)

10.0

Tennis*/paddle (21)

19.0

Football/futsal (37)

16.2

Rugby (41)

12.2

Handball (30)

23.3

Volleyball (24)

4.2

Basketball (58)

24.1

Water polo (31)

16.1

Swimming (9) 0.0 Synchonised swimming (11)

18.2

Figure roller skating (5) 0.0 Rowing/canoeing (8)

12.5

Athletics (22)

18.2

Horse jumping (14)

7.1 0

20 30 40 50 60 70 80 90

*Tennis/beach tennis/table tennis.

Figure 1: Prevalence (%) of stress urinary incontinence within each sport (2). Reproduced with permission from The British Journal of Sports Medicine

TABLE 1: PREVALENCE OF STRESS URINARY INCONTINENCE Adapted from Lasak A et al. (1) Specific group

Percentage (%) Odds ratio (OR)

Gender: Women 20.8 Men 1.5

THE PATHOPHYSIOLOGY AND REVIEW OF GRAY’S ANATOMY

Age (years): 20–29 3.5 >80 38

No, not a flashback to McDreamy in Grey’s Anatomy, more of a flashback to your undergraduate anatomy class. Reviewing the exact anatomy, physiology and pathogenesis of the pelvic floor will aid in better visualisation and instruction, ensuring correct contraction of the musculature. SUI is believed to arise from two major pathogenic mechanisms that can exist alone or in combination:

Bodyweight: Obese 2.3 Overweight 1.4 Physical activity: High-impact exercise 24.6 Low impact/no exercise 14.3 Obstetric history: Singleton (vaginal delivery) 40.3 Caesarian section 28.8

1. Urethral or bladder neck hypermobility The loss of anatomic support (muscular and collagen-dependent tissues) to the urethra and bladder neck, termed ‘urethral hypermobility’, results in an exaggerated change in the urethrovesical angle leading to involuntary leakage (1). That exaggerated change in urethrovesical angle is defined as greater than 30° from baseline. During strenuous activity, as a result of weakness in the surrounding musculature and connective tissue (suburethral fascia and arcus tendinous) (1), the urethra and bladder neck fail to close against the anterior vaginal wall resulting in leakage. Urethral hypermobility can be assessed clinically using the standard Q-tip test or by using the vaginal swab test (6*). These are described in further detail in Link 1. 2. Intrinsic sphincter deficiency SUI results from the loss of urethral tone via damage to the bladder sphincter mechanism, otherwise known as intrinsic sphincter deficiency (ISD). Urethral hypermobility and ISD are probably not unique clinical entities and can coexist in many women – it is thought that ISD is present to some degree in all women with SUI (1). The functional anatomy of the pelvic floor is formed by three layers: 1. A superficial perineal layer consisting of four muscles: bulbocavernosus, ischiocavernosus, superficial transverse perineal muscle, and external anal sphincter. 2. The deep urogenital diaphragm layer consists of the external urethral sphincter and the deep transverse perineal muscles. These two layers, the deep and superficial perineal layers are innervated by the pudendal nerve. 3. The third layer, called the pelvic

diaphragm comprises large muscle groups innervated by the sacral nerve roots arising from S3–S5 or the levator ani nerve that originates from S3–S5 nerve roots. The pelvic diaphragm is composed of the ischiococcygeus and the levator ani muscles. The levator ani itself consists of three muscle groups: the puborectalis, the pubococcygeus and the iliococcygeus (1). The puborectalis and pubococcygeus form the U-shaped sling that runs from the posterior pubic bone bilaterally and passes behind the rectum, whereas the iliococcygeus makes a shelf for the pelvic organs to ‘sit’ on. These muscles form the structural support of the bladder and urethra. The PFMs, along with the suburethral fascia and the arcus tendinous provide the firm ‘embrace’ to withstand the increase in intra-abdominal pressure. Normal physiological action of the PFM is a necessary prerequisite to maintain urethral closure ensuring continence. Damage to the PFM, fascial attachments or muscle denervation result in pelvic floor dysfunction which can lead to incontinence and even pelvic organ prolapse (1). Voluntary micturition involves complex coordination of both autonomic (sympathetic and parasympathetic) and somatic nerve function. Pre- and post-ganglionic excitation, activation of inhibitory and excitatory receptors, cholinergic transmission, smooth muscle and striated muscle contraction and relaxation in the correct sequence – emptying your bladder or preventing that from happening is a very complex conscious and unconscious meticulous task. Essentially, therefore, total urethral closure depends on two mechanisms: (1) an intrinsic urinary sphincter closure mechanism; and (2) an extrinsic urethral- and vaginal-wall support

INCONTINENCE IS A MORE COMPLEX ISSUE THAN JUST PELVIC FLOOR MUSCLE (PFM) WEAKNESS AND GREATER UNDERSTANDING OF THE INTERACTION OF THE PFMS WITH THE CORE AND ABDOMINAL MUSCLES IS NEEDED 16

mechanism. Aetiological factors affecting one or both of these mechanisms can result in SUI as follows (7*): 1. Intrinsic (urethral) closure mechanism n a trophy of the tunica mucosa and the tunica spongiosa (oestrogen deficiency, eg. postmenopausal) n d ysfunctional tunica muscularis (eg. due to surgical interventions, such as transurethral prostate resection or radical prostatectomy or trauma) 2. Extrinsic support mechanism n weak PFMs and ligaments n pregnancy n vaginal delivery n instrumental delivery (vacuum or forceps) n episiotomy nm aternal age at first delivery ≤30 years n parity, increasing after three or more deliveries n being overweight [25≤body mass index<30] n consuming carbonated drinks n age. The prognosis for recovery in SUI depends on the nature of the underlying disorder and/or disease process. It has been found that trials in which women trained longer (6 months vs 6–8 weeks) and those in which women were younger (mean age 50 years old) reported higher cure rates (8). And women diagnosed with SUI by urodynamic testing were 17 times more likely to report a cure, compared with the 2–2.5 times likelihood of cure reported in women diagnosed with urgency urinary incontinence (8). Prognostic factors for recovery, spontaneous or following physical therapy, have been identified through prospective cohort studies (7*): 1. Reduced chance of recovery (7*) n increasing severity of the SUI n previous conservative treatment for SUI with an unfavourable outcome n SUI during pregnancy and during the first 3 months after delivery Co-Kinetic Journal 2019;79(January):14-23

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n number of pregnancies n prolonged second stage of labour n severe prolapse [Pelvic Organ Prolapse Quantification system (POP-Q) stage 3 or 4] n being overweight n presence of other diseases or disorders, such as chronic obstructive pulmonary disease and cardiovascular diseases n psychological strain n patient-perceived low physical condition 2. Increased chance of recovery (7*) n higher educational level n higher level of motivation for and adherence to a pelvic floor training programme.

SPECIFIC TESTS AND MEASURES Pelvic floor muscle testing, via internal or external techniques should focus on giving information regarding: n strength, endurance, coordination n symmetry and bulk n awareness n presence of pain or tension. Digital palpation of the vagina PFM is the standard when assessing the ability to contract the PFM by most physical therapists. The quality of contraction and upward movement can be assessed digitally (9). The examiners index and middle fingers are inserted vertically (palm up) to the second interphalangeal joint or approximately 4–6cm. A modified Oxford grading system is then used, as shown in Table 2 (10). The ‘PERFECT’ scheme was developed to simplify and clarify PFM assessment. The PERFECT scheme has demonstrated reliability and validity as an assessment tool through use in many clinical trials. Furthermore it is proposed to provide guidelines for the planning of specific, individualised patient-specific exercise programmes which satisfy the principles of muscle training (10,11). PERFECT, mnemonic, described by Laycock et al. (10,11), is as follows: P – POWER, (or pressure, judged manually by examiner, or the use of a manometric perineometer); may use the modified Oxford grading scale E – ENDURANCE, the time (in seconds) Co-Kinetic.com

that a maximum contraction can be sustained R – REPETITION, the number of repetitions of a maximum voluntary contraction F – FAST CONTRACTIONS, the number of fast (1 second) maximum contractions ECT – EVERY CONTRACTION TIMED, reminds the therapist to continually overload the muscle activity for strengthening. Additional assessment tools include outcome measures that may comprise a variety of questionnaires or symptom and condition-specific quality-of-life measures, subjective improvement, pad test, number of leakage episodes and number of voids per 24 hours (8). All of these tools can be useful in monitoring progress and improvement in condition through the training process, keeping the patient motivated and adjusting the exercises over time. Two questionnaires that may be of value to use in your clinic are: 1. The PRAFAB (Protection, Amount, Frequency, Adjustment, Body Image) questionnaire (12*,13) This questionnaire measures UI severity in terms of use of absorptive products (protection), volume (amount), and occurrences (frequency, leakage scale), impact in terms of patient adjustment to UI in everyday life (adjustment) and consequences of patients self-image (body image, perceived impact scale) (7*,12*,13). It can be used to record changes in individual health status. A downloadable form of the PRAFAB questionnaire is available at Link 2 and full details are available in the open access paper by Hendriks et al. at Link 3. 2. The ICIQ-UI-SF (Incontinence Questionnaire-Urinary IncontinenceShort Form) (Link 4) This provides a highly accurate, noninvasive exploration of the condition giving impairment rating of UI (14). This short form questionnaire is quick and simple to use in daily practice. Other outcome measures can include: 1. Pad tests Quantify UI by weighing incontinence pads used after a specific time period. 2. Patient-specific complaints

TABLE 2: MODIFIED OXFORD GRADING SYSTEM FOR THE ASSESSMENT OF PELVIC FLOOR MUSCLE STRENGTH Grade Muscle contraction 0 Nil

Strength Nil

1 Flicker

Flicker

2 Increase in tension, no discernible lift

Weak

3 Lift of muscle belly and elevation of post Good vaginal wall/in-drawing of perineum 4 Good contraction/elevation of posterior Moderate vaginal wall against resistance 5 Strong resistance to elevation of post vaginal wall/finger drawn into vagina

Strong

The patient-specific complaints instrument enables the patient to indicate the main activities in which they feel restricted and helps the physical therapist determine the patients subjective functional status before and after treatment, making the instrument suitable for an effect evaluation (7*). Ultrasonography is a low-cost, noninvasive tool that can identify urethral hypermobility during episodes of increased intra-abdominal pressure in women with SUI (1). With the availability of 3D technology, these tests now have the capacity to measure muscle thickness and volume, and could contribute to monitoring progress through PFMT and changes over time (15*).

THE TRAINING ROUTINE PFMT was first reported in the literature by Arnold Kegel in 1948 as a conservative treatment for female UI. To date, there are multiple studies giving ample evidence on the efficacy of PFMT in SUI. It has been studied in multiple randomised controlled trials (RCTs) and is recognised as level 1 evidence and grade A recommendation in the management of SUI. These recommendations are referenced in multiple reviews or consensus statements regarding the management of SUI (1,7*,8,16*,17*,18*). 17

TWO QUICK AND EASY-TO-USE SUI ASSESSMENT METHODS INCLUDE THE PRAFAB AND THE ICIQ-UI-SF QUESTIONNAIRES Although there is consensus about the use and benefit of PFMT, the protocols used in over 21 trials with more than 1,200 women vary in the number of maximal voluntary contractions, duration of holding, resting time, number of sets per day, frequency of exercises per week and maintenance programmes. Control groups also varied with some having no treatment, others only verbal command, use of anti-incontinence device, pad use and diet and lifestyle changes. Remembering the primary functions of the pelvic floor may aid in the rehab focus. The functions performed by the PFMs can be remembered by the 5S’s: 1. support 2. sphincteric 3. sexual 4. stability 5. sump pump/lymphatic return. But, don’t forget its role in posture, balance and breathing! The PFMs are made up of both type 1 (slow-twitch) and type 2 (fasttwitch) fibres. The majority are type 1 (about 70%), which provide sustained support and are fatigue resistant. The remaining type 2 fibres provide the quick compressive forces necessary to oppose leakage during increased abdominal pressure. Like any other skeletal striated muscle, the PFMs can be strengthened through exercise. Increases in motor unit recruitment and muscle hypertrophy, expected changes to muscle morphology and physiology induced by exercise, are seen with PFMT (1). As with any individual, and any muscle group, response to training is varied and determined by genetics and the specific type of training. Although improvements could result from any type of physical activity, proper strength training should follow the four basic principles of specificity, 18

overload, progression and maintenance, to achieve the maximal desired effect. Voluntary contraction of the PFM are specific, targeted exercises. In the initial stages of training, specific PFM strengthening exercises are recommended to address the weak PFMs. Remember, ‘if you only do Kegels at the traffic light, you will only be continent at the traffic light.’ As with all rehabilitation programmes, it is crucial to progress from this to generalised exercises, such as Pilates or regular physical activities, and functional daily activities while maintaining PFM cocontraction. The PFMs co-contract with abdominal and hip muscles during normal activities. Likewise the PFMs form part of the core muscles – abdominals, back muscles and diaphragm – and have been shown to strengthen during trunk and back rehabilitation (1). In order to overload a muscle one needs to execute more work than usual, generally muscle strength training is done with heavier weights or resistance and fewer repetitions. Overloading for PFM can be done with vaginal cones or vaginal weights. The weights are placed above the levator ani muscle and the patient is asked to hold the weight while standing or walking. The time and/or weight can be increased to progress the exercise. Preliminary studies showed improvements between 30–63%; however, high dropout rates were reported (19). Should you wish to learn more about the use of weighted vaginal cones refer to this Cochrane Review (Link 5) (20*). Overloading with weights is not easy to apply during PFMT as vaginal weights may not be practical, acceptable, or even appropriate for many patients. Therefore, overloading can be achieved without weights by: n holding contractions for a longer duration n shorter rest periods between contractions n increased number of repetitions n increased frequency of exercise routine n longer duration of exercises n adding a few fast contractions during a prolonged maximum contraction

n u sing different positions: lying, sitting, standing, walking, squatting. Because the weight-training approach for PFM has limitations, voluntary contractions of PFM need to be done at the maximum ability to ensure maximal loading. Greater strength improvements are generally seen in previously untrained than in trained individuals (1). It is suggested that more intense strengthening exercises with progressive overloading and weekly visits for medical supervision provides better results than a home exercise programme alone (1). Medical supervision of PFMT reinforces proper technique of exercise with the use of different methods, that is, biofeedback and neuromuscular electrical stimulation, and ensuring close monitoring of the patient’s progress. One of the ways to promote the progression of the exercises is to create different levels of difficulty (without and against gravity), by changing positions like sitting, standing, side lying. A standing position increases pressure on the bladder and PFM, and may decrease the effectiveness of PFM contraction, affecting the reduction of muscle strength sometimes seen in standing postures (16*). This reinforces the need to progress exercises into functional positions/postures to ensure continence during daily activities. The PFM reflex contraction in response to increased intra-abdominal pressure may be inherent to the mechanism of urinary continence, but coordination of the different patterns may be acquired as a learned behaviour and is currently considered complementary to PFMT, a determining factor in any PFM re-education protocol (16*). Standard pelvic floor physiotherapy concentrates on voluntary contractions even though the situations provoking SUI (for example, sneezing, coughing, running) require involuntary fast reflexive PFM contractions. Training procedures for involuntary reflexive muscle contractions are widely implemented in rehabilitation and sports but not yet in pelvic floor rehabilitation (21*). An exciting study is underway with a progressive rehabilitation programme Co-Kinetic Journal 2019;79(January):14-23

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involving reflexive training for SUI women, with results due out towards the end of 2018 into 2019 (21*). The study protocol with the thorough progressive training schedule that may be useful to refer to can be found at Link 6 (21*). As the PFMs are composed mainly of type 1 fibres one must not forget the importance of including endurance training to the routine. Fatigue during exercise or simply through the duration of the day and the ‘weight’ of gravity on the PFMs may lead to increase in urine leakage in the latter parts of the day as the muscles fatigue. Studies have confirmed that PFM fatigue can influence the development and/ or worsening of SUI (22). Endurance training requires lighter weights but a greater number of repetitions and over a longer period of time (1,23).

SO, WITH ALL OF THIS IN MIND, WHAT SHOULD BE DONE? Step 1: Correct Contraction Technique Ensure a good contraction and awareness of the correct way in which to contract the PFM before starting any actual training. Technique is crucial and may require digital palpation by the patient, biofeedback, visualisation using anatomy diagrams to understand the placement of the muscles and good verbal command. Verbal cues can be any of the below (and you may need to try different ones on different individuals before achieving the correct contraction): n close the openings, lift up and in n imagine pulling a tampon up and in n contract as if trying to hold back gas n ‘wink’ your anus n move your clitoris or penis n pull your underwear in n bring your sit bones together n lift your perineum/lift your testicles up off the chair (if sitting). The correct co-contraction includes the pelvic floor lifting, while the deep abdominals draw inwards and there is no change in breathing. Incorrect contraction includes pulling the belly button in towards the spine, and holding your breath which results in a Co-Kinetic.com

bearing down of the PFMs. Watch for substitutions during the contraction where patients may hold their breath, contract their thighs and glutes, use toes and upper chest, bulging abdomen, bear down through the pelvis. Motor learning during this early associative stage may vary across women with and without SUI and the severity of the SUI. Research has shown that by the fifth session of training the proportion of women who could correctly contract their PFM for more than 9 out of 10 repetitions had increased significantly more in the non-SUI group of women versus the SUI group of women. The proportion of women achieving the associative stage of correct PFM contraction did not differ after the sixth session (24). In one of the latest reviews (16*), PFMT programmes (strengthening exercises) including adjuvant therapies such as biofeedback, digital palpation and vaginal cones report high rates of cure (80, 50 and 58%, respectively) (16*). A systematic review by Neumann et al. (25*), demonstrated that strengthening exercises PFM (SEPFM) combined with adjuvant therapies were effective in the treatment of SUI, reaching a cure rate of 73%. These PFM strengthening techniques allow identification, awareness of correct muscle contraction, and inhibition of synergistic muscles, enhancing results (16*).

Step 2: Number of Contractions Most of the PFMT studies have shown consistency in the repetition frequency parameter (ten initial repetitions), some starting with 15 repetitions per set. This parameter corroborates the parameters of strength training to obtain muscular hypertrophy advocated by the American College of Sports Medicine (26*), which recommends 8 to 12 contractions per series. The current evidence for the principles of strength training recommends that the frequency of three times weekly is sufficient for muscle hypertrophy (26*). However, clinical trials showing significant cure rates using PFMT have all advocated between 1 and 3 times per day, with 6–7 days a week as a frequency parameter (16*).

Step 3: Duration of Training Programme PFMs are skeletal muscles and, therefore, the recommendations of strength training should not differ from other skeletal muscles; accordingly the recommendations of the American College of Sports Medicine are that a strength training programme should last at least 15–20 weeks (26*). In the first 8 weeks of training, the changes are essentially neural (increased number and frequency of motor unit activation), followed by muscle hypertrophy due to increased volume and number of myofibrils, essential for morphological or structural adaptations. Training programmes of 8 to 12 weeks seem to reduce the amount of urine leakage, and/or to increase PFM strength, inferring that short-term training is equally effective in the treatment of SUI. However, caution should be considered when viewing this as the gain of muscular strength in this period was sustained by an increase in number and synchronism of the motor units, without any mention of patient follow-up after training in some of the studies (15*,16*). As with most strength training programmes, deconditioning starts within approximately 2 weeks of cessation of training. This too may be the case with PFM and long-term maintenance programmes should be considered. A recent review demonstrated that increasing the strength of PFM in this short period of time (8–12 weeks) may not be related to a significant reduction in the amount of urine loss. This suggests that the increase in PFM strength and urethral resistance does not seem to guarantee the mechanism of urinary continence (16*). Coordination between early contraction of PFM and increased intra-abdominal pressure may be the most relevant factor in reducing urine leakage compared to the strength gain alone, which may justify the positive results of shorter training programmes (16*).

Step 4: Supervised, Home Programme or Group Sessions? In contrast to self-directed regimens, a clinician-guided PFMT programme with regular supervision is recommended to ensure effectiveness (27*). A recent 19

study reported that patients with more healthcare professional contact and patients who trained in group sessions were more likely to report a cure and improvement; overall, they found that use of direct PFMT with weekly supervision was optimal (28). However in a study by Felicissimo et al. (29), an intensive supervised group (two weekly group sessions of 50 min each, aided by verbal instructions given by a physiotherapist as well as daily home protocol printed with figures containing the positions as well as the number of contractions and the sustaining times) versus an unsupervised group (all exercises performed solely at home with just a handout of printed images and repetition numbers) showed that there were no differences between the two groups regarding improvement in PFM strength after 8 weeks and that compliance in weekly exercise sessions was equal (29). The authors concluded that supervised PFMT and unsupervised PFMT appear to be equally effective for improving female SUI (29). So, it seems from the reviews and multiple trials that both options, supervised or unsupervised, home alone and/or group training sessions can all be beneficial and success may vary depending on the individual. It is, therefore, down to your judgement to consider the patient and their needs, personality, motivation as to whether they should be more regularly supervised and encouraged or whether their compliance will be adequate performing the training mostly unsupervised. Three of 10 women treated with PFMT achieve continence. Some women prefer supervised training, whereas others prefer to manage the training on their own (30*). Women can perform PFMT without face-to-face contact. SUI treatment with a focus on PFMT provided via the internet is associated with marked improvements in symptoms and quality of life in both the short and the long term (30*). It also seems to be a cost-effective alternative. Most women with no or mild pelvic floor disorders can correctly contract their PFM after a simple verbal cue, suggesting that population-based prevention interventions or awareness campaigns can be initiated without clinical confirmation of correct PFM 20

technique (31*). PFM contraction was done correctly on first attempt in 85.5%, 83.4%, 68.6% and 85.8% of women with pelvic organ prolapse (POP), SUI, both POP and SUI, and neither POP nor SUI, respectively (31*). An RCT evaluated the efficacy of a mobile app treatment for SUI in 123 women. Compared with the control group, after 3 months, women in the app group (Tät® application) had significant and clinically relevant improvements in symptoms and quality of life (30*). Two years after this app-based treatment regime for SUI, improvements in symptoms and quality of life were still highly significant. This type of training using a ‘social media’ type technology could offer promising long-term treatment options and support for patients.

Step 5: Maintenance Little literature is available about patient adherence after termination of a study. In a Norwegian review two studies with 5-year follow-up were found having an adherence percentage of 10–70% (32). Follow-up investigations after 10 and 15 years found that 15–28% of women still trained regularly and 47–50% had undergone incontinence surgery (3). A systematic review concluded that the long-term success (defined as 1 year or more after treatment) of PFMT was between 41 and 85%, with a surgery rate of 4.9–58% (30*). Maintenance training must involve an exercise programme to prevent a decline in muscle strength over time. Strength can be maintained if the frequency of training is reduced but intensity of exercise is maintained. There is a paucity of long-term data on PFM exercises but no reduction of strength of PFM was observed when exercises were performed at least once a week as a maintenance option (33).

Step 6: The Knack Manoeuvre The Knack manoeuvre essentially is a voluntary contraction performed in response to a specific situation. Teach your patients a voluntary contraction of the PFMs with appropriate timing, for example, just before a cough or sneeze. It is a useful strategy in patients with SUI (34*).

Step 7: Adjuncts to PFMT Behavioural modification includes a combination of a voiding diary, fluid or dietary changes, and bladder training through timed voiding. The use of a volume chart or voiding diary may reveal excessive fluid intake or triggers such as caffeinated beverages or alcohol. Timed voiding consists of setting intervals for bladder emptying (such as hourly) to reduce leakage. The intervals are later increased gradually as bladder capacity improves (1). Electrical stimulation delivered via a vaginal probe can be used in treatment. It is a form of neuromodulation that has been shown to be useful in the treatment of SUI. The postulated mechanism of action is contraction of the PFMs via an effect on the muscle fibres and stimulation of the pudendal nerve. Cortical changes in addition to spinal involvement have also been proposed. Electrical activation of pelvic muscles allows for increased sensory awareness of muscle activity and induces a training effect (1). Other forms of electrical stimulation that are used in the treatment of pelvic floor disorders include sacral root neuromodulation (via an implantable device) and posterior tibial nerve stimulation. However, these modalities are used primarily in the treatment of urinary frequency or urgency urinary incontinence (1).

Step 8: Pelvic Floor, Core and Beyond PFMs play a dual role in providing trunk stability besides their function in bladder and bowel physiology (1) as the PFMs are a part of the core muscles. The major core muscles consist of the PFMs, transversus abdominis, multifidus, internal and external obliques, rectus abdominis, erector spinae (sacrospinalis), and the diaphragm. Minor core muscles include the latissimus dorsi, gluteus maximus, and trapezius. Correct timing and coactivation of core muscles can be lost in patients with pelvic floor dysfunction. Retraining of the correct patterns of core muscle recruitment should be included in all PFMT programmes (1). The pelvic floor with its muscles form part of a kinetic chain for whole Co-Kinetic Journal 2019;79(January):14-23

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body mechanics. Dysfunction of the pelvic floor unit may affect the other parts of the musculoskeletal system and vice versa. Weakness of abdominal muscles is very often observed in patients with low back pain (LBP) (1). Interestingly, pelvic floor dysfunction has been associated with development of LBP (1). In addition, a recent RCT focusing on PFM in patients with LBP and SUI concluded that increasing the PFM strength and endurance of the transversus abdominis muscle improve both SUI and LBP (1). Electromyographic activity of PFMs has been observed prior to initiation of an extremity movement, not unlike the core muscles. Properly timed contractions of PFMs and other core muscles are necessary for normal function (1). Women with UI demonstrate not only altered core muscle activation patterns but also difficulty in performing voluntary contraction of PFM and a tendency for substitution of other muscles. Therefore, timing may be an integral part of retraining. With jumping and impact activities such as trampolining, EMG studies have shown, in healthy women, the PFMs pre-activate or produce a reflex contraction at 33–43ms prior to foot strike, almost pre-empting the increase in intraabdominal pressure to control urethral closure (35). Running also appears to trigger pre-activation before and reflex-activation after heel-strike and should therefore not only be regarded with caution due to its SUI related effects. Higher running speeds, over 11km/h, showed higher activity of the PFMs than lower running speeds (36). Running training stimuli may serve as a beneficial complement to a PFMT rationale, leading to reflex activity of the PFMs, when used in the sense of power training methodology (37). The retraining of correct patterns of core muscle recruitment with diaphragmatic breathing, deep abdominal muscles, and PFMT exercises must be considered when treating SUI. Rehabilitation of pelvic floor dysfunction is usually focused only on the PFM, whereas training of other parts of the core muscles and its integration with the entire body is often neglected. Co-Kinetic.com

INNOVATIVE TREATMENT IDEAS ‘Women-Up’ The WOMEN-UP consortium, collaborates on an innovative intervention to expose women with SUI to the benefits of pelvic floor physiotherapy, optimise adherence and reduce costs. This novel intervention involves a wireless vaginal biofeedback device and an abdominal belt, both with surface electromyography sensors, connected via Bluetooth to a smartphone with access to ‘serious games’. Both vaginal and abdominal biofeedback are obtained, enabling patients to improve their training technique. Exercise performance and results can be monitored by patients and their therapists through an online web portal with two-way messaging functionality. In serious gaming, interactive training games are used for a primary purposes other than pure entertainment, that is to improve knowledge, skill or attitude with the added value of fun and competition (38*). Serious games have been successfully used in rehabilitation programmes and for promoting health behaviour. In the WOMENUP project, serious games will be employed to make PFMT more appealing and thereby possibly improve adherence. Contracting and relaxing the pelvic floor operates a game on a smartphone via a Bluetooth biofeedback signal. Medical professionals indicated that 97% of them who did not use biofeedback would change their practice if research evidence supported its use and where 89% of respondents indicated that they had no experience of serious gaming, 92% said they would consider it could be useful. More scientific evidence is considered a prerequisite to incorporate such innovations into clinical practice (38*).

Hypopressive Techniques (HT) To be accurate, HT combines postural and breathing exercises performed in a supervised, rhythmic and progressive sequence (19). The basic fundamentals for all HT exercises involve: (1) spine elongation with neutral pelvis; (2) ankle dorsiflexion; (3) knee flexion; (4) scapular girdle muscle activation; (5) three normal breathing cycles which involve latero-costal breathing and slow deep exhalation; (6) breath-holding following ribcage expansion and lift, which involves the activation of the inspiratory muscles such as serratus anterior, sternocleidomastoid and scalene (not exclusively intercostal muscle). This breathing technique leads to a noticeable abdominal draw-in of the entire abdominal wall and expansion of the ribcage. An observational study using EMG showed activation of the transversus abdominus and PFM when performing HT. Studies have shown that

PFMS ARE SKELETAL MUSCLES AND SHOULD BE RETRAINED LIKE ANY OTHER MUSCLE USING FOUR BASIC PRINCIPLES: SPECIFICITY, OVERLOAD, PROGRESSION AND MAINTENANCE 21

hypopressive exercises may be beneficial to women using PFMT following POP. Hypopressive exercises added to PFMT was no better than PFMT alone; however, both treatment options showed significant increases in maximum voluntary contraction of the PFM (39). Similarly, PFMT and hypopressive exercises produced similar significant improvements in cross sectional area of the levator ani muscle in women with POP (40*). In a recent review of physical therapy treatment for SUI, hypopressive exercises were shown to be effective in improving PFM strength (18*). However, there is not yet strong evidence of RTC using hypopressive exercises alone for women with pelvic floor dysfunction or SUI.

Electroacupuncture Among women with SUI, treatment with electroacupuncture involving the lumbosacral region, compared with sham electroacupuncture, resulted in less urine leakage after 18 sessions spanning 6 weeks. In the electroacupuncture group, 64.6% of participants had a decrease of at least 50% in the amount of urine leakage after treatment, a clinically meaningful benefit (41*). The mechanisms of electroacupuncture for benefiting SUI remains unclear. Pelvic floor electric stimulation could increase the

maximum urethral closure pressure. Electroacupuncture involving the lumbosacral region could cause muscle contraction and simulate PFM training. Electroacupuncture may stimulate S3 via BL33 and the pudendal nerve via BL35 at the lumbosacral region. Thus, electroacupuncture may facilitate the reinnervation and strengthening of PFMs, improving symptoms of SUI (41*). To learn more about the technique and placement of acupuncture needles, frequency and more, follow Link 7 to the paper. Further research is needed to understand long-term efficacy and the mechanism of action of this intervention (41*).

produce effective and well-tolerated contractions of skeletal muscle (42*). Further RCT are needed to demonstrate efficacy in SUI patients.

CONCLUSION

A percutaneously implantable and wireless microstimulator (NuStim) to exercise the PFMs for the treatment of SUI has been developed. It produces a wide range of charge-regulated electrical stimulation pulses and trains of pulses using a simple electronic circuit that receives power and timing information from an externally generated radio-frequency magnetic field (42*). The complete system has been validated in vitro and in vivo in preclinical studies demonstrating that the NuStim can be successfully implanted into an effective, lowthreshold location, and the implant can be operated chronically to

It is trusted that this article has further enhanced or reviewed your understanding of the contribution of PFM integrity to effectively treat pelvic floor disorders. Despite the fact that 25% of all women will experience SUI during their lifetime, available conservative and surgical managements for this debilitating condition are still not completely effective at this time. Thorough knowledge of the functional anatomy of the pelvic floor, and the principles of exercise physiology as it applies to the PFMs, will hopefully help guide your treatment protocol. More research is required in this field to better understand other treatment options, including yoga, for example. Remember the PFMs should be treated like any other skeletal muscle progressing rehabilitation from specific, selective exercises to functional or sports-specific exercises where possible. Considering the psychological component of SUI, let’s help empower women to take back control and restore their dignity, so they can live a happier and healthier active life.

validity and internal consistency of the PRAFAB questionnaire in women with stress urinary incontinence. BMC Urology 2008;8:1 https://doi.org/10.1186/1471-2490-8-1 Link 4: ICIQ-UI-SF (Incontinence Questionnaire-Urinary IncontinenceShort Form), available from the British Association of Urology Surgeons website https://spxj.nl/2DMBnmY Link 5: Herbison GP, Dean N. Weighted vaginal cones for urinary incontinence. The Cochrane Database of Systematic Reviews 2013;8;(7):CD002114 https://spxj.nl/2qVgjlw Link 6: Stress Urinary Incontinence Physiotherapy – Therapy Plan

(https://spxj.nl/2QSQHkL) is Additional File 1 of Luginbuehl H, Lehmann C, Baeyens JP et al. Involuntary reflexive pelvic floor muscle training in addition to standard training versus standard training alone for women with stress urinary incontinence: study protocol for a randomized controlled trial. Trials 2015;16:524 https://spxj.nl/2FxmbeZ Link 7: Liu Z, Liu Y, Xu H et al. Effect of electroacupuncture on urinary leakage among women with stress urinary incontinence: a randomized clinical trial. JAMA 2017;27;317(24):2493–2501 https://spxj.nl/2KfUjef.

Neurostimulation

LINKS Link 1: Further details of methods for the clinical assessment of urethral hypermobility are available in Meyer I, Szychowski JM, Illston JD et al. Vaginal swab test compared with the urethral Q-tip Test for urethral mobility measurement: a randomized controlled trial. Obstetrics and Gynecology 2016;127(2):348–352 https://spxj.nl/2DwZhlu Link 2: Downloadable version of PRAFAB (Protection, Amount, Frequency, Adjustment, Body Image) questionnaire https://spxj.nl/2zg68Na Link 3: For full details of the PRAFAB questionnaire, see Hendriks E, Bernards A, Staal JB et al. Factorial

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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/2BiLNbl

RELATED CONTENT omen’s Health through Active Living: Content W Marketing Campaign for Therapists https://spxj.nl/2yhgHye

DISCUSSIONS onservative management techniques of this C debilitating condition are still not completely effective at this time. Having read this article are there things you might change or add to your training protocol when next treating a patient with stress urinary incontinence? What tests and outcome measures would you use to assess and then monitor progress during pelvic floor muscle (PFM) retraining? Is there scope in your practice to use modern technology, such as ‘serious gaming’, as a tool to treat PFM, or to recommend a smartphone app for patients to use long term? 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

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Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: The prevalence of stress urinary incontinence is 3 times higher in elite athletes than in controls https://spxj.nl/2DStStK Tweet this: The prognosis for recovery from incontinence depends on the nature of the underlying disorder https://spxj.nl/2DStStK Tweet this: Like other skeletal striated muscles, the pelvic floor muscles can be strengthened through exercise https://spxj.nl/2DStStK Tweet this: Retraining of core muscle recruitment should be included in pelvic floor muscle training programmes https://spxj.nl/2DStStK

KEY POINTS n 1 in 4 women will suffer from SUI at some stage in their lifetime, including young elite athletes and well-trained individuals. nW omen involved in ball sports involving jumping and high impacts have a 116% chance of getting SUI. n Two hypotheses for and against physical activity and SUI exist – firstly increased impact of raised abdominal pressure and groundreaction forces during exercise may lead to simultaneous or reflex precontraction of the pelvic floor muscles (PFMs), resulting in a training effect of the muscles. The second hypothesis suggests that strenuous physical activity without simultaneous co-contraction of the PFM may overload, stretch and weaken the pelvic floor, even causing damage to the endopelvic fascia. nR ecent studies suggest there may be more complexity to the issue of SUI than simply PFM weakness and greater understanding of the interactions of PFMs with the core and abdominal muscles as well as other pelvic girdle muscles may require further research. n Modified Oxford grading with the PERFECT scheme, in addition to other outcome tests, including PRAFAB and ICIQ-UI-SF questionnaires, are validated tools to assess and monitor progress during PFMT. nP rimary functions of the pelvic floor are the 5S’s – support, sphincteric, sexual, stability, sump/pump. Consider these when planning your PFM training (PFMT). nP FMs are skeletal muscles and should be retrained like any other muscle using four basic principles: specificity, overload, progression and maintenance, to achieve maximal desired effect. n F rom specificity and selective exercises, training must progress to functional and sporting tasks, incorporating PFM co-contraction in varied postures and activities engaging the body’s entire kinetic chain. nW omen can have success with PFMT whether heavily supervised, home alone or group sessions are prescribed. n Modern technology using gaming and smartphone apps have been shown to be effective in treating SUI and monitoring PFM rehabilitation programmes. Electroacupuncture and percutaneous implantable wireless microstimulators are also showing positive outcomes in treating SUI.

PELVIC FLOOR TRAINING FOR STRESS URINARY INCONTINENCE: AN UPDATE REFERENCES 1. Lasak AM, Jean-Michel M, Le PU et al. The role of pelvic floor muscle training in the conservative and surgical management of female stress urinary incontinence: does the strength of the pelvic floor muscles matter? PM&R Journal 2018;10(12):1198-1210 https://spxj.nl/2rwGBLn 2. Carvalhais A, Natal Jorge R, Bø K. Performing high-level sport is strongly associated with urinary incontinence in elite athletes: a comparative study of 372 elite female athletes and 372 controls. British Journal of Sports Medicine 2017;52(24) Open access: https://spxj.nl/2B83jOb 3. Hagovska M, Svihra J, Bukova A et al. The impact of physical activity measured by the International Physical Activity questionnaire on the prevalence of stress urinary incontinence in young women. European Journal of Obstetrics, Gynecology, and Reproductive Biology 2018;228:308– 312 4. Hagovska M, Švihra J, Buková A et al. Prevalence and risk of sport types to stress urinary incontinence in sportswomen: a cross-sectional study. Neurology and Urodynamics 2018;doi:10.1002/nau.23538 5. Dos Santos KM, Da Roza T, Mochizuki L et al. Assessment of abdominal and pelvic floor muscle function among continent and incontinent athletes. International Urogynecology Journal 2018;doi:10.1007/s00192-018-3701-8 6. Meyer I, Szychowski JM, Illston JD et al. Vaginal swab test compared with the urethral Q-tip Test for urethral mobility measurement: a randomized controlled trial. Obstetrics and Gynecology 2016;127(2):348–352 Open access: https://spxj.nl/2DwZhlu 7. Bernards ATM, Berghmans BCM, Slieker-ten Hove MCP et al. Dutch guidelines for physiotherapy in patients with stress urinary incontinence: an update. International Urogynecology Journal 2014;25:171 Open access: https://spxj.nl/2S2QQCq 8. Dumoulin C, Hay-Smith J, HabéeSéguin GM et al. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women: a short version Cochrane systematic review with metaanalysis. Neurology and Urodynamics 2015;34:300–308 9. Bø K, Sherburn M. Evaluation of female pelvic-floor muscle function and

strength. Physical Therapy 2005;85:269– 282 10. Laycock J, Jerwood D. Pelvic floor muscle assessment: the PERFECT scheme. Physiotherapy 2001;87(12):631–642 11. Laycock J. Pelvic muscle exercises: physiotherapy for the pelvic floor. Urologic Nursing 1994;14:136–140 12. Hendriks E, Bernards A, Staal JB et al. Factorial validity and internal consistency of the PRAFAB questionnaire in women with stress urinary incontinence. BMC Urology 2008;8:1 Open access: https://spxj.nl/2PFjFYI 13. Hendriks EJ, Bernards AT, Berghmans BC. The psychometric properties of the PRAFAB-questionnaire: a brief assessment questionnaire to evaluate severity of urinary incontinence in women. Neurology and Urodynamics 2007;26(7):998–1007 14. Timmermans L, Falez F, Mélot C. Validation of use of the International Consultation on Incontinence QuestionnaireUrinary Incontinence-Short Form (ICIQ-UI-SF) for impairment rating: a transversal retrospective study of 120 patients. Neurology and Urodynamics 2013;32(7):974–979 15. Tosun OC, Solmaz U, Ekin A et al. Assessment of the effect of pelvic floor exercises on pelvic floor muscle strength using ultrasonography in patients with urinary incontinence: a prospective randomized controlled trial. Journal of Physical Therapy Science 2016;28(2):360–365 Open access: https://spxj.nl/2S0cCGJ 16. Oliveira M, Ferreira M, Azevedo MJ et al. Pelvic floor muscle training protocol for stress urinary incontinence in women: a systematic review. Revista da Associação Médica Brasileira 2017;63(7):642–650 Open access: https://spxj.nl/2zh2m6f 17. de Vries A, Heesakkers J. Contemporary diagnostics and treatment options for female stress urinary incontinence. Asian Journal of Urology 2018;5(3):141–148 Open access: https://spxj.nl/2OOQPzW 18. Mateus-Vasconcelos E, Ribeiro A, Antônio FI et al. Physiotherapy methods to facilitate pelvic floor muscle contraction: a systematic review. Physiotherapy Theory and Practice 2018;34(6):420–432 Open access: https://spxj.nl/2KgbQTl 19. Bø K. Vaginal weight cones. Theoretical framework, effect on pelvic floor muscle strength and female stress urinary incontinence. Acta Obstetricia et Gynecologica Scandinavica 1995;74(2):87–92 20. Herbison GP, Dean N. Weighted

vaginal cones for urinary incontinence. The Cochrane Database of Systematic Reviews 2013;8;(7):CD002114 Open access: https://spxj.nl/2qVgjlw 21. Luginbuehl H, Lehmann C, Baeyens JP et al. Involuntary reflexive pelvic floor muscle training in addition to standard training versus standard training alone for women with stress urinary incontinence: study protocol for a randomized controlled trial. Trials 2015;16:524 Open acccess: https://spxj.nl/2FxmbeZ 22. Thomaz RP, Colla C, Darski C et al. Influence of pelvic floor muscle fatigue on stress urinary incontinence: a systematic review. International Urogynecology Journal 2018;29(2):197–204 23. Teng M, Kervinio F, Moutounaïck M et al. Review of pelvic and perineal neuromuscular fatigue: Evaluation and impact on therapeutic strategies. Annals of Physical and Rehabilitation Medicine 2018;61(5):345– 351 24. Yoshida M, Murayama R, Hotta K et al. Differences in motor learning of pelvic floor muscle contraction between women with and without stress urinary incontinence: evaluation of transabdominal ultrasonography. Neurology and Urodynamics 2017;36:98–103 25. Neumann PB, Grimmer KA, Deenadayalan Y. Pelvic floor muscle training and adjunctive therapies for the treatment of stress urinary incontinence in women: a systematic review. BMC Women’s Health 2006;6:11 Open access: https://spxj.nl/2Qa8EOu 26. American College of Sports Medicine. American College of Sports Medicine position stand. Progression models in resistance training for healthy adults. Medicine and Science in Sports and Exercise 2009;41(3):687–708 Open access: https://spxj.nl/2Dy0nxn 27. Faiena I, Patel N, Parihar J et al. Conservative management of urinary incontinence in women. Reviews in Urology 2015;17(3):129–139 Open access: https://spxj.nl/2Bg7Sr4 28. Herderschee R, Hay-Smith EC, Herbison GP et al. Feedback or biofeedback to augment pelvic floor muscle training for urinary incontinence in women: shortened version of a Cochrane systematic review. Neurology and Urodynamics 2013;32:325–329 29. Fellicissimo M, Carneiro M, Saleme CS et al. Intensive supervised versus unsupervised pelvic floor muscle training for the treatment of stress urinary incontinence: a randomized comparative trial. International

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Urogynecology Journal 2010;21(7):835– 840. DOI: 10.1007/s00192-010-1125-1 30. Hoffman V, Söderström L, Samuelsson E. Self-management of stress urinary incontinence via a mobile app: two-year follow-up of a randomized controlled trial. Acta Obstetricia et Gynecologica Scandinavica 2017;96:1180–1187 Open access: https://spxj.nl/2FuVWpr 31. Henderson J, Wang S, Egger MJ et al. Can women correctly contract their pelvic floor muscles without formal instruction? Female Pelvic Medicine & Reconstructive Surgery 2013;19(1):8–12 Open access: https://spxj.nl/2DxMeQM 32. Bø K, Hilde G. Does it work in the long term? A systematic review on pelvic floor muscle training for female stress urinary incontinence. Neurology and Urodynamics 2013;32:215–223 33. Bø K, Talseth T. Long-term effect of pelvic floor muscle exercise 5 years after cessation of organized training. Obstetrics and Gynecology 1996;87:261–265 34. Miller JM, Sampselle C, Ashton-Miller J et al. Clarification and confirmation of the Knack maneuver: the effect of volitional pelvic floor muscle contraction to preempt expected stress incontinence. International Urogynecology Journal and Pelvic Floor Dysfunction 2008;19:773–782 Open access: https://spxj.nl/2FsZHLZ 35. Saeuberli PW, Schraknepper A, Eichelberger P et al. Reflex activity of pelvic floor muscles during drop landings and mini-trampolining-exploratory study. International Urogynecology Journal 2018;doi:10.1007/s00192-018-3664-9 36. Luginbuehl H, Naeff R, Zahnd A et al. Pelvic floor muscle electromyography during different running speeds: an exploratory and reliability study. Archives of Gynecology and Obstetrics 2016;293(1):117–124 37. Leitner M, Moser H, Eichelberger P et al. Evaluation of pelvic floor muscle activity during running in continent and incontinent women: An exploratory study. Neurourology and Urodynamics 2017;36(6):1570–1576 38. Kastelein AW, Dicker MFA, Opmeer BC et al. Innovative treatment modalities for urinary incontinence: a European survey identifying experience and attitude of healthcare providers. International Urogynecology Journal 2017;28(11):1725– 1731 Open access: https://spxj.nl/2FI48mD 39. Resende AP, Stüpp L, Bernardes BT et al. Can hypopressive exercises provide additional benefits to pelvic floor muscle training in women with pelvic organ prolapse? Neurology and Urodynamics

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2012;31(1):121–125 40. Bernardes BT, Resende AP, Stüpp L et al. Efficacy of pelvic floor muscle training and hypopressive exercises for treating pelvic organ prolapse in women: randomized controlled trial. Sao Paulo Medical Journal 2012;130(1):5–9 Open access: https://spxj.nl/2OTfdQL 41. Liu Z, Liu Y, Xu H et al. Effect of electroacupuncture on urinary leakage among women with stress urinary incontinence: a randomized clinical trial. JAMA 2017;27;317(24):2493–2501 Open access: https://spxj.nl/2KfUjef 42. Huang X, Zheng K, Kohan S et al. Neurostimulation strategy for stress urinary incontinence. IEEE Transactions on Neural Systems and Rehabilitation Engineering 2017;25(7):1068–1078 Open access: https://spxj.nl/2qSH61U.

THE BENEFITS OF BLOOD FLOW RESTRICTION TRAINING FOR REHABILITATION BY KATHRYN THOMAS BSC MPHIL All references marked with an asterisk are open access and links are provided in the reference list.

19-01-COKINETIC FORMATS WEB MOBILE

MEDIA CONTENTS Blood Flow Restriction Training Manual by Novo MG. Lifters Clinic 2016 https://spxj.nl/2S2JX47

There are many situations when patients experience loss of muscle mass and function, for example, after a sports injury, surgery, fracture or joint degeneration. Resistance training is known to be effective for strength training but is often not advised for these patients because of the increased injury risk. Low-load blood flow restriction training, however, has been found to cause beneficial responses in skeletal muscle while avoiding heavy loads. This article reviews blood flow restriction training, the theories about how it works and how to use it, so that your patients can get stronger quicker. It is useful in a wide range of clinical applications including prehabilitation, rehabilitation after injury or postoperatively, as well as for athletes looking for those elusive marginal gains when the benefits from their current training programme seem to have plateaued. Read this article online https://spxj.nl/2BHPLue 24

BACKGROUND In your everyday practice, and probably several times a day, you are faced with patients requiring some form of strength training. It may follow a sports injury, surgery, fracture, ageing or joint degeneration. Whatever the cause of the inactivity, pain, instability and/or immobilisation results in loss of muscle mass and function. As a result, both the risk of reinjury and overall recovery time are a prime concern for clinicians and therapists trying to minimise these adverse side effects. Although we know that resistance training has been demonstrated to be highly effective in combating loss of muscle mass and function, it is often not advised for postoperative or injured patients because of elevated risk of injury or exacerbating existing injury sites, by overloading healing tissues. So, what techniques can you use for patients who require strengthening, be it for prehabilitation or rehabilitation, that keeps the low-intensity exercises interesting, dynamic and most importantly effective? Low-intensity resistance exercise [<30% 1 repetitionmaximum (1RM)] performed with mild to moderate blood flow restriction (BFR) has been observed to elicit beneficial anabolic and functional responses in skeletal muscle, similar to the responses seen following high-intensity resistance exercise. Low-load (LL) BFR training could possibly find its niche in the patients mentioned above, but perhaps is even more useful in clinical settings (1*,2). BFR training is not essentially ’new’ – having been around since the 1970s – but didn’t thrive in the sports and rehabilitation world until around 2015. BFR training involves placing a pneumatic restriction cuff (similar to

a blood pressure cuff) proximal to the target muscle. During properly performed BFR, blood is able to enter the muscle via arterial flow; however, the veins are restricted so that blood is partially prevented from leaving the working muscle. The muscle is then trained at a low intensity (20–30% of maximum capacity or 1RM). The reason these recent findings are such a big deal is that, traditionally, increases in muscle size and strength were thought to only be achievable by lifting weights of at least 70% 1RM (3*). BFR training has been shown to increase muscular strength and hypertrophy using loads less than half that recommended by the American College of Sports Medicine (>60% of 1RM). Increasing muscular strength and size would be advantageous for most, if not all, clinical population groups, especially when heavy lifting (>60% of 1RM) is contraindicated for painful conditions, postoperatively or until the latter stages of rehabilitation (2,3*). BFR creates an anaerobic environment. At the lower oxygen tension level the body recruits muscle fibres normally reserved for more strenuous exercise. In return, the mechanical stress on the muscle fibres leads to upregulation of the muscle hypertrophy-signalling cascade (1*,3*). BFR has recently and quickly gained interest as an exercise technique that could be a revolutionary tool to decrease the time to return to sport post-injury/postoperatively, for general rehabilitation, strength training, prehabilitation, and as a treatment option in vulnerable populations such as the elderly, frail and patients with reduced mobility. This article will review BFR training, the theories and physiology behind it, clinical application Co-Kinetic Journal 2019;79(January):24-31

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and where the current research and clinical trials can guide your choice of BFR in your daily practice.

BFR TRAINING: IS IT RELEVANT? Physical therapists (PTs) are intricately involved in the recovery and rehabilitation of various ailments and injuries. Every day PTs treat individuals who are limited in their function of daily or recreational activities. Treatments target specific impairments through a variety of methods: therapeutic exercise, neuromuscular re-education, manual therapy and therapeutic modalities. Ultimately you want to maximise the patient’s potential for rehabilitation. Dysfunction of the musculoskeletal system, in particular, often provides challenges for the patient and rehabilitation professional alike. Pain and dysfunction present in damaged muscle or connective tissue may commonly affect range of motion, muscular strength and neuromuscular control, leading to continued impairment and deficiencies in functional ability. Muscle weakness is a large contributor to functional impairment and treatment aims to stimulate muscular hypertrophy and subsequent strength gains (1*). The American College of Sports Medicine recommends using 75–85% of 1RM for strength training to induce hypertrophy (4). Unfortunately, a highload (HL) strengthening programme may not always be feasible for the average individual rehabilitating an injury. Following muscle and/ or ligament tears, tendon strain or surgical procedures, patients are typically limited in their ability to perform activities with high loads in an attempt to protect the tissues’ integrity. Co-Kinetic.com

BLOOD FLOW RESTRICTION (BFR) TRAINING HAS BEEN SHOWN TO INCREASE MUSCULAR STRENGTH AND HYPERTROPHY USING LOADS LESS THAN HALF THAT RECOMMENDED BY THE ACSM The challenge is to mitigate muscle atrophy while promoting/protecting the healing process. PTs and other medical professionals have begun implementing BFR in their strengthening protocols to improve function and reduce pain (1*). Recent systematic reviews (1*,2, 3*,5,6*,7,8,9*,10*,11*,12) of the growing body of evidence indicate that BFR can produce “positive training adaptations at intensities lower than previously believed.”(5). Another review indicated that “BFR alone can attenuate muscle atrophy during periods of disuse.” (3*). Therefore, individuals who are impaired by weakness and pain, or those who are restricted from HL training owing to post-surgical precautions, can experience a productive training response with LL-BFR protocols. Furthermore, individualised BFR training may provide a comparable surrogate for HL training while minimising pain during training (1*,3*). Within most clinical musculoskeletal (MSK) conditions there is a high prevalence of muscle weakness. However, this is not just applicable to sports injuries. Loss of strength is a major risk factor for osteoarthritis (OA), the most common MSK disease responsible for reduced function and quality of life of sufferers. Muscle weakness is increasingly evident in non-injured populations and can be caused by, for example, poor postural adaptations as well as sarcopenia

in older adults (3*). There are many situations where high loading of a joint or muscle may not be feasible. Therefore, training with LL effectively may be useful, as the early addition of muscle mass and function in rehabilitation may be beneficial for individuals who have suffered from atrophy (3*).

INDIVIDUALISED BFR TRAINING MAY PROVIDE A COMPARABLE SURROGATE FOR HEAVY-LOAD TRAINING WHILE MINIMISING PAIN DURING TRAINING muscle fibres used to perform that work (1*). In short, combined LLBFR training is thought to mimic highvolume/HL training in skeletal muscle but is achieved with minimal resistance and reduced risk (3*). It is hypothesised that the mechanics of BFR cause an ischaemic and hypoxic muscular environment, which results in high levels of metabolic stress alongside mechanical tension when BFR is used in tandem with exercise. ‘Primary hypertrophy factors’ is the term used to describe both the metabolic stress and mechanical tension that are thought to activate other mechanisms for the induction of muscle growth (3*). Although as yet only hypothetical and theoretical, the proposed mechanisms of BFR include (3*,13): n elevated systemic hormone production n cell swelling n production of reactive oxygen species (ROS) n intramuscular anabolic/anticatabolic signalling pathways n increased fast-twitch fibre recruitment n satellite cell activity. These proposed mechanisms are not fully understood in their involvement in BFR-induced hypertrophy and require more research in the future. A more in-depth explanation of these proposed physiological responses to BFR and the resultant muscle adaptations is explained in a recent free-access review by Lambert et al. (Link 1) (1*). A recent study by Christiansen et al. provides further convincing

evidence on the potential for BFR exercise to augment skeletal muscle signalling responses, particularly related to the physiological mechanisms associated with fatigue resistance and mitochondrial capacity (14*). Recreational athletes (with a reasonable VO2 max of ~57ml/min/ kg) completed interval running sessions performed alone, with BFR and under normobaric hypoxic conditions (FIO2 of 14%) (14*). By ensuring the level of skeletal muscle hypoxia was consistent between the BFR and hypoxic conditions the investigators were able to ascertain whether hypoxia per se was involved in the adaptive process (as might have been expected with the use of BFR) (14*). BFR augmented the increase in mRNA expression of the Na+/K+-ATPase (NKA) complex ancillary protein phospholemman-1 (encoded by the FXYD1 gene). This contributes to the maintenance of transmembrane Na+ and K+ ion gradients, which is critical in preserving skeletal muscle membrane excitability and contractile function. The expression of specific isoforms of peroxisome proliferator-activated receptor-ϒ coactivator 1α (PGC-1α), which are widely considered to be the key factor mediating exercise traininginduced adaptations in mitochondrial capacity were also augmented by BFR exercise. This study also supports the debate on the potential for BFR exercise interventions to have wider implications for performance. More studies like this will further add to the understanding of the physiological effects of BFR (14*). Phenotypic adaptations to exercise training are more difficult to elicit in well-trained athletes, particularly those who already possess the necessary physiology to be competitive in their chosen event (6*). Research has highlighted that the reduced plasticity of skeletal muscle and a blunting of the adaptive scope in trained individuals or in response to exercise training, is reflected at a molecular level (6*). Where Christiansen et al. used participants of ‘trained’ status, their results suggest that regardless of exercise intensity or modality, BFR may overcome the blunted nature of the acute signalling response to

exercise and act as a potent stimulus in enhancing a broad range of adaptive processes (14*). Improvements in muscle physiological processes and morphological adaptations could result in an enhanced performance capacity, particularly at high exercise intensities where limits of exercise tolerance, or task failure have been reached (6*). A primary goal in training elite athletes is to maximise the magnitude of event-specific performance adaptation, and BFR exercise may provide wellconditioned athletes with more “bang for their buck” (6*) in augmenting their response to training or in patients who have plateaued. A greater understanding of the mechanisms and potential benefits of BFR exercise training might provide the incentive for integration into training practice. Research has demonstrated that 6 weeks of LL-BFR training resulted in significant gains in muscle size and strength with no significant changes in central and peripheral neuromuscular function yet moderate-to-large effect sizes in central activation and evoked torque. This suggests that further research on the neuromuscular variables with BFR training is necessary (15*). The exact science behind BFR training in not fully understood; however, for individuals who are unable to tolerate HL exercises and high joint forces, regardless of the mechanism, the benefit of LL-BFR training to their MSK rehabilitation could be hugely significant (3*,13). Interest in the use of BFR training as a clinical rehabilitation tool is mounting, given the practicality that this training mode may offer in a clinical setting. Most clinical trials involve healthy individuals and historically implementing this novel training method has come with safety and validity questions (3*), as well as practicality and optimisation issues (6*). However, there is a growing body of research and ongoing clinical trials including specific clinical populations (for example patients with anterior cruciate ligament (ACL) reconstruction, chronic postoperative weakness, tendinopathy, fracture healing and ageing) that will shed more light on the benefit of this technique in daily practice. Co-Kinetic Journal 2019;79(January):24-31

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BFR TRAINING: CLINICAL APPLICATION Early application of BFR training was demonstrated in the geriatric population in efforts to address age-related cardiovascular changes and muscle atrophy. Research by Abe et al. used a KAATSU-walk training programme (4). Kaatsu is Japanese in origin and involves performing LL exercise while externally-applied compression partially restricts blood flow to the active skeletal muscle. The research showed significant increases in skeletal muscle mass and increases in functional ability (4). The study helped spark further research on the combination of exercise intensity and duration in conjunction with BFR (16*,17*). Today, the application of BFR training for enhanced rehabilitation or for modifying effects to exercise programmes is gaining momentum in the sports medicine and athletic communities. A number of systematic reviews have been published recently highlighting the benefits of BFR training, and the greater diversity with which it can be applied (1*,2 ,3*,5,6*,7,8,9*,10*,11*,12).

1. The Lower Extremity Many studies have focused on kneeextension exercises showing significant increases in quadriceps strength and thigh girth in the BFR groups, especially when usual resistance training was augmented with BFR (18*,19,20). Most of these studies have focused on healthy subjects; however, recently, research on BFR training that is more clinically relevant has been conducted on patients following a period of injury or deconditioning after injury or surgical intervention. Postoperative rehabilitation can require prolonged treatment to achieve pre-injury muscular strength and some surgical interventions require delays in high-intensity training to allow healing of repaired or reconstructed joints. Ligament Injury Outcomes after knee ligament reconstruction are often plagued with weakness and dysfunction. One of the greatest impairments following surgery is quadriceps weakness. Insufficiency of the extensor complex Co-Kinetic.com

can lead to decreased function and increased probability of an unsuccessful return to sport or the development of osteoarthritis later in life (1*). Studies have shown that low-level isometric exercises with BFR, early after ACL reconstruction surgery, can improve muscle activation. And, for those with limited weight-bearing status, positive benefits can be expected using BFR combined with low-level isometric and open-chain activities to prevent muscle atrophy before returning to full weightbearing (1*). As tolerance and weightbearing status progresses, functional activities with BFR (using lower loads at high repetitions) can be used with positive outcomes (1*). Studies using BFR techniques on postoperative ACL reconstruction patients have shown significant decreases in postoperative extensor muscle atrophy; similarly in postoperative arthroscopic knee patients (21), those performing BFR exercises showed significant increases in thigh cross-sectional area, greater improvements in timed stair ascents, and patient reported outcome measures significantly improved as did extension and flexion knee strength (1*,2,3*,5,6*,7,8,9*,10*). Joint Replacement Total knee arthroplasty (TKA) can result in postoperative impairments similar to those seen in ACL reconstruction patients. Individuals can lose up to 80% of their knee-extension strength in the first few days following TKA, especially those with extended hospitalisation (1*). This is similar for patients following total hip replacement who can suffer substantial loss in hip and quadriceps strength, which can hinder their progress, functional ability and subsequent recovery time. Typically, most individuals are allowed to bear weight early after TKA, but are still restricted from HL or impactrelated activities. PTs are able to use LL strengthening exercises (eg. light leg-press, straight leg raises, long-arc quads, body-weight squats) to elicit a productive strengthening response. Incorporating BFR training early on for these patients would seem beneficial and could result in faster recovery

times (8), owing to reduced muscle loss and improved strength and function (1*). Achilles Tendon Injury Case reports have shown that BFR training incorporated into a rehabilitation programme may be a beneficial treatment option for patients with Achilles tendon injuries (22). ‘Patient 1’ sustained an Achilles tendon rupture while playing competitive football and required surgical repair of the tendon (22). Following a traditional rehabilitation programme, the patient was unable to ambulate without crutches because of persistent weakness. The patient subsequently started a 5-week returnto-run programme using BFR training and experienced plantarflexion peak torque improvements of 522% and 108.9% and power gains of 4475% and 211% at 60°/s and 120°/s, respectively. The patient was able to ambulate without crutches 5 weeks after starting the BFR training. ‘Patient 2’ sustained a complete Achilles tendon rupture while exercising and had received a non-operative, accelerated rehabilitation programme (22). The patient complained of persistent, significant strength and functional deficits following rehabilitation. The patient subsequently underwent a 6-week BFR training programme and experienced plantarflexion strength improvements of 55.8% and 47.1% and power gains of 68.8% and 78.7% at 60°/s and 120°/s, respectively. The patient was able to return to running and sports on completion of 6 weeks of BFR therapy. These two case reports clearly illustrate that incorporating BFR training with rehabilitation programmes significantly improved strength, endurance and function after Achilles tendon rupture (22). Patellofemoral Pain Patellofemoral pain (PFP) is one of the most common conditions among active individuals. The hallmark symptom being anterior knee pain with loading of the patellofemoral joint. Quadriceps strengthening is considered a cornerstone of rehabilitation and is found to reduce anterior knee pain. 27

STUDIES USING BFR TECHNIQUES ON POSTOPERATIVE ACL RECONSTRUCTION PATIENTS HAVE SHOWN SIGNIFICANT DECREASES IN POSTOPERATIVE EXTENSOR MUSCLE ATROPHY However PTs are often not able to adequately load the quadriceps and joint because of pain and aggravation of the patientâ&#x20AC;&#x2122;s symptoms. The use of LL-BFR may be the solution to this loading conundrum associated with the quadriceps (23). LL-BFR for PFP may be used in two stages: (1) reduction of pain immediately after the treatment session to encourage compliance; and (2) improved quadriceps strength along with chronic reduction in pain. Research has shown that BFR training in PFP subjects had a 93% greater reduction in pain with activities of daily living than the standard treatment group. Participants with painful resisted knee extension also had greater increases in knee extensor torque with BFR than standard treatment. After 6 months, both groups were equal on all outcome measures (23).

2. The Upper Extremity When performing BFR on upper body musculature, it should be noted that the smaller limb circumference and girth in this region may require alterations in BFR application. In current studies examining BFR for the upper extremity, occlusion pressures seem to be grossly arbitrary and inconsistent (1*,21). On the basis of the data available, exercises may be performed with the same repetition scheme as with the lower extremity, but some studies indicate that proximal upper extremity muscle groups may require greater repetitions (up to 165) to achieve comparable improvement (1*,24). Several benefits have been observed for musculature in the chest, back, shoulders and arms with regards to rehabilitative upper extremity strengthening at lower loads (24). It is postulated that patients who suffer from complications due to tendinosis, ligament rupture, or fracture may be able to improve their upper extremity function using BFR during rehabilitation. 28

Outcomes for BFR with specific upper extremity injuries are largely unknown at this point and provide an intriguing paradigm for future research (1*).

3. Muscle Injuries Muscle injuries are common, especially for those participating in sports. We have already mentioned the proven benefit of BFR training in increasing muscle strength and cross-sectional area, and it is therefore an ideal tool for rehabilitation following muscle strain (25*). A common intervention to prevent and rehabilitate muscle injuries is the application of eccentric exercises to the injured muscle group. Unfortunately, many individuals cannot tolerate the eccentric load after injury, nor the associated muscle soreness following eccentric training. BFR training can be incorporated into eccentric loading, although this can result in muscle soreness (25*). The effectiveness of training only the eccentric portion of the exercise in combination with BFR is currently limited; the majority of the studies suggest that concentric-only BFR exercise was capable of increasing muscle size and strength, yet this was not observed with eccentric-only BFR exercise (25*).

4. A Proximal Rather than Distal Effect Since BFR training requires the use of a tourniquet-like cuff to be applied proximal to the portion of the limb/ muscle to be trained, it would be assumed that a cuff could not be applied to isolate muscles proximal to the limbs, ie. closer to the trunk than the axilla or groin. However research by Dankel et al. found several instances of proximal gains in muscle strength and size while applying BFR to the limbs (24). BFR training is able to increase muscle strength in the shoulders and back, but may require greater volume of exercise than

muscles distal to the cuff (24). The mechanism suggested for this phenomenon included the typical high-repetition characteristic of BFR exercises (upwards of 75 total repetitions per exercise), alleged synergistic effects of proximal musculature as the distal muscles fatigue and higher recruitment of type II muscle fibres, and muscle cell swelling occurring during BFR (1*,3*,5).

5. The Elderly The progressive loss of muscle mass (sarcopenia) and strength (dynapenia) leads to reduced functional capacity in the elderly. Sarcopenia is a loss of physical function due to the decrease in muscle mass and strength, vascular function and bone mineral density that occur with ageing. Traditional aerobic and resistance exercises are prescribed to enhance health and mitigate ageing-related performance deficits. However, sarcopenia appears to be underpinned by the reduced sensitivity of ageing muscle to anabolic stimuli such as resistance exercise (3*). BFR training has gained scientific merit recently with the publication of more research and a better understanding of its physiological responses and the fact that it is a suitable treatment application for the elderly. BFR training incorporated into walking, body-weight exercises, elastic band exercises and weight training in the elderly has shown muscle hypertrophy increases ranging from <1% to 2.6% per week and muscle strength gains ranging from <1% to 5.9% per week (26,27). Given the number of orthopaedic surgeries performed in the ageing population, the anabolic potential of BFR training has gained even more interest as a clinical rehabilitation tool following this MSK insult. In particular older patients recovering from procedures may benefit from BFR exercises in order to regain muscle strength and Co-Kinetic Journal 2019;79(January):24-31

PHYSICAL THERAPY

function reducing their risk of further complications. In at risk populations – frail, elderly, postoperative – the benefit of including BFR exercises is becoming more apparent (26,27). HL training may be contraindicated in older adults because of pre-existing health conditions (eg. osteoarthritis). For patients with profound weakness and mobility limitations LL-BFR training offers a safe alternative to HL with potentially similar strength improvements (28).

6. The Athlete Current evidence suggests that LL-BFR can enhance muscle hypertrophy and strength in well-trained athletes, who would not normally benefit from using light loads. For healthy athletes, LL-BFR training performed in conjunction with normal HL training may provide an additional stimulus. As LL-BFR exercise does not appear to cause measurable muscle damage, supplementing normal HL training using this novel strategy may elicit beneficial muscular responses in healthy athletes (29). However, other studies have shown that 8 weeks of lower-body BFR training at 50% occlusion does not appear to have an added effect on measures of muscular strength or body composition in resistance-trained females (30). This may relate back to the challenges of phenotypic alterations in trained individuals (mentioned earlier) and possibly even technique of BFR application. Many studies have used a 60% occlusion – could the 10% difference make all the difference in a trained individual?

7. Aerobic Training Current evidence suggests that the addition of BFR to dynamic exercise training is effective, with consistent changes for both resistance training and aerobically-based exercise (11*). Although BFR resistance training is well-studied, its effects on haemodynamic and cardiorespiratory responses to aerobic exercise are not clearly established. During aerobic exercise testing, when compared to normal conditions, BFR results in significantly increased myocardial oxygen consumption, cardiac work, Co-Kinetic.com

ventilation, perceived exertion, ratings of discomfort/pain, numbness/tingling and soreness as well as significantly decreased total test time and predicted VO2 max (31). Although benefits have been shown with performance in BFR walking and treadmill running, one may need to judge the intensity of the aerobic activity and the individual as to whether BFR training used in an aerobic activity will be beneficial (31).

8. Prehabilitation Within this background, ‘fast recovery’ programmes are created, aiming to reduce the hospital length of stay (LOS), thereby reducing costs and supporting an accelerated transition into a specific rehabilitation programme. Fast recovery programmes mostly focus on perioperative pain management or early mobilisation post-surgery. In the case of pre-arthroplasty, most patients experience significant osteoarthritis in the affected joints. Pain and dysfunction are common with significant weakness in surrounding musculature. These individuals may not be able to pursue high-intensity training and can be unsuccessful in attempts to avoid surgery or even prepare for surgery. The use of combined LL-BFR training may provide patients with pain relief as well as higher success rates in conservative care. The inclusion of BFR in preoperative exercise has shown initial promise in improving strength before TKA, early results are positive in BFR training for prehabilitation (1*,32*). Through the shift from a mechanically to a more metabolically challenging exercise regime, BFR training appears to be a promising prehabilitation strategy. As a result of potential gains in muscle mass and strength preoperatively in association with reviewed molecular adaptations, BFR has the potential to counteract post-surgery side effects, thereby reducing LOS and altering patients’ postoperative subjective feeling (32*).

9. The Osteoporotic Patient Research has shown that LL-BFR training, compared with HL increases, increases the expression of bone

formation markers (eg. bone-specific alkaline phosphatase) and decreases bone resorption markers (eg. the aminoterminal telopeptides of type I collagen) after both aerobic and anaerobic exercise across several populations. This confirms a positive effect of BFR training on bone metabolism, formation and resorption (33). So, BFR may not only be a safe technique for the ‘frail’ osteoporotic patient who sometimes requires a more gentle exercise regime because of their fracture risk profile, but may actually have physiological benefits for their condition too.

10. Other Areas of Application Studies have indicated that while using BFR training on the lower limb, there was an increase in the unilateral arm strength. The findings from this research supports the evidence of a BFR trainingderived remote strength transfer that may be relevant to populations with localised movement disorders (34).

BFR TRAINING: CONCERNS AND RISKS Although no complications have been reported, there is concern for endothelial damage and the effects on the coagulation cascade with venous stasis in the extremities. Some research has shown improvements in vascular endothelial function and peripheral blood flow with significant decreases in von Willebrand factor (1*). Other safety evaluations have assessed the effects of LL-BFR on plasma volume reduction which was significantly greater after BFR exercise, suggesting that in healthy patient populations, BFR does not activate the coagulation system (1*). The systematic review by Scott et al. noted no venous thrombosis, but subjects with a previous history of deep venous thrombosis and/or presence of varicosities were excluded (7). Many of the studies to date have been performed in small patient sample sizes, and some concern remains for possible complications associated with venous occlusion. BFR does not increase the myocardium load and has no significant effect on coronary vascular function (35*). Partial blood flow restriction affects the change in blood pressure during 29

repetition schemes have been employed in the BFR literature ranging from 45 to 75 repetitions; however, the most commonly used protocol is one set of 30 repetitions followed by three sets of 15 repetitions (75 repetitions). Novel ways of incorporating LL-BFR into rehab include adding neuromuscular electrical muscle stimulation (NMES), which has shown promising results in increasing muscle strength (36). A progression model for using BFR in early rehabilitation through to HL resistance training has been proposed by Loenneke et al., which encompasses a four-step approach: (1) BFR alone during periods of bed rest; (2) BFR combined with low-workload walking exercise; (3) BFR combined with LL resistance exercise and (4) LL-BFR training in combination BFR TRAINING: PRACTICAL with HL exercise (37). Considering APPLICATION TIPS evidence from this review, a progressive To exercise with BFR, one must apply model of BFR training may provide an a pressure-controlled tourniquet to the effective rehabilitation tool from early most proximal portion of the limb being ambulation to return to HL exercise (3*). trained. For the lower extremity, the It is important that practitioners rule cuff would be placed at the proximal out potential causes of rhabdomyolysis, thigh, just distal to the inguinal crease. such as infections and prolonged In the upper extremity, a cuff would be placed just distal to the axilla. In order to immobilisation before implementing BFR training, and include measures of muscle prevent complications due to pressure damage markers (eg. serum creatine over a peripheral nerve (neurapraxia), kinase) throughout the training period. the tourniquet is used over regions with This also emphasises the need for an higher mass and limb width. individualised approach to BFR training Despite concerns of disturbed when selecting cuff pressure for both haemodynamics and ischaemic safety and effectiveness (3*). reperfusion injury, BFR training has Many risks can be mitigated by been reviewed in depth and correct accounting for methodological factors, implementation has been affirmed to such as cuff width, cuff type, and the present no greater risk than traditional exercise modes (1*,2,3*,5,6*,7,8,9*,10*,11*). individual to which the pressure is being applied. The pressure applied should The effectiveness of the BFR technique has been demonstrated across be relative to the cuff used (wider cuff, lower pressure) and to the individual to a variety of populations, such as the whom the cuff is being applied (larger injured, healthy individuals, elderly and limb circumference, greater pressure) athletes, and has the potential to be rather than applying the same absolute efficacious for astronauts! At present, pressure to each individual (3*,25*). there are no complete standardised Selection of cuff width and material as recommendations for use even in well as restrictive pressure and how to healthy populations (3*). A variety of exercise in an ambiguous way. Systolic ABP values continue to be higher during the change in blood pressure, whereas diastolic ABP changes are not expressed. There is no additional strain on cardiac function during BFR training (35*). There have been rare case reports of rhabdomyolysis after BFR with an incidence of 0.008% (1*). An epidemiological study in Japan reported low occurrence of any of the above adverse effects other than skin bruising (3*). Finally, the effect that BFR training has on tendon strength and the possibility of connective tissue injuries related to increased muscle strength without concomitant tendon conditioning remains unknown.

ATHLETES DRIVEN TO BETTER PERFORMANCE OR PATIENTS WHO HAVE PLATEAUED IN THEIR PROGRESS WITH TRADITIONAL REHABILITATION MAY BENEFIT FROM THE ADDITION OF BFR TRAINING 30

calculate it is best explained in this paper Mattocks et al. (25*). Reading through Hughes et al. (Link 2) (3*), Mattocks et al. (Link 3) (25*) and the Blood Flow Restriction Training Manual from the Lifters Clinic (Link 4) (38*) will best guide you in your clinical decision making and application of BFR.

CONCLUSION Based on the present evidence, maximum muscle strength and hypertrophy may be optimised by specific training methods, whereas both HL resistance training and BFR training seem equally effective in increasing muscle mass. Importantly, BFR training is a valid and effective approach for increasing muscle strength in a wide spectrum of ages and physical capacities, although it may seem particularly of interest for those individuals with physical conditions that limit their engagement in HL training. BFR training provides a safe method to begin strength training at earlier stages of rehabilitation, and is an augmentation method that may have promising influences in the goal to achieve accelerated function and recovery. As an adjunct to standard strength training, athletes driven to better performance or patients who have plateaued in their progress with traditional rehabilitation may benefit from the addition of BFR training. Further large-scale clinical trials need to be completed in order to obtain a better understanding of BFR physiology, complications, side effects, standardised treatment algorithms and long-term patient outcomes. However, research on this treatment modality is seemingly snowballing and is definitely something you may want to keep abreast of and possibly use now (or in the future) to stay ahead in the rehab race! 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/2qUPle3 Co-Kinetic Journal 2019;79(January):24-31

PHYSICAL THERAPY

KEY POINTS n F ollowing injury or surgery, inactivity due to pain, instability or immobilisation results in loss of muscle mass and function. This increases both the risk of reinjury and overall recovery time. n Resistance exercise has been demonstrated to be highly effective in combating muscle wasting and functional loss, but is often not advised for postoperative or injured patients because of elevated risk of injury or exacerbating healing tissue. n Low-load (LL) blood flow restriction (BFR) training has been shown to elicit substantial muscular hypertrophy and strength gains in healthy and athletic populations. n Recent studies now show that low-load BFR training in clinical populations demonstrates effectiveness in attenuating strength loss and facilitating strength rehabilitation in clinical populations suffering from musculoskeletal (MSK) weakness. n LL-BFR training can have a positive impact on muscle size and numerous other physiological adaptations, and may act as a surrogate for heavy-load strength rehabilitation training in a broad range of clinical populations. n Lower and more tolerable pressures (40% limb occlusive pressure) may elicit sufficient MSK adaptations while minimising the risk of adverse events and pain, highlighting the need for individualised prescription of clinical BFR training. n Two to three LL-BFR training sessions per week with progressive overload is sufficient for enhanced strength adaptations. n A progression model for using BFR in early rehabilitation through to high-load resistance training has been proposed which encompasses a four-step approach: (1) BFR alone during periods of bed rest; (2) BFR combined with low-workload walking exercise; (3) BFR combined with LL resistance exercise and (4) LL-BFR training in combination with high-load exercise. n Despite concerns of disturbed haemodynamics and ischaemic reperfusion injury, BFR training has been reviewed in depth and correct implementation has been affirmed to present no greater risk than traditional exercise modes. n The LL nature of BFR training marks its potential as an effective clinical rehabilitation tool.

DISCUSSIONS FR training is an emerging ‘hot topic’ in the UK B and all around the world at present – having read this article, what are your thoughts on using this technique in clinical MSK rehabilitation? What criteria and which MSK conditions or patients would you use LL-BFR training on? Is there scope in your practice to use LL-BFR training in healthy individuals who would benefit from additional strength gains, for example elderly or osteoporotic persons? 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

LINKS Link 1: Lambert BS et al. Blood flow restriction therapy for stimulating skeletal muscle growth: practical considerations for maximizing recovery in clinical rehabilitation settings. Techniques in Orthopaedics 2018;33(2):89–97 https://spxj.nl/2FpaAyz Link 2: Hughes L et al. Blood flow restriction training in clinical musculoskeletal rehabilitation: a systematic review and meta-analysis. British Journal of Sports Medicine 2017;51:1003–1011 https://spxj.nl/2PZI6PT Link 3: Mattocks KT et al. The application of blood flow restriction: lessons from the laboratory. Current Sports Medicine Reports 2018;17(4):129–134 https://spxj.nl/2zVa6dy Link 4: Novo MG. Blood Flow Restriction Training Manual. Lifters Clinic 2016 https://spxj.nl/2S2JX47.

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THE BENEFITS OF BLOOD FLOW RESTRICTION TRAINING FOR REHABILITATION REFERENCES 1. Lambert BS, Hedt C, Moreno M et al. Blood flow restriction therapy for stimulating skeletal muscle growth: practical considerations for maximizing recovery in clinical rehabilitation settings. Techniques in Orthopaedics 2018;33(2):89–97 Open access: https://spxj.nl/2FpaAyz 2. Patterson SD, Hughes L, Head P et al. Blood flow restriction training: a novel approach to augment clinical rehabilitation: how to do it. British Journal of Sports Medicine 2017;51:1648–1649 3. Hughes L, Paton B, Rosenblatt B, et al. Blood flow restriction training in clinical musculoskeletal rehabilitation: a systematic review and meta-analysis. British Journal of Sports Medicine 2017;51:1003– 1011 Open access: https://spxj.nl/2PZI6PT 4. Abe T, Sakamaki M, Fuita S et al. Effects of lowintensity walk training with restricted leg blood flow on muscle strength and aerobic capacity in older adults. Journal of Geriatric Physical Therapy 2010;33(1):34–40 5. Pearson SJ, Hussain SR. A review on the mechanisms of blood-flow restriction resistance training-induced muscle hypertrophy. Sports Medicine 2015;45(2):187–200 6. Ferguson RA. Blood flow-restricted exercise: providing more bang for buck in trained athletes? Acta Physiologica 2018;223(2):e13065 (Editorial) Open access: https://spxj.nl/2Tlpc4K 7. Scott BR, Loenneke JP, Slattery KM et al. Blood flow restricted exercise for athletes: a review of available evidence. Journal of Science and Medicine in Sport 2016;19(5):360–367 8. Jessee MB, Mattocks KT, Buckner SL et al. (2018). Mechanisms of blood flow restriction: the new testament. Techniques in Orthopaedics 2018;33(2):72–79 9. Vanwye WR, Weatherholt AM, Mikesky AE. Blood flow restriction training: implementation into clinical practice. International Journal of Exercise Science 2017;10(5):649–654 Open access: https://spxj.nl/2DHJmkV 10. Muhammad K, Hassan I. Moderate blood flow restriction training. Mini review. MOJ Sports Medicine 2017;1(3):42-44 Open access: https://spxj.nl/2BaD4rA 11. Slysz J, Stultz J, Burr JF. The efficacy of blood flow restricted exercise: A systematic review & meta-analysis. Journal of Science and Medicine in Sport 2016;19(8):669–675 Open access: https://doi.org/10.1016/j.jsams.2015.09.005 12. Lixandrão ME, Ugrinowitsch C, Berton R et al. Magnitude of muscle strength and mass adaptations between high-load resistance training versus lowload resistance training associated with blood-flow restriction: a systematic review and meta-analysis. Sports Medicine 2018;48(2):361–378 13. Hwang P, Willoughby DS. Mechanisms behind blood flow restricted training and its effect towards muscle growth. Journal of Strength & Conditioning Research 2018;48(2):361–378

14. Christiansen D, Murphy RM, Bangsbo J et al. Increased FXYD1 and PGC-1- mRNA after blood flowrestricted running is related to fibre type-specific AMPK signalling and oxidative stress in human muscle. Acta Physiologica 2018;223(2):e13045 Open access: https://spxj.nl/2TjvvWz 15. Cook SB, Scott BR, Hayes KL et al. Neuromuscular adaptations to low-load blood flow restricted resistance training. Journal of Sports Science & Medicine 2018;17(1):66–73 Open access: https://spxj.nl/2zZGkEz 16. Abe T, Kearns CF, Sato Y. Muscle size and strength are increased following walk training with restricted venous blood ow from the leg muscle, Kaatsu-walk training. Journal of Applied Physiology 2006;100:1460–1466 Open access: https://spxj.nl/2FnM29i 17. Abe T, Yasuda T, Midorikawa T et al. Skeletal muscle size and circulating IGF-1 are increased after two weeks of twice daily “KAATSU” resistance training. International Journal of KAATSU Training Research 2005;1(1):6–12 Open access: https://spxj.nl/2OPyva1 18. Luebbers PE, Fry AC, Kriley LM et al. The effects of a 7-week practical blood ow restriction program on well-trained collegiate athletes. Journal of Strength and Conditioning Research 2014;28(8):2270–2280 Open access: https://spxj.nl/2Dp99xn 19. Yamanaka T, Farley RS, Caputo JL. Occlusion training increases muscular strength in division IA football players. Journal of Strength and Conditioning Research 2012;26(9):2523–2529 Open access: https://spxj.nl/2zeHFb0 20. Cook CJ, Kilduff LP, Beaven CM. Improving strength and power in trained athletes with 3 weeks of occlusion training. International Journal of Sports Physiology and Performance 2014;9(1):166–172 21. Tennent DJ, Burns TC, Johnson AE et al. Blood flow restriction training for postoperative lower-extremity weakness: a report of three cases. Current Sports Medicine Reports 2018;17(4):119–122 22. Yow BG, Tennent DJ, Dowd TC et al. Blood flow restriction training after Achilles tendon rupture. The Journal of Foot and Ankle Surgery 2018;57(3):635–638 23. Giles L, Webster KE, McClelland J et al. Quadriceps strengthening with and without blood flow restriction in the treatment of patellofemoral pain: a double-blind randomised trial. British Journal of Sports Medicine 2017;51(23):1688–1694 24. Dankel SJ, Jessee MB, Abe T et al. The effects of blood flow restriction on upper-body musculature located distal and proximal to applied pressure. Sports Medicine 2016;46:23–33 25. Mattocks KT, Jessee MB, Mouser JG et al. The application of blood flow restriction: lessons from the laboratory. Current Sports Medicine Reports 2018;17(4):129–134 Open access: https://spxj.nl/2zVa6dy

26. Hackney KJ, Brown LTCWJ et al. The role of blood flow restriction training to mitigate sarcopenia, dynapenia, and enhance clinical recovery. Techniques in Orthopaedics 2018;33(2)98–105 27. Clarkson MJ, Conway L, Warmington SA. Blood flow restriction walking and physical function in older adults: a randomized control trial. Journal of Science and Medicine in Sport 2017;20(12):1041– 1046 28. Cook SB, LaRoche DP, Villa MR et al. Manini. Blood flow restricted resistance training in older adults at risk of mobility limitations. Experimental Gerontology 2017;99:138–145 29. Scott BR, Loenneke JP, Slattery KM et al. Blood flow restricted exercise for athletes: a review of available evidence. Journal of Science and Medicine in Sport, 2016;19(5):360–367 30. Hicks AA, Brandon G, Chandler D et al. The effects of blood flow restriction training on measures of strength and body composition in college age females. International Journal of Exercise Science: Conference Proceedings 2018;2(10): article 67 31. Stovall JH, Hunter SD, Walker JL. Effects of blood-flow restriction on hemodynamic and cardiorespiratory responses to aerobic exercise testing, International Journal of Exercise Science: Conference Proceedings 2018;2(10): article 93 32. Franz A, Queitsch FP, Behringer M et al. Blood flow restriction training as a prehabilitation concept in total knee arthroplasty: a narrative review about current preoperative interventions and the potential impact of BFR. Medical Hypotheses 2018;110:53– 59 Open access: https://spxj.nl/2PuFLgo 33. Bittar S, Pfeiffer P, Santos H et al. Effects of blood flow restriction exercises on bone metabolism: a systematic review. Clinical Physiology and Functional Imaging 2018;doi: 10.1111/cpf.12512 34. May AK, Russell AP, Warmington SA. Lower body blood flow restriction training may induce remote muscle strength adaptations in an active unrestricted arm. European Journal of Applied Physiology 2018;118(3):617–627 35. Bunevicius K, Sujeta A, Poderiene K et al. Cardiovascular response to bouts of exercise with blood flow restriction. Journal of Physical Therapy Science. 2016;28:3288–3292 Open access: https://spxj.nl/2Dr1YoD 36. Slysz J, Burr J. The effects of blood flow restricted electrostimulation on strength & hypertrophy. Journal of Sport Rehabilitation 2017;27(3):257–262 37. Loenneke JP, Abe T, Wilson JM et al. Blood flow restriction: an evidence based progressive model (review). Acta Physiologica 2012;99(3):235–250 38. Novo MG. Blood flow restriction training manual. Lifters Clinic 2016 Open access: https://spxj.nl/2S2JX47.

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Figure 1: The Clinical Puzzle is a reflection tool to help organise the assessment findings

HAMSTRING | THORAX | 19-01-COKINETIC FORMATS WEB MOBILE PRINT

MEDIA CONTENTS Downloadable template of the Clinical Puzzle reflection tool https://spxj.nl/2QshUO4

the relationship between, and the contribution of, various body regions, systems, thoughts, beliefs, and social behaviours or contexts that are ultimately manifesting as cognitive, emotional or sensorial dissonance or altered performance. The broad understanding of the whole person’s experience, or the biopsychosocial components that collectively constitute their reality, can either overwhelm both the individual and the clinician, or highlight a path to change. The path is clearer when the patient’s information is organised, prioritised, and the clinical relevance of each component and finding determined. This requires a theoretical framework, or model, for both assessment and treatment of the individual patient. The Integrated Systems Model (ISM) has been developed to aid the biopsychosocial assessment and treatment of the patient. The ISM helps to identify the: n patient’s meaningful complaints n patient’s cognitive beliefs n patient’s emotional status n patient’s meaningful tasks as well as strategy analysis of the screening tasks that pertain to the meaningful task n drivers for the loss of function (alignment, biomechanics and/or control) Co-Kinetic Journal 2019;79(January):32-38

MANUAL THERAPY

n t he underlying system impairment that is related to the loss of function of the driver. ISM treatment includes: 1. releasing the barriers (cognitive, emotional and physical) and align; tools to improve**alignment**; followed by 2. teaching optimal strategies for function that relate to the patient’s goals and meaningful tasks (connect, control and move). To aid this, the information gathered from the patient can be organised with the help of a reflection tool, the ‘Clinical Puzzle’ (Fig. 1). The outer circle of the puzzle represents the strategies for function and performance that the patient currently uses for the screening tasks that relate to their meaningful task. The centre circle of the puzzle represents several systems that relate to the person and the sensorial, cognitive and emotional components of their current experience. It is the place where the meaningful complaint, and goals and barriers to recovery are noted. The four other pieces of the puzzle represent the various systems in which impairments are assessed and noted during the clinical examination. A downloadable template of the Clinical Puzzle is available to help you organise your assessment findings (See Media contents). Further information on these ideas and concepts is available in the author’s book The Thorax – An Integrated Approach. The next section, ‘Steve’s Story’, is a case study from this book demonstrating how these ideas and concepts can be applied to an individual.

STEVE’S STORY At the time of his initial assessment, Steve was a 26-year-old premier league elite soccer player who 2.5–3 years ago had suffered an acute tear of the right proximal biceps femoris. His meaningful complaints were: n a feeling of weakness in the right leg, n feeling ‘heavy on the field’, and n reduced agility and speed since the hamstring injury. He had received traditional soft tissue rehabilitation coupled with stretching Co-Kinetic.com

1. Prone hip extension task Pelvis: Loss of control RSIJ (PD) Thorax: 4th and 6th thoracic rings translated left and rotated right, 5th thoracic ring translated right and rotated left. 2. R sacrotuberous ligament tender to palpation but not to nutation of the sacrum 3. a) Delayed recruitment of the RTrA b) Early recruitment of the right biceps femoris c) Late recruitment of the right gluteus maximus 4. MC: R ight PGP, loss of speed and agility, verge of hamstring grabbing CB: H amstring will tear if he ‘goes hard,’ right hamstring is weak

1 3 2

EB: A nxiety re ability to continue to be on the team MT: V ertical loading in a variety of directions

Steve’s Current Meaningful Complaints Of primary concern for Steve was his loss of performance on the soccer field (agility and speed) and his ‘fear’ that the hamstring would tear again if he ‘goes as hard as he wants.’

Steve’s Cognitive Beliefs Steve believed that his right proximal hamstring was still weak and felt that more strengthening exercises were needed to help him reach his athletic

goals. Although he had tried, he could not seem to improve the strength of his right leg. His exercises were not improving his speed and agility on the field.

Meaningful Tasks and Screening Tasks Chosen for Strategy Analysis Steve’s meaningful tasks were to be able to run forwards, backwards, and sideways, manipulate the soccer ball with either foot, and do all this with speed and agility. Multiple screening tasks could be chosen for this sport, including: n double leg loading (squat); nw eight shift to single leg standing,

THE INTERCONNECTEDNESS OF THE THORAX MEANS THAT IT CAN NO LONGER BE CONSIDERED IN ISOLATION FROM THE REST OF THE BODY 33

and stepping forward in a variety of directions; n the same tasks with both congruent and incongruent rotation of the thorax and pelvis and the thorax and neck. However, the first screening task chosen during the initial assessment was a prone hip extension task with resistance. This screening task was chosen to: n address Steve’s cognitive belief that his right hamstring was weak; n provide information about his ability to control the pelvis during single leg extension; and n assess the impact that providing a controlled platform (ie. the pelvis) could have on his hip extension strength.

EMG onset relative to motion onset

The findings from this screening task alone were sufficient to begin to develop a treatment plan for Steve. The key findings from Steve’s story are noted in the centre of his Clinical Puzzle (Fig. 2) and include: n Meaningful complaint: Loss of speed and agility on the soccer field, feeling that the right upper hamstring is ‘on the verge of grabbing.’ n Cognitive belief: The proximal upper

THE INTEGRATED SYSTEMS MODEL IS A FRAMEWORK THAT AIDS THE BIOPSYCHOSOCIAL ASSESSMENT AND TREATMENT OF THE PATIENT right hamstring is still weak and will tear if he ‘goes hard.’ n Meaningful tasks: Running and rotating in all directions, looking left and right, while manipulating a soccer ball with either foot.

SCREENING TASK ANALYSIS – PRONE HIP EXTENSION WITH RESISTANCE During a single-leg-loading task in standing, Hungerford et al. (1) reported that healthy subjects recruited the deep muscles responsible for control of the pelvis before the biceps femoris and the gluteus maximus (Fig. 3). Additionally, they noted that the healthy controls recruited the gluteus maximus before the biceps femoris in this task. In subjects with both pelvic girdle pain and a sacroiliac joint (SIJ) control impairment, a recruitment delay was noted in both the transversus

400 300 200 100 0

l Control l Pelvic girdle pain l Symptomatic side

-100 -200 -300 IO/TrA

ADDL

GMAX

GMED

TFL

Surface EMG was used in this study; therefore, recruitment of these muscles could not be differentiated. Healthy controls are shown in blue and subjects with pelvic girdle pain associated with ipsilateral SIJ control impairment are shown in orange. The subjects demonstrated delayed onset during a weight shift of IO and TrA and MF and a reversal of recruitment timing of BF and GMAX with BF being recruited earlier and GMAX later, shown in yellow. ADDL, adductor longus; BF, biceps femoris; GMAX, gluteus maximus; GMED, gluteus medius; IO, internal oblique; MF, multifidus; TFL, tensor fascia lata; TrA, transversus abdominis. Figure 3: Mean EMG onset of IO and TrA (lowest fibres of internal oblique and transversus abdominis) for the supporting leg during single leg standing

abdominis (TrA) and internal oblique muscles as well as the multifidus. Additionally, a reversal of the timing of recruitment of the gluteus maximus and biceps femoris occurred (the biceps femoris contracted before the gluteus maximus). Proximally, the biceps femoris attaches to the sacrotuberous ligament (2), which is a known contributor to the form closure mechanism of the SIJ (3,4). When the motor control strategy for control of the pelvis is suboptimal, it is common to find overactivation of the biceps femoris and delayed or absent activation of the gluteus maximus. If these findings were present, this could be a biologically plausible mechanism to explain Steve’s sense of weak hamstrings. When prone, Steve could flex both the left and right knee independently without losing control of either his left or right SIJ. However, he was unable to maintain control of his right SIJ when asked to extend his right hip with the knee straight (higher load task). His ability to generate force during single leg hip extension was much weaker on the right side. Without resistance, he noticed that the right leg was heavier to lift than the left. Was this weakness due to the previous right hamstring injury or due to his inability to control the right SIJ? When the right side of the sacrum was passively nutated, thereby increasing the form closure mechanism, which is a pelvic correction for this task, his ability to generate force during right single leg hip extension was much improved. This finding negates his cognitive belief that the hip extension weakness is due to a weak right hamstring. When prone, the right TrA was not recruited when Steve contracted his pelvic floor. The left TrA response was normal. During active extension of the right hip, the biceps femoris contracted before the gluteus maximus. When he was cued specifically to activate the right TrA (stage 1 intrapelvic ring Co-Kinetic Journal 2019;79(January):32-38

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control training), and then to maintain this recruitment as he extended his right leg, he could control the right SIJ and generate notably more right hip extension force. The recruitment sequencing of his biceps femoris and gluteus maximus reverted to a more optimal pattern (gluteus maximus before biceps femoris) when he contracted his deep system before extending his hip. Steve’s thorax was also noted to translate to the left when he extended his right hip (4th and 6th thoracic rings translated left and rotated right, 5th thoracic ring translated right and rotated left). Correcting and controlling his thorax before extending his right hip did not restore his right SIJ control, did not change the recruitment strategy of his abdominals or the timing of the biceps femoris and gluteus maximus, and did not improve his ability to generate more right hip extension force. The thorax was not the current driver for this task. Controlling the pelvis was the best correction for this task; therefore, the pelvis was considered the current primary driver and the best place to begin treatment. Further tests were required to determine specifically what would need to be treated or trained to restore pelvic control for right hip extension. Steve believed that his pain was coming from the proximal insertion of his right hamstring. Palpation confirmed that the proximal hamstring was not tender to palpation; however, the right sacrotuberous ligament was, although nutation of the sacrum did not exacerbate his pain.

VECTOR ANALYSIS OF THE DRIVER – THE PELVIS There was no restriction of active or passive mobility of either the left or right SIJ; therefore, no vectors to release. This was a pelvic control impairment.

HYPOTHESIS TO EXPLAIN STEVE’S PAIN AND IMPAIRMENTS From this initial assessment, it was determined that the pelvis was Steve’s primary driver for the screening task of prone hip extension. Although his previous rehabilitation had addressed his initial acute right hamstring strain, a residual control impairment of his pelvis had remained, and may have preceded his injury. Without optimal strategies Co-Kinetic.com

1. Prone hip extension task Pelvis: Both SIJs controlled Thorax: 4th and 6th thoracic rings translated left and rotated right, 5th thoracic ring translated right and rotated left (PD) 2. Seated thoracic rotation Decreased RRot 4th thoracic ring ← 5th thoracic ring → PD 6th thoracic ring ← 3. Squat Pelvis starting position: RTPR and RIPT Low thorax starting position: LTPR Pelvis RTPR and RIPT increased during squat 4th thoracic ring ← 5th thoracic ring → PD 6th thoracic ring ← 4. O veractivation of a fascicle of the left iliocostalis attaching to the left 5th rib 5. R sacrotuberous ligament less tender to palpation

1 4 2

6. MC: R ight hamstring strength improving, no change in speed or agility on field CB: N o longer believes his hamstring is the only thing he needs to work on EB: H e’s been here before in therapy, not convinced yet that this ‘will work’ MT: V ertical loading in a variety of directions

CB, cognitive belief; EB, emotional belief; MC, meaningful complaint; MT, meaningful task; PD, primary driver; RIPT, right intrapelvic torsion; RRot, right rotation; RTPR, right transverse plane rotation; SIJ, sacroiliac joint; ←, left translation; →, right translation. Figure 4: Steve’s completed Clinical Puzzle from his second session

for pelvic control it is very difficult to generate force in either lower extremity and certainly difficult to perform with the speed and agility an elite athlete requires. Steve was attempting to gain control of his right SIJ by overusing the right biceps femoris to increase tension in the right sacrotuberous ligament to increase the form closure mechanism. The sacrotuberous ligament was possibly generating peripheral nociception and the overworked biceps femoris was likely to be creating the sensation that the ‘hamstrings were on the verge of grabbing.’

INITIAL ISM TREATMENT FOR STEVE’S PELVISDRIVEN HAMSTRING Steve was prescribed stage 1 motor control training for intrapelvic ring control, specifically targeting the recruitment of the right TrA. The goal was to develop better neuromuscular

recruitment strategies for load transfer through the pelvis. Stage 2 strategy capacity training for intrapelvic ring control (massed practice with focused attention on coactivation of the TrA, pelvic floor, and deep lumbosacral multifidus) with progressive leg loading (single bent leg lifts in supine, single leg extension in prone, circles both in supine and prone) and stage 3, Level 1 motor control and movement training (small double leg squats with centred weight shifts) were prescribed over the next 4 weeks.

FOLLOW-UP – SECOND SESSION (1 MONTH LATER) Steve was diligent with his home practice and felt some improvement in his hamstring strength but minimal change in his on-field speed or agility. The stage 1, stage 2, and stage 3, Level 1 motor control training exercises prescribed are fundamental 35

CORRECTING, AND MAINTAINING, THE ALIGNMENT OF THE 4TH TO 6TH THORACIC RINGS MARKEDLY IMPROVED STEVE’S RIGHT HIP EXTENSION STRENGTH to intrapelvic ring control but are not whole-body tasks, nor were they specific to his sport. That is to come! The Clinical Puzzle in Figure 4 illustrates this follow-up session.

SCREENING TASK ANALYSIS – PRONE HIP EXTENSION Steve was now able to extend his right hip and maintain control of the right SIJ. The effort required to lift his right leg was now similar to the left. When the right SIJ was controlled with passive nutation of the sacrum, his ability to generate more force during right single leg hip extension was not different, which indicated that the pelvis was no longer the driver for this task. His 4th and 6th thoracic rings continued to translate further left and rotate right and the 5th thoracic ring (the primary ring of the three thoracic rings) translated further right and rotated further left during right hip extension. Correcting, and maintaining, the alignment of these three thoracic rings now markedly improved his right hip extension strength. For the prone hip extension task, the thorax was now the primary driver.

SCREENING TASK ANALYSIS – THE SQUAT Steve stood with a right transverse plane rotation (RTPR) of his pelvis associated with a right intrapelvic torsion (RIPT), and a left transverse plane rotation of his lower thorax (incongruent to his pelvis). During a squat task the RTPR of his pelvis increased as did the right lateral translation and left rotation of the 5th thoracic ring. He could squat and maintain intrapelvic control which indicated that the work he had done over the previous month was facilitating better function of his pelvis. The 4th and 6th thoracic rings translated left and rotated right (and approximated towards each other on the left) and the 5th thoracic ring translated further 36

right and rotated further left during this squat task. Correcting the pelvic alignment and biomechanics during the squat task made the alignment of the thorax worse and did not improve Steve’s experience of strength or efficiency for the task. Correcting the alignment of the three thoracic rings (4th, 5th, and 6th) improved the alignment and biomechanics of the pelvis and while there was minimal change in his experience, it was noted to be easier to return to standing from the squat position. The thorax was now the primary driver for this task.

SCREENING TASK ANALYSIS – SEATED ROTATION OF THE THORAX During seated rotation of the thorax, Steve noticed it was more difficult to rotate his thorax to the right and reported a ‘pinching sensation’ in his midthorax in the region of the 4th to 6th thoracic rings at the end of his available range. Correcting the alignment and facilitating optimal biomechanics of the 4th to 6th thoracic rings improved the amplitude of right thoracic rotation and eliminated the pinching sensation in his midthorax.

VECTOR ANALYSIS OF THE DRIVER – THE THORAX Vector analysis of the 4th to 6th thoracic rings (passive listening on release of the correction) revealed the 5th thoracic ring to be the first to lose alignment. The first rib of the 5th thoracic ring to move was the left 5th rib, which posteriorly rotated. The entire 5th thoracic ring then translated right and rotated left followed by simultaneous left lateral translation and right rotation of the 4th and 6th thoracic rings. The vector was in the back, on the left and long. Palpation of the spinal extensors revealed overactivation of the right and left iliocostalis, the longissimus and the segmental multifidus and rotatores.

ISM TREATMENT – SECOND SESSION The iliocostalis and longissimus were released using a muscle recoil technique followed by segmental dry needling to T5–T6. Following this, the alignment and biomechanics of the 4th to 6th thoracic rings were improved and the effort to rotate the thorax to the right was less. Steve reported that the pinching sensation at the end of right rotation was gone. To maintain the alignment and the range of rotation gained from this release, thoracic ring stack, breathe and right rotate (5) was given as home practice. Steve was to check his right thoracic rotation frequently during the day and to repeat this release exercise whenever he felt a reduction in his range, or a return of the pinching sensation (home selfcheck). In addition, he was advised to follow this with thoracic ring stack (manually first and then using imagery), connect (recruit the deep muscles responsible for lumbopelvic control with the cues taught in the first session, ie. stage 1 intrapelvic ring motor control training), and squat to begin to build a new ‘brain map’, or motor control movement strategy for better alignment and biomechanics for his squat task. Combined, this movement practice is still stage 2 motor control and movement training of two body regions. The thorax and pelvis are controlled in static alignment and the lower extremity moved (squat). Massed practice with focused attention was encouraged to facilitate the speed of synaptic connectivity and thus the ease of use of the strategy (principles of training using neuroplasticity).

FOLLOW-UP – THIRD SESSION (2 WEEKS LATER) Once again, Steve was diligent with his home practice and this session could focus more on optimal strategies for the more complex movements required for his sport. On review of his current training regimen, it appeared that Steve had been taught to cocontract and brace his trunk while training. Although this strategy may be useful for aspects of some sports and tasks, it was not what he needed for speed or agility on the soccer field. He needed to be able to generate Co-Kinetic Journal 2019;79(January):32-38

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centred thoracopelvic rotation during single leg loading, which is a stage 3, level 3 task. He was encouraged to think about ‘creating space between the middle thoracic rings’ (release cue) and to initiate the rotation of his thorax from his chest and not his arms. The sensation or experience of performing this single leg thoracopelvic rotation task with different strategies and cues (bracing, floating, initiating the rotation using the thorax versus the arms, etc.) was repeated until Steve could determine which combination of movements and cues worked best for him to create fluid, easy movement. When he used his old strategy that limited his ability to rotate his thorax, the pinching sensation in the midthorax quickly returned and he also noticed more balance and control challenges (intermittent) when the task was performed with right single leg loading. The right biceps femoris would intermittently activate before the gluteus maximus on the times

when he felt more control challenges in his pelvis. Steve was beginning to understand the role that his thorax was having on his pelvic control and persistent hamstring ‘pulling’. The first step for motivating a change in behaviour is to create awareness as to why behaviour needs to change. Changing the experience of the body in a meaningful way is a powerful way to motivate behavioural change.

ON-FIELD VISIT (2 WEEKS LATER) I had the opportunity to watch and video Steve both during a field practice and in a game 2 weeks later. Immersed in the context of his sport, it was difficult for him to integrate the new strategies for thoracopelvic rotation and load transfer through his pelvis and right lower extremity and he tended to revert to a co-contraction bracing strategy for his trunk control. I shared the videos I had taken of his training and asked him how he felt during the practice.

BOX 1: STEVE’S RESPONSE TO VIDEO FEEDBACK “My hamstring and glute felt really good last night. I didn’t notice any stiffness and it felt quite loose. I felt a few twinges very high up in the tendon just below the glute area a couple of times and I have some very minor soreness today. I can just tell I played last night but this is as good as I have felt after a session in a while. The last 20–30 minutes I really pushed as hard as I could so I am happy with how I feel today. My back was still a little stiff when I was doing the rotation exercises and I was trying to focus on keeping my upper body a little looser but it is still something I really need to be conscious of. Honestly, I don’t realise how stiff my back is until I do the rotation exercises and I may need to spend a little more time loosening up my trunk before training. “Thanks for the videos, it is awesome to have some visual footage to look at. Wow did I look rigid on Tuesday, even in the game footage there is a lot of room for improvement. I really took a lot of extra time loosening up my chest and back on Saturday so I think that helped a bit. I really appreciate all the work and effort you have put in so far. I can’t tell you how many times I have gotten to where I was about 4 to 5 weeks ago and told different physiotherapists that it still doesn’t feel right, only to have them tell me everything looks good, pelvis is way better and the strength in the hamstring is great, just keep stretching that hamstring every day. I really do feel like my chest/back is the final piece, the last week I have felt great and last night I felt the best I have felt physically in a game in a long, long time. I know I still have a lot of work to do going forward but I am feeling positive and hopeful that I will be able to stay healthy and continue to progress. I could feel the hamstring a bit last night but nothing like it has been over the last couple of years so that is progress and for once I am cautiously a little excited.” Co-Kinetic.com

See Box 1 for Steve’s response to the video feedback.

CONCLUSION Steve continued to work on his strategies for thoracopelvic rotation and load transfer through single leg loading to ensure that his right biceps femoris was not overworked and that loads were shared throughout his body. With focused attention, massed practice and training tasks that relate to meaningful goals, learning and change can occur. Over time, he learned to move better on the field and noticed his speed and agility returning. He also developed more confidence in his right hamstring and could ‘go hard’ at his sport. Stimulating neuronal activation and growth and then building up the speed of synaptic connectivity for ease and agility requires neuroplastic training. Steve’s story is a good example of how poor strategies for pelvic control and thoracic biomechanics had created a persistent hamstring impairment.

Acknowledgment All figures have been taken from the author’s book The Thorax – An Integrated Approach ©Handspring Publishing 2018, and are reproduced here with permission. In addition, the book includes a number of videos detailing Steve’s assessment and movement re-training approaches/ development. References 1. Hungerford B, Gilleard W, Hodges PW. Evidence of altered lumbopelvic muscle recruitment in the presence of sacroiliac joint pain. Spine 2003;28(14):1593–1600 2. van Wingerden JP, Vleeming A, Snijders CJ. A functionalanatomical approach to the spine-pelvis mechanism: Interaction between the biceps femoris muscle and the sacrotuberous ligament. European Spine Journal 1993;2(3):140 3. Vleeming A, Stoeckart R, Snijders CJ. The sacrotuberous ligament: A conceptual approach to its dynamic role in stabilizing the sacroiliac joint. Clinical Biomechanics 1989;4(4):201–203 4. Vleeming A, van Wingerden JP, Snijders CJ et al. Load application to the sacrotuberous ligament: Influences on sacroiliac joint mechanics. Clinical Biomechanics 1989;4(4):204–209 5. Lee L-J. The thoracic ring approach: A whole person framework to assess and treat the thoracic spine and rib cage. In: Magee DJ, Zachazewski JE, Quillen WS, et al. (eds) Pathology and Intervention in Musculoskeletal Rehabilitation, pp.436–470, 2nd edn. Elsevier 2016. ISBN 978-0323310727. Buy from Amazon (Print £64.99 Kindle £61.74) https://amzn.to/2P215oI.

RELATED CONTENT Other Co-Kinetic articles adapted from books published by Handspring include: Spinal Motions: Structure and Function https://spxj.nl/2JfyVV7 Efficacy of Manual Therapy for Chronic Musculoskeletal Pain http://spxj.nl/2oOMCls Connectivity: Fascia-Related Therapies http://spxj.nl/2h9ii4i D. Lesondak, Fascia: What it is and Why it Matters http://spxj.nl/2BSph6F Adding Lessons from TCM to Your Manual Therapy Toolbox http://spxj.nl/2s6Tk9n

THE AUTHOR Diane Lee BSR, FCAMT, CGIMS is an orthopaedic musculoskeletal physiotherapist (FCAMT) and designated as a Clinical Specialist in Women’s Health by the Canadian Physiotherapy Association. She has long been interested in the biomechanics of the thorax and the impact of sub-optimal thoracic alignment, mobility and control in multiple conditions throughout the whole body. She has written several chapters on both the pelvis and the thorax as well as published two peer-reviewed articles (1993, 2015 JMMT) on her biomechanical model of the thorax. She self-published two books on the thorax (Manual Therapy for the Thorax 1994 and The Thorax – An Integrated Approach 2003), which are both no longer available and is excited to collaborate with Handspring Publishing on this new edition of The Thorax – An Integrated Approach (2018). The intent is to describe a biopsychosocial approach that incorporates the novel, updated biomechanical model of the thorax to facilitate wise decisions for clinicians working with musculoskeletal, urogynecological and respiratory conditions. Diane lectures internationally on the thorax and other topics and provides online education through her company Learn with Diane Lee. Website: www.learnwithdianelee.com Twitter: @DianeLeePT Facebook: www.facebook.com/DianeLeeAssocPhysio/ LinkedIn: www.linkedin.com/in/diane-lee-3ba4024/

DISCUSSIONS hink about your knowledge of the anatomy of the thorax. Do you know T the structures involved and how they connect the thorax to even distant parts of the body? In your treatment of patients, do you consider a biopsychosocial approach? Would using the Integrated Systems Model and the Clinical Puzzle reflection tool help you to improve your holistic treatment? Discuss how you might pay more attention to the role of the thorax in your patients’ conditions.

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: Owing to the interconnectedness of the thorax, optimal thorax function is paramount for good health https://spxj.nl/2Qwjxu8 Tweet this: The Integrated Systems Model aids a biopsychosocial assessment and treatment of the patient https://spxj.nl/2Qwjxu8 Tweet this: Creating awareness about why behaviour needs to change is the first step towards changing behaviour https://spxj.nl/2Qwjxu8

KEY POINTS n C urrent thinking about the thorax sees it as not just a ‘box’ in the middle of the spine but as a region that is interconnected to all parts of the body. n The interconnectedness of the thorax means that poor thorax biomechanics often play a role in multiple conditions and at regions far removed from the thorax. n The Integrated Systems Model is a framework that considers the patient as a whole and allows organisation of all the biopsychosocial information gathered during assessment. n Steve, an elite soccer player, had had an acute tear of the right proximal biceps femoris 2.5–3 years ago but, despite traditional rehabilitation, still had persisting symptoms. n Cognitive and emotional beliefs: Steve believed that his leg was still weak but his exercises were not improving his speed and agility and he was concerned about losing his place on the team. n Meaningful tasks: Steve needed to be able to run forwards, backwards and sideways, while manipulating the ball with either foot, with speed and agility. n The first screening task, prone hip extension with resistance, revealed an inability to control his right SIJ, indicating an impairment of pelvic control. n After improving intrapelvic ring control, reassessment revealed that malalignment of three thoracic rings was now the primary driver of his symptoms. n After treatment and exercises for thoracic release, Steve developed better alignment and thoracopelvic rotation. n Video feedback was useful for demonstrating the issues that the therapist wanted to address with the patient.

The Thorax – An Integrated Approach By Diane Lee Handspring Publishing 2018; ISBN: 978-1-912085-05-7 Buy it from Handspring - https:// handspringpublishing.com/product/ the-thorax-an-integrated-approach/ This clinical textbook will update the reader on the relevant anatomy, known biomechanics, clinical assessment, musculoskeletal conditions and treatment of the thorax and how these relate to the function of the whole body. An integrated biopsychosocial model (the Integrated Systems Model – ISM) will be highlighted in this text and used as a foundation for clinicians to organise their knowledge from multiple sources. The text emphasises the current suggestion from the evidence that treatment be individualised and that clinical reasoning form the basis for treatment decisions. Richly illustrated with 3D-rendered colour anatomical drawings, and over 250 clinical photographs, The Thorax: An Integrated Approach is the definitive manual on the thorax for all bodyworkers helping patients improve mobility and control of the trunk. CONTENTS Chapter 1. Anatomy of the thorax Chapter 2. Biomechanics of the thorax Chapter 3. Assessment of the thorax and its relationship to the whole body Chapter 4. Principles of the integrated systems model for treatment of the individual patient Chapter 5. Case reports that highlight the relationship of the thorax to the whole body Chapter 6. Release techniques for the system impairments Chapter 7. Motor learning and movement training

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FOR THE KNEE Manual therapy (MT) is a commonly used therapeutic technique, which may be applied to both joints and soft tissue. As we saw in the article ‘Clinically Effective Manual Therapy for the Hip’, MT has quantifiable effects on pain and movement, but its effects are likely to sit within a biopsychosocial rather than purely mechanistic model of healthcare. In this article we will use examples of MT on the knee to show how this technique may be used as a central part of a rehabilitation process. Read this article online https://spxj.nl/2PaI8QI EMPOWERING OR DISEMPOWERING THE PATIENT?

USING MANUAL THERAPY TO INSTIGATE REHABILITATION ENABLES THE PATIENT TO MANAGE THEIR OWN TREATMENT OUTCOME Co-Kinetic.com

KNEE | 19-01-COKINETIC FORMATS

WEB

MOBILE

MEDIA CONTENTS Set of six videos demonstrating knee mobilisation technique. See online version of article

TECHNIQUE ONE: CAPSULAR STRETCH Following knee injury, tightness and limitation to flexion can suggest intracapsular swelling. The increased fluid volume, synovial irritation and pain

Video 1: Capsular stretch for the knee joint https://spxj.nl/2PaI8QI

Video 2: Antero-posterior glide for the knee joint https://spxj.nl/2PaI8QI

Video 3: Home mobilisation exercises for the knee https://spxj.nl/2PaI8QI

Video 4: Close-up of home exercises for knee mobilisation https://spxj.nl/2PaI8QI 40

can limit active movement resulting in a reduction of flexion range which is noticeably greater than the reduction of extension range – the capsular pattern of the joint. Increasing flexion range can be brought about by using exercise therapy, which is either general (for example walking, stair climbing) or specific (active or passive knee bending). However, the volume of fluid and degree of tissue tightness can make moving into end range flexion both painful and stiff. To ease these symptoms, placing a support such as a rolled towel behind the knee within the popliteal region is often helpful. A common and effective MT procedure for limited flexion with subacute pain is the ‘capsular stretch’ technique, which mimics flexion with popliteal support. Although symptoms of stiffness and pain are eased with this technique, the force required to stretch the capsule is unlikely to be created. The mechanism of action is likely to be neuromuscular, causing a reduction in pain and alteration in proprioception. With the patient in supine lying, and where the right leg is to be treated the therapist stands to the right, taking up a walk standing stance (Video 1). Passive flexion range if first assessed determining the distance of the heel to the buttock. The right forearm is then placed behind the patients knee and the left hand grips the shin to press the knee into flexion. The forearm is positioned so the thickest part of the muscle mass contacts the patient, reducing contact pressure. Where the therapist has a very slim forearm, a towel may be wrapped around it to create extra padding. The force is applied with a slow build-up and release, using a 5 progressing to 10 second hold. Patient tolerance limits force and holding time, and the technique is repeated 3–5 times before retest of motion range (heel to buttock distance). A simple home exercise may be used to mimic the MT technique. The patient places a towel, rolled lengthways, behind their knee high up into the crook of the joint (popliteal fossa). They then grip their shin with one or both hands and apply overpressure to press the joint into

further flexion. Patient education points include tolerance of mild discomfort (stretching), avoidance of sudden movement (jolting), and avoidance of intense pain, generally beyond 6 out of 10 on a numerical rating scale. Where the patient is unable to position the towel correctly a partner may be required, and where the patient is unable to grasp their shin a belt or second towel may be used, looped around the shin towards the ankle.

TECHNIQUE TWO: GROSS ANTERO-POSTERIOR GLIDE An antero-posterior (AP) glide may be performed with the tibia moving on the fixed femur (Video 2). Have the patient in supine lying with a firm block (compressed folded towel or dense foam block) placed beneath their femur above the popliteal region of the knee. Pressure is placed over the tibial tuberosity with the hands surrounding the knee. Traditionally the grip is with the thumbs together, thumb pads pressing on the tuberosity and fingers folded around the knee avoiding fingertip pressure into the popliteal region. An alternative is to V contact between the thumb and first finger, supporting one hand over the other. Pressure is produced by the therapist leaning their body weight forwards and directing it downwards through the hands. Importantly the hands direct, but do not create the AP force. The patient’s symptoms are monitored and the aim is to reduce pain, and increase pain-free movement at retest. The AP glide moves the tibia backwards relative to the fixed femur, a movement equivalent to moving the femur forwards on the fixed tibia. This second action occurs when the foot is on the ground and the bodyweight moves forwards, as in running or jumping forwards to a sudden stop (Videos 3 & 4, first part). These actions can be used as part of a progressive rehabilitation programme to build knee resilience. Begin with the foot on the ground, knee slightly flexed or ‘soft’ (10–15° flexion). Swing the arms and trunk forwards transferring the body weight from the heel to the toe region of the foot. Build this to a slow and then fast walk, stopping suddenly on the spot. Initially make this predictable Co-Kinetic Journal 2019;79(January):39-42

MANUAL THERAPY

(‘3 steps and then stop’) and then unpredictable (‘walk and stop when I say’). Build to a slow and then fast jog, and then progress to jumping. Jumping actions build from bilateral (jump with both feet together) to unilateral (land on one foot), and from flat surface to jumping from a step to perform plyometric actions.

TECHNIQUE THREE: VALGUS OR VARUS GLIDE Knee collateral ligament injuries are a common occurrence in both competitive sport and general exercise (4), and medial joint pain is often seen in conditions such as knee osteoarthrosis. Using a MT technique aimed at the medial aspect of the knee joint is often clinically effective at modifying symptoms in the shortterm. When symptom modification is demonstrated in this way to a patient, compliance is likely to be greater with exercise therapy designed to place a valgus stress on the knee. The patient is lying in supine with the therapist in walk standing, half facing the patient (Video 5). When treating the left leg, the therapist grasps the leg with their left arm, placing the shin beneath their arm for stability, pressure is applied with the left hand below the knee joint. The knee is unlocked by placing it into 10–15° of flexion. The valgus stress (knee joint opening medially) is imposed with the right hand, using the heal of the hand (fingers cup the knee) placed over the lateral joint line. Force is transmitted through the forearm which lies perpendicular to the joint and applied but not created by the hand. Where varus glide (knee joint opening laterally) is required, the therapist’s body position is reversed. The therapist stands against the treatment couch placing the patients leg on the therapist’s right side. The right hand grasps the patients shin and the heel of the left hand is placed over the medial joint line to create the varus gliding force (Video 5). In each case, low grade rhythmic oscillations are used; for example, grades 1 or 2 (low amplitude movement at the beginning of range) for 20–30 seconds. Where pain is reduced, the mobilisation is repeated for two or three sets (see Table 1: Manual therapy Co-Kinetic.com

(a)

(b)

Figure 1: Valgus stress exercise: (a) stage 1 and (b) stage 2

application framework, in the article ‘Clinically Effective Manual Therapy for the Hip’). Exercise therapy is used to impose valgus and varus stress on the knee to build resilience and patient confidence (Fig. 1). Standing on the affected leg, the action is to step to the side with the contralateral leg, and then to cross the leg in front of the ipsilateral leg. Again, step to the side, and then behind the affected leg. This static action can progress to slow and then faster side step actions. Initially this is performed on flat even ground (Fig. 1a), and then on a slope or from a step bench (Fig. 1b) to vary the imposed force and challenge muscle control and proprioception (Videos 3 & 4, second part).

over the knee joint line during a leg movement which is limited or painful (for example squatting or lunging). When originally described, the technique was claimed to squeeze the

INCREASED PATIENT SELFEFFICACY ENABLES THE PATIENT TO MOVE FURTHER ALONG THE RECOVERY TIMESCALE

TECHNIQUE FOUR: MOBILISATION WITH MOVEMENT (SQUEEZE TECHNIQUE) The squeeze technique, used for treating knee meniscus injury, is a classic example of the potential clinical benefit of changing sensory inflow to the body and altering associative learning. The principle behind this effect would appear to be that pain is a warning of potential harm or threat to the body. When this threat occurs, several factors interact in the brain (neuromatrix) and become associated together. Over time, specific movements and pain become linked, often as a result of the movement being similar to that which originally created the pathology. The squeeze technique (5) uses a focused pressure

Video 5: Valgus and varus stresses to the knee https://spxj.nl/2PaI8QI

Video 6: Squeeze technique for the knee https://spxj.nl/2PaI8QI 41

medial meniscus back into shape. It seems unlikely that manual pressure over the joint line would affect the meniscus (which is attached to the bone via the coronary ligament), and any effect that is created would only be temporary. The patient begins in a full weight-bearing starting position with the foot of the affected leg on a low step or taking up a squatting position (hand holding a support for balance) (Video 6). Initially a squat or lunge is performed to recreate the patient’s symptoms. The mobilisation is then performed by placing the edge of one thumb over the painful region of the

knee joint line and creating force by pressing on the finger with the other hand. A firm pressure is used, directed in towards the joint as the patient performs the painful squat or lunge action. The aim is to increase pain-free motion range, and the direction of the MT technique is varied to produce the best outcome. The action is repeated 2 or 3 times and then the patient (or their partner) is taught to produce the mobilisation on themselves. They perform the mobilisation with movement over a period long enough to remove symptoms (typically 3 or 4 sessions), and then re-strengthen the knee incorporating a variety of

KEY POINTS n Manual therapists need to be careful that the way the diagnosis and treatment is presented will result in empowering the patient to manage their own treatment outcome and eventual decreased reliance on the therapist. n Manual therapy usually produces temporary changes in motion that result from short-term reduction in muscle tone, probably through associated neuromuscular factors. n The aim of manual therapy is to remove the immediate ‘block’ to movement to allow the patient to continue with a progressive regimen of rehabilitation exercises at home. n Knee injury can cause limited flexion as a result of intracapsular swelling, which can be addressed by the use of the capsular stretch technique when inflammation has resolved. n Educating the patient about tolerance of mild discomfort is useful for encouraging adherence to home exercise regimens. n Antero-posterior glides to mobilise the tibiofemoral joint mimic the action that occurs when walking, running or jumping to a sudden stop. These actions can be used to build resilience in the knee. n Valgus and varus glides at the knee are used to treat knee collateral ligament injuries. n The pain from some knee meniscus injuries can be treated using the squeeze technique, which seems to alter the sensory inflow in the body and undo the learned association of movement and pain. n All of the manual therapy techniques demonstrated here are accompanied by descriptions of associated exercises for the patient to do at home to build strength in the knee.

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: Manual therapy as part of a progressive rehabilitation programme can increase patient self-efficacy. https://spxj.nl/2PaI8QI Tweet this: Changes in motion caused by manual therapy most likely result from neuromuscular effects. https://spxj.nl/2PaI8QI Tweet this: Manual therapy usually causes temporary effects resulting from short-term reductions in muscle tone. https://spxj.nl/2PaI8QI Tweet this: Exercise therapy is used to build resilience and patient confidence in the knee following injury. https://spxj.nl/2PaI8QI

lunge and squat actions into a general rehabilitation programme (4–6 weeks). References 1. Langridge N. Manual therapy – feeling for cracks in the theories and practices. Chews Health 2017 Podcast: https://spxj.nl/2BnjeJY 2. Bereznick DE, Ross JK, McGill SM. The frictional properties at the thoracic skin–fascia interface: implications in spine manipulation. Clinical Biomechanics 2002;17(4):297–303 3. Cleland JA, Childs JD, McRae M, et al. Immediate effects of thoracic manipulation in patients with neck pain: a randomized clinical trial. Manual Therapy 2005;10:127–135 4. Norris CM. Sports and soft tissue injuries: a guide for students and therapists, 5th edn. Routledge 2018. ISBN 9781138106598 (Print £39.99 Kindle £37.99). Buy from Amazon https://amzn.to/2OXZP5Q 5. Mulligan BR. Manual therapy: nags, snags, MWM, 6th edn. Orthopedic Physical Therapy & Rehabilitation 2010. ISBN 978-1877520037 (£49.99). Buy from Amazon https://amzn.to/2R16yxN.

DISCUSSIONS iscuss the effects of manual therapy on motion and D how they are likely to be caused. Think about how you present your manual therapy to your patients. Do you educate them adequately about the role it plays and the role that they need to play in their rehabilitation? What conversations can you have with your patients to encourage increased adherence to home exercise regimens and self-efficacy?

RELATED CONTENT linically Effective Manual Therapy for the Hip C https://spxj.nl/2LWMwku Patellofemoral Pain Syndrome: A Practical Treatment Approach http://spxj.nl/2s6sWwA Osteoarthritis of the Knee: A Practical Treatment Approach http://spxj.nl/2EmeS8S For more Co-Kinetic articles written by Dr Chris Norris visit https://www.co-kinetic.com/profile/14 THE AUTHOR Dr Chris Norris PhD, MCSP is a physiotherapist with over 35 years’ experience. He has an MSc in Exercise Science and a PhD in Backpain Rehabilitation, together with clinical qualifications in manual therapy, orthopaedic medicine, acupuncture, and medical education. Chris is the author of 12 books on physiotherapy, exercise, and acupuncture and lectures widely in the UK and abroad. He is a visiting lecturer and external examiner to several universities at postgraduate level. He runs private clinics in Cheshire and Manchester and his postgraduate courses for therapists are on his website: http://www.norrishealth.co.uk/. Email: cmn@norrishealth.co.uk Twitter: @NorrisHealth LinkedIn: https://uk.linkedin.com/in/dr-christopher-norris-aa366115/ Facebook: https://www.facebook.com/NorrisAssociates/

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THE BLUEPRINT FOR RUNNING A SUCCESSFUL OPEN CLINIC EVENT:

OPEN CLINIC

Part 1 Concept and Planning This article will help you to plan your Open Clinic event in a way that allows you to focus on the goals that you want to achieve. Read this article online https://spxj.nl/2rrhPME OVERVIEW In 2016, I ran our first Open Clinic event. I had absolutely no experience of running an Open Clinic and had never even attended one before, and naturally instead of going small, and starting with an evening or relatively a simple one day option, I decided to run an entire Open Clinic Week. Needless to say, it was a big learning curve and one I’m going to share with you over the next few articles. Three years down the line it’s the biggest event in our calendar, we gather 100s of email addresses from prospective new customers, have over 100 new clients visit the clinic during the week and deliver around 400 free appointments. Most therapy businesses are constantly looking for new or innovative ways to promote their business, and running an Open Clinic event is an AMAZING way to do it. There are lots of different ways of doing it, and the key is to test and see what works best for you, but typically it involves a 1- or 2-day event where current and potential clients can come and visit your premises, try out some taster sessions, meet the practitioners and access some exclusive offers. It boosts morale within the clinic, brings practitioners together with clients who need their help and is a great opportunity to help answer any of those questions that are holding potential clients back from booking that first appointment with you. Open Clinic events can come in any shape and size; it could be just you, opening the doors to your home practice, inviting clients to a free talk, or Co-Kinetic.com

it could involve collaborating with other practitioners in your area, making it a real Health & Wellness event, reaching as many new clients as possible. No matter what type of event you decide to run there is a very simple blueprint for ensuring success. In this series of articles, I’ll talk you through the 6 Step Blueprint for creating a winning Open Clinic event so that by next year you too will be getting over 100 new clients booking in a single day.

WHY you are Going to Run this Open Clinic Event? Concept For your first event focus on just ONE of the following areas. If you’ve already had experience in running an Open Clinic before then use this list to see what you’re already doing well and which other areas you can develop for your next event. 1. Brand Awareness Stage 1 of any marketing plan is getting more people to hear about you and your business, understand what you offer and how it can help them. If this is your goal then you’ll focus on marketing in the local area around your clinic, reaching as many people as possible. Consider offering at LEAST one workshop or talk to help increase the

number of people who can attend your event. 2. Lead Generation This involves collecting new email addresses of potential clients. With this as your goal you’ll focus more on the long-term benefit of this event. Of course you want attendees on the day but you’ll really focus on your content marketing AFTER the event to help bring in those sign-ups who didn’t actually make it in on the day. If the number of email addresses is more important than the immediate attendees, you’ll want to ensure you set up your marketing funnel to collect email addresses EVEN if they aren’t attending, so you can contact them in future by using a lead page and contact form. This requires more technical knowledge to really do well here (or of course a subscription with Co-Kinetic which will help cover this technical aspect for you).

19-01-COKINETIC FORMATS WEB MOBILE PRINT BY VICKI MARSH, MASSAGE THERAPIST, OWNER OF THE HEADSTART CLINICS

3. Conversions Getting that first paying appointment booked. For most clinic owners this seems the most obvious goal of an Open Clinic event, to get new clients in, attending your event and booked into the diary for future appointments. To see a high number of clients from an Open Clinic rebooking for a paid appointment in the weeks after the event you’ll have to do two things: firstly, deliver an AMAZING experience during the event; and secondly, have a really enticing offer on the table encouraging them to book there and then. By all means set ‘conversions’ as your goal, especially if you are setting up 43

a second location, have just relocated or you are struggling to find ways to get new clients in, but I do caution against it as your primary goal. I’ve seen it take up to 2 years for an Open Clinic new client to come back for a full price appointment, simply because there was nothing wrong with the client during that time and they didn’t need our services. It can be very easy to get disheartened and give up when you don’t make millions from your first Open Clinic event, and that’s the last thing we want to happen. For more information about “Short vs Long Sell: Converting clients from promotions to paying full price” my presentation on p45. 4. Client Retention Often never considered but this can be one of the most successful goals when running an Open Clinic event. If you look to focus on reactivating old clients AND saying thank you to your regular clients, you’ll keep costs low, and attendance high, as well as having great rebooking rates. If you love the idea of running an Open Clinic but get intimidated by marketing I strongly suggest you make this your goal for your first event. You’ll feel amazing by the end of the event and you’ll get a great return on your investment in terms of time and money. 5. Split Testing This involves being able to test different marketing strategies, appointment types and learn what your audience wants. This is a more advanced goal, so only consider this if you already have a sizeable client base to market to or you are already running Open Clinic events or free taster sessions. I personally love this goal. By having different appointment names available you can literally see what your clients want, do they prefer your Chronic Pain Clinic, or Mobility for Athletes sessions? Which new service should you bring in? By assessing which sells out first you gain a lot of useful information for growing your business over the coming months. The same applies with marketing. Each year I build upon the marketing from the previous year. This time I created an offer on the thank you page for early registrations to the event and 44

was able to cover my entire Facebook Advertising budget from those bookings before the event had even started! But that took time for me to achieve, I certainly did NOT manage that in Year 1. 6. Interviewing & Training Use this as your goal if you’re looking to build a six-figure business. We have some therapists who adore delivering 60-minute sports massages, which is great, but it often leaves 30-minute gaps in their diary. So, for those of you who run a larger clinic offer 30-minute taster appointments at your Open Clinic day to help train the team to be more confident and efficient delivering shorter sessions. This helps to fill more diary time and increase profits. It’s also a great opportunity to interview other health professionals you’re looking to work with, or refer to. Are they easy to work with? Do they use their initiative? What is ‘their’ rebooking rate like? How much time did they take to manage in comparison to other therapists you are working with? It’s an ideal way to fast-track your recruitment experience as the business owner to quickly understand what you’re really looking for in your ideal employee or associate.

HOW are you Going to Run this Open Clinic Event? Planning Now you have decided on your primary goal for the Open Clinic event you’ll see how decision-making becomes so much easier. Answer these questions to help you plan your event, and note down any more questions you think of during the process. Scheduling What time of year do you want to run the event? I’ve found that it’s worked really well to run them during our normal quiet times such as in the summer or over the Christmas break, to boost attendance.. n Can you schedule your event to align other events you’re attending locally? This is important because instead of trying to sell offers or appointments at these events, you can point EVERYONE to your Open Clinic day. It allows you to practise how to market the day, understand what the

common questions are that crop up, and then have your marketing copy perfected ready for launching to your list or through paid marketing. n What days of the week are you going to run the event on? What type of clients do you want to attract? If you are already busy at weekends but quiet on weekday mornings then consider holding your event at a time that will naturally attract the types of clients that you are looking for. This is great to consider, because even an event at 50% capacity but held during your quiet times, is a much bigger win than running an event at 100% capacity but at a times when you’d normally be fully booked. n Which times are easiest for you to hold this event? This is where you want to consider things like restrictions on local parking, rush hour, organising it at a time where you won’t be disturbing other practitioners if you are in a multidisciplinary practice, or when you can easily be on call for any emergencies other practitioners have. Appointments and Services n What are the appointment types or services you are going to offer on the day? n What length of appointment are you going to offer and why? n How are you going to plan for being over- or under-booked? What break or handover times are there, if you are busy? And what could you do if on the day the appointments/ services aren’t fully booked, to help you still hit your goal? n Are you going to continue to offer some normal appointments during the event? This allows you to care for your regular clients and help maintain your cashflow. n How many appointments or workshop places are you going to have available? It can be really tempting to cram as many clients in as possible for an event like this, but remember to factor in handover times, therapists (and clients) running late and break times for example. Pick a number of spaces that will be a stretch for you to fill (a challenge is always good) but is also realistic in terms of scheduling. Co-Kinetic Journal 2019;79(January):43-45

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Trying to fit 100 appointments into a 1-day event with just one room simply isn’t going to happen! In the next article in this series we’ll look into how to market your event, focusing on how to maximise the free marketing available to you BEFORE you launch into any paid marketing. We’ll then look at running your event, selling and converting clients to paying customers and how to review your results so you can improve it next time. If you can’t wait for the next articles, then you can listen to Episodes 25–29 of the Massage Therapists’ Business & Marketing Podcast. https://spxj.nl/2L9wMf6

RELATED CONTENT ow to Generate £3,000 in H Revenue in Just 6 Hours – Blizard Physiotherapy Running MOT [Case Study] https://spxj.nl/2wLbRZW he Overwhelming Case T for “Try Before You Buy” Conversion Events [Article] https://spxj.nl/2StXxgS

Vicki Marsh teaches massage therapists and clinic owners how to start, grow and scale their business freeing up their time, building confidence and earning more money. She is the founder of the Massage Therapist Business School, hosting the Massage Therapists’ Business & Marketing Podcast and running the Clinic Business Growth Membership site which provides actionable business advice tailored to massage therapists & clinic owners. To find out more visit www.massagetherapistbusinessschool.com or www.massagetherapistbusinessschool.com/ clinicbusinessgrowth to get your 7 day trial of Clinic Business Growth.

FIVE GO ON A PATIENT JOURNEY: Practical Advice for Building Your Business Through the Customer Journey [Video Presentations] This is a series of short video presentations re-recorded (in a quieter environment) after the COPA Show 2018. The presentations take you from how to get your business in front of prospective new clients, through to converting them into paying customers, and then wowing them with an amazing customer experience. Every session is packed with practical advice and if you use what you’ll learn, you’ll recoup your viewing time investment, hundreds of times over.

5 Offline Tactics to Start Filling Your Practice Marketing Funnel Everyone is focused on digital marketing but ultimately in healthcare you are still a local business. In this video I will talk you through 5 offline tactics you can use to start drawing more local people into your practice marketing funnel. http://www.jillwoods.com By Jill Woods, podiatrist and marketing specialist, Practice Momentum Healthcare

5 Online Tactics for Filling Your Clinic Marketing Funnel Following on from Jill Wood’s previous presentation, this presentation looks at ways to introduce new customers to your business. The session will focus on online tactics you can use in

combination with offline tactics to get your brand and business in front of people. We’ll then look at ways that you can collect new customer leads and nurture these towards becoming paying customers. By Tor Davies, marketing specialist and founder of the Co-Kinetic Marketing System

How to Convert Patients from Promotions to Paying Full Price Turning your marketing into paying patients doesn’t have to be a dark art. Learn two simple strategies to convert interested patients into paying ones. With real life examples from our Open Clinic Week I show you how to approach your promotions, free workshops and trial appointments to create loyal full price patients by positioning yourself as their top clinic of choice. By Vicki Marsh, therapist, marketing specialist and Massage Business School founder

The Secret to Delivering An Amazing Customer Experience In this session, we’ll

Co-Kinetic.com

examine specific ‘expectation matching’ techniques which help develop trust, likeability and rapport. And we’ll show you exactly where you can apply these techniques throughout the entire customer journey from the early discovery/awareness stage, through to nurturing the relationship, enquiring about booking and then attending the first appointment. It is a key ingredient in the process of building loyal customers. By Andy Hosgood, physiotherapist and founder of Your Perfect Practice

Grow Your Business by Making your Patients WANT to Come Back You work hard to market your clinic, you spend money on adverts, and time growing your reputation, but what do you do to make sure that you keep hold of those patients? This session will show you how to feel comfortable about re-booking your patients, and creating a list of engaged patients who not only want to come back, but will tell the world about how great your service is! By Andy Byrne, physiotherapist and founder of Triad Health

The Overwhelming ” Y U B U O Y E R Case for O F E “TRY B Conversion Events BY TOR DAVIES, CO-KINETIC FOUNDER

19-01-COKINETIC FORMATS WEB MOBILE

WHAT IS A ‘TRY BEFORE YOU BUY’ EVENT? A ‘try before you buy’ conversion event does exactly what it says on the tin! It gives people a chance to ‘meet’ you and try your services, preferably for free, before they commit to booking a fully-paid appointment. Some therapists feel that offering free trials, devalues their profession, skills and qualifications and makes them look cheap and desperate for business. And this is an understandable concern. We’ve all seen it, as restaurants, desperate to stay open, make increasingly ridiculous offers – most of which end up failing ultimately. And I tried really hard to find more to say about the disadvantages but struggled to come up with anything else. If you’re reading this and starting to feel that I haven’t given the cons their due justification, then please jump on the discussion panel below the online version of this article, and share those cons with me and I will happily update this piece of content. But honestly, I couldn’t find any additional legitimate cons. The pros of ‘try before you buy’ conversion events are overwhelming. Before we explore them in more detail, let’s look at what I mean by ‘try before you buy’ events.

One of the best ways of bringing in new paying customers, is to offer ‘try before you buy’ or ‘conversion’ events. These could involve anything from a free consultation, assessment, open day, treatment or education event. Your imagination is your only limit. There are so many advantages to these ‘open’ events, it’s hard to imagine why anyone wouldn’t embrace them, but some people are vehemently opposed to them because they don’t feel they should devalue themselves, by offering their services for free. In this article, I’m going to explore the pros and cons, and leave you to decide. Read this article online https://spxj.nl/2StXxgS That’s just a handful of ideas. In reality, you can do whatever you want. The key is to pick something you’re good at and that you love doing because you’re likely to be more passionate and that will come across strongly to your attendees.

WHY ARE ‘TRY BEFORE YOU BUY’ CONVERSION EVENTS GREAT? From a prospective client perspective n Meeting you/your therapists and becoming familiar with your clinic, parking options, how to get there, etc, will increase familiarity and reduce barriers to booking.

EXAMPLES OF ‘TRY BEFORE YOU BUY’ CONVERSION EVENTS F ree consultations – telephone/Skype/in person Education events – evening lectures/presentations/seminars Mini-assessments/injury screening – muscle balance, gait analysis, bike fit Topic-specific events like running injury clinics, ski fit, headache prevention, back pain, etc Open clinic days – range of free events/trials Webinars – online presentation with Q+A Free treatments – free 20-minute massage – great if you’ve got therapists with free appointment slots or students in for work experience n Packages and discounts – ‘buy one, get one free’, 50% off your first treatment n n n n n n n

nY ou will get qualified leads so you know who to focus your attention on. For example, if they visit your clinic you know that (a) they are local (not something you can ascertain from your social media followers without using paid ads) and (b) they’re interested in your services. n Potential customers will know exactly what to expect from you/ your team moving forward. n They are a great opportunity to help answer any questions that are holding potential clients back from booking that first appointment with you. n A physical visit gives you a chance to show off facilities and equipment and communicate much more than what’s on your website – let’s be realistic, very few people have the time to pour over a website anyway, however pretty it might look. n A face-to-face meeting, even a telephone call, can help you build a level of rapport and trust that is much more difficult to build through digital methods. n It gives you the opportunity to learn more about your prospective clients, Co-Kinetic Journal 2019;79(January):46-47

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where you may be able to help them most, what specific problems they need solving and how that can impact what’s important to them in their daily life, ie. identifying the ‘so what’ factor (see Andy Byrne’s presentation on p45). n You will reach a greater diversity of potential customers who may not have even known that they needed what you offer. n Offer special deals and incentives to sign up to a package on the night. n Use it to reward loyal customers, people who have referred friends to you, anyone who stands out and who you want to encourage to keep spreading the word. From a therapist/team/clinic/ business owner perspective n It helps you get your business in front of people (the first goal of marketing). n It helps you collect new email leads. n Team-run events boosts morale as you can work on something as a team rather than always working individually. n It can be a great way to say thank you to existing or regular clients which boosts client retention. n If your competition does not offer free trials, this could be a competitive differentiator. And if they do and you don’t, you’re at a disadvantage. n And even if they don’t convert to a paying ‘service’ or product on the night, you can still benefit by: - Asking for Google/Facebook reviews if they’ve found the evening useful - Handing out ‘refer a friend’ offers - Asking for feedback about anything relevant to their experience, the clinic, your therapists, etc. n It’s also an ideal opportunity to try out new things before you launch them on your paying customers, like new sessions. n You could use it as part of your interview process with new staff and new therapists. n Why not forge connections with a local university or college and take on students for work experience? (Just make it clear to your prospective clients if they’re on work experience.) Co-Kinetic.com

If you don’t have a reception or admin person, they could be useful in a ‘meet or greet’ or administration capacity (make sure they know what they’re doing so they reflect well on you/your business). n It gives you a chance to ‘split test’ appointment types and learn what your audience wants. As Vicki Marsh says in her previous article, do they prefer your Chronic Pain Clinic or Mobility for Athletes sessions? You could even test different names for the same session and see which gets more bookings. n It’s a great way to fill up appointments that would otherwise be empty and unused.

LAST THOUGHTS If you start thinking about it, you’ll probably find lots more uses for ‘try before you buy’ events. As you can see, the benefits are not limited to your clients, they can also be incredibly useful and informative for you and your business. The more you can squeeze out of these events, to help inform your business moving forward, the better use of your time investment. Something as simple as Google Reviews can have a surprising impact on your findability on Google and on people making a decision which clinic or therapist to visit when they search for osteopathy services in Melbourne or Manchester for example. If you’ve got 100+ Google reviews, you’re going to stand out head and shoulders above your nearest rival and no prizes for guessing who Google is going to show at the top of the local search results, the one with 3 reviews, versus the one with 100 reviews?

FURTHER RESOURCES n Grow Your Business by Making Your Patients Want to Come Back [Video Presentation] https://spxj.nl/2J91Wlk n How to Generate £3,000 in Revenue in Just 6 Hours – Blizard Physiotherapy Running MOT [Case Study] https://spxj.nl/2wLbRZW n F ive Go on a Customer Journey – Practical Advice for Building Your Business Through the Customer Journey [Video Presentations] https://spxj.nl/2J91Wlk THE AUTHOR Tor Davies began her professional life training as a physiotherapist at Addenbrookes Hospital, Cambridge, UK. She went on to complete a BSc in Sport & Exercise Science at the University of Birmingham while also achieving a WTA international tennis ranking. After graduation she worked in marketing with a London agency and then moved into medical journalism where her passion for publishing was born. At 27 she established sportEX medicine, a quarterly journal for physical and manual therapists. With a passion for technology as well as publishing, Tor’s leadership grew sportEX into the Co-Kinetic journal and website which included a more collaborative, royalty-based form of publishing as well as a wider content remit. Tor’s focus is on providing resources to help therapists develop their professional authority and brand, and grow their own businesses while working more efficiently and effectively, a topic that she speaks regularly on at global conferences. Twitter: @CoKinetic Facebook: https://www.facebook.com/sportex.tor

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FALL PREVENTION YOUR EXERCISE PROGRAMME This programme has specific exercises to promote general body movement in your neck and upper back but also your legs and feet. It will help strengthen your lower limbs and keep you mobile helping to reduce your risk of falls. Ensure you perform the exercises in a safe environment without loose carpets or a slippery floor and always have a support (table, handrail etc) close by for balance if needed. These exercises should be done at least once a day, preferably twice a day time permitting. It is important to ensure the exercises are performed with good technique and good postural control. Make sure to repeat the same number of exercises on both sides where applicable. We have given suggested sets and repetitions. Remember everyone is different

so your therapist may give guidance that is more specific to you.

WARM UP AND COOL DOWN It is important to warm up (unless advised otherwise by your practitioner) with a walk for 5-10 minutes before you start your exercises. Marching on the spot is also a good warm-up. This increases your circulation and helps prepare the muscles for the activity to come. When you have finished your exercises, end the session with a 5 minute gentle walk to allow your heart rate to slow down gradually.

NECK ROTATIONS SITTING

ELBOW TO KNEE SITTING

Sit upright with good posture. Rotate your neck slowly to the left by looking over your left shoulder. Take your neck to a comfortable end of range. Repeat to the right. Make sure you keep your shoulder and back relaxed. This is an excellent exercise to improve rotation and mobility in your neck. Perform 2 times daily | Repeat 8 times | Hold for 3 seconds | Perform both sides Video: https://youtu.be/7TNeGcg2JoM

Lift knee upward toward your chest and touch your knee with your right elbow. Slowly return to the starting position, then repeat with the right leg and left elbow. This exercise will help improve your coordination, core strength, leg strength and hip mobility. Perform 2 times daily | Repeat 8 times | Hold for 1 second | Perform both sides Video: https://youtu.be/idIt-wzbg4Q

MARCHING ON THE SPOT WITH SUPPORT

CLIMB A ROPE SITTING

Stand upright with good posture, holding on to a wall or table for support. March on the spot. Keep your knees up as high as feels comfortable. This exercise is good for knee mobility, endurance, balance and co-ordination. Perform 2 times daily | Repeat 20 times Video: https://youtu.be/rdEeYykXZUQ

Sit upright with good posture, and imagine you have a rope in front of you. Climb up the imaginary rope using your arms. This exercise will help improve posture and strengthen your arms and core. Perform 2 times daily | Repeat 8 times | Perform both sides Video: https://youtu.be/x8vuJPisFOg

HEEL RAISES AND TOE LIFTS SITTING

1/4 SQUAT STANDING WITH SUPPORT

Sit upright with good posture, with your feet flat on the floor. You can do this exercise in your shoes, or with bare feet. Lift your heels going up on to your toes, and then return to the floor. Lift your toes going up on your heels, and then return to the floor. This exercise will help strengthen your lower legs and ankles. Perform 2 times daily | Repeat 8 times | Perform both sides exercise. Video: https://youtu.be/-7AF6kP3n-8

Stand upright with good posture. Hold on to a wall or table for support. Open your legs slightly wider than shoulder width, and bend your knees to the 1/4 squat position. Return to the start position. Make sure you keep the middle of your knee-cap in line with the middle toes of your foot.This is a strengthening exercise for the legs. Perform 2 times daily | Repeat 10 times Video: https://youtu.be/LMLz1Z1CFCs

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. ÂŠCo-Kinetic 2017

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BUILDING BONE STRENGTH AND PREVENTING BONE LOSS IN LATER LIFE YOUR EXERCISE PROGRAMME This programme has specific exercises to promote bone strength which is beneficial in both the prevention and treatment of osteoporosis. The exercises also help strengthen your lower limbs and improve balance which can reduce your risk of a fall and subsequent fracture. Ensure you perform the exercises in a safe environment without loose carpets or a slippery floor and always have a support (eg. table, handrail) close by for balance, if needed. These exercises should be done at least once a day, preferably twice a day if possible. A brisk walk or participation in yoga/ exercise classes may have additional benefit. It is important to ensure the exercises are performed with good technique and good postural control. Make sure to repeat the same number of exercises on both

STEP UP AND DOWNS UNSUPPORTED WITH WEIGHTS Place an ankle weight around each ankle. If you donâ&#x20AC;&#x2122;t have a weight you can leave it off. Stand upright in front of the bottom step of your staircase. Step up onto the first step with one leg, and bring the other leg to the step to meet it. With control, lower this same foot back to the floor, followed by the other. If you feel unstable, hold the wall or handrail for balance. Repeat 8 times | Perform both sides Video: https://youtu.be/ejb2B8Hc2cM

WALL SLIDES (1/2 SQUAT) Stand upright, with your back resting against a wall and your feet slightly away from the side of the wall. Open your legs slightly wider than shoulder width, and bend your knees to the 1/2 squat position. Make sure you keep the middle of your knee-cap in line with the middle toes of your foot. Return to the start position. This is a strengthening exercise for the legs. Repeat 8 times | Hold for 3 seconds Video: https://youtu.be/WKVYRXcIqA4

WALL PRESS-UP Stand upright with good posture, position yourself in front of a wall in a press-up position with your arms straight and palms flat on the wall. Drop your chest towards the wall by bending your elbows. Hold this position for 1-2 seconds. Return to the start position by pushing through your arms. This is a chest, back and shoulder strengthening exercise. You can make the exercise harder by standing further back from the wall. Repeat 10 times | Hold for 2 seconds Video: https://youtu.be/ox18YHnWTsU

sides where applicable. We have given suggested sets and repetitions. Remember everyone is different so your therapist may give guidance that is more specific to you.

WARM UP AND COOL DOWN It is important to warm up (unless advised otherwise by your practitioner) with a brisk walk or a gentle jog for 5-10 minutes before you start your exercises. Marching on the spot is also a good warmup. This increases your circulation and helps prepare the muscles for the activity to come. When you have finished your exercises, end the session with a 5 minute gentle walk or slow jog to allow your heart rate to slow down gradually.

1/2 SQUAT STANDING UNSUPPORTED Stand upright with good posture. Stand close to a wall or table for support if you require it. Open your legs slightly wider than shoulder width, and bend your knees to the 1/2 squat position. Reutrn to the start position. Make sure you keep the middle of your knee-cap in line with the middle toes of your foot. This is a strengthening exercise for the legs. Repeat 10 times Video: https://youtu.be/SblA5zn9Dlo

WEIGHT SHIFT SIDEWAYS UNSUPPORTED Stand upright with good posture, next to a wall or rail just in case you need support. Lift one leg off the floor as you shift your weight onto the stationary leg. Point your toes to the side to touch the space to the side of you, and then back to the start position. This exercise improves strength and co-ordination in the legs. Repeat 10 times | Perform both sides Video: https://youtu.be/fh5_yg6ahes

SHOULDER FLEXION SITTING Sit upright with good posture. Lift both arms gently in front of you. Take your arms as far as feels comfortable. If you cannot get your arms above your head, just take your arms to your comfortable end of range. Slowly lower your arms. This will help mobilise your shoulders and upper back, and strengthen your arms. if you have a weight or medicine ball or any object (a bag of sugar) hold that in you hands and raise the weight over you head for added strengthening. Repeat 10 times | Hold for 2 seconds at the top Video: https://youtu.be/vWHiLBHOhts

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UNDER PRESSURE:

STRATEGIES FOR REDUCING AND PREVENTING STRESS INCONTINENCE

YOUR EXERCISE PROGRAMME This programme has specific exercises for stress incontinence. They are designed to strengthen the deep core muscles that work together with your pelvic floor muscles. These exercises should be done at least once a day, preferably twice a day, time-permitting, along with the Kegel exercises done regularly throughout your day. It is important to ensure the exercises are performed with good technique and good postural control. Make sure to repeat the same number of exercises on both sides (where applicable). We have given suggested sets and repetitions. Remember everyone is different so your therapist may

give guidance that is more specific to you.

WARM UP AND COOL DOWN It is important to warm up (unless advised otherwise by your practitioner) with a brisk walk or a gentle jog for 5-10 minutes before you start your exercises. This increases your circulation and helps prepare the muscles for the activity to come. When you have finished your exercises, end the session with a 5 minute gentle walk or slow jog to allow your heart rate to slow down gradually.

SUPINE BRIDGE BASIC

LEG SLIDE

Lie flat on your back, with your knees bent, squeeze your bottom muscles and lift your body upwards. Keep your arms by your side and use them to help you balance. Make sure you maintain good posture (do not over-arch your lower back) and contract the deep abdominal muscles by squeezing your tummy towards your spine. This exercise helps to strengthen the abdominal, lower back, gluteal and hamstring muscles. You can progress this by straightening one leg/knee alternately. Repeat 10 times | Hold for 10 seconds Video: http://youtu.be/fK_xUE3OKIE

Lie on your back, with both legs straight, activate your deep abdominal muscles by drawing your tummytowards the floor. Slide one heel towards your bottom. Maintain only the slightest contact with your heel on the ground. Keep the leg slide slow and controlled. You can progress the exercise by lifting the opposite leg just a few inches off the ground, while sliding the other heel towards your bottom. This is a great core control exercise to work the abdominal muscles. Repeat 10 times | Perform both sides Video: http://youtu.be/hi4nb-isyZ8

HORSE-STANCE SAME SIDE LIFT

HIP ABDUCTION LYING BILATERAL

Go on to all fours, and keep good posture. Draw your tummy inwards (towards the ceiling). Lift your hand and same side knee upwards 10-20cm and hold this position. To make the exercise harder, keep your hand and knee closer to the floor. This is an advanced core stability and core control exercise to work the abdominal muscles. Repeat 10 times | Hold for 5 seconds | Perform both sides Video: http://youtu.be/1Tz66Yhq2zo

Lying on your side, flatten your lower back by gently tucking your tummy in. Keeping your legs together, lift your legs several inches in the air. You can either hold this position, or return your legs down and then repeat the exercise. Ask your therapist which they would prefer you to do. This exercise strengthens the pelvic, gluteal, core and lower back areas. Repeat 10 times | Hold for 2 seconds | Perform both sides Video: http://youtu.be/6tgLIUqEuP0

PLANK

2 POINT KNEELING HORIZONTAL

Rest on your forearms and your toes. Hold this position. Keep good straight posture, and do not let your back arch too much. This is a core strengthening exercise. Try to build up how long you can hold the plank for, then rest and repeat the hold, aiming for 1 minute hold without a rest. Repeat 5 times | Hold for 10 seconds Video: http://youtu.be/noeBz0JoW-4

Adopt a 4 point position on your hands and knees. Maintain good posture, and gently contract the deep abdominal muscles by drawing your belly button in (towards your spine). Lift one arm in front of you, and your opposite leg behind you. Then alternate. This exercise strengthens the deep core muscles. Repeat 10 times | Hold for 5 seconds | Perform both sides Video: http://youtu.be/MAzd-kxnH18

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