Co-Kinetic Journal Issue 80 - April 2019 by Co-Kinetic

ISSUE 80 APRIL 2019 ISSN 2397-138X

Formerly published as....

medicine & dynamics

whatâ&#x20AC;&#x2122;s inside PRACTICAL 14-16 MOVING MEDICINE: NEW RESOURCES FOR HEALTH PRACTITIONERS

48-50 CLIENT RESOURCES

40-43

35-39

26-34

OPTIMISING THERAPUTIC OUTCOMES

A START UP GUIDE TO FACEBOOK ADVERTISING

ASSESSMENT OF FASCIAL DYSFUNCTION

12-13

MANUAL THERAPY & PHYSICAL THERAPY INFOGRAPHICS

THE BLUEPRINT FOR RUNNING A SUCCESFUL OPEN CLINIC EVENT: PART 2

BLUEPRINT FOR 44-46 THE RUNNING A SUCCESSFUL

OPEN CLINIC EVENT: PART 2

SHORT

04-11

JOURNAL WATCH

17-25

FEMOROACETABULAR IMPINGEMENT SYNDROME PART: 1

TECHNICAL

LONG APRIL 2019 ISSUE 80 ISSN 2397-138X

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

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

ISSUE 80 APRIL 2019 ISSN 2397-138X

Formerly published as....

medicine & dynamics

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

CLICK ON RESEARCH TITLES TO GO TO ABSTRACT

HAMSTRINGS AND QUADRICEPS MUSCLES FUNCTION IN SUBJECTS WITH PRIOR ACL RECONSTRUCTION SURGERY. Faxon JL, Sanni AA, McCully KK. Journal of Functional Morphology and Kinesiology 2018;3(4):56 Eight young healthy female subjects who had had knee reconstruction surgery more than one-year previously were tested. The skeletal muscle endurance index of the hamstrings and quadriceps muscles was determined as the decline in the specific muscle acceleration in response to 2Hz, 4Hz, and 6Hz electrical stimulation. Maximal isometric muscle strength (MVC) was measured in the hamstrings and quadriceps muscles. The hamstrings muscles in the injured leg had less endurance than the non-injured leg at 6Hz stimulation. Muscle endurance was not reduced in the quadriceps muscles in the injured leg compared to the non-injured leg at 6Hz stimulation. There were no differences in MVC between the injured and noninjured legs for either the hamstrings or quadriceps muscles. Autografts (bone– patella tendon–bone, hamstrings and quadriceps) and synthetic grafts were included in the study.

Co-Kinetic comment On the face of it these results indicate a muscle imbalance probably because of a lack of endurance training during rehab. But eight subjects! Is this enough to draw a conclusion? The average postop time of measurement was 4.5 years and a lot can happen in that time. Then there is the issue of the graft harvest site. Four are mentioned (with eight subjects) but there is no correlation between harvest sites and subsequent results. So, good idea, but a bigger study is needed.

SYSTEMATIC REVIEW OF THE ADDITION OF HIP STRENGTHENING EXERCISES FOR ADULTS WITH PATELLOFEMORAL PAIN SYNDROME. Elliot C, Green F, Hang K et al. Internet OPEN Journal of Allied Health Sciences and Practice 2018;16(4):Article 10 A search was made of the usual medical databases to find studies of participants aged 18 to 40, who had been diagnosed with patellofemoral pain syndrome by a healthcare practitioner, or reporting peripatellar or retropatellar pain with common functional tasks. Five randomised controlled trials of varying methodological quality met the inclusion criteria. The duration of the intervention ranged from 4 to 6 weeks consisting of 12 to 30 supervised exercise sessions. Studies used varying outcome measures for each of the three outcomes. Overall, the studies demonstrated that the addition of hip strengthening exercises to standard physiotherapy care consistently improved pain and function, but the impact on strength was variable.

Co-Kinetic comment Strange! A study looking into whether or not hip strengthening exercises improve knee pain finds that it does but doesn’t actually improve strength. Maybe it is something to do with the fact that yet again the reviewers comment on the poor methodology of the selected studies.

TIME FOR A DIFFERENT APPROACH TO ANTERIOR CRUCIATE LIGAMENT INJURIES: EDUCATE AND CREATE REALISTIC EXPECTATIONS. Zadro JR, Pappas E. Sports Medicine 2018;doi:10.1007/s40279-018-0995-0 [Epub ahead of print] “Following an anterior cruciate ligament (ACL) injury, patients are often reassured that timely surgery followed by intensive physiotherapy will ‘fix their knee’. Not only does this message create a false perception of uncomplicated return to sport (RTS), it also ignores the large body of evidence demonstrating a high RTS re-injury rate following ACL reconstruction.” It goes on to make the point that patients need to be aware that conservative management of ACL injuries is not inferior to early surgery for improving symptoms and that the likelihood of developing 4

knee osteoarthritis is no different between either approach. Rehabilitation must target strength and functional performance, avoid rapid increases in training load, and be guided by a RTS timeframe that is no shorter than 9 months (postoperative rehabilitation only). Home exercise is not inferior to physiotherapist-led rehabilitation following ACL reconstruction, but there is no research comparing home exercise to physiotherapist-led rehabilitation following non-operative management but the level of physio supervision during rehabilitation should be dictated by the patient’s preferences and the resources available.

Co-Kinetic comment Honesty is the best policy. Another quote from the paper is, “Patients largely do not understand the seriousness of an ACL injury.” They see the pro footballers getting back to the first team and think they will as well. They might if they have an army of therapists working on them every day backed up by regular scans to mark progress, nutrition advice or even someone making their food for them, plus the hydro pools and gyms full of rehab toys. They also don’t see them hobbling about after they retire. Co-Kinetic Journal 2019;80(April):4-7

RESEARCH INTO PRACTICE

Physical Therapy

Journal Watch PHYSICAL THERAPY VERSUS NATURAL HISTORY IN OUTCOMES OF ROTATOR CUFF TEARS: THE ROTATOR CUFF OUTCOMES WORKGROUP (ROW) COHORT STUDY. Dickinson RN, Ayers GD, Archer KR et al. Journal of Shoulder and Elbow Surgery 2018;pii:S1058-2746(18)30732-8 From February 2011 to June 2015, a multicentre cohort of patients with rotator cuff tears undergoing non-operative treatment completed a detailed health and demographic questionnaire and the Shoulder Pain and Disability Index (SPADI) at baseline and 3, 6, 12, and 18 months. Among the 55 patients in the cohort, the performance of physical therapy within the first 3 months predicted better SPADI scores versus non-performance of physical therapy at 3 months. Scores were similar between groups at 6, 12, and 18 months. A threshold of 16 physical therapy sessions was observed for pain and functional improvement during follow-up, after which significant improvement was not seen.

Co-Kinetic comment Getting physio in the first 3 months is beneficial. Most of you probably knew that, but here is some proof for you.

EXERCISING ON DIFFERENT UNSTABLE SURFACES INCREASES CORE ABDOMINAL MUSCLE THICKNESS; AN OBSERVATIONAL STUDY USING REAL TIME ULTRASOUND. Gibbons TJ, Bird M-L. Journal of Sport Rehabilitation 2018;doi:10. 1123/jsr.2017-0385 [Epub ahead of print] Thirty young, healthy adults performed three graded, isometric exercises on a Pilates table, foam roller and an Oov®. Muscle thickness was measured by ultrasound. Core abdominal activation was greater on the foam roller than the Oov® and Pilates table during crook lying (bilateral leg support). Both the Oov® and foam roller elicited greater contralateral transversus abdominus (TrA), internal oblique abdominus thickness than the Pilates table during table top and straight leg raise (unilateral leg exercises). For TrA only, the foam roller elicited more muscle thickness than the Oov® during straight leg raise. The Oov® was rated more comfortable than the foam roller, which may help with compliance.

Co-Kinetic comment The Oov® is basically a foam

ATHLETIC HIP INJURIES IN MAJOR LEAGUE BASEBALL PITCHERS ASSOCIATED WITH ULNAR COLLATERAL LIGAMENT TEARS. Kantrowitz DE, Trofa DP, Woode DR et al. Orthopaedic Journal of Sports Medicine 2018;6(10):2325967118800704 Of 145 major league baseball players who underwent ulnar collateral ligament (UCL) reconstruction between 2005 and 2017, 40 (27.6%) endured a proximal lower extremity injury within 4 years of their surgery. Specifically, 16 pitchers sustained hip injuries, 13 suffered hamstring injuries, and 14 experienced groin injuries. A significantly lower rate of hip- and groin-related injuries (17.9%) was identified in matched controls during a similar time frame. This means that pitchers with a UCL construction are 74% more likely to have a hip, groin Co-Kinetic.com

cushion shaped to fit the back. It is designed to be unstable which apparently helps to activate core muscles. It is so unstable in fact that one UK supplier carries a disclaimer on its website. You can pick up a decent foam roller for £10–20 on Amazon. The Ovo® will cost you up to 10 times that. You decide. Comfort or cost? Is exercise supposed to be comfortable?

or hamstring injury. Additionally, nearly twice the number of hip injuries occurred before UCL reconstruction compared with after, indicating that pitchers who have undergone UCL surgery are more likely to have sustained a hip injury before their surgery. Which lead the authors to the conclusion that hip injuries, specifically femoroacetabular impingement and labral lesions, may lead to overcompensation at the elbow during overhand throwing, potentially leading to the development of UCL tears.

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Co-Kinetic comment Your hip bone is connected (eventually) to your elbow bone. The fastest guys are chucking a ball at over 100 miles/hour from basically a standing start, so they put a particular high rotational force through the stance leg. This is bad enough in itself, but when you add in consciously or unconsciously changing kinetic chain biomechanics because of a damaged hip it is unsurprising that they break one of the links in the chain. 5

ANKLE BRACING IS EFFECTIVE FOR PRIMARY AND SECONDARY PREVENTION OF ACUTE ANKLE INJURIES IN ATHLETES: A SYSTEMATIC REVIEW AND META-ANALYSES. Barelds I, van den Broek AG, Huisstede BMA. Sports Medicine 2018;8(12):2775–2784 This review searched the usual medical databases for randomised controlled trials that studied ankle bracing versus no intervention for athletes. They identified six that found in favour of primary and secondary prevention. Primary prevention aims to stop the injury happening. Secondary aims to reduce the impact of the injury if it does. Both semi-rigid and lace-up braces were used in most of the trials. No differences of effect between the types of braces could be observed. However, the literature is still inconclusive as to which type of brace is most effective for the reduction of acute ankle injuries. No significant differences were found between non-rigid, semi-rigid, or rigid braces. Perceived comfort, hindrance to movement, and stability were important factors in athletes’ choices of a particular type of brace. They also mention that other prevention strategies [neuromuscular/proprioceptive training and ankle tape (rather than a full brace)] are used.

Co-Kinetic comment

A WEARABLE EMBEDDED SYSTEM FOR DETECTING ACCIDENTS WHILE RUNNING. Carletti V, Greco A, Saggese A et al. In Proceedings of the 13th International Joint Conference on OPEN Computer Vision, Imaging and Computer Graphics Theory and Applications (VISIGRAPP) 2018;4:541–548 This gets your attention straight away by stating, “the difference between fatal and not fatal accidents often is the presence of other people able to promptly provide first aid or call for help. Unfortunately, even during the practice of group activities (e.g. team sports) an accident can happen when a person is alone or out of sight.” It goes on to describe a wrist wearable device that detects falls and whether or not the wearer is still moving. There is a great deal of science about gyroscopes and algorithms, but the bottom line is that they have tested it on runners set up to fall onto a mattress and the accuracy of the results is promising.

Co-Kinetic comment There have been fall detectors for the elderly for some time but most of them have a base station somewhere in the house. If this group perfect one that is completely contained in a light-weight wrist device they are going to make a fortune. Good luck, people.

There are a few tasty stats quoted in this paper about the extent of ankle injuries. They make up 15.9% of basketball injuries, 45.6% of volleyball, 21.2% for soccer and that more than 75% of all acute ankle injuries are lateral ankle sprains. Recurrence rates vary from 3 to 24%, so reducing them will significantly reduce lost playing time. Sadly the authors of this review complained (as do so many others) about the quality of the evidence.

MECHANISMS OF ACUTE ADDUCTOR LONGUS INJURIES IN MALE FOOTBALL PLAYERS. Serner A, Maosler AB, Tol JL et al. British Journal of Sports Medicine 2019;53:47 Videos of acute adductor longus injuries in 17 professional male football players were analysed. Most injuries occurred in non-contact situations (71%), following a quick reaction to a change in play (53%). Injury actions were: change of direction (35%), kicking (29%), reaching (24%) and jumping (12%). Change of direction and reaching injuries were categorised as closed chain movements (59%), characterised by hip extension and abduction with external rotation. Kicking and jumping injuries were categorised as open chain (41%), characterised by a change

from hip extension to hip flexion, and hip abduction to adduction, with external rotation.

Co-Kinetic comment There are training implications here. Work on the ability to perform the movement without over-loading the system. The British Journal of Sports Medicine produces an infographic to go with this which is basically an abstract with pictures for the social media generation. There are over 100 of them on their website available to subscribers.

Co-Kinetic Journal 2019;80(April):4-7

RESEARCH INTO PRACTICE

ASSOCIATION BETWEEN DOUBLE-LEG SQUAT AND SINGLE-LEG SQUAT PERFORMANCE AND INJURY INCIDENCE AMONG INCOMING NCAA DIVISION I ATHLETES: A PROSPECTIVE COHORT STUDY. Eckard T, Padua D, Mauntel T et al. Physical Therapy in Sport 2018;34:192–200 A convenience sample of 111 athletes in their first year of competing in 10 NCAA Division I sports were recruited. They were injury free or at least had no injury that contraindicated doing the double-leg squat (DLS) and single-leg squat. They performed a total of 15 consecutive squats in each category. They were instructed to squat to maximum comfortable knee flexion, returning to the original starting position between each repetition. Both were observed in an anterior and lateral view with DLS having the addition Necrotising fasciitis (NF), also known as necrotising soft-tissue infection, is a lifethreating bacterial infection of the subcutaneous tissue, fascia and muscles. It is sometimes called the flesh-eating disease, although the bacteria don’t actually eat the tissue they release toxins that damage it. It is rare but it can start with a relatively minor injury such as a small cut, insect bites or traumatic injury. In the USA, the Center for Disease Control and Prevention estimates between 700 and 1200 cases a year but cautions that this may be an underestimate. Retrospective data were collected from all equine-related accidents at a German Level I Trauma Centre between 2004 and 2014. A cohort of 770 patients was included (87.9% females). Falling off the horse (67.7%) and being kicked by the horse (16.5%) were the two main injury mechanisms. Men and individuals of higher age showed higher odds for all tested parameters of serious injury. Patients falling off a horse had higher odds for being treated as inpatients, whereas patients who were kicked had higher odds for a surgical therapy and intensive care unit/intermediate care unit treatment (ICU/IMC). The head was the body region most often injured (32.6%) and operated on (32.9%). Patients with head injuries had the highest odds for being hospitalised. Head or trunk injuries Co-Kinetic.com

of a lateral view. A single observer assessed performance including the amount of forward trunk lean, weight shift, valgus/varus movement and foot position. Squats were rated as ‘poor’ or ‘non-poor’. Lower extremity injury information was collected during the following year. Those who had been rated ‘poor’ had a greater incidence of injury.

Co-Kinetic comment There is much more detail in the paper about how to actually do the

test and the scoring protocol to get to ‘poor’ or ‘non-poor’. What is missing is a discussion on why there is a correlation between this and future injury although you can speculate about motor control and core stability. What was important was that the authors, while lauding the link between the squat performance and future injury, state very clearly that it should not be used in isolation as a predictor. The big question is whether a training programme to improve the squat performance would reduce injuries?

NECROTIZING FASCIITIS INFECTION IDENTIFICATION AND MANAGEMENT. Brennan MR, LeFevre F. Nursing 2019 Critical Care 2019;14(1):6–11 The most common causes of NF are Gram-positive bacteria, such as Escherichia coli and Klebsiella. Additional bacterial organisms include Group A streptococcal infections, methicillin-resistant Staphylococcus aureus, and methicillin-sensitive Staphylococcus aureus; some cases are caused by fungal infections such as Candida. Patients will present with intense pain, erythema, and swelling. There may not be a visible wound but a recent history of trauma. According

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to the NHS information site, there may be high temperature and other flu-like symptoms. Tissue destruction occurs very quickly. It is life threatening. Treatment is to get the patient to hospital ASAP.

Co-Kinetic comment This is rare, but it is just the sort of presentation that physical therapists may encounter. A minor issue that quickly accelerates. Rare it might be but it happens. This article is an excellent introduction, but it really is scary.

ASSESSING THE RISK FOR MAJOR INJURIES IN EQUESTRIAN SPORTS. Krüger L, Hohberg M, Lehmann W et al. BMJ Open Sport & Exercise Medicine 2018;4(1):e000408

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lead to the highest odds for an ICU/IMC treatment. Upper and lower limb injuries showed the highest odds for a surgical therapy.

Co-Kinetic comment This paper has the prize for the understatement of the year. “The power of a horse can expose the rider to a potential high-energy trauma.” No kidding – maybe the horses don’t like being ridden! Some authors rate equestrian sports as more dangerous than American football, skiing or motor sports. One study even found that participants were equally at risk of serious injury when mounted and unmounted. Another states that 34% of

horse kicking injuries are potentially life threatening. Yet another cited 10 deaths a year in the UK. In the spirt of evenhandedness we should point out that the Medical Equestrian Society states that there are considerably fewer deaths than from cycling or motorcycling. 7

CLICK ON RESEARCH TITLES TO GO TO ABSTRACT

THE EFFECTIVENESS OF MULLIGAN’S MOBILISATION WITH MOVEMENT (MWM) ON PERIPHERAL JOINTS IN MUSCULOSKELETAL (MSK) CONDITIONS: A SYSTEMATIC REVIEW. Westad K, Tjoestolvsen F, Hebron C. Musculoskeletal Science and Practice 2019;39:157–163 This research involved searching seven electronic databases for randomised controlled trials and identified seven published trials which presented positive evidence for Mulligan’s mobilisation with movement (MWM). Moderate quality evidence was found for the effectiveness of MWM in pain and

function in patients with chronic ankle instability and hip osteoarthritis. Low quality evidence was found for shoulder impingement syndrome and very low quality evidence for lateral epicondylalgia. Overall, MWM seems to be superior to placebo and no intervention controls.

Co-Kinetic comment It is great to see positive evidence whatever the quality for manual therapy but why-oh-why in days when there are loads of quality checklists for research do we still see studies described as low or very low quality? Come on researchers, run your own work through the checklists and you will get more plaudits.

MANAGEMENT OF THORACIC SPINE PAIN AND DYSFUNCTION: A SURVEY OF CLINICAL PRACTICE IN THE UK. Heneghan NR, Gormley S, Hallam C et al. Musculoskeletal Science and Practice 2019;39:58–66 This was a survey of 485 physiotherapists in the UK about the examination and treatment of thoracic problems. The work split was NHS 32%, private 28% or 32% mixed (e.g. NHS and private). Other settings included sport (5%), military (2%), and academia (1%). Numbers were also broken down by sex, age, NHS banding, years qualified, years in musculoskeletal practice and physiotherapy qualification (19.2% had a Master’s degree). The

results revealed that there are around half the number of patients with thoracic pain compared with cervical, and a third compared to lumbar. Physios usually examined the neck, low back and shoulder when examining the problem area. Exercise is widely used despite the paucity of evidence supporting it. Passive hands-on interventions including soft tissue massage are more likely to be used in the private practice and sport settings than the NHS.

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Co-Kinetic comment The authors insist that 485 is a big enough sample for a valid result. Really? There are 53,000 physios in the UK! There were actually more surveys returned but 167 were not included because they were not fully completed. The big question is why the handson treatment is more prevalent outside the NHS? Of the private practice respondents 58% said they used it, compared with 36% in the NHS and 35% in sport. The latter figure is a bit of a surprise. Is that perhaps because the sports physios farm out massage to specialist massage practitioners?

THE EFFECTS OF SPORTING MASSAGE ON MOTIVATION AND SITUATIONAL ANXIETY IN FEMALE FOOTBALLERS. Abakay Z, Biçer M, Abakay U. The Online Journal of Recreation and Sport 2018;7(4):http://doi.org/10.22282/ojrs.2018.40 Nineteen female footballers aged 18–25 years underwent three interventions over 3 days. The first involved no physical activity, the second involved 30min of active warming up (flat racing, jumping, stretching) specific to football, the third saw footballers receiving 10min of sporting massage performed by a researcher with a sports massage certificate before the active warm-up. Afterwards all groups completed the Sports Motivation Scale questionnaire developed by Pelletier et al. (1995) and adapted to Turkish by Erdem (2008), and the Anxiety Scale questionnaire developed in 1970 by Spielberger

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et al. and adapted to Turkish. The results revealed that the massage plus warm-up group had a higher level of motivation and a lower level of situational anxiety than the other groups.

Co-Kinetic comment We are biased. We like massage! So, we will take these results as another positive for the noble and ancient art but it would have been so much better if they had completed the questionnaires before an actual competitive match rather than the experimental protocol they did use. Can someone have a go, please? Co-Kinetic Journal 2019;80(April):8-11

RESEARCH INTO PRACTICE

Manual Therapy

Journal Watch ECONOMIC EVALUATION OF MANUAL THERAPY FOR MUSCULOSKELETAL DISEASES: A SYSTEMATIC REVIEW AND NARRATIVE SYNTHESIS OF EVIDENCE. Kim CG, Kim KN, Shin BC et al. Journal of Orthopedic Research and Therapy 2018;JORT-1119:doi:10.29011/2575-8241.001119 A search of clinical and economic electronic databases and the reference list of related systematic reviews up to February 2017. All costs were converted to US Dollars. The results showed 3,327 economic evaluation-related references were found and that included a total of 18 randomised controlled trials. The economic evaluation was conducted as a comparison of the effectiveness of manual therapy intervention with Twenty-five students aged between 22 and 28 years old (10F, 15M). They were given a sports restorative massage lasting 45min to the back, upper and lower limbs and one with the addition of a relaxing 3D virtual reality video through stereoscopic glasses linked to a smartphone. The video files contained nature pictures and sounds, kaleidoscopes with different colours and other relaxing influences. It lasted for 45min to

other alternatives in pain reduction. Manual therapy techniques were more cost-effective for improving low back and shoulder pain and lateral epicondylalgia than spinal stabilisation, general practitioner care or injection, etc. Moreover, manual therapy was better than general practitioner care, physiotherapy, self-management programme, traction therapy in improving neck, musculoskeletal chest

pain, osteoarthritis of the hip or knee, cervical spondylotic radiculopathy, and hand injury.

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Co-Kinetic comment This is one for those of you who have to put a cost on treatment and argue for a budget. The bottom line is that in 10 out of 18 studies manual therapy was cost-effective; in 5 out of 10 studies manual therapy was better in the treatment of musculoskeletal diseases. Fly the flag for hands-on treatment.

APPLICATION OF THE VISUALIZATION THROUGH STEREOSCOPIC GLASSES IN THE MASSAGE THERAPY. Angelov V, Gotova J, Albert E et al. Exercise Medicine 2019;3:2 doi:https://doi.org/10.26644/em.2019.002 match the massage time. The headline result was that pre- and post-test heart rate measurements dropped from an average of 74.4bpm to 65.7bpm for the massage alone group and to 57.6bpm for the massage plus visualisation group.

Co-Kinetic comment This might lose a bit in its translation form Bulgarian. The massage

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protocol is described as, ‘smoothing, squeezing, friction, squeezing, strong friction, squeezing, continuous vibrations, squeezing, and smoothing’ which doesn’t give much hope to anyone who may want to repeat the procedure. There was also an outcome measure regarding five participants who reported low back pain but that was completely lost in the translation other than the fact that reported pre-intervention pain in the pictures group dropped to zero. That aside, the concept of the addition of a 3D visual to supplement the massage is worth further exploration.

SCOLIOSIS: ‘CLINICAL ORTHOPEDIC MANUAL THERAPY TREATMENT’. Muscolino JE. Journal of the Australian Traditional-Medicine Society 2018;24(4):220–226 This is an instructional essay about treating scoliosis. It is a lateral flexion deformity that whatever the underlying cause results in soft tissue being ‘locked short’ or ‘locked long’. Tight muscles tend to resist lengthening and, therefore, limit motion. The facet joints and the vertebral bodies on the concave side will become compressed. The same structures on the convex side will be under tension stress. This leads to increased physical stresses on the joints that can cause pain and dysfunction, and perhaps lead to greater osteoarthritic degeneration in time. Treatment should, therefore, Co-Kinetic.com

be aimed at both loosening the tight musculature involved and mobilising the joint dysfunction hypomobilities that occur. One modality is soft tissue massage and the other extols the virtues of circular massage strokes and these capture muscle fibres in all orientations with particular attention to the ‘short locked’ examples. This should be followed with stretching but the scoliotic curve will resist stretching so great care should be taken to ensure the stretch is targeted at the curve. Pillows and bolsters can assist as can dropping the treatment table in ‘banana shape’ if you have that type of equipment (they are officially called

‘flexion break feature’ couches). Finally grade 4 joint mobilisations are used to work on the stiff spinal structures.

Co-Kinetic comment Scoliosis can have a number of causes. About 8 in 10 are described as idiopathic. The author of this paper mentions that flat feet can do it. There are many others. In children, it tends to get noticed in puberty growth spurts. Sadly but understandably parents go into a panic and far too many people end up under surgeon’s knife. None of the above treatments in trained hands should do any harm. They are worth a try. 9

EFFECTS OF MASSAGE AS A COMBINATION THERAPY WITH LUMBOPELVIC STABILITY OPEN EXERCISES AS COMPARED TO STANDARD MASSAGE THERAPY IN LOW BACK PAIN: A RANDOMIZED CROSSOVER STUDY. Leonard H J, Hancharoenkul B, Sitilertpisan P et al. International Journal of Therapeutic Massage & Bodywork 2018;11(4):16–22

A total of 16 professional, female, elite weightlifting athletes who were training for Olympic weightlifting, and complained of chronic low back pain, were randomised into three sessions of combination therapy (CT) and massage therapy (MT) with a time interval of 24hr within sessions and a wash-out period of 4 weeks between the sessions. The MT was applied to the dorsal region of the trunk extending from occiput to the iliac crest at a moderate pressure for 20min. The CT was massage plus lumbopelvic stability exercises using a Pilates power gym reformer device (Thane Fitness, UK). Exercises were performed in supine crook lying position and with contraction of core stabilisation muscles in hip flexion and knee flexion at 70° and 90°, respectively, with a pressure biofeedback placed beneath the lumbar spine between the levels of the second lumbar spine and the first sacral spine. A list of outcome variables related to pain, physiological change in the lumbar soft tissue, and motor function of the lumbopelvic region were measured pre- and post-intervention applications on Day 1, Day 2, and Day 3. The results showed that the CT significantly demonstrated greater effects in reducing pain perception (45–51%), improving pain pressure threshold (15% up to 25%), and increasing tissue blood flow (131–152%) than MT.

Co-Kinetic comment This is one for the people who promote a ‘handsoff’ approach to treatment. The results suggest that massage combined with exercise produce excellent results. Value is added. The pity is that there was not a further comparison with exercise. COMPARISON OF SPORT MASSAGE AND COMBINATION OF COLD WATER IMMERSION WITH SPORT MASSAGE ON DECREASE OF BLOOD LACTIC ACID LEVEL. Romadhona NF, Sari GM, Utomo DN. Journal of Physics: Conference Series 2019;1146:doi:10.1088/1742-6596/1146/1/012012

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Twenty-four male runners (aged 20–30 years) were randomly assigned to either a group who received recovery sport massage (K1), a combination of cold water immersion (15°) with sport massage (K2), or a control group (K3). Both groups performed sub-maximal physical exercise by doing a fast walk on the treadmill to reach 80% of maximum heart rate for 5min, followed by recovery process. The winner in the lactic acid reduction rate was the immersion with massage followed by massage alone with the control group taking the wooden spoon.

Co-Kinetic comment We mention this paper not because of its results but because it is evidence of the poor quality of research that manages to get published. ‘Take with a pinch of salt’ may be the best way to describe it. They are very small sample groups, there is no description of the massage protocol, no time for given for the immersion, and no mention of what the control group actually did. It states that the 24 subjects met the inclusion and exclusion criteria but not what the criteria were. Pity because it is a fine research question. You can do better. 10

ACUTE EFFECTS OF MUSCLE OPEN ENERGY TECHNIQUE AND JOINT MOBILIZATION ON SHOULDER TIGHTNESS IN YOUTH THROWING ATHLETES: A RANDOMISED CONTROLLED TRIAL. Reed ML, Begalle RL, Laudner KG. International Journal of Sports Physical Therapy 2018 13(6):1024–1031 Forty-two asymptomatic high school baseball and softball players were randomly assigned to one of three groups [14 to muscle energy technique (MET); 14 to joint mobilisation; 14 to control]. Glenohumeral (GH) passive adduction and internal rotation ROM were measured in all participants in a pre-test / post-test fashion. Between testing, the joint mobilisation group received one application of GH posterior joint mobilisations. The MET group received one cycle of MET applied to the GH horizontal abductors. The control group received no intervention. Post-test measures were completed immediately following intervention or a similar amount of time resting for the control group and then again 15min later. The results showed that the MET group had significantly more horizontal adduction ROM post-treatment compared to the control group. No significant differences existed between groups in horizontal adduction or internal rotation or at the 15min posttests. The MET protocol was that the subjects were positioned supine on the examination table with the examiner stabilising the lateral border of

EFFICACY AND SAFETY OF MASSAGE FOR OSTEOARTHRITIS OF THE KNEE: A RANDOMIZED CLINICAL TRIAL. Perlman A, Fogerite SG, Glass O et al. Journal of General Internal Medicine 2018;12:1–8 doi.org/10.1007/s11606-018-4763-5 A total of 222 adults with knee osteoarthritis enrolled in the study, 200 completed 8-week assessments, and 175 completed 52-week assessments. Other assessments were at baseline and weeks 16, 24, 36. They were randomly placed into a massage group, a lighttouch group or a ‘usual care’ control group. Subjects in massage or light-touch groups received eight weekly treatments, then were randomised to bi-weekly intervention or usual care to week 52. The original usual care group continued to week 24. The intervention groups received a full body massage or light-touch protocol lasting 60min. At 8 weeks, massage significantly improved Western Ontario and McMaster Universities Arthritis Index (WOMAC) Global scores compared to light-touch and usual care. Additionally, massage improved pain, stiffness and physical function WOMAC subscale scores compared to light-touch and usual care. At 52 weeks, the omnibus test of any group difference in the change in WOMAC Global from baseline to 52 weeks was not significant, indicating no significant difference in change across groups. Adverse events were minimal.

Co-Kinetic comment A tick in the box for short-term relief then. Co-Kinetic Journal 2019;80(April):8-11

RESEARCH INTO PRACTICE

THE EFFECT OF FOOT MASSAGE ON PAIN INTENSITY AND ANXIETY IN PATIENTS HAVING UNDERGONE A TIBIAL SHAFT FRACTURE SURGERY: A RANDOMIZED CLINICAL TRIAL. Pasyar N, Rambod M, Kahkhaee FR. Journal of Orthopaedic Trauma 2018;32(12):e482–e486

the scapula. The examiner passively horizontally adducted the arm until the first barrier to motion by applying pressure to the distal humerus. This passive stretch was applied for 3s. The examiner then instructed the participant to attempt to horizontally abduct the test arm at 25% of their maximal effort while the examiner applied manual resistance at the distal humerus to create an isometric contraction lasting 5s. The examiner then brought the participant’s arm back into horizontal adduction, for a 3s active assisted stretch. Four of these application cycles were completed totalling approximately 60s. The control group rested in a supine position for 1min in between pre- and post-tests.

Co-Kinetic comment Not sure why anyone needs an RCT to prove that MET can improve range in the short term. Anyone who does it can see that it does. However, for those hooked on evidence-based treatment here it is. One thing that no one can standardise is the contraction time or force or the number of application cycles. This has yet another variation. The question is would an increase in force and timings have resulted in the effects lasting more than 15min?

Sixty-six patients who underwent tibial shaft fracture surgery were enrolled and randomly assigned to intervention and control groups (33 patients each). The intervention included a 10min foot massage (5min per leg). After intervention, the mean scores for pain intensity, and anxiety in the intervention and control groups were shown to significantly different between the intervention and control groups concerning pain intensity and anxiety.

Co-Kinetic comment There is nothing more frustrating than seeing an athlete with an immobilised limb and knowing that there is little you can do to help the actual injury. (Yes, you can do a lot for the

rest of the body). This paper shows that a bit of TLC to the tootsies takes some of the pain away. What do you do if your patient is ticklish? Seriously, there is a similar study for postlaparoscopic cholecystectomy surgery that has the same pain relief following foot massage so it may be useful for other pain-relief requirements. This one had 167 subjects and the massage was immediately after the procedure, therefore, reducing the need for postop pain relief; see Koraş K, Karabulut N. The effect of foot massage on postoperative pain and anxiety levels in laparoscopic cholecystectomy surgery: a randomized controlled experimental study. https://www.jopan.org/article/ S1089-9472(18)30298-3/fulltext.

EFFECT OF PHYSICAL METHODS OF LYMPHATIC DRAINAGE ON POSTEXERCISE RECOVERY OF MIXED MARTIAL ARTS ATHLETES. Zebrowska A, Trybulski R, Roczniok R et al. Clinical Journal of Sport Medicine 2019;29(1):49–56 Eighty mixed martial arts athletes aged 27.5±6.4 years were allocated to four groups who received 30min of the following treatments. 1. MLS group who received manual lymph drainage of the neck, the supraclavicular area and axillary lymph nodes, the elbow lymph nodes, and the forearm toward the bend of the elbow, according to the protocol developed by Dr Asdonk. 2. A BF group who received electro-stimulation with the Bodyflow device (Bodyflow International, Port Melbourne, Australia) using four electrodes distributed along the venous and lymph flow (6±1mA). 3. The DO group who received deep oscillation (Physiomed Elektromedizin, Schnaittach, Germany) using a 5cm diameter head (90±10Hz for the first 18min and 50±10Hz for the remaining 2min). 4. A control group who received a simulation of the subjects’ forearms with nontherapeutic light emitted by a laser scanner that made the same sounds as during real procedures.

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Blood flow velocity in the cephalic vein was measured with an ultrasound Doppler velocity meter. Maximal strength of the forearm muscles (Fmax), muscle tissue tension, pain threshold, blood lactate concentration (LA), and activity of creatine kinase were measured in all groups at rest, after the muscle fatigue test (post-exercise) and then 20min, 24 and 48hr after the application of the interventions. The muscle fatigue test reduced Fmax in all subjects, but in the groups receiving MLS, DO, and BF significantly higher Fmax was observed at recovery compared with post-exercise values. The application of MLS reduced the post-exercise blood LA and postexercise muscle tension.

Co-Kinetic comment The implications of the success of this study are probably more relevant to post-injury recovery than that of recovery time.

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HOW DOES EXERCISE TREATMENT COMPARE WITH ANTIHYPERTENSIVE MEDICATIONS? A NETWORK METAANALYSIS OF 391 RANDOMISED CONTROLLED TRIALS ASSESSING EXERCISE AND MEDICATION EFFECTS ON SYSTOLIC BLOOD PRESSURE British Journal of Sports Medicine

5 1

AMERICAN MEDICAL SOCIETY FOR SPORTS MEDICINE POSITION STATEMENT ON CONCUSSION IN SPORT British Journal of Sports Medicine

British Journal of Sports Medicine

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ASSOCIATION OF EARLY PHYSICAL THERAPY WITH LONG-TERM OPIOID USE AMONG OPIOID-NAIVE PATIENTS WITH MUSCULOSKELETAL PAIN JAMA Network Open

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British Journal of Sports Medicine

PEAK OXYGEN UPTAKE IN CHRONIC FATIGUE SYNDROME/MYALGIC ENCEPHALOMYELITIS: A META-ANALYSIS International Journal of Sports Medicine

IS INTERVAL TRAINING THE MAGIC BULLET FOR FAT LOSS? A SYSTEMATIC REVIEW AND META-ANALYSIS COMPARING MODERATE-INTENSITY CONTINUOUS TRAINING WITH HIGH-INTENSITY INTERVAL TRAINING (HIIT) British Journal of Sports Medicine

OUT-RUNNING ‘BAD’ DIETS: BEYOND WEIGHT LOSS THERE IS CLEAR EVIDENCE OF THE BENEFITS OF PHYSICAL ACTIVITY British Journal of Sports Medicine

ISOMETRIC TRAINING AND LONG-TERM ADAPTATIONS: EFFECTS OF MUSCLE LENGTH, INTENSITY, AND INTENT: A SYSTEMATIC REVIEW Scandinavian Journal of Medicine & Science in Sports

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PROGRESSING REHABILITATION AFTER INJURY: CONSIDER THE ‘CONTROL-CHAOS CONTINUUM’

British Journal of Sports Medicine

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SUBACROMIAL DECOMPRESSION SURGERY FOR ADULTS WITH SHOULDER PAIN: A SYSTEMATIC REVIEW WITH META-ANALYSIS

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COST-EFFECTIVENESS EVALUATION OF MANUAL PHYSICAL THERAPY VERSUS SURGERY FOR CARPAL TUNNEL SYNDROME: EVIDENCE FROM A RANDOMIZED CLINICAL TRIAL

Journal of Orthopaedic & Sports Physical Therapy

A 12-WEEK TAILORED MANUAL THERAPY AND HOME STRETCHING PROGRAM BASED ON LEVEL OF IRRITABILITY AND RANGE OF MOTION IMPAIRMENTS IN PATIENTS WITH PRIMARY FROZEN SHOULDER CONTRACTURE SYNDROME: A CASE SERIES WITH 9-MONTHS FOLLOW-UP Journal of Orthopaedic & Sports Physical Therapy

MANIPULATION-INDUCED HYPOALGESIA IN MUSCULOSKELETAL PAIN POPULATIONS: A SYSTEMATIC CRITICAL REVIEW AND META-ANALYSIS Chiropractic & Manual Therapies

THE IMMEDIATE EFFECTS OF CERVICAL SPINE MANIPULATION ON PAIN AND BIOCHEMICAL MARKERS IN FEMALES WITH ACUTE NON-SPECIFIC MECHANICAL NECK PAIN: A RANDOMIZED CLINICAL TRIAL Journal of Manual & Manipulative Therapy

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A RANDOMIZED CLINICAL TRIAL COMPARING NON-THRUST MANIPULATION WITH SEGMENTAL AND DISTAL DRY NEEDLING ON PAIN, DISABILITY, AND RATE OF RECOVERY FOR PATIENTS WITH NON-SPECIFIC LOW BACK PAIN Journal of Manual & Manipulative Therapy

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204 10 10 133 3 11 75 2 6 53 0 0 38 1 7 29 1 3 33 0 0 23 2 0 14 3 2 17 1 0

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EXERCISE IS MEDICINE | 19-04-COKINETIC FORMATS WEB MOBILE

MEDIA CONTENTS Co-Kinetic Handouts, Leaflets and Client Resources https://spxj.nl/2BN8vbF Physical and manual therapists are highly educated healthcare professionals who diagnose and treat individuals of all ages who have medical or other health problems that limit their abilities to move and perform daily activities. We aim to help patients maintain, recover or improve physical ability that may be impaired because of a condition or injury and specialise in achieving this through treatment primarily by physical means. Yes, I am sure you know exactly what it is that you trained in and do every day. By this definition alone we are also excellently qualified to teach, empower and motivate our patients, as well as the wider community, to be physically active. It would, therefore, seem reasonable that people would respect and adhere to any advice we give. However, this is not always the case, and the reasons may boil down to two problems: firstly the messenger and secondly the recipient – and most importantly the communication between them. The evidence for the benefits of physical activity for health is becoming overwhelming and continues to grow every day. It seems like it should be a ‘no-brainer’ to make these lifestyle changes – so why isn’t everyone doing it? The truth is that initiating and supporting behaviour change is hard and often frustrating work. It’s also a huge opportunity to expand the range of services you can offer, and broaden your potential customer base. So, having the right tools and tactics at your disposal for achieving these goals will not only help you improve your outcomes but also build your business.

THE MESSENGER (AKA YOU, THE HEALTHCARE PRACTITIONER) Do you ever sit back and reflect on a consultation or a patient and think: 14

MOVING MEDICINE: NEW RESOURCES FOR HEALTH PRACTITIONERS The benefits of physical activity and maintaining a sensible weight for helping to prevent and reverse many health conditions are becoming increasingly better known and appreciated. But how do you broach the topic with a patient who doesn’t realise or perhaps doesn’t want to know that their lifestyle is damaging their health? How do you encourage lasting behavioural change? Physical and manual therapists are uniquely placed to begin these conversations and this article, in conjunction with the resources at Moving Medicine and Co-Kinetic, provides the tools and confidence to go about it in the most effective way in however much or little time you have available. In addition to doing the best for your patients, it might also enable you to broaden the services you offer and your client base. Read this article online https://spxj.nl/2GViG1W BY KATHRYN THOMAS BSC MPHIL n I treat people with a lifestyle that I know is affecting their health, but feel I’m stepping outside my boundaries by trying to help them. n I sometimes hesitate and struggle to start conversations about behaviour change or physical activity. n I don’t have enough time to discuss physical activity during a treatment session but I know it would help. n I’ve tried to offer advice, but they don’t seem to want to listen. If you answered yes to any of these then maybe we have a solution

or at least some tools to help you firstly introduce the subject, and then secondly get better results from your physical activity counselling. It goes without saying that leading by example by being active yourself is pretty important, but that’s closely followed by making sure that you know your facts about the physical activity guidelines in order to give them the right the information. We discussed this in detail in a recently published article ‘Are We Leading by Example? Physical Activity Guidelines and Their Role in Physical Therapy’ (1). If you missed it or

THE MOVING MEDICINE WEBSITE GIVES YOU SOME GREAT TECHNIQUES FOR STARTING THE CONVERSATION AND GETTING KEY POINTS ACROSS IN THE TIME YOU HAVE AVAILABLE Co-Kinetic Journal 2019;80(April):14-16

PHYSICAL THERAPY

I SOMETIMES HESITATE AND STRUGGLE TO START CONVERSATIONS ABOUT BEHAVIOUR CHANGE OR PHYSICAL ACTIVITY can’t remember what it said, a quick (re-)read may be a good idea. However, just at the end of 2018 a new, interactive, web-based tool called Moving Medicine was launched in a joint initiative between the Faculty of Sport and Exercise Medicine in partnership with Public Health England and Sport England (see Further Resources for details). Its goal is to work with clinicians, hospitals and patients to spread the word about the positive effects that even just a little bit of movement can have on people’s symptoms and diseases as well as the role of activity in the prevention of those conditions. They have developed an accredited, structured and moderated online education platform to help you develop the skills and knowledge required to have good quality conversations with people about physical activity, no matter how short or long the conversation may be. People listen to your advice – and you have unique access to some of the least active members in your community. This means you can play a vital role in helping them lead more active, healthier and happier lives. It is also believed that physical therapists have more talk-time available during treatment sessions than many other healthcare professionals, as well as repeat contacts with their patients, which gives them a greater opportunity to start and work through discussions about physical activity. Encouraging behaviour change is rarely easy or quick, so the Moving Medicine website has three different consultation frameworks to guide you through the ins and outs of having effective conversations with patients about physical activity, no matter how much (or little) time you have with them. Frameworks of questions and discussion points for a 1 minute conversation, a 5 minute conversation and then an ‘open’ or unlimited time Co-Kinetic.com

frame, termed the ‘more minutes conversation’ are provided. Having a guideline and asking the right questions within a given amount of time can still result in a constructive discussion about physical activity.

The Structure of the Conversations n The 1 minute conversation For when there really is no time, this toolkit describes the three most important messages to share. n The 5 minute conversation This toolkit comprises three steps: 1. Ask: assess patient behaviour and beliefs and introduce the subject. 2. Explore: find out how much they know already, and share any relevant extra information. 3. Agree: start to make a plan and signpost activities. n The more minutes (open timeframe) conversation If ever you have the luxury of more minutes, this is the Rolls-Royce of physical activity conversations. All the content of the 5 minute consultation with extra, in-depth features including: - calculating current physical activity levels - guidance and responses on answering common concerns - clear diagrams explaining how physical activity improves symptoms - ideas on how to build activity into the daily routine - four planning options and PDF downloads - diary printouts for people to take away - signposting to a network of activities. You want to ensure that you engage the patient in the conversation from the beginning without them shutting

you down, or simply shutting off; this requires some skill. The resources at Moving Medicine provide a very structured plan, with examples of how to ask the questions: 1. Ask permission to talk about physical activity or ask permission to talk about something that will greatly benefit their future health and wellbeing. 2. Assess Impact. How has their current illness, condition, injury, lifestyle impacted on their activity levels and what do they enjoy? 3. Review their activity level and possibly use an Activity Calculator. 4. Explore the benefits. What do they know about the benefits of physical activity, especially relevant to their disease or condition? Use questions or statements such as: a. “Can I share with you what we now know?” or “Can I tell you some more information to see what you make of it?” b. “What do you make of what I have just said?” c. “What would be the top two to three reasons for you personally becoming more active, if you decided to?” d. “Imagine you were able to become and stay more active, and imagine that you kept this up for 1 to 2 years. What do you think you would notice?” e. “What would help move your confidence higher up the scale of maintaining an active lifestyle?”

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THE RECIPIENT (AKA THE PATIENT OR PUBLIC) Rather than just trying to tell them, and force it down their throats, asking permission to talk about physical activity can open a constructive person-centred conversation around behaviour change. This keeps the person actively engaged in the conversation and the decisionmaking process. 15

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Most people are ambivalent about, rather than resistant to, increasing their physical activity levels. There are pros and cons to both maintaining the same physical activity levels as well as increasing them. Your challenge is to help an individual to consider and share their own ‘pros’ for increasing their physical activity levels and help them to develop these ideas into a workable plan that fits into their life. This would obviously involve discussing the benefits of physical activity with them, especially any specific benefits relevant to their condition or disease. Key benefits are discussed on the Moving Medicine website and at Co-Kinetic we’ve developed a range of supporting advice leaflets and a patient newsletter (see Media Contents), which can also be rebranded with your details. These are designed to help you discuss the benefits with the individual, who can then take information home for further thought after your session. Essentially what you are aiming for is ‘recipient buy-in.’ However, knowing the benefits may not be enough. Many people have deep-seated concerns about being active, which can be based on cultural differences, fear, confidence, financial worries, lack of knowledge, fatigue, etc. Unless you are able to uncover these concerns and address them, you will never get ‘buy-in,’ no matter how prettily you paint the picture. The Moving Medicine website gives you some great techniques for starting the conversation and getting key points across in the time you have available. The Co-Kinetic leaflets give you something that patients can take away and digest after they have left. They also address some of the main

concerns that create barriers to getting started, and include lots of tips and advice aimed at relieving these worries, and encouraging a slow progressive start. The goal is that the more barriers you are able to break down (through both your conversations, your role as an advice giver, and with the follow up leaflets) the greater the chance of motivating your clients into becoming more active.

ADDITIONAL TOOLS Although the goal is to achieve the target amount of activity that’s explained in the guidelines, the reality is that many people will battle to get there, never reach it at all, or be totally put off by it from the beginning, because they are overwhelmed by coming from a base of very little or no activity. But evidence has shown that anything is better than nothing, even half the recommended amount of weekly physical activity can still give significant benefit when it comes to reducing the risk of disease. So the philosophy embraced by Moving Medicine is to encourage people to get moving in any way, shape or form. Being active every day, even in small bouts that may accumulate over the day and hopefully over time towards achieving the recommended guideline levels, is the focus of addressing physical inactivity with the general population. It is felt that by doing this people may be more receptive to taking that first step in making a lifestyle change. Moving Medicine also offers workbooks for people to record their goals and document their commitment to changing their behaviour, as well as a daily and weekly diary to plan and record their activities.

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: The evidence for the benefits of physical activity for health is becoming overwhelming https://spxj.nl/2GViG1W Tweet this: The Moving Medicine website has 3 different frameworks for conversations about physical activity https://spxj.nl/2GViG1W Tweet this: Asking permission to talk about physical activity can open a useful person-centred conversation https://spxj.nl/2GViG1W Tweet this: Evidence has shown that doing any physical activity is better than nothing https://spxj.nl/2GViG1W

Having the right support may be key to success, but it doesn’t all have to fall on you: including family and friends is important, which makes this a great topic for evening seminar sessions and for getting more people along to your clinic. Between the CoKinetic and Moving Medicine resources, you’ll have plenty of information to share. For each medical condition covered under Moving Medicine, there are also lists of online support services, as well as signposts for people looking for specific activities within their area, co-ordinated by County Sports Partnerships.

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FURTHER RESOURCES 1. Moving Medicine website https://movingmedicine.ac.uk/ References 1. Thomas K. Are we leading by example? Physical activity guidelines and physical therapy. Co-Kinetic Journal 2018;76(April):12–19. http://spxj.nl/2oOgOgK

RELATED CONTENT re We Leading by Example? Physical Activity Guidelines A and Their Role in Physical Therapy [Article] http://spxj.nl/2oOgOgK o-Kinetic Handouts, Leaflets and Client Resources C https://spxj.nl/2BN8vbF 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

Co-Kinetic Journal 2019;80(April):14-16

PHYSICAL THERAPY

FEMOROACETABULAR IMPINGEMENT SYNDROME PART 1: All references marked with an asterisk are open access and links are provided in the reference list BY KATHRYN THOMAS BSC MPHIL

Femoroacetabular impingement (FAI) is not a new idea but hip arthroscopy has allowed identification and surgical treatment of a greater number of patients. This increase is also partly the result of the confusion use of terminology which has resulted in ‘morphology’ being mistaken for ‘pathology’. This article clearly describes the difference between these two states, with a clear definition for the pathological state of FAI syndrome (FAIS), as well as the battery of tests needed to exclude or include a diagnosis of FAIS. This allows you to be confident about deciding whether FAIS is the cause of your patient’s hip/groin pain or not, enabling them to potentially avoid unnecessary and invasive surgery. Additionally, the article explains how the cam morphology is thought to occur, allowing you to advise children and adolescents on their activity levels during the crucial ‘growth spurt’ stage and so reduce the risk of cam development. Read this article online https://spxj.nl/2tKjfTo HIP | LOWER BODY | LOWER LIMB | 19-04-COKINETIC FORMATS WEB MOBILE PRINT

MEDIA CONTENTS 5 YouTube videos for the assessment of hip impingement (Courtesy of Physiotutors) https://spxj.nl/2tKjfTo

Co-Kinetic.com

Hip and groin pain is a common cause of loss of function in young and middle-aged adults. The prevalence of hip and groin pain is known to be as high as 49% in athletes and 21% in general population cohorts (1*). The occurrence of hip and/or groin pain increases with age, and its impact often extends beyond activity reduction, to reduction in participation in work and family activities. Many different structures, sometimes referred to as clinical entities, may contribute to the development of hip and groin pain. The hip and groin is a complicated and often complex issue, which has resulted in much confusion over the years. The recent Warwick Agreement (2*) focused specifically on clarifying femoroacetabular impingement (FAI), a process necessary because of the reasons explained below. The concept of hip impingement has been around since the 1930s. However, in recent years the number of patients being treated for FAI has risen sharply. This may, in part, be the result of new surgical techniques and concerns over the links of FAI with osteoarthritis (OA). With the introduction of an arthroscopic approach to surgery in the 2000s an even greater interest was sparked in the condition, with a larger number of patients being identified and treated – a 400% increase in just over a decade (3). This sharp rise in a previously

unrecognised condition has raised concerns among clinicians, funders and countries’ healthcare systems. Costs, uncertainties in treatment and outcomes, a lack of clarity in the epidemiology and ambiguity of the diagnostic criteria all required better clarity and understanding. FAI syndrome (FAIS) now refers to the intra-articular pathology and subsequent symptoms and signs that develop in susceptible individuals when the femoral and acetabular components of the hip repetitively and prematurely abut against each other. Typically, hip joint shapes associated with FAIS includes cam and pincer morphology, which will be discussed in more detail later. The majority of people who have cam and/or pincer morphology do not have FAIS and remain asymptomatic throughout life. Unfortunately, there has been confusion in clinical practice and in research, where the terms describing ‘cam’ or ‘pincer morphology’ and ‘FAIS’ have been used interchangeably. This has resulted in individuals with cam or pincer morphology being treated as patients with FAIS, and undergoing prophylactic surgery, even in the absence of any symptoms. In the face of such aggressive intervention, claims of overdiagnosis and overtreatment are likely to be well justified. So we need to acknowledge there are many young and middle-

THE MAJORITY OF PEOPLE WHO HAVE CAM AND/OR PINCER MORPHOLOGY DO NOT HAVE FEMOROACETABULAR SYNDROME (FAIS) AND REMAIN ASYMPTOMATIC THROUGHOUT LIFE 17

THE DEFINITION OF FAIS INVOLVES A TRIAD OF SYMPTOMS, CLINICAL SIGNS AND IMAGING FINDINGS

Video 1: FADDIR (flexion-adduction-internal rotation) test (Courtesy of YouTube user Physiotutors) https://youtu.be/xyJUIhsL4lg

Video 2: Patrick’s / Faber / Figure Four Test (Courtesy of YouTube user Physiotutors) https://youtu.be/89Qiht82zmg

Video 3: Active Range of Motion (Hip Joint) (Courtesy of YouTube user Physiotutors) https://youtu.be/3OiJqAtPQUc

Video 4: Passive Range of Motion (Hip Joint) (Courtesy of YouTube user Physiotutors) https://youtu.be/3lTv4gpRWxg 18

aged adults suffering a loss of quality of life because of the symptoms of FAIS; however, there are also many people who may have cam or pincer morphology on radiographs, but who do not have FAIS because they are asymptomatic. The accurate diagnosis of FAIS is critical to determine appropriate treatment. In addition, it is important to recognise that not all hip pain is due to FAIS. Before one can consider management options, clear understanding and an accurate diagnosis is essential. This article aims to do just that, making clear (and user friendly) the process of FAIS diagnosis and recognising the underlying morphology as a part of the clinical picture but not in isolation of the person.

WHAT IS FAIS? The Warwick Agreement (2*) from 2016 bought together experts within the field of hip and groin pain aiming to find clarity and consolidate evidence for best practice outcomes. From this the following definition was established. ”FAI syndrome is the motion-related clinical disorder of the hip with a triad of symptoms, clinical signs and imaging findings. It represents symptomatic premature contact between the proximal femur and the acetabulum.” (2*) Two important points need to be made about the definition. Firstly it is a ‘triad’: all three components have to be present otherwise a diagnosis of FAIS cannot made. Radiological findings alone are not enough anymore to classify patients as having FAIS. Secondly this is a syndrome, not simply FAI. Femoroacetabular impingement (as previously named) would simply imply a mechanical condition which could lead to inaccurate diagnosis and subsequent treatment. Addition of the word ‘syndrome’ ensures and

makes clear the need for clinical signs and symptoms to be present. The infographic in Link 1 summarises the diagnostic requirements for FAIS. Before starting an objective examination of the patient, remember the importance of the subjective assessment and history taking. During the subjective assessment, identify the patient’s previous activity levels, specifically during adolescence, as this may be associated with an increased risk of developing FAI (this will be discussed in further detail later in the article). Ask if there is a family history of hip problems or hip replacements, as there may be a genetic predisposition to developing a cam morphology.

Red Flags It is important not to ignore the following red flags for a differential diagnosis. n T here should be a high index of suspicion of a slipped upper femoral epiphysis in adolescents presenting with hip or groin pain. These typically occur in overweight males between the ages of 10 and 13 years, but it can occur in females too. Patients commonly present with hip or knee pain and, on assessment, patients have a shortened or rotated leg. It may be appropriate to refer for further imaging to rule out the presence of a SUFE in adolescents (8–14-yearolds) presenting with hip or groin pain. nP elvic or femoral stress fractures may present in females with a low BMI, especially those with risk factors for female athlete triad. nC linicians should also be cautious of malignancy, especially in patients with a past medical history of cancer. Ask about past history of cancer during the subjective assessment and always refer these patients on if there are any concerns. Co-Kinetic Journal 2019;80(April):17-25

PHYSICAL THERAPY

DIAGNOSIS OF FAIS Step 1: The Symptoms In short, the primary symptom of FAIS is motion-related or positionrelated pain in the hip or groin. Pain may also be felt in the lower back, buttock or thigh (2*). Patients usually point to their hip or anterior groin area. However, there is wide variation in the location, nature, radiation, severity and precipitating factors that characterise this pain. Most patients report pain in the groin or hip, but pain is also reported in the lateral, anterior or posterior thigh, and knee (2*). Because FAIS pain is typically motion-related or position-related it can encompass a wide range of patients, from those who experience symptoms during or after vigorous activity (eg. football), to those who have pain with a supraphysiological range of motion (ROM; eg. dance, gymnastics, ballet), to those who get symptoms despite leading a sedentary lifestyle (seated for long periods). With regards to sporting activities common aggravating movements include flexion and rotation of the hip, such as playing football, hockey, water polo and tennis. Some patients report pain at rest or at night which may be due to synovitis of the joint. In addition to pain, patients may also describe clicking, catching, locking, stiffness, restricted ROM or giving way. These are referred to as mechanical symptoms (2*). A common problem when working in this area is determining whether pain is really arising from the hip joint or from other structures in the groin and hip region. It can be helpful to use an image-guided (X-ray or ultrasound) local anaesthetic injections to resolve this situation (2*). Pain relief following a local anaesthetic injection would support a diagnosis of FAIS, as long as the other diagnostic criteria are met.

Step 2: The Clinical Signs Like so many other syndromes, diagnosis does not depend on a single clinical sign. There are a number of problems when deciding on the best examination technique or test: that being specificity and sensitivity or the lack thereof, the clinician’s application Co-Kinetic.com

and interpretation, inter and intratester reliability, lack of consistency across different professions, patients and peers. Hence, a battery of clinical tests needs to be performed in order to narrow down the options and focus the lens. That being said, assessment of the patient’s entire kinetic chain, posture and movement patterns is not to be neglected. 1. Hip Impingement Tests Hip impingement tests usually reproduce the patient’s typical pain and are the most commonly used test. Flexion-adduction-internal rotation (FADDIR; Video 1), is sensitive (usually positive when FAIS is present) but not specific (often positive when FAIS is not the correct diagnosis). So, hip impingement tests are good screening tests, in that they can rule the condition out, but are poor diagnostic test (3). 2. Hip ROM Although controversial and often contradictory, restricted hip ROM is usually associated with FAIS. The FABER (flexion abduction external rotation) or Figure Four test can be used in assessing hip ROM (Video 2). Greater hip flexion ROM is associated with improved outcomes in patients with FAI (Videos 3 & 4). To measure hip ROM, position the patient in supine with their legs flat and instruct them to actively extend the opposite leg into the bed. Place an inclinometer 5cm above the patella and ask the patient to actively bend their knee as far as comfortable towards their chest. Flexion ROM should be used as an objective marker to assess the effectiveness of treatment interventions. 3. Movement Patterns Abnormal movement patterns around the hip and pelvis are present in patients with FAIS. Specifically, patients with FAIS have lower peak hip extension, total sagittal plane ROM and peak hip internal rotation during stance phase of walking (4*). Patients also present with a lesser squatting depth (4*). The reduced squat depth often seen in FAIS patients who still have good hip flexion ROM, may reflect poor motor programming, pain or fear

of the task. Before recommendations can be made, greater investigations into the barriers to squat depth need to be explored. Since squatting type movements are required during everyday activities, patients with FAIS may benefit from skill retraining as a component of conservative management strategies (4*). Impairments in hip frontal, sagittal and transverse plane ROM are seen during gait, squatting and stair climbing (5*). Patients are also unable to control hip flexion in one or more aspects, mostly seen as the trunk leaning forwards and the hip moving into increased flexion (6*). Patients also demonstrate poorly controlled hip internal rotation (6*). Neuro-muscular function may be compromised, especially during dynamic tests. Biomechanically, it has been reported that symptomatic FAIS can affect walking by reducing speed (7*). Reduced hip extension may be a strategy to reduce load on the anterior hip during walking. However, this behaviour has also been hypothesised to be maladaptive, decreasing the stimulus to anterior hip musculature, which can negatively affect hip stability over time. At this time, the implications of lower peak hip extension angle during walking are not known (4*). Studies have shown that patients with FAIS produced lower peak external rotation torque, and lower peak hip internal rotation angles during walking compared with controls. These adaptations may represent a strategy to avoid positions of internal rotation, which are often reported to be painful in patients with FAIS (4*). As external moments are offset by internal moments of the antagonistic muscle groups/movements, a lower peak external rotation joint torque may decrease the demand on the internal rotators to minimise pain and discomfort. These movement patterns, associated with FAIS, may lead to pain or dysfunction in other regions, such as the spine, pelvis, posterior hip or abdominal wall. Patients with FAIS exhibit alterations in hip movement strategies in activities such as walking and squatting, but possibly also in tasks such as stair ascent, sit-to-stand, 19

THE PRIMARY SYMPTOM OF FAIS IS MOTIONRELATED OR POSITIONRELATED PAIN IN THE HIP OR GROIN, BUT THERE IS WIDE VARIATION IN THE NATURE OF THE PAIN

Pincer derformity Cam derformity

Mixed impingement

Figure 1: Femoroacetabular impingement (FAI)

Internal rotation and flexion

Video 5: Resisted Isometric Testing (Hip Joint) (Courtesy of YouTube user Physiotutors) https://youtu.be/k12rDoTog4w 20

drop landings, single-leg hops and balance. This can affect the patient’s daily life and sporting ability and should be considered in assessment and treatment of the FAIS patient. 4. Muscle Weakness Muscles around the hip are frequently weak in patients with FAIS (2*). Individuals with symptomatic FAIS have demonstrated deficits in hip muscle strength (Video 5): traditionally, weak hip flexors and adductors, and reduced dynamic balance on one leg. Patients may demonstrate reduced balance via increased medial–lateral sway and worse anterior–posterior control during a dynamic single-leg squat task (7*) (as mentioned above with poor movement control). Muscle strength can be assessed using a hand-held dynamometer and improvements can be monitored during the treatment process. Bear in mind the importance of movement patterns and pelvic/hip control, rather than isolated muscle strength, especially given that FAIS is a dynamic motion-related condition. It is, therefore, recommended that when FAIS is suspected, gait be examined, single-leg control, muscle tenderness around the hip and hip ROM (including internal rotation in flexion) and the FABER distance be assessed. Impingement testing should be performed, and to be positive it must reproduce the patient’s familiar pain. It is essential to examine the groin for other structures that can produce similar pain.

Step 3: Diagnostic Imaging Morphological assessment of the hip is required in order to diagnose FAIS, identifying cam or pincer morphology. Positive imaging findings indicating an increased alpha (α) angle, increased acetabular or femoral retroversion, and increased lateral centre-edge angle can

support the diagnosis of FAIS. However, note that positive imaging findings in the absence of symptoms and signs are not indicative of FAIS (3). An anteroposterior radiograph of the pelvis and a lateral femoral neck view of the symptomatic hip should initially be performed to obtain an overview of the hips, identify cam or pincer morphologies, and identify other causes of hip pain (2*). Where further assessment of hip morphology and associated cartilage and labral lesions is desired, cross-sectional imaging is appropriate. Traditionally there are three types of FAI morphology (Fig. 1): 1. Cam: cam morphology refers to a flattening or convexity at the femoral head–neck junction. The extra bone growth is most common in athletic populations. 2. Pincer: pincer morphology refers to either global or focal overcoverage of the femoral head by the acetabulum. 3 Mixed: combination of cam and pincer. It must be emphasised that the presence of morphology in the absence of appropriate symptoms and clinical signs does not constitute a diagnosis of FAIS. A substantial proportion of people in the general population are thought to have cam or pincer morphology (2*). As mentioned, the starting point for imaging assessment would be plain radiographs. A pelvic radiograph allows an overall assessment of the pelvis and hips, and exclusion of other painful conditions, such as fracture, acetabular dysplasia and osteoarthritis. Ideally, this radiograph should be centred on the pubic symphysis, without rotation, and with neutral pelvic tilt (2*). The shape of the acetabulum can be interpreted from this radiograph, but visualising the shape of the proximal femur requires

A BATTERY OF CLINICAL TESTS IS NEEDED TO EITHER RULE OUT FAIS OR NARROW DOWN THE CAUSE OF THE PATIENT’S SYMPTOMS TOWARDS FAIS Co-Kinetic Journal 2019;80(April):17-25

PHYSICAL THERAPY

an orthogonal view of the femoral neck. A number of such views have been described, such as the cross-table lateral, Dunn and frog laterals (2*). A recent study by Atkins et al. in 2019 showed that clinicians should consider using the Meyer lateral and 90° Dunn views to evaluate patients with suspected FAIS (8). However, the α angle (explained further below) and head–neck offset measurements from these and other plain film views could describe less than half of the overall variation in the shape of the proximal femur and cam lesion (8). There are some difficulties in interpreting 3D shapes from plain radiographs. For example, the spatial orientation of the acetabulum may be affected by the position of the pelvis. Posterior tilt increases in standing position and the parameters that describe anterior and posterior acetabular coverage, which are important in describing pincer morphology, may change (2*,9*). Also, two orthogonal views of the femoral neck may not be sufficient to identify all instances of cam morphology (2*). In combination, these radiographs are only moderately sensitive for identifying the typical morphology of FAIS, but are specific (9*). Caution, therefore, needs to be exercised when using only plain film radiographs (8), particularly in cases where surgery is being considered. The morphology can be better characterised through cross-sectional imaging, either computed tomography (CT) or magnetic resonance imaging (MRI) (2*,9*). MR arthrography is usually more accurate than plain MRI to assess the labrum and articular cartilage (2*). Soft tissue lesions that may result in hip or groin pain may also be identified on MRI. When performing crosssectional imaging of the hip in FAIS, limited images of the distal femoral condyles allow assessment of femoral torsion, while 3D reformatting of CT or radial MRI allows assessment of focal morphological abnormalities, particularly of the proximal femur (2*). Measurements Currently there is a lack of consensus in the literature, with different authors suggesting different values for cam Co-Kinetic.com

DIAGNOSTIC IMAGING IS A NECESSARY PART OF FAIS DIAGNOSIS, BUT THE PRESENCE OF FAI MORPHOLOGY IN THE ABSENCE OF APPROPRIATE SYMPTOMS AND CLINICAL SIGNS DOES NOT INDICATE FAIS and pincer morphology. A panel of experts were unable to find agreement on common measures to define pathological morphology in routine clinical practice (2*). The reason being that impingement needs to be recognised as a dynamic, complex interaction, during motion, between the acetabulum and femoral neck and not a static morphological measurement that defines the condition. The concern is that the depth, orientation and rim of the acetabulum, and the head–neck profile, neck angle and torsion of the proximal femur all vary in the general population. It is when a particularly unfavourable combination of these characteristics occur together, along with provocative movement or position, that a patient may present with FAIS (2*). It has not been possible to capture all of this in a single measurement or even a simple set of shape criteria (2*). In simple terms, the most common site for impingement is the anterior superior region (see Fig. 1). The development of FAIS requires a combination of morphology and activity. A patient may have altered morphology but if their movement patterns do not take them into end of range positions then they may never develop FAIS. Radiographic measures of cam and pincer morphology have been described, including the α angle (cam), cross-over sign and centre-edge angle (pincer) (2*). 1. The α angle is used to identify cam deformity (for how to measure the α angle see Links 2a and 2b). An angle >60° is considered a positive finding. A measurement >78° is considered pathological and is associated with a high risk of developing hip OA later in life. In the skeletally immature hip, the ossified femoral head is small relative to the metaphysis, giving rise to raised bone α angles that do not necessarily reflect

cam morphology. Bone α angle measurements must be interpreted with caution in the immature skeleton (10*). 2. A pincer deformity can be identified by the lateral centre-edge angle (Link 3). A larger angle means a deeper acetabulum. A measurement >40° represents a pincer deformity. Not all clinicians stick to these exact measurements. Some clinical trials (eg. UK FASHIoN) of treatments for FAIS have included patients with an α angle >55° at any position on the head–neck junction for cam morphology and a positive cross-over sign or a centre-edge angle >39° for pincer morphology (11*). However, α angles cannot accurately discriminate between patients with cam type FAIS and asymptomatic volunteers, despite changes to the threshold value. This, again, reinforces the importance of using the imaging findings as a part of the whole picture and patients should

CHANGES IN HIP MORPHOLOGY ARE COMMON AND MAY BE A PHYSIOLOGICAL RESPONSE TO LOADING AND ACTIVITY not be ruled in or out based on 1 or 2° difference in their angle measurements (12*). Measurements are still routinely performed on patients with suspected FAIS, but it is crucial to remember the dynamic nature of the condition and heed to the diagnostic criteria for FAIS being a triad of clinical signs and symptoms together with radiological findings.

UNDERSTANDING THE MORPHOLOGY Morphology does not equal pathology! As already mentioned (and discussed below), changes in hip morphology are common across a range of population cohorts. The explanation for such changes is not completely understood, possibly involving a genetic connection but also a physiological response to loading and activity. Morphological changes could be the body’s way of protecting itself from injury. Additionally, the level of morphological abnormality does not necessarily coincide with the severity of symptoms or pain. Cam deformities of the femoral head contribute to FAI and correlate strongly with development of osteoarthritis. Surgery is increasingly performed on these patients, with little known about any benefits for the prevention of OA development in later life (13). Research has shown that cam deformity is triggered during late puberty by impact loading of the hip, so the important things to consider when looking at your patient and their history are detailed below.

1. Sex, Genetics and Physical Activity Appear to Influence Whether or not a Cam Morphology Develops 1. The lower prevalence of cam morphology among females 22

compared with males suggests a possible gender-specific pathogenesis (10*). As seen in the table in Link 4, cartilage α angle and epiphyseal extension were greater in males than females, as has been widely reported (10*,14*), but the sex-related difference in prevalence remains unexplained. Interestingly, the sex ratio for cam morphology is similar to slipped upper femoral epiphysis (10*), and perhaps the epiphysis is more responsive to load in males. Where BMI is strongly associated with SUFE it is not associated with cartilage α angle or epiphyseal extension (a precursor to osseous cam morphology development) (10*). 2. The prevalence of cam morphology is as high as 89% in athletes participating in activities that result in impact loading of the hip, compared to only 9% in non-athletic controls (13). Cam deformity results from bone adaptation in response to vigorous hip loading, which means that it should be preventable by adjusting the hip loads during a certain period of skeletal growth. 3. Cam deformity is seen with a stepwise increase from participants who play no regular sport, to participants who play sport for a school or club, and then participants who compete at a national or international level (Link 5) (10*). 4. The prevalence of cam deformity seems especially high in weightbearing sports that require high flexion together with rotational movements of the hip (eg. soccer, basketball and ice hockey). Ice hockey players were 4.5 times more at risk for having a cam deformity than skiers (15). As mentioned above, a dose–response relationship seems to exist. Elite soccer players who practised more than three times a week before the age of 12 years were 2.6 times more likely to have a cam deformity than elite soccer players who practised three times or less per week before the age of 12 years (16).

2. Bone and Growth Plate Adaptations 1. Bone and cartilage adapt to their

mechanical environment and the cartilaginous growth plate is likely to be affected in its differentiation and ossification process by mechanical loads. 2. Cam deformity on radiographs gradually develops from approximately 13 years until closure of the growth plate (Link 6) (13). 3. Finite element models of the hip have shown high mechanical stress patterns with impact loading of the growth plate and surrounding bone exactly where the cam deformity usually develops (17). This is further exaggerated when the hip is in flexion and external rotation. 4. High stresses are only present in hips with an open growth plate (adolescents), while in models with closed growth plates the high stress patterns normalise (13).

3. Dose–Response in Children 1. It appears that the age of around 12 to 13 years, in boys especially, is critical in the development of cam deformity. During these years of the adolescent growth spurt, the skeleton is especially responsive to mechanical stimuli, when levels of growth hormone, testosterone and IGF-1 increase and when bone modelling is highly active (18*). This might be a critical period since subtle mechanical triggers might interact with molecular stimuli and easily lead to bone formation. 2. Studies have shown that α angles were uniform across all boys aged 9 years; however, with increasing age there was an increasing range of α angle values consistent with cam development in a proportion of individuals (10*). Cartilage α angles increased as early as age 10 years and qualitatively this represented soft tissue hypertrophy at the head– neck junction. It has been proposed that this hypertrophy precedes extension of the ossified epiphysis. Bone α angles, elevated secondary to cam morphology, seem not to develop before the age of 12 years (10*). 3. The observation above suggests that measurements confined to osseous morphology are insensitive to early cam development and Co-Kinetic Journal 2019;80(April):17-25

PHYSICAL THERAPY

explains why loss of internal rotation precedes radiographic cam morphology. Clinically, the loss of internal rotation due to soft tissue hypertrophy may be of clinical importance when treating children who are at risk of developing cam deformity. 4. The growth spurt is, therefore, an interesting period of time for children’s activity coaches or sports programmes to prevent the development of a cam deformity by changing the loads applied to the hip (18*). However, children should not stop playing sports altogether, simply a modification of activity or awareness should be advocated (13).

CLINICAL CONSIDERATIONS People with both large cam morphology and reduced hip internal rotation are 25 times more likely to develop future hip osteoarthritis (OA) (19*). The existence of such a high odds ratio cannot be ignored; however, many with such morphology do not develop future hip OA (19*), and confounding variables could explain some of this relationship. In the same way over 50% of athletes have cam morphology, and over 65% of asymptomatic people, including athletes, have acetabular labral tears (20). Some imaging findings (eg. pincer morphology) previously considered pathological might actually be protective (21*). In addition to this, imaging may have limited clinical utility owing to its poor association with hip pain (22), making it difficult to distinguish a clinically significant imaging finding from benign variation. Thus, it is strongly supported that the term cam ‘morphology’, replace ‘deformity’ in the clinical setting (22).

Don’t Rush to Imaging Although imaging may be indicated in some patients with hip or groin pain, determining with confidence which patients need imaging and which findings should guide diagnosis and treatment requires careful correlation with history (eg. traumatic onset or not), physical examination findings and factors such as age and activity levels. Consideration of alternative causes for hip or groin pain is critical, Co-Kinetic.com

while correlation with diagnostic joint infiltration to confirm an articular aetiology, may be useful.

pharmacological) is superior to the others (2*). This will be discussed in more detail in Part 2 of this article.

Interpret Imaging Cautiously

Consider the Whole Person

When imaging is performed, report findings using the CLEAR principle (23).

Treat the individual and not their imaging findings (22). Musculoskeletal pain is influenced by multiple factors including training load, sleep, stress, fatigue, attitudes, beliefs and mood, as well as structural morphology. Imaging findings are only one part of the jigsaw puzzle. These ‘non-structural’ factors influence the pain experience as well as tissue resilience and local sensitivity, reinforcing the need to carefully interpret aggravating patterns and physical examination tests. Modifiable factors such as these often represent more potent therapeutic targets than structural tissue changes.

Consistent Language Minimally threatening language with accurate and easily understood words should be used to communicate imaging findings, without increasing fear that pain is always caused by structural ‘damage’.

Epidemiological information Comparisons to age-matched findings for asymptomatic populations could help patients and healthcare professionals contextualise the findings.

Assessment of Relevance Explaining what imaging findings do, and do not, mean for individual patients in isolation from clinical features can be challenging. There is no clear cut-off that signifies pathology, as hip morphology is influenced by multiple factors, such as sex, ethnicity, age and loading history. Learn from the past. Technical advances in surgery have increased imaging and surgery rates without obvious clinical benefit in some clinical contexts, for example, lumbar discectomy as well as arthroscopic subacromial decompression and partial meniscectomy (22). It seems possible that history may be repeating itself at the hip joint; patients with common changes in tissue morphology that are presumed to be pathological undergo surgery. With respect to FAIS, even when cam morphology is identified and appears closely linked to pain, there is no strong evidence that any specific management approach (surgical, conservative care, rehabilitation or

A FINAL WORD ON FAIS DIAGNOSIS AND MORPHOLOGY In most patients who seek treatment for FAIS, symptoms are not mild or subtle. They are often severe and limiting in everyday life, which is concerning given that the patients are usually young, economically active adults. Symptoms of FAIS can lead to a significant and lasting cost burden for society as well as being individually debilitating. The correct diagnosis will better direct management and treatment of the patient and possibly reduce the number of unnecessary surgical procedures. The flowchart in Link 7 summarises the management of FAIS and may be a handy reference tool. Hopefully this article has clarified and simplified the process of identifying patients with FAIS. Part 2 of this article will delve into treatment choices and how or when to decide whether surgery is an option.

THE PREVALENCE OF CAM DEFORMITY SEEMS ESPECIALLY HIGH IN WEIGHTBEARING SPORTS THAT REQUIRE HIGH FLEXION TOGETHER WITH ROTATIONAL MOVEMENTS OF THE HIP 23

References 1. Heerey JJ, Kemp JL, Mosler AB et al. What is the prevalence of imaging-defined intra-articular hip pathologies in people with and without pain? A systematic review and meta-analysis. British Journal of Sports Medicine 2018;52:581–593 Open access: https://spxj.nl/2BHtOuT 2. Griffin DR, Dickenson EJ, O’Donnell J et al. The Warwick Agreement on femoroacetabular impingement syndrome (FAI syndrome): an international consensus statement. British Journal of Sports Medicine 2016;50:1169–1176 Open access: https://spxj.nl/2V3Q9Kl 3. Kemp JL, Beasley I. 2016 international consensus on femoroacetabular impingement syndrome: the Warwick Agreement—why does it matter? British Journal of Sports Medicine 2016;50:1162–1163 4. King MG, Lawrenson PR, Semciw AI et al. Lower limb biomechanics in femoroacetabular impingement syndrome: a systematic review and meta-analysis. British Journal of Sports Medicine 2018;52:566–580 Open access: https://spxj.nl/2InpC9t 5. Diamond LE, Dobson FL, Bennell KL et al. Physical impairments and activity limitations in people with femoroacetabular impingement: a systematic review. British Journal of Sports Medicine 2015;49:230–234.10.1136/ bjsports-2013-093340 Open access: https://spxj.nl/2GPGi7o 6. Botha N, Warner M, Gimpel M et al. Movement patterns during a small knee

bend test in academy footballers with femoroacetabular impingement (FAI). Working Papers in the Health Sciences 2014;1:1–24 Open access: https://spxj.nl/2DNcoNO 7. Freke MD, Kemp J, Svege I et al. Physical impairments in symptomatic femoroacetabular impingement: a systematic review of the evidence. British Journal of Sports Medicine 2016;50:1180 Open access: https://spxj.nl/2toJO0o 8. Atkins P, Shin YJ, Agrawal P et al. Which two-dimensional radiographic measurements of cam femoroacetabular impingement best describe the three-dimensional shape of the proximal femur? Clinical Orthopaedics and Related Research 2019;477(1):242–253 9. Rakhra KS, Sheikh AM, Allen D et al. Comparison of MRI alpha angle measurement planes in femoroacetabular impingement. Clinical Orthopaedics and Related Research 2009;467:660–665 Open access: https://spxj.nl/2tpakqB 10. Palmer A, Fernquest S, Gimpel M et al. Physical activity during adolescence and the development of cam morphology: a crosssectional cohort study of 210 individuals. British Journal of Sports Medicine 2018;52:601–610 Open access: https://spxj.nl/2EhoCzJ 11. Griffin DR, Wall PD, Realpe A et al. UK FASHIoN: Feasibility study of a randomised controlled trial of arthroscopic surgery for hip impingement compared with best conservative care. Health Technology Assessment 2016;20:1–172

Open access: https://spxj.nl/2DPxQ4F 12. Sutter R, Dietrich TJ, Zingg PO et al. How useful is the alpha angle for discriminating between symptomatic patients with camtype femoroacetabular impingement and asymptomatic volunteers? Radiology 2012;264:514–521 Open access: https://spxj.nl/2Sb9xTU 13. Agricola R, Weinans H. What causes cam deformity and femoroacetabular impingement: still too many questions to provide clear answers. British Journal of Sports Medicine 2016;50:263–264 14. Laborie LB, Lehmann TG, Engesæter IØ et al. Prevalence of radiographic findings thought to be associated with femoroacetabular impingement in a population-based cohort of 2081 healthy young adults. Radiology 2011;260:494–502 Open access: https://spxj.nl/2TW3Afg 15. Philippon MJ, Ho CP, Briggs KK et al. Prevalence of increased alpha angles as a measure of cam-type femoroacetabular impingement in youth ice hockey players. American Journal of Sports Medicine 2013;41:1357– 1362.10.1177/0363546513483448 16. Tak I, Weir A, Langhout R et al. The relationship between the frequency of football practice during skeletal growth and the presence of a cam deformity in adult elite football players. British Journal of Sports Medicine 2015;49:630–634 17. Roels P, Agricola R, Oei EH et al. Mechanical factors explain development

LINKS

2016;24(6):949–961 https://spxj.nl/2TP9AXf Link 3: Fig. 2. Centre-edge angle (CEA) measurement on an AP pelvis X-ray. In Bisciotti GN, Di Marzo F, Auci A, et al. Cam morphology and inguinal pathologies: is there a possible connection? Journal of Orthopaedics and Traumatology 2017;18(4):439– 450 https://spxj.nl/2V4QUCS Link 4: Table 2. Radiographic findings for FAI in 868 male and 1192 female healthy participants at skeletal maturity on basis of worse hip and bilateral findings. In Laborie LB, Lehmann TG, Engesæter IØ et al. Prevalence of radiographic findings thought to be associated with femoroacetabular impingement in a population-based cohort of 2081 healthy young adults. Radiology 2011;260:494– 502 https://spxj.nl/2V2PWav Link 5: Fig. 3. Maximum cartilage alpha angle with age for participants who play no regular sport (‘no sport’), play sport for their school or a club team (‘sport’) or compete at a national or international level (‘athlete’). In Palmer A,

Fernquest S, Gimpel M et al. Physical activity during adolescence and the development of cam morphology: a cross-sectional cohort study of 210 individuals. British Journal of Sports Medicine 2018;52:601–610 https://spxj.nl/2GLYCxU Link 6: To see how children’s bones can change through adolescence see Fig. 1 in Agricola R, Weinans H. What causes cam deformity and femoroacetabular impingement: still too many questions to provide clear answers. British Journal of Sports Medicine 2016;50:263–264 https://spxj.nl/2SIiFVr Link 7: Fig. 1 Pathway for the management of femoroacetabular impingement (FAI) syndrome. In Griffin DR, Dickenson EJ, O’Donnell J et al. The Warwick Agreement on femoroacetabular impingement syndrome (FAI syndrome): an international consensus statement. British Journal of Sports Medicine 2016;50:1169–1176 https://spxj.nl/2ScBATf

Link 1: Infographic. The Warwick Agreement on femoroacetabular impingement syndrome. In Griffin DR, Dickenson EJ, O’Donnell J et al. The Warwick Agreement on femoroacetabular impingement syndrome (FAI syndrome): an international consensus statement. British Journal of Sports Medicine 2016;50:1169–1176 https://spxj.nl/2X9gtop Link 2a: Fig. 3. Alpha angle (α) measurement on a Dunn view X-ray. In Bisciotti GN, Di Marzo F, Auci A et al. Cam morphology and inguinal pathologies: is there a possible connection? Journal of Orthopaedics and Traumatology 2017;18(4):439– 450 https://spxj.nl/2V4QUCS Link 2b: Fig. 2. Diagrammatic representation of how to measure an alpha angle in a hip with a cam deformity. In Dickenson E, Wall PDH, Robinson B et al. Prevalence of cam hip shape morphology: a systematic review. Osteoarthritis and Cartilage

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of cam-type deformity. Osteoarthritis and Cartilage 2014;22:2074–2082 18. MacKelvie KJ, Khan KM, McKay HA. Is there a critical period for bone response to weightbearing exercise in children and adolescents? A systematic review. British Journal of Sports Medicine 2002;36:250–257 Open access: https://spxj.nl/2BElxIo 19. Agricola R, Waarsing J, Thomas G et al. Cam impingement: defining the presence of a cam deformity by the alpha angle: data from the CHECK cohort and Chingford cohort. Osteoarthritis and Cartilage 2014;22:218– 225 Open access: https://spxj.nl/2SHqyKE 20. Frank JM, Harris JD, Erickson BJ et al. Prevalence of femoroacetabular impingement imaging findings in asymptomatic volunteers: a systematic review. Arthroscopy 2015;31:1199–1204 21. Agricola R, Heijboer MP, Roze RH et al. Pincer deformity does not lead to osteoarthritis of the hip whereas acetabular dysplasia does: acetabular coverage and development of osteoarthritis in a nationwide prospective cohort study (CHECK). Osteoarthritis and Cartilage 2013;21:1514– 1521 Open access: https://spxj.nl/2XcHas6 22. O’Sullivan K, Darlow B, O’Sullivan P et al. Imaging for hip-related groin pain: don’t be hip-notised by the findings. British Journal of Sports Medicine 2018;52:551–552 23. Darlow B, Forster BB, O’Sullivan K et al. It is time to stop causing harm with inappropriate imaging for low back pain. British Journal of Sports Medicine 2017;51:414–415.

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

Co-Kinetic.com

KEY POINTS n F AIS is a motion-related clinical disorder of the hip with a triad of symptoms, clinical signs and imaging findings. Diagnosis is dependent on the presence of all three. n Diagnosis includes a set of clinical symptoms; a battery of tests, including FADDIR, FABER, ROM, functional movement control analysis and strength tests; and imaging for morphological changes. n FAIS represents symptomatic premature contact between the proximal femur and the acetabulum. n FAIS is associated with pain, reduced quality of life, and potentially increased risk of developing OA in later years. n Osseous cam morphology is preceded by cartilaginous hypertrophy at the femoral head–neck junction. This appearance is first evident at 10 years of age. n Sporting activity during adolescence is strongly associated with the development of cam morphology with a dose–response relationship. n Cam morphology is significantly more prevalent in males. n Imaging in isolation should be used with caution in patients with hip pain. Morphological change does not necessarily mean pathology. n Intra-articular hip pathologies found on imaging have been a catalyst for potentially unnecessary surgical interventions, particularly in those asymptomatic patients. n Uncertainty surrounds the relationship between imaging-defined intraarticular pathology and pain.

RELATED CONTENT F emoroacetabular Impingement (FAI): Management Techniques Using Postural Restoration: Part 1 [Article] http://spxj.nl/1AhmF0n F emoroacetabular Impingement (FAI): Management Techniques Using Postural Restoration: Part 2 [Article] http://spxj.nl/2zziL80 F emoroacetabular Impingement: Mechanisms, Diagnosis and Treatment Options using Postural Restoration®: Part 3 [Article] http://spxj.nl/2zzYJug ip Impingement Redefined: Symptoms, Diagnosis, Treatment and H Rehabilitation [Video] https://spxj.nl/2X7KDZ0

DISCUSSIONS sing the diagnosis criteria laid out from the Warwick Agreement, do U you feel there is better clarity in identifying FAIS from the many other hip and groin pain syndromes? In your practice what other clinical tests or functional movements would you use to help identify motor control problems in patients with FAIS? Should asymptomatic patients presenting with cam morphology be treated or left with a ‘wait and see’ response?

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: Femoroacetabular impingement syndrome typically involves cam and/or pincer hip morphology https://spxj.nl/2tKjfTo Tweet this: Femoroacetabular impingement hip morphology (cam/pincer) does not equal pathology! https://spxj.nl/2tKjfTo Tweet this: Research has shown that cam deformity is triggered during late puberty by impact loading of the hip https://spxj.nl/2tKjfTo Tweet this: Reducing hip loading levels during a child’s growth spurt might reduce risk of cam development https://spxj.nl/2tKjfTo

ASSESSMENT OF FASCIAL DYSFUNCTION FASCIA | 19-04-COKINETIC FORMATS WEB MOBILE PRINT

THE SUBJECTIVE EXAM Geoffrey Maitland, one of the grandfathers of manual physiotherapy, had a significant global impact on the profession. One of the most important messages he conveyed to physiotherapists was the importance of a thorough subjective evaluation. “Not only will a thorough subjective exam tell you what the problem(s) are,” he would say, “but also how to treat them.” This is true for all cases of musculoskeletal pain: it is particularly important for cases of fascial dysfunction. The typical questions asked in a good subjective evaluation include the following topics: n areas of pain and their relationship to each other n complaints of paraesthesia, numbness or other neurological symptoms n previous history of the complaint n previous medical history, including medications taken n medical tests performed and their results n previous treatments tried and their effects n behaviour of pain throughout the day/ night n factors that provoke and ease symptoms n functional difficulties n patient’s goals for treatment.

You have probably read articles about fascia, what it is and how it connects everything, and you have probably read articles about how to treat fascia-related problems; however, do you know how to identify if fascial dysfunction is the cause of your patient’s symptoms? This article is the missing link and provides all you need to know to diagnose fascial dysfunction or to make a differential diagnosis. Making the correct diagnosis is the first step to providing the right treatment for your patient’s problems to achieve long-term results. This article has been extracted from the author’s book Mobilizing the Myofascial System: A clinical guide to assessment and treatment of myofascial dysfunctions. Read this article online https://spxj.nl/2Tat7Fi BY DOREEN KILLENS FCAMT A patient with fascial dysfunction may present with the following additional subjective complaints. n “My skin is too small for my muscles.” n “I feel tension in my leg overall, as if I were wearing a twisted pair of tights.” n “I know that other therapists and doctors have told me that my right leg and arm symptoms are separate problems, but that’s not how it feels to me.” Other characteristics of myofascial pain include the following symptoms. n Pain is dull, aching, and often deep. n Pain may be low-grade to severe in intensity. n There are frequently many areas of

local tenderness. n T here are disturbed sleeping patterns with morning stiffness. n Pain does not follow dermatomal, myotomal or sclerotomal patterns. Does this last category of symptoms not sound suspiciously like fibromyalgia? Clinically, I have found that clients with this condition tend to manage their symptoms well with a combination of active exercise, dry needling, craniosacral techniques and fascial techniques as well as appropriate medication, such as pregabalin, to tone down the nervous system. Patients with fascial dysfunction are rarely able to identify specific provocative movements that consistently reproduce

‘MY SKIN IS TOO SMALL FOR MY MUSCLES’ IS A CHARACTERISTIC COMPLAINT OF MYOFASCIAL DYSFUNCTION 26

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their symptoms, unless the activity adds tension to a tight fascial line [eg. low back pain brought on by walking or standing for a period of time if the Deep Front Line (DFL) of fascia is restricted]. We must, however, rule out other dysfunctions that can reproduce these symptoms such as hypomobility or hypermobility of the facet joints, poor mobility and/or dynamic control of the foot, knee, hip, lumbar spine, pelvis or thorax that may contribute to the low back pain. Given the connectivity and relationship between body regions, every region of the body can contribute to low back pain. There can be other clues that we may be dealing with dysfunction of the fascial system: n The patient has difficulty maintaining effects of treatment despite good results obtained during treatment. n The patient has difficulty maintaining effects of treatment despite being diligent in doing recommended flexibility, postural or stabilisation exercises. n There has been a recent growth spurt in adolescence. n The patient has difficulty maintaining an optimal posture.

PATIENTS WITH FASCIAL DYSFUNCTION ARE RARELY ABLE TO IDENTIFY SPECIFIC PROVOCATIVE MOVEMENTS THAT CONSISTENTLY REPRODUCE THEIR SYMPTOMS Active Range of Motion n T he area in question may demonstrate normal, or near normal, range of motion (ROM), but the range may be decreased if the body is positioned differently. For example, if the Superficial Back Line of fascia is tight, testing active cervical flexion in sitting may be more restricted than if it is tested in standing. n Active ROM may or may not produce pain, but the patient frequently reports a sense of ‘stiffness’ or ‘pulling’. n Testing of individual joint mobility or muscle length is within normal limits (or, at times, hypermobile) but restriction is noted with combined, functional movements.

Muscle Length Tests

The objective exam involves several aspects, which, along with their common findings, are described below.

These are often within normal limits. If a muscle is restricted and treatment is targeted to the local muscle, both the patient and the therapist may feel that results from treatment are short-lived and the muscle soon tends to stiffen up again.

Observation

Joint Mobility

Positional faults are noted in observing the patient’s posture but testing the accessory movements of the joints only gives a partial explanation for this positional fault. For example, ideally, when assessing the position of the femoral head relative to the pelvis, the therapist is hoping to find a centred femoral head, a key requirement for optimal biomechanics of the hip. An example of a positional fault is one in which the femoral head is positioned anteriorly in relation to the ilium. If the therapist thinks only of articular factors, they will presume that the capsule of the hip joint is the cause of this positional fault. However, optimal biomechanics require not only normal capsular mobility around the hip joint but also balanced activation of all muscle and fascial vectors.

Testing joint mobility includes both passive physiological movements and passive accessory movements. Passive physiological movements are movements in which the practitioner produces the motion while supporting the limb or spine. The technique is chosen in order to assess the joint with the muscle in a relaxed position. Accessory or joint play movements are joint movements that cannot be performed by the individual. These accessory movements, including roll, spin and slide, accompany physiological movements of a joint. Manual therapists have been taught that when assessing passive physiological or passive accessory movements of a joint, attention must be paid to the sensation throughout the whole movement and not simply the end feel of the movement.

THE OBJECTIVE EXAM

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All joints have ROM divided into two zones: 1. A neutral zone (NZ) in which no resistance is felt. The NZ ends once the beginning of the first resistance to movement is perceived (R1). 2. An elastic zone (EZ) in which the first resistance to movement (R1) gradually increases until firm resistance is felt (R2) at the end of range. In a normal joint, it is considered that R2 is due to tension in the ligaments and capsule of the joint (Chapter 4 ‘Principles of treatment with Mobilisation of the Myofascial System’ of the author’s book Mobilizing the Myofascial System discusses this in more detail). A normal accessory movement for a joint, although small in amplitude (usually a few millimetres of glide or roll), will have a small NZ, where no resistance is felt at the start of the movement, and a gradually increasing EZ until R2 is felt. Training is required in order to determine a normal or abnormal feel for an accessory movement of a joint. n When there is a myofascial restriction, accessory movements of the joints have a ‘bouncy’ or ‘rubberlike’ end feel as opposed to the end feel of a fibrotic or stiff joint, which is crisper and harder. n A number of levels in the lumbar spine may exhibit stiffness with PIVM (passive intervertebral movement) testing for flexion, for example. If a fascial line is restricted, mobilising these joints often results in only partial release. n The patient’s joints may have a tendency to be hypermobile, but they still present with decreased ROM when active ROM is tested.

Vector Analysis: Load and Listen Test This test derives from listening courses developed by Gail Wexler for the Barral Institute. These listening 27

THE ‘LOAD AND LISTEN’ TEST IS PARTICULARLY USEFUL TO USE BEFORE AND AFTER A MOBILISATION OF THE MYOFASCIAL SYSTEM (MMS) TECHNIQUE techniques differentiate active and passive listening. ‘Load and listen’ encompasses both aspects of listening. I find it invaluable in helping to detect the primary myofascial vectors that may be impacting a joint. When an accessory movement for a joint is assessed, not only is the resistance of this accessory movement noted, but, in this test, particular attention is paid to the release component of the accessory glide. In other words, when you let go of a correction, where does it pull you? This is what is termed ‘vector analysis’. Vector analysis in the Integrated Systems Model (ISM) approach has taken the ‘load and listen’ concept of the Barral visceral approach and applied it to the musculoskeletal system to help identify the underlying system impairment that is creating suboptimal alignment, biomechanics and/or control of a body region. n I n a healthy hip, when the therapist glides the femoral head posteriorly, it floats back up to the surface, much like the type of ‘soap on a rope’ that

CASE REPORTS The following case reports demonstrate how effective treatment of myofascial dysfunction can be (Boxes 1 and 2).

pops back up to the surface of the water after it has been pushed down (Diane Lee, personal communication). n If the load and listen test points to an articular restriction, the therapist will feel that the accessory glide may be stiff with a relatively harder, capsular end feel. Upon the release of the accessory glide, a small amplitude movement occurs to allow the joint to re-establish a more neutral position. n If the load and listen test points to a myofascial restriction, the therapist feels the resistance to the accessory movement but the end feel will not be as hard. More importantly, upon release of the glide, there will be a vector of pull towards the area that is ‘tugging’ on the joint. This myofascial restriction may be a combination of neuromuscular vectors (increased tone in muscles due to increased neural drive), visceral vectors, muscular and fascial vectors. (Keep in mind that fascia surrounds all of these systems.) This test may be used as a ‘before’

and ‘after’ test, when using any type of release technique. It is particularly useful to use before and after a mobilisation of the myofascial system (MMS) technique. It guides the therapist as to which myofascial vector(s) have the most impact on a particular joint and encourages exploration of that myofascial vector. Release can be done both locally to the involved muscle and also along its myofascial line (based on Anatomy Trains myofascial meridians). (Chapter 11 of the author’s book ‘The lower extremity’ outlines the load and listen test for the hip joint.) The same concepts for the load and listen test apply to other joints. For example, if the glenohumeral (GH) joint is positioned anteriorly in relation to the acromion, on the load and listen test we may find some limitation in the posterior glide of the GH joint (the loading aspect of the test): but upon the release of the anteroposterior (AP) glide (the listening aspect of the test), we may feel a vector that pulls the humeral head caudally toward the biceps if the Superficial Front Arm Line

BOX 1: CASE REPORT – BEVERLY’S STORY This 45-year-old patient had initially come for treatment with complaints of tension in her right arm whenever she performed reaching movements requiring abduction. Evaluation revealed positive neurodynamic tension tests for the median and radial nerve on the right, with mobility issues at the interfaces of the mid-cervical spine (Cx), especially with lateral shears to the left and AP mobilisations from C2 to C7. Treatment was directed to improving the mobility of the median nerve (positioning the arm in abduction, external rotation, elbow extension and wrist and finger extension) and then adding AP mobilisa¬tions and lateral shear movements from C2 to C7. (Keep in mind that fascia around the nerve extends beyond the usual levels of C5 to C7.) In addition, the nerve mobility test itself was used as a treatment technique, both as a sliding technique and a tensioning technique. A similar approach was used for the radial nerve, the only difference being that the arm was positioned in internal rotation and the wrist and fingers were flexed. Three treatments later, she reported that abduction movements were no longer problematic but that when she reached forward into flexion to get something from a cupboard, she could still feel her arm symptoms. Previously positive tests and techniques were negative, so I then proceeded to test the mobility of the anterior cervical fascia in left side-lying with passive physiological shoulder flexion (technique above). Although she had very little tension in the mid-Cx with passive shoulder abduction and external rotation, 45° of shoulder flexion increased tension in the anterior mid-Cx, as if the myofascial tissues in this direction were tethering the cervical spine anteriorly. We used this mobilisation of the myofascial system (MMS) technique until she was able to obtain full shoulder flexion without subsequent pull on the mid-Cx and successfully treated her remaining symptoms. Before this patient, I had not explored the anterior cervical fascia with shoulder flexion. This was a perfect case of “listen to the patient. He/she will tell you what the problem is and how to treat it” (Maitland 1992; Vail IFOMPT Conference, Vail, Colorado, 1992).

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is shortened. It is then appropriate to check the myofascial tissues of the Superficial Front Line. (Chapter 13 ‘The upper extremity’ outlines the load and listen test for the GH joint.)

forefoot in neutral position in relation to the hindfoot. n The thorax: no lateral shift of the thoracic rings should occur with functional tests of OLS and squat (1).

Dynamic Stability Tests

Patients with fascial dysfunction frequently exhibit signs of dynamic instability, especially in the area of fascial tightness. Recruiting muscles that help in motor control is often a frustrating experience for both the therapist and the client, as fascial tension is frequently a factor that inhibits these stabiliser muscles from ‘kicking in’.

Dynamic instability may be defined as a patient exhibiting a failed load transfer when performing functional tasks such as the half squat or OLS (one leg stand) test. The failed load transfer in these functional tests may present in one or several areas (1): n The pelvis: ‘unlocking’ of the pelvis may occur. In this situation, the sacroiliac joint fails to maintain a position of sacral nutation in relation to the ilium (the position of optimal stability for the sacroiliac joint). The therapist may perceive this as the ilium moving into anterior rotation (relative counternutation of the sacrum) when doing a half squat or OLS test. n The hip: ideally the femoral head should stay centred in relation to the pelvis throughout a OLS or a squat manoeuvre. A common clinical pattern of dysfunction is a femoral head that glides anteriorly and/or internally rotates instead of staying centralised. n The foot: the foot should be able to maintain its neutral position, with the talus directly under the tibia, the

ASSESSMENT OF THE FASCIAL SYSTEM Testing for Fascial Restriction with Recurring Joint Dysfunction If a joint restriction is recurrent despite good effects with previous treatment, good compliance with mobility and stability exercises, and awareness of posture, it may be that the fascial component to the restriction needs to be addressed. For example, if anteroposterior (AP) mobilisations of the C4 and C5 levels are chronically stiff despite good release with treatment, we may consider whether this dysfunction is perhaps connected elsewhere along a fascial line, and whether this may possibly be a contributing factor

toward its recurrence. If the therapist suspects that fascia may be a factor in movement restriction, he/she can then explore which line of tension is most problematic. The MMS techniques described in this text have two components: 1. The therapist stabilises an area of recurrent dysfunction with one hand stabilising either an accessory movement of a joint or a recurring myofascial trigger point. 2. The therapist’s other hand becomes the hand that explores and mobilises lines of fascia, always using the ‘star concept’ (described below). Continuing with the same example of the restricted AP mobilisation at C4, the C4 level can be stabilised with an AP mobilisation angled cranially and then the following considered. n To explore the SFL the therapist may add: – an AP mobilisation to the ipsilateral or contralateral scapula – an AP pressure directed caudally to the tissue anterior to the sternum – the rest of this line may then be explored with an AP pressure directed caudally to the rectus abdominis area and/or the symphysis pubis (see Chapter 5 for details).

BOX 2: CASE REPORT – MICHAEL’S STORY This case hits close to home as it involves my son Michael, who is presently 25 years old. When he was 14 years old, he fell skateboarding and sustained a severe fracture of his left clavicle – it had fractured into three pieces, with the middle portion angled vertically. He was initially placed in a sling and told to go home – the assumption was that the bone would heal on its own. Lyn Watson, a shoulder specialist in Melbourne, Australia, whom I consulted, stated that, in Australia, they would operate on such a case. Needless to say, I made sure to go with Michael to his follow-up appointment. I had a number of concerns about the long-term function of his shoulder girdle, including the possibility that it would heal in a shortened position and forever impact his upper quadrant function. Unfortunately, I could not convince the chief orthopaedic doctor to perform surgery. He assured me that healing was coming along and I should just allow nature to take its course. Knowing that bone was essentially dense fascia, I proceeded to remodel the clavicular fascia, initially with a listening approach and later, as healing progressed, with a more directive, MMS mobilisation approach. The clavicle fascia was tight in a number of directions (see techniques above), particularly in relation to the Superficial Front Line (clavicle in relation to the pectoral muscles and rectus abdominis) and the anterior functional line of fascia (left clavicle with right ilium). The intraclavicular fascia also was remodelled to encour¬age healing in the most lengthened position possible. This work was followed up with a strengthening programme to his scapular upward rotators. Initial treatment was performed weekly, and then periodically over the next year, as bone (and fascia) remodelling took place. Throughout his growth spurt, Michael could feel the need for more fascial release and periodically through the years, as his system adjusted to a new gym programme. Today, he is fully functional and grateful that his mother is a physiotherapist with skills in MMS!

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TABLE 1: CONTRAINDICATIONS TO MANUAL THERAPY Contraindications specific to the patient

n n n n n n

Bone contraindications

n relevant recent trauma (fractures, dislocations) n past or present cancer that produces bone metastases (breast, bronchus, prostate, thyroid, kidney, intestine, lymphoma) n active infection (osteomyelitis, tuberculosis, previous bone infection) n significant foraminal or spinal canal reduction on radiography or other imaging examinations (for techniques done in extension)

Neurological contraindications • CNS disease or injury

n n n n n n n n n n n n

•S pinal cord injury or disease

n extrasegmental pain below the level of the lesion, which can increase with passive flexion of the neck n bilateral or quadrilateral multisegmental paraesthesia below the level of the lesion, which can increase with passive flexion of the neck n bilateral or quadrilateral multisegmental weakness or spastic weakness below the level of the lesion n hyperreflexia below the level of the lesion n possible presence of hyporeflexia at the level of the lesion n presence of Babinski or Oppenheim sign n presence of Hoffmann’s sign if the lesion is above C5–6 n clonus below the lesion level n ataxia n neurological spasticity below the level of the lesion n reflex bladder (the bladder empties when it is distended)

•C auda equina compression

n n n n n n n

Vascular contraindications

n vertebral artery insufficiency n vascular disease (aneurysm) n bleeding problems (eg. haemophilia)

Contraindications related to collagen disease

n n n n n

lack of consent disturbed psychological or emotional state inability to communicate/unreliable historian inability to relax constant or continuous undiagnosed pain intoxication/highly medicated

extrasegmental pain increased by passive flexion of the neck bilateral or quadrilateral multisegmental paraesthesia, augmented by passive flexion of the neck paresis or multisegmental paralysis hyperreflexia presence of Babinski/Oppenheim/Hoffmann/clonus ataxia neurological spasticity bladder or bowel dysfunction dysphagia/dysphasia Wallenberg syndrome (inferoposterior cerebellar artery) other signs/symptoms of cranial nerves nystagmus (if associated with dizziness/vertigo, requires more diagnostic differentiation)

hyporeflexia or areflexia (bilateral or multisegmental) paraesthesia/bilateral or multisegmental pain initially overactive bladder (urgency and increased frequency) then paralysis of the bladder (overflow urination) faecal retention with overload and overflow of faeces loss of genital sensation loss of erection reflex or ejaculation signs and symptoms of bilateral or multisegmental nerve root lesions

Ehlers–Danlos syndrome Marfan syndrome osteogenesis imperfecta benign hypermobility syndrome (precaution) – laxity of the connective tissue acute post-traumatic phase (precautionary for 6–8 weeks)

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continued Age-related contraindications

n children (skeletal immaturity, consent issues) n elderly (increased risk of osteoporosis, vascular disease, spinal stenosis)

Metabolic contraindications

n bone disease (eg. osteoporosis, Paget’s disease)

Systemic contraindications

n diabetes (precaution) n asthma (pay attention to the side effects of corticosteroids) n endocrine disorders (precaution) – hypothyroidism, hyperthyroidism, hyperparathyroidism n e ndocrine disorders (contraindication if treated with drugs that affect collagen) n pregnancy, contraindicated in the presence of: o any history of miscarriage o hypermobility/instability – recent postpartum (joint instability, risk of postpartum haemorrhage)

Medication

n a ctive inflammatory disease (e.g., rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, Reiter’s syndrome) n inactive inflammatory disease (precaution) n anticoagulants (Coumadin (warfarin), heparin) – pay attention to ASA (acetylsalicylic acid, aspirin) n any medication that affects collagen – corticosteroids, tamoxifen n any medication related to osteoporosis (see list below) n antidepressants (precaution) n harmful medications for bones o glucocorticoids diseases treated with glucocorticoids – rheumatoid arthritis, osteoarthritis, bursitis – asthma, COPD, allergic rhinitis – liver disease – lupus, psoriasis, severe dermatitis – cancers: leukemia, lymphoma – ulcerative colitis, Crohn’s disease – multiple sclerosis – post organ transplant – inflammation and eye diseases (glaucoma) o methotrexate diseases treated with methotrexate – cancers – immune disorders – resistant arthritic conditions o cyclosporin diseases treated with immunosuppressive drugs – post transplantation – immune diseases o

other medicines – heparin – cholestyramine (control of blood cholesterol levels) – thyroid hormones – anticonvulsants – antacids containing aluminium

n To explore the DFL the therapist may add: – an AP mobilisation directed caudally to the tissue posterior to the sternum (pericardium) – an AP mobilisation directed caudally to the right and/or left diaphragm – active dorsiflexion/eversion of the ankles to pre-tense the DFL by putting a stretch on the tibialis posterior, which is at the tail end of this line (see Chapter 5 ‘The cervical spine’ for details). n T o explore the Lateral Line the therapist may position the client in side-lying, stabilise the mid-cervical spine with an AP mobilisation and explore the intercostal fascia on the side of the trunk (see Chapter 5 ‘The cervical spine’ for details). How Does the Therapist Know when a Particular Line of Fascia is Restricted? The therapist will feel an almost immediate increase in tension of the stabilising hand (in this case, the AP mobilisation of the C4) as he/ she applies a gentle pressure on the anterior aspect of the sternum with the exploratory hand (for a SFL restriction). It is normal to feel a certain resistance between the two areas at the end of a caudal pressure on the sternum, but it is not normal to feel this resistance at the very start of the manoeuvre being performed by the exploratory hand. There should be (in Geoff Maitland’s terms) a ‘toe region’ where there is little resistance at the beginning of movement (discussed further in Chapter 4 ‘Principles of treatment with Mobilization of the Myofascial System’). When the fascial line is restricted, this toe region is absent or quite limited and early resistance between the two hands of the therapist will be felt. The patient may perceive this as the therapist pushing harder on the level being stabilised (in this case, C4) when in reality the therapist is simply preventing the fascial tissues at C4 from gliding caudally. Using the Star Concept The star concept implies that the therapist must not think along the lines of an articular glide but rather explore multiple directions: somewhat like the

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shape of a star. The aim is to discover where there is most tension between the stabilising hand and the fascial tissues anterior to the sternum (for this example of a problem with the Superficial Front Line). The therapist ‘corrals’ the myofascial tissue, ‘sniffing out’ the vector where most tension between the two hands is felt. In the example above, the caudal pressure on the tissues anterior to the sternum may be done in a straight caudal direction, caudal to the right of the patient, caudal to the left of the patient, or perhaps in a medial/ lateral direction or even in a clockwise/anticlockwise direction. Restriction may be felt in several directions. Treatment begins by using the most restricted direction and, once released, exploring and releasing the other restricted directions in that fascial line. The same ‘star concept’ applies to any MMS technique, for any line of fascia. Exploring Lines of Fascia n Tom Myers’s Anatomy Trains lines, although very pertinent to MMS, are not the only way a therapist can explore the fascia. The Anatomy Trains is simply a map of the ‘grain’ in the myofascial fabric, and so, like most maps, only an indication of a good place to look (2). n The nervous system may also be used as a guideline (see the femoral nerve fascial technique in Chapter 9 ‘The lumbar/pelvic region’ as an example). n The patient’s functional problems may also give us a clue as to what to explore. Refer to Chapter 5 (Anterior cervical in relation to glenohumeral movements) for an example where the patient complains of arm pain with reaching forward as opposed to reaching sideways with abduction. n “It hurts right here.” The location of the patient’s main complaint of pain may also be a good place to start, stabilising that area and exploring fascial lines that may be ‘tethered’ to that painful area. The area of pain is frequently a ‘victim’ of another dysfunction nearby (eg. the lower lumbar area may become symptomatic during standing 32

or walking if it is compensating for an extension dysfunction in the upper lumbar area, and/ or poor hip extension). However, the symptomatic area may also be tethered by a tight fascial line, and this may also play a role in its recurrence. Reposition and Test Another way to help differentiate an accessory joint movement restricted by the joint capsule from one restricted by myofascial vectors, is to repeat an accessory movement with other regions of the body under tension. For example, an AP mobilisation of the C4 level in the mid-cervical region may be compared to the same mobilisation (same grade of movement) with the ipsilateral arm in 70° of abduction. If the AP at C4 is stiffer (which may or may not reproduce pain), then it implies that fascia may be a factor in this recurrent restriction. The fascia may be related to the muscular system (eg. scalenes), the clavicle, the neural system (eg. median nerve), the visceral system (eg. pericardium) or perhaps a combination of all four areas. Another example is to explore the DFL of fascia in relation to the recurrent C4 dysfunction. This is done by stabilising C4 as above and simply adding active (or passive) combined dorsiflexion/eversion of the ankles to see if this affects C4. (Keep in mind that tibialis posterior is at the tail end of Tom Myers’s DFL, so adding dorsiflexion/eversion puts it under tension). If there is abnormal tension in the DFL of fascia, then adding dorsiflexion/eversion will cause an immediate increase in tension in the hand that is stabilising C4 in an AP glide (see Chapter 5 for MMS technique).

Testing for Fascial Restriction with a Recurring Muscle Trigger Point Myofascial tension may have a tendency to recur if the following factors are not addressed: n optimising balance between muscle groups in the area (ie. stretching tight muscles, strengthening weak ones) n u sing dry needling or IMS techniques

to de-facilitate muscles that are hypertonic secondary to increased neural drive n c onsidering other areas of the body that may be impacting the symptomatic area (ISM concept of drivers) n last but not least, considering that there may be a myofascial component to the restriction that needs to be addressed. The following paragraph describes an example of this last concept using MMS. Recurrent tension in the upper fibres of trapezius (UFT) may be due to tension of the Superficial Back Arm Line (SBAL), which needs to be addressed in order to get optimal results. In this example, the therapist ‘stabilises’ the recurrent myofascial trigger point in the UFT by pinching it in an AP direction. If there is tension in the SBAL, the therapist will feel an immediate increase in tension of the ‘stabilising’ hand on the UFT as soon as he/she adds a component of passive wrist and finger flexion. Keep in mind that the wrist and finger extensors are at the tail end of the SBAL (see Chapter 2 ‘A brief summary of Tom Myers’s Anatomy Trains fascial lines and clinical implications’). Using oscillatory movements of wrist flexion while maintaining the pinch on the trigger point will help to release this line of tension (see Chapter 5 for MMS technique).

Testing for Fascial Restriction with a Neural Mobility Test In order to address problems of decreased mobility of a particular nerve, the usual approach in manual therapy is to mobilise the interfaces of the nerve in question. The median nerve, for example, may involve positioning the arm in some degree of shoulder abduction, external rotation, elbow extension, and wrist and finger extension (depending on irritability of the tissues and where first resistance is felt when doing the median nerve mobility test) and then adding AP mobilisations or lateral shear movements at C5, C6, and C7. As well, the nerve mobility test itself may be used as a treatment technique, either as a sliding technique or a tensioning technique. If, however, tension of the Co-Kinetic Journal 2019;80(April):26-34

MANUAL THERAPY

nervous system persists despite this approach to treatment, it is suggested that the therapist explore a little more broadly than the usual interfaces of the nerves. For example, the therapist may use a mobilising technique in the anterior cervical spine with the arm in abduction, external rotation, wrist and finger extension to pre-tense the median nerve and then explore the SFL of the trunk. Or the therapist may also explore other regions of the cervical spine, frequently as high as C1 or C2, that may have an impact on the mobility of the median nerve (see Chapter 5 for MMS techniques).

Indications/Contraindications to MMS Treatment The contraindications to treatment with MMS are similar to the contraindications for manual therapy in general (Table 1). CNS, spinal cord or cauda equina disease and injury are an obvious contraindication to any manual therapy, but there are also other conditions to consider such as vascular issues and metabolic and systemic contraindications. MMS is particularly indicated for subacute or chronic conditions. If the condition is acute, the therapist may work either proximally or distally (craniocaudally) to the symptomatic region, following Myers’s fascial lines of tension. When first working with tissues that are in the subacute phase of healing, it is wise to use ‘listening techniques’ rather than be too directive until such time that the body gives you a green light to go ahead (see Chapter 4 for principles of treatment with MMS). Recent fractures must be given time to heal before using fascial techniques directly on the fracture site, but areas above and below the fracture may be explored and treated.

References 1. Lee L-J, Lee D. Techniques and tools for addressing barriers in the lumbopelvic–hip complex. In Lee D (ed.), The pelvic girdle: an integration of clinical expertise and research, 4th edn. Elsevier 2011. ISBN 978-0443069635 (Print £52.99 Kindle £41.27). Buy from Amazon https://amzn.to/2GLv7gs

2. Myers T. Anatomy trains: myofascial meridians for manual and movement therapists, 3rd edn. Churchill Livingstone 2013. ISBN 978-0702046544 (Print £39.99 Kindle £27.41). Buy from Amazon https://amzn.to/2Xhhvih

KEY POINTS n A thorough subjective exam is crucial for the correct analysis and treatment of fascial dysfunction. n Some symptoms of myofascial pain can sound like the symptoms of fibromyalgia. n It is often difficult for fascial dysfunction patients to identify specific movements that reproduce their symptoms. n Difficulty in maintaining good treatment results with conventional manual therapy approaches can indicate fascial dysfunction. n A cornerstone of the objective exam is to test whether joint position is balanced during functional movements that are relevant to the subjective complaint. n The end feel of accessory movements of the joint is ‘bouncy’ when fascial restriction is present. n Mobilisation of the myofascial system (MMS) techniques are also useful for testing fascial restriction. n MMS is particularly indicated for subacute or chronic conditions. n ‘What the therapist perceives as recurring joint stiffness may actually have a component of fascial dysfunction – a myofascial vector that pulls on the joint making it more difficult for the patient to obtain optimal biomechanics. This recurrent ‘joint stiffness’ will remain until the appropriate myofascial vectors are examined and treated.’

THE AUTHOR Doreen Killens FCAMT is an orthopaedic musculoskeletal physiotherapist with 40 years of clinical experience. For 25 years she was an instructor for the Canadian Orthopaedic Manipulative Division of the Canadian Physiotherapy Association, teaching manual therapy courses across Canada. In addition, she was an Examiner and former Chief Examiner for the same association. She is presently in private practice in Montreal and has a particular interest in the field of headaches and myofascial dysfunction. She is the developer of a physiotherapy approach to treatment of the myofascial body called Mobilization of the Myofascial System (MMS) (Upper Quadrant, Lower Quadrant and Advanced Integration). In addition, she teaches a two-level course system entitled Manual Therapy for the Cranium, courses she teaches across Canada and Europe, both in English and in French. Email: Doreen.Killens@gmail.com

THE MMS TECHNIQUE USES BOTH HANDS: ONE TO STABILISE THE AREA OF DYSFUNCTION; THE OTHER TO EXPLORE AND MOBILISE THE LINES OF FASCIA Co-Kinetic.com

RELATED CONTENT F ascia: What it is and Why it Matters [Article] http://spxj.nl/2BSph6F onnectivity: Fascia-Related Therapies [Article] C http://spxj.nl/2h9ii4i atest News from Fascia Research: Implications for L Manual and Movement Therapy [Video] https://spxj.nl/2NqIAL9 iotensegrity: A Balance of Forces [Video] B https://spxj.nl/2tCgVxW

DISCUSSIONS aving read this article are you clearer in your mind H about how to decide if your patient’s symptoms are caused by fascial dysfunction? Can you map out the 12 fascial lines (or Anatomy Trains)? Revise these if necessary. Practise thinking about and using the star concept to identify lines of fascial restriction.

Mobilizing the Myofascial System A clinical guide to assessment and treatment of myofascial dysfunctions By Doreen Killens Handspring Publishing 2019; ISBN: 978-1-909141-90-2 Buy it from Handspring https://www.handspringpublishing.com/ product/mobilizing-myofascial-system/ Fascia has become the new buzzword in the field of rehabilitation and movement re-education. Until recently its contribution to musculoskeletal dysfunction had been underestimated. We know now that fascia plays an important role in health, wellbeing and mobility. It transmits the power of the muscles, communicates with the nervous system and serves as a sense organ. Many different groups of professionals are now exploring the world of fascia, as evidenced by the explosion of research in this field. However, many physical therapists are still unfamiliar with fascia and continue to think of it as the ‘dead packing material’ that is pushed aside during dissections in order to visualise the ‘important stuff’ like muscles and nerves. Physical therapists with their varied skill-set in manual therapy techniques are well-placed to take on this important tissue. Mobilization of the Myofascial System aims to help them to do that. Mobilisation of the Myofascial System (MMS), the technique described in this book, has its origins in manual physical therapy for the articular, muscular and neural systems. Tom Myers’ book Anatomy Trains, which examines the myofascial meridians for manual and movement therapists, has been the framework and inspiration for the development of MMS. In this book the author outlines the theory and pathophysiology of fascial dysfunctions. A full description of the MMS assessment and treatment approach is given as well as guidance on ways in which it may be integrated into the other methods normally used by manual therapists. Subsequent chapters offer full descriptions and colour photos of the MMS techniques. The chapters are organised into various anatomical regions simply to facilitate learning. These divisions are, of course, artificial, as fascia is a continuum, from the top of the head, down to the toes. Mobilization of the Myofascial System is primarily intended for physical therapists who have been trained in manual therapy, but it will also be valuable for osteopaths, chiropractors, massage therapists, structural integrators and other body workers who are seeking an alternative way to work with this important and fascinating tissue.

CONTENTS

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: Patients with fascial dysfunction can struggle to maintain good treatment results https://spxj.nl/2Tat7Fi Tweet this: Fascial restriction may be revealed only when testing joint mobility with combined movements https://spxj.nl/2Tat7Fi Tweet this: When there is a myofascial restriction, accessory movements of the joints have a ‘bouncy’ end feel https://spxj.nl/2Tat7Fi Tweet this: When the fascial line is restricted, early resistance between the therapist’s hands will be felt https://spxj.nl/2Tat7Fi Tweet this: Mobilisation of the myofascial system is particularly indicated for subacute or chronic conditions https://spxj.nl/2Tat7Fi

Introduction Section 1: Understanding fascia Chapter 1: Understanding fascia Chapter 2: A brief summary of Tom Myer’s Anatomy Trains fascial lines and clinical implications Chapter 3: Assessment of fascial dysfunctions Chapter 4: Principles of treatment with Mobilization of the Myofascial System Section 2: MMS techniques for fascia Chapter 5: The cervical spine Chapter 6: The craniofacial region (cranium, temporomandibular joint) Chapter 7: Dural mobility Chapter 8: The thorax Chapter 9: The lumbar/pelvic region Chapter 10: The pelvic floor Chapter 11: The lower extremity Chapter 12: The shoulder girdle Chapter 13: The upper extremity Section 3: Optimizing treatment Chapter 14: Movement and fascia Chapter 15: Optimizing therapeutic outcomes Co-Kinetic Journal 2019;80(April):26-34

MANUAL THERAPY

19-04-COKINETIC FORMATS WEB MOBILE

TREATMENT IN A HOLISTIC CONTEXT When treating a patient, it is important to consider the body and the person as a whole and that many other systems may influence musculoskeletal and brain health. Nutrition, the gut microbiome, hydration, hormone health, stress, exercise and overuse syndromes all play a role, perhaps through increasing levels of inflammation. It is also postulated that these things may affect the health of the fascial system by modifying the viscosity of loose connective tissue within fascia, causing ‘densification’ (1). If your patients have difficulty with maintaining effects of treatment with any kind of manual therapy, or if they plateau with treatment, it is wise to consider appropriate professional help to address these additional dimensions of health.

CREATING AN OPTIMAL THERAPEUTIC ENVIRONMENT FOR THE PATIENT It is important for the patient to receive treatment in an environment that optimises the therapeutic outcome. The following are a few suggestions to consider. n Treat in private spaces when possible. This privacy not only helps control the level of noise, but also allows for confidential and safe conversations between therapist and patient. n Use ambient lighting (preferably natural). n Ensure neutral to warm room temperature (it stimulates the parasympathetic nervous system). n Consider the whole person – biopsycho-social model – energetic and spiritual dimensions.

OPTIMISING THERAPEUTIC OUTCOMES When treating patients, we all want to create the ideal outcome opportunities for them, but how often is the ideal outcome achieved? Are there times when, in spite of both you and the patient doing their best, progress stalls? It is important to remember that fascial and musculoskeletal health can be affected by many factors. Treatment for some of these aspects might need referral to an appropriately trained medical specialist, whereas others are more under our own control. This article provides much food for thought about how to create the best environment for you and your patient so that the best treatment outcomes are attained. This article has been extracted from the author’s book Mobilizing the Myofascial System: A clinical guide to assessment and treatment of myofascial dysfunctions. Read this article online https://spxj.nl/2C0qjzN BY DOREEN KILLENS FCAMT n In addition to treating with manual therapy and exercise, the therapist may also consider educating the patient on ways to desensitise the sympathetic nervous system. These tools can help to tone down the vagus nerve, decrease anxiety, and deal with negative thoughts: - slow, rhythmic, diaphragmatic breathing. Breathing from the diaphragm and into the pelvic floor and sacrum, rather than shallowly from the top of the lungs,

IT IS IMPORTANT FOR THE PATIENT TO RECEIVE TREATMENT IN AN ENVIRONMENT THAT OPTIMISES THE THERAPEUTIC OUTCOME Co-Kinetic.com

stimulates and tones the vagus nerve. alternate nostril breathing humming mindfulness meditation MUSE – a brain sensing headband that helps one to focus during meditation as it gently guides a meditation session through changing sounds of weather, based on the real-time state of the brain.

CREATING AN OPTIMAL THERAPEUTIC ENVIRONMENT FOR THE THERAPIST Creating an optimal environment also applies to the therapist. A number of issues come to mind here, gleaned not only from my past 40 years’ experience as a physiotherapist, but also from the 35

WE DO NOT ‘FIX’ OR HEAL PATIENTS. IN REALITY WE FUNCTION MORE AS A COACH insights of many other therapists, whose opinions and reflections I value.

Accessing Both Sides of the Brain I believe that the best treatment approach is a combined approach, one that appreciates the importance of sound assessment, based on a left-brain, linear, structured approach but that also makes room for another element, the right-brain, creative, intuitive approach. Unfortunately, many physiotherapists are either left-brain thinkers or right-brain thinkers. A few state their views passionately on social media, dismissing or even vilifying the approaches of fellow therapists who think differently. Therapists who rely solely on the intuitive, creative aspects of the brain tend to ‘go with the flow’ often not explaining what they are doing for the patient. This approach unwittingly creates a more passive role for the patient, and frames treatment as a process in which the therapist alone does the ‘healing’. Few objective tests are used to evaluate the effects of their treatments. Diagnosis is based mainly on palpatory findings and clinical reasoning is often lacking. By contrast, left-brained, analytical minds may be great at creating structure, using a test/retest approach to see if they are on the right track with their therapies, but they may have difficulty thinking ‘outside of the box’ when their standard tools are not working for the patient. Such an approach may lead the therapist to conclude that the patient must have a central pain component to their problem. Admittedly, many chronic conditions do have a mixture of both primary nociceptive and central pain phenomena, but my personal experience, based on treating mostly chronic conditions, is that the pendulum has swung too far to the side of believing that all pain is of central origin. In reality, “The magic happens 36

in the middle” [Peter O’Sullivan (2)]. The optimal therapeutic intervention involves accessing both the scientific literature and structured learning in the classroom in order to create a solid base from which to begin the clinical reasoning process as well as tapping into the resources of intuition, deep wisdom and creativity. Working with the fascial system is a great way to combine both perspectives. Heather Williamson-Vint, a physiotherapist from British Columbia, Canada (3), sums it up well: “Our ego serves us well in life. It allows us to conquer fears, attend school and grind out papers and acquire knowledge. Our ego can also get in the way of the ‘art’ of healing. If we learn to lead with the heart as well as the mind, then intuition can play a role in our treatments, rather than reason alone. Ego is our link to control. It is cultivated by fear, whereupon many of us diminish this sense of fear through developing our egos, our inner ‘control freaks’ that sadly, when put in the lead, can take us down paths that aren’t our ultimate best routes. The art of letting go, physically and subconsciously, isn’t taught in physiotherapy programmes but can be cultivated with experience.”

The importance of a good subjective exam “Listen to your patients. Not only will they tell you what the problem is but also how to treat it.” This was the single most important take-home message I received from Geoffrey Maitland’s presentation on the subjective exam at the International Federation of Orthopaedic Manipulative Physical Therapists’ (IFOMPT) Conference in Vail, Colorado, in 1992. In particular, I remember a slide in which he demonstrated the use of posteroanterior pressures on the upper lumbar spine with the patient in a prone position, his lumbar spine extended and the ipsilateral knee flexed. At the time, there was very little discussion in the world of manual physiotherapy about the importance of maintaining mobility of the nerves but, essentially, Maitland was depicting

a technique that later came to be described as a way to improve mobility of the femoral nerve. Maitland had offered no explanation for why he used this technique, except to say that it corresponded with the patient’s subjective complaints and brought about positive treatment outcomes. He was certainly ahead of his time! Maitland’s message has served me well throughout my career. Patients live in their body and have a sense of what is going on, even if it is subconscious. They can convey important cues to the therapist if the therapist pays careful attention to what they are saying.

Manual therapy The fact is that any time we skilfully lay our hands on a patient, we are performing manual therapy. The idea that there is a dichotomy between ‘hands on’ or ‘hands off’ is essentially saying that we give up what makes us truly physiotherapists. For too long, certain people have looked at manual therapy as a purely passive treatment; clearly, it is not. We touch people when they are moving. We touch people to facilitate moving. We touch people to enhance movement. This is manual therapy (4).

Dialoguing with the tissues n When using any manual therapy, it is important to ‘dialogue with the tissues’. When we move any tissue of any kind, we must connect to the resistance in the tissues between our hands. Maitland’s movement diagram helps put on paper what we are feeling in terms of early or late resistance, and the end-feel. n “Rather than forcing a tissue to do something, pull a certain way, trying to mould it physiologically to respond, we must listen to the tissue, our own intuition, as to line of pull, tolerance of tissue to handling, load, stress and stretch. Once the listening element is put into practice regularly, it becomes instinctual, just like noting anteriorly tipped scapula or asymmetric load bearing.” [Heather Williamson-Vint (3)] n Patients can feel threat in their bodies when your hands produce a movement that is interpreted as ‘unsafe’. This ‘unsafe’ interpretation Co-Kinetic Journal 2019;80(April):35-39

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may be due to the following: - the manoeuvre is being performed too quickly, without waiting for ‘permission’ from the patient’s tissues - the therapist is producing a movement that is too deep or a grade of movement that is too high for the state of the irritability of the tissues - the manoeuvre is done automatically, the therapist not ‘tuning in’ to what they are sensing under their hands. n ‘Seduce the tissues’ rather than imposing a certain direction and force into the patient’s tissues. Knock on the door and ask to be ‘let in’: Wait for the body’s response. When wondering if the patient can tolerate a certain manoeuvre, use the ‘listening’ approach (see Chapter 4 of the book). In doing so, we can be reassured that the body will not allow any changes that it is not ready to receive. n Trust your hands. They never lie. Listen to the body’s response – a system-wide response in the parasympathetic direction, much like a system ‘sigh’, is a sign that you are moving in the right direction. Increased sweating, anxiety, and a shallow, apical breathing pattern are all signs of a sympathetic reaction, and signal that we must change something in our treatment approach.

Art and Science n What we do in healthcare is both an art and a science. One cannot exist without the other. Art and science butt heads beginning in elementary school, where physical education and art are often abandoned as unnecessary topics expendable in the face of such subjects such as maths and reading. However, art allows our species to learn. Art makes sense of the unspeakable, and gives us insight when there are no words (5). n Manual therapy is an art form. We have to work at it in order to improve. The brain map for a new manual approach is initially small. Practice and the neuroplastic changes in the brain will make the Co-Kinetic.com

brain map for this experience larger. Subtle changes then become huge (4).

Research n Clearly, there is a need for ongoing research in every field of manual therapy and the ‘Mobilising the Myofascial System’ approach is no exception. n However, we cannot expect for there to be evidence for every patient we see. Randomised controlled trials are not the best way to measure optimal treatment options – individual programmes that follow a clinical reasoning approach are the way to go (6). n There are many variables that we must consider in a treatment session and these variables make the clinician’s daily experience with patients difficult to research. Your treatment room is your research lab (4,7).

Psycho-SocioEmotional Versus Physical n “As physiotherapists, we get to work on the physical body, which I think of as a membrane between the external world all around us, and each individual’s own internal world. Their perceptions of pain, health, stress, life fulfilment, and general day-to-day thoughts and emotions, can influence this physical vessel. We would be remiss as clinicians to not fully embrace the psycho-social and spiritual elements in the process of healing from injury.” [Heather Williamson-Vint (3)] n “As we plod along in our human journeys through life, we can’t help but spend a bit of time at ‘the bottom of the barrel’. We experience challenges, tragedies, and difficult situations aplenty. A lot of how we navigate this and come out the other side, for worse or for better, comes down to socio-emotional resilience: ‘An ability to recover from or adjust easily to misfortune or change’.

Our own tissues also experience resilience: ‘The capability of a strained body to recover its size and shape after deformation’. Using this comparison, our physical body is the barrier between our internal and our external worlds. Basically, how we cope with our external environment displays itself in our physical self. We can come out of a difficult experience jaded, distrustful and at the same time, stooped, dehydrated and poorly oxidised. Or we emerge more knowledgeable of our physical, emotional and mental limits and can redirect ourselves with our tools, avoiding some major health challenges.” [Heather Williamson-Vint (3)]

Things I Wish I Had Known as a Young Therapist n We do not ‘fix’ or heal patients. In reality we function more as a coach – helping to bring awareness to our patient’s mind/body. Only they can make a difference in their brain map (4). n There is no such thing as a cure in the body. We only help the patient manage it better by helping them understand their condition and by empowering them to take charge of their healing. n Education is a large part of what we do for a patient, whether that is teaching them how to position their back to safely brush their teeth or simply de-escalating their fear. Don’t underestimate education. Part of the education piece for our patients is to watch for their ‘languaging’ of their painful experience. For example, “I’m falling apart”, “My body is killing me” or “I have to expect this at my age”. Our reality is shaped by our thoughts. Negative thought patterns adversely affect the experience of pain as they contribute to the Danger in Me (DIM) neurotags. Instead, we can empower our patients with messages such as “You can be

NURTURE COMPASSION, BOTH FOR YOUR PATIENTS AND, PERHAPS MORE IMPORTANTLY, FOR YOURSELF 37

sore but safe. Your hurts won’t harm you” (8). Ageism is a negative perception of getting older and of older people. It is a really big personal and societal DIM neurotag and it needs to be challenged. Young and old people can be ageist. Older people can be ageist about themselves. Health professionals and sometimes government departments and companies are ageist. Let us challenge it, first by obliterating some myths about pain and ageing (9). Even though X-rays and scans may show things such as narrowing of joint spaces, such alterations have NO relation to increased pain. These are age changes and more age does not equal more pain (9,10). “We are what we focus on. As therapists, we all have the ‘pain chasers’ who try to relocate the pain as soon as their treatment is finished. That pain pathway is so etched into their nociceptive memory banks (especially those with more chronic pain) that it is easy enough to find. I tell clients to trust in their body’s potential to heal. Once they ‘buy in’ to this process, the rest follows fairly smoothly. Giving a gentle nudge of selfresponsibility and self-management to people is both worthwhile and empowering. As a clinician, I find it most rewarding to see the evolution of body and thought awareness take place in some patients. Once a client becomes aware of the stretches, exercises, breathing patterns, postures, imagery and/ or mantras that they find useful for self-care, they can use these to pre-empt old pain patterns or toxic thoughts before they take hold of the whole person. Being able to control our thoughts and re-align our bodies consciously is a huge part of living a life in balance and wellness.” [Heather Williamson-Vint (3)] Look out for patients who may feel that they are victims of their pain. Perhaps they feel that their workplace or their family dynamic is the perpetrator. The corollary to this is that we, as physiotherapists and body workers, can become the

n n

rescuer. “Be careful of this triangle. We are none of these things. These are simply a perception of our reality that plays out in our physical world. We can change all this with a perspective shift and the right encouragement. Patients with healthier perspectives and the ability to change a negative internal script to a more positive one have better results, regardless of what tricks are up the therapist’s sleeve.” [Heather Williamson-Vint (3)] Nurture compassion, both for your patients and, perhaps more importantly, for yourself. Therapists tend to have perfectionist traits. Developing compassion for yourself and your imperfections is vital to your well-being. Don’t be so hard on yourself. We cannot help everyone. We can only facilitate the path for the patient but it is up to him/her to choose the path. Don’t compare yourself to any of your colleagues. Only compete with yourself – are you a better therapist than you were last year? Follow your intuition. Don’t suppress it because it isn’t ‘scientific’. But back it up with critical thinking and clinical reasoning. Be willing to shift your beliefs and paradigms as data and clinical experience guides us (2). Stay curious and hungry for knowledge. I frequently end the fascia courses that I teach with a quote from Tom Myers: “The more I learn, the farther the horizon of my ignorance extends.” I hope I never get to the point where I feel that I have all of the answers. Then there would be no more room to grow. Value intellectual humility (2) What you have learned at university is just the tip of the iceberg. You learn from treating your patients, especially the more challenging cases. You learn through taking postgraduate courses. You learn through asking questions. You learn by teaching. Don’t stop. Take as many postgrad courses as you possibly can – they stimulate your brain and keep challenging your paradigms. A word of caution, however; don’t get hung up on

any one approach to treatment and believe that it will solve all your patients’ problems. It is best to have many tools in your clinician’s toolbox. Pull out what you need for the right patient at the right time. Good clinical reasoning will help you sort out which tool(s) you will need for your particular client. n Find yourself a mentor who can facilitate your learning. I have had many mentors in my career and I learned a great deal from each of them. In turn, I hope and believe that I have ‘given back’ by mentoring another generation of skilled clinicians. n Embrace social support. Cultivate friendships that will feed your mind, body, and soul. n Deepen your spiritual connection. References 1. Pavan PG, Stecco A, Stern R and Stecco C. Painful connections: densification versus fibrosis of fascia. Current Pain and Headache Reports 2014;18(8):441 2. Professor Peter O’Sullivan. Specialist Musculoskeletal Physiotherapist and Professor of Musculoskeletal Physiotherapy at Curtin University, Perth, Australia [https://spxj.nl/2tOHpwo]; [https://spxj.nl/2TtICYj]; [https://spxj.nl/2GYhBXe] 3. Heather Williamson-Vint. Physiotherapist, British Columbia, Canada https://spxj.nl/2TkhJ9e 4. Diane Lee. Physiotherapist, British Columbia, Canada https://spxj.nl/2U9bvGo 5. Garner G. Medical therapeutic yoga: biopsychosocial rehabilitation and wellness care. Handspring Publishing 2016. ISBN 978-1-909141-13-1 (Print £31.24 Kindle £30.02). Buy from Amazon https://amzn.to/2EjBQLe 6. Jull G. Keynote address. Presented at the International

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Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) Conference 2012, Quebec City, Canada 7. Grieve G. Modern manual therapy of the vertebral column, 1st edn. Churchill Livingstone 1986. ISBN 978-0443030093. For the most recent edition, see Jull G, Moore A, Falla D, et al. Grieve’s modern musculoskeletal physiotherapy, 4th edn. Elsevier 2015. ISBN 978-0702051524 (Print £79.99 KIndle £75.99). View on Amazon https://amzn.to/2GQ8YOb 8. NOI notes. Metaphors we feel by. Neuro Orthopaedic Institute (NOI) 2017 Open access: https://spxj.nl/2TlkXcl 9. NOI notes. Oldies are goldies. Neuro Orthopaedic Institute (NOI) 2018 Open access: https://spxj.nl/2EDwuvF 10. VOMIT (Victim of medical imaging technology). Advanced Physical Therapy Education Institute (APTEI) 2014 Open access: https://spxj.nl/2Xun78V.

RELATED CONTENT F ascia: What it is and Why it Matters [Article] http://spxj.nl/2BSph6F onnectivity: Fascia-Related Therapies [Article] C http://spxj.nl/2h9ii4i Treating Persistent Musculoskeletal Pain: Reclaiming a Holistic Framework for Massage and Manual Therapy [Article] https://spxj.nl/2ElEOyM I t’s All in the Mind: Psychosocial Interventions to Improve Recovery [Article] https://spxj.nl/2VwOihH

DISCUSSIONS I n your treatment, how much thought do you give to the patient as a whole, including their nutrition, hydration, hormones and stress levels? How could you incorporate this into your practice? Think about the space where you provide your treatment – could anything be improved or changed? Think about how you interact with your patients. Are you doing anything that might be interpreted as ‘unsafe’? How much attention do you pay to the feel of the tissues under your hands and is there anything that you might do or think about differently?

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: When using any manual therapy, it is important to ‘dialogue with the tissues’ https://spxj.nl/2C0qjzN Tweet this: Education is a large part of what we do for a patient https://spxj.nl/2C0qjzN Tweet this: As manual therapists, we do not ‘fix’ or heal patients. In reality we function more as a coach https://spxj.nl/2C0qjzN Tweet this: Patients with healthier perspectives have better treatment results. We can facilitate this shift https://spxj.nl/2C0qjzN

Co-Kinetic.com

CONTENTS Introduction Section 1: Understanding fascia Chapter 1: Understanding fascia Chapter 2: A brief summary of Tom Myer’s Anatomy Trains fascial lines and clinical implications Chapter 3: Assessment of fascial dysfunctions Chapter 4: Principles of treatment with Mobilization of the Myofascial System Section Chapter Chapter Chapter Chapter Chapter Chapter Chapter Chapter Chapter

2: 5: 6: 7: 8: 9: 10: 11: 12: 13:

Section 3: Chapter 14: Chapter 15:

MMS techniques for fascia The cervical spine The craniofacial region (cranium, temporomandibular joint) Dural mobility The thorax The lumbar/pelvic region The pelvic floor The lower extremity The shoulder girdle The upper extremity Optimizing treatment Movement and fascia Optimizing therapeutic outcomes

COMMUNICATION | 19-04-COKINETIC FORMATS WEB MOBILE PRINT BY TOR DAVIES, CO-KINETIC FOUNDER

INTRODUCTION As I write today, there has arguably never before, been such a powerful advertising and marketing resource, available at the literal fingertips of every single person that owns a computer and has access to the internet (or even just a mobile phone). That resource is currently Facebook (although LinkedIn may not be far behind). Facebook, today, gives you enormous potential to grow your business. Unfortunately, thanks to some unscrupulous, so-called Facebook ad experts, many people have been stung and have lost valuable hard-earned money, without seeing any results, which has also made many people nervous of Facebook ads. It’s also partly why I paid nearly £1,000 to put myself through a very thorough, and reputable Facebook advertising course, which I can wholeheartedly recommend to those of you interested in taking your Facebook ad understanding to a deeper level. However I’ve also produced a series of short videos to go with this article, which will talk you through each stage, step by step (see Further Resources for more details). As with everything “marketing”, it’s extremely dangerous to delegate responsibility for jobs that involve parting company with cash, without first having a good understanding of what that delegation involves (that’s one of my marketing 101s!). Unfortunately internetrelated activities, are an easy way for less scrupulous individuals, who want to make a quick buck, to take advantage of people who don’t know much about the topic they need help with (SEO and Google Ads also offer rich pickings). Added to which, the Facebook ads platform and user interface is pretty ugly, not very intuitive and quite difficult to master, which is why so many people do delegate and end up getting ripped off. So I’m going to try and help with that. The goal of this article is to explain why Facebook advertising is so powerful, and 40

A Start Up Guide to

FACEBOOK ADVERTISING Advertising through Facebook is probably the single most impactful marketing activity that you can pay for, to grow your business (possibly with the exception of search engine optimisation). This article explains how you can best use Facebook advertising, the steps you need to take to get started, and an accompanying step-by-step video course. Read this article online https://spxj.nl/2TA2bhH how it can help you build your business. I’ve also produced a series of short videos, to help you get the basics in place, which then progress by showing you step-by-step, how to run ads to a geographically and interest-targeted group of people, to generate new email leads who can then be followed up with retargeting ads, to promote sign-ups to related conversion events. So let’s get started. There are two main ways you can utilise Facebook advertising to grow your business: 1. By using the Facebook Pixel to track digital interactions with the content on your website, Facebook page and other third party websites such as the Co-Kinetic Marketing System. 2. By running targeted ads to hone in on prospective customers using interests, demographics, geographical location and a whole host of other criteria that help you get laser focused.

WHAT IS THE FACEBOOK PIXEL AND WHY IS IT IMPORTANT?

In a nutshell, the Facebook Pixel lets you filter and target people, based on interests which it picks up through interactions people have in three key areas: 1. On your own website pages 2. On any other platform that integrates with the Facebook Pixel such as the Co-Kinetic Marketing System landing pages 3. Through your Facebook page and post content

Here are some examples of how it might be used In terms of your website, if for example you publish a blog post about cycling injuries – and someone visits that page, you immediately know that they’re likely to be interested in cycling and you can use ads on Facebook to tell them about other resources you have, that they might be interested in, or events you are running, relating to that same topic. Remember, unless you get them to sign up for something, you don’t know WHO those people are, because Facebook doesn’t tell you, but you can still retarget them with ads through Facebook.

The Facebook Pixel is a small piece of code, which tracks what people do on your website (or other web pages where you install your Pixel). It’s very similar to Google Analytics.

If you have a subscription to the CoKinetic Marketing System, the same goes for tracking visits to the landing pages that we host for you. So, for example, you can advertise to people who visited the lead collection page of a certain campaign, say back pain, but

TIP: If you haven’t got either installed on your website, then do both the Facebook Pixel and Google Analytics at the same time because your web ‘dude’ shouldn’t charge you any more to do both. It’s a copy and paste job.

TIP: The Pixel really only comes into its own, when it’s combined with Custom Audiences. These are audiences you need to set up, that you may want to retarget in future with advertising, based on the pages they’ve visited and the actions they’ve taken (more info below).

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didn’t sign up to download the resources. Or you could advertise events, to people who visited either the lead collection page AND/OR the success page where they downloaded the resources. In terms of your Facebook page, you can track all sorts of interactions that happen on your page from visits and likes, to engagement with specific posts you publish. Again if you’re running a cycling injury campaign, you could target anyone who interacted with any of the social media posts you published that month, that related to cycling injuries. Your imagination really is the limit, but it’s best to get started small and don’t get carried away or alternatively overwhelmed, by the opportunities.

TIP: Remember that your numbers will be pretty small, and the more targeted you get, the smaller those numbers will become. That said, the more targeted you are, the greater the chance you have of getting people to take the action you want them to take if your call to action is well-suited to those interests. If you promote a cycling injury workshop, to people you already know are interested in cycling through the activities they’ve taken on your Facebook page, website and the Co-Kinetic Marketing System, the chance of them signing up to attend that workshop, is considerably higher than if you promote it to people who visit your site or signed up to your email list, but haven’t given you any indication that they’re interested in cycling. However, the power of Facebook advertising, doesn’t stop with the Pixel.

WIDENING THE NET WHILE ALSO STAYING FOCUSED One of the advantages of using the Pixel, is that you’re working with ‘warm’ leads ie. people who have had some sort of contact (albeit digital) with your business, either through your website, your Facebook page or external landing pages, like those that come with our marketing system. Warm leads are generally much more responsive than cold leads ie. people who haven’t had previous contact with your business or had that contact a long time ago. Co-Kinetic.com

But by using the audience-building tools in Facebook ads, you can pitch the right content, directly in front of warm, super-qualified, highly targeted audiences. Say for example that you want to target cyclists for a cycling injury email lead collection campaign which culminates in the cycling injury workshop we mentioned. You can target people who are joined to cycling clubs, people who are interested in cycling pages, businesses or even magazines, people who are fans or followers of big cycling events or charity events and the most powerful thing for you as a local business, is that you can narrow this targeting down geographically, to targeting people within just a few miles of your place of work. This is where the magic happens.

HOW DO YOU USE THE TARGETING POTENTIAL OF FACEBOOK ADS? In the context of the marketing model that we advocate, you can use Facebook in two key ways: 1. Grow your email list by interest areas by pitching relevant content specifically focused on collecting new email addresses, to a very targeted group of people with matching interests, within a given radius of your place of work (in my view email collection should be one of the primary goals of Facebook advertising if you want to see a return on your social media investment). 2. You use Facebook ads to promote sign-ups to open-day/open-clinic/‘trybefore-you-buy’ conversion events to anyone who has interacted with relevant posts, visited relevant pages on your website ie. blog posts etc, or in the case of our Co-Kinetic Marketing System, visited our lead collection and lead delivery pages for a relevant topic.

USING FACEBOOK ADS TO BUILD INTEREST-BASED EMAIL LISTS Remember that I’m writing this article on the basis that you have access to the content in our marketing kits, but if you don’t you can follow exactly the same strategy, using your own marketing material.

1. Run a Lead Generation ad from within Facebook The first decision you have to make when setting up a Facebook ad, is what objective you would like to achieve. One of those objectives is Lead Generation. Lots of people dismiss lead generation but for the purpose I’m describing, it works extremely well. There is a unique feature about a Lead Generation ad, which is that you tell Facebook what information you want to collect ie. first name, last name, email address (the less fields, the greater the chance of successful completion) and Facebook pre-populates that data in the form for the viewer, making it super-quick and easy, to submit the information because they don’t need to type anything. This tends to result in much higher conversion rates than sending someone to an external lead collection page, particularly if the content or download you’re offering, involves a quick, easy decision. When you set up the ad, you enter a URL where Facebook then takes the person, after they have submitted the form, to download the promised resources. If you have a Co-Kinetic marketing subscription, the easiest, and most impactful thing you can do, is give them the Success Page URL for that campaign. If you don’t have our subscription it’s no problem, just give them a link to the file (or a folder if you’re giving them multiple files), that you host externally for example on Google Docs or Dropbox. Whichever way you do it, you should always follow up with an email, introducing yourself and giving the new person a link where they can download the resources at a later date, because the chances are that they will have signed up on a mobile device which means it’s a bit more tricky to download and save files.

TIP: In the campaign I’m running at the time of writing this article, I’ve collected 272 new leads in 5 days, of which 260 (95.6%) have come from the Mobile News Feed. In the not too distant past, triggering an email off a new lead sign-up from a Facebook Lead Gen ad was a real pain, you had to use third party integration tools like Zapier, to make it happen. Fortunately there are a lot more direct 41

integrations now. You can find a list in the Further Resources section. 2. Use social media posts linked to a lead collection page This is how all the organic (unpaid) social media posts in our marketing campaigns work. Each campaign is based on a dedicated topic like cycling/ running/tennis injuries for example. And each campaign has about 30 preprepared social media posts, enough to run one a day for a month. Each post links to a lead collection page which offers a high-value downloadable resource. When someone completes the form, they are taken to a page where they can download their resources (the Success page) AND they’re automatically sent a pre-written, but fully-editable email (which you can also disable if you want to) with an introduction and a reminder link to the resources. To boost your lead collection efforts you could wait to see which posts perform the highest and then either boost, or preferably create an ad directly from these posts. The benefits of choosing the ‘boost’ option is that it’s easy to do, but if you know what you’re doing (and that’s the goal of my short video course), you’ll get much better results from creating a specific advert from that post (there’s a really great optimisation trick you can use here too).

USING FACEBOOK ADS TO GENERATE SIGN-UPS TO “CONVERSION” EVENTS So this is the third way you can use Facebook ads to support the marketing model we advocate, which in an ideal world, has three ongoing, cyclical stages - lead collection > lead nurture > conversion of prospect to customer using “conversion” events. The idea here is to promote some sort of free or trial event that gets people through your doors, offers value to them, but also gives you the opportunity to evaluate who you can help the most, and a chance to explain how you can do that, and where appropriate, give them an incentive to get started. We’ve written lots about conversion events in the past, so I won’t go into them here but I’ve included links 42

in the Further Resources section. The idea is to run an advert which explains briefly what the event is, and gives them a link or a call to action, to book onto the event. Now, I’ll confess right here, that I haven’t tried creating events on Facebook, and inviting Facebook followers to them, so I can’t offer any advice about using that strategy. So if you are taking sign-ups to physical events using this channel then I’d love to hear your thoughts, feedback or advice you have for anyone considering it. You can either comment in the discussion area below this article on the website or just jump on the chat tool and talk to me directly. My gut feel is that it’s got to be worth a go. However, on the flip side, these people will already be followers of your page, and may also already be customers, so if your goal is to target completely new prospects, this needs to be factored in. If you use our marketing system, each marketing campaign comes with a fully-editable web sign-up page which we host for you (I call it a Customisable Sign-Up Page). You just edit the text on the page to reflect the event you’re running and give essential information like dates etc, decide how you want the person to sign up ie. call you, fill out a form, book through a booking system etc. and our form takes care of it for you. Whatever you do, make sure your call to action (ie. the action you want them to take) in the advert you’re running is super-clear. And make sure you explain clearly how the viewer of your ad (or landing page) will benefit from your conversion event (remember to focus on the benefits of the event, not its features – if you’re not sure of the difference, Google it before you start writing anything!). It’s worth mentioning here, that getting someone to sign up to attend an event, is a much bigger ‘ask’ than offering them a file to download, so it’s going to be much harder to get conversions (ie. getting people to take this action). So be realistic about your expectations. Facebook ads are brilliant for generating new leads when you’ve got quick, easily accessible resources to offer. And if you’re a good marketer, you’ll be consistently keeping these

leads warm, by sending them monthly nurture emails, with loads of helpful resources. Which means when you come to invite them to your conversion events through those emails, they’ll be beautifully warm, and well-primed to snap up those places. Getting people to take meaningful, committed actions, like attending an event, off the back of a Facebook ad is much more difficult.

TIP: If you have a tight budget, and you have to make a choice about only running one type of ad, definitely focus your money on generating new email leads and then use a follow-up email to invite those leads to your events, rather than on trying to get sign-ups to physical events through a Facebook ad.

TIP:This is why using social media to build your own email list, is so important. It puts you in charge of that communication channel, instead of relying on running paid Facebook ads to get to those people every single time. Using a Facebook ad to get sign-ups can however be effective, if you have some extra budget and you retarget people you know are already interested and who are already warm ie. familiar with your business. And if you pick up a handful of brand new sign-ups, which you may well do if your targeting is good, your ad is well-written and your event is considered highly desirable, then that’s a bonus.

TIP: One thing I would definitely advise against, is using a Lead Generation ad for this purpose. I learnt this lesson with one client. We got loads of sign-ups (because it’s easy), but very few actually converted to attending a physical event. Easy come, easy go!

So who should you target? Just for clarification, Facebook actually call this retargeting because you’re concentrating your efforts on people who have already interacted with your Facebook Pixel, meaning they’ve already visited your website page, or your Facebook page or somewhere else where your Pixel is installed. Here are some ideas for who you might retarget through your conversion ad, if you’ve been running a campaign on for example back pain, through your Facebook page for the last month. n People who have engaged with your Co-Kinetic Journal 2019;80(April):40-43

ENTREPRENEUR THERAPIST

Facebook posts within the period you’ve been running the back pain ones n People who have visited pages on your website that are relevant to back pain – that could be blog posts (publishing our pre-written one on your website should be one of the first things you do before you set your social media campaign going), ebook downloads, or any other information pages specific to back pain n If you use the Co-Kinetic system (and you’ve added your Facebook Pixel to the Integrations section) you should target people who have visited both the lead collection form (your Lead Collection Campaign URL) as well as the Success page.

CREATING CUSTOM AUDIENCES That leads me onto the final part of this article, custom audiences. Arguably this should have been the first section of the article, rather than the last, because you should do this BEFORE you run ANY Facebook ads! If you don’t, you won’t be able to retarget, ie. advertise things to people who have visited your site or your Facebook pages, because Facebook won’t be tracking those visits. The key thing to know, is that custom audiences need to be created before Facebook can start tracking people who take the actions you specify. Facebook can’t collect data retrospectively. This makes setting up your custom audiences as important as installing your Facebook Pixel on your website. You can create as many custom audiences as you want, so take the time now to set them up, for as many interest areas as you can. The sooner you set them up, the sooner Facebook starts collecting data for you and the more people you’ll have in the audience, when you come to use it.

THE

The Facebook Pixel does have purposes that don’t rely on custom audiences, like the tracking of specific goals on your website (if you set them up), but its real power comes when it’s combined with custom audiences that you’ve created. There’s a PDF download in the online version of this article which outlines the custom audiences that EVERYONE should set up by default and my short video course will run through how to set custom audiences up. The custom audiences I’ve mentioned below are relevant to running a specific marketing campaign. If you’re running a topic-based marketing campaign, you should set up the following custom audiences (see video in the training course for more details): nP eople who visit the lead collection page for your campaign (this is where you collect email addresses). n People who visit the lead delivery/ success page (this is where you deliver the lead magnets if you use a page, rather than a link). n If you’ve publish a new blog post on the same topic of your campaign you should create a custom audience for visitors to that page as well as separate custom audiences for any other pages on your website that are related to the topic of your campaign (for example if you are running a campaign on cycling injuries, and you have a page on your site about bike fit services, create an audience for this). nA custom audience of people who have engaged with your Facebook page during the period you have been running the posts on the campaign in question. n While you’re at it, set up any other custom audiences for visitors to web pages on topics that you might want to run conversion events on, or promote resources for.

GETTING SET UP TO 5 STEPS TOADVERTISE ON FACEBOOK

1 Set up a Facebook ad account 2 Create a Pixel if you don’t already have one 3 Install the Pixel on your website (or ask your web ‘dude’ to do it) 4 Set up some custom audiences

TIP: You can only track visits to pages outside Facebook (ie. your website or the Co-Kinetic landing pages) over the last 180 days, whereas you can track audiences who interact with your Facebook page, for 365 days. Which is why it’s so important to use campaigns to collect email addresses of people. That way you still know they’re interested in that topic, regardless of when they visited the pages.

THE LAST WORD… FOR NOW As you are probably starting to appreciate, the power of Facebook for generating new leads, either as email leads or sign ups to events, is huge and exciting and I take you through exactly how to do it, as well as explain in more detail everything that I’ve discussed above in my series of short step by step videos (see link below).

FURTHER RESOURCES n The Facebook Ad Manager by Rick Mulready, founder of the superb Art of Paid Traffic podcast https://rickmulready.com/ n Harness the Power of Facebook to Drive Your Business Forward in 2018 ebook https://spxj.nl/2IqqVzb n Facebook Lead Ad Integrations - https://spxj.nl/2HgBDLD n The Overwhelming Case for ‘Try Before You Buy’ Conversion Events [Article] https://spxj.nl/2StXxgS n The Blueprint for Running a Successful Open Clinic Event: Part 1 Concept and Planning [Article] https://spxj.nl/2rrhPME n Tor’s Facebook Lead Generation Facebook Course! https://spxj.nl/2Hoxw06 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/cokinetic.tor

5 Run some targeted advertising based on locality, behaviours and interests Co-Kinetic.com

THE BLUEPRINT FOR RUNNING A SUCCESSFUL OPEN CLINIC EVENT:

OPEN CLINIC

Part 2 Strategies for Marketing Your Event for Free Running an Open Clinic event can bring in many new clients if you get your marketing right. This article shares with you some of the most effective ways of doing this for free. Read this article online https://spxj.nl/2VBzE8V 19-04-COKINETIC FORMATS WEB MOBILE PRINT BY VICKI MARSH, MASSAGE THERAPIST, OWNER OF THE HEADSTART CLINICS

In Part 1 I shared with you how we build an Open Clinic event that 3 years on is our biggest new customer generator in our calendar. From it we gather hundreds of new email addresses, have over 100 new clients visit the clinic during the week and deliver around 400 free appointments. These days it’s very easy to get carried away with marketing online, particularly with the power of audience targeting on Facebook. But no matter what paid advertising you are doing, you should always be working to maximise your free marketing options first. By taking tried and tested free methods, you can have 100% confidence that you won’t be throwing money down the drain on the paid side of things. The great news is that all of the strategies listed below can be used to market your clinic in general as well. These are all strategies that may require your time (which of course is worth money) but doesn’t require cash up front, and you can still reach a great number of people, even more so if you’ve been doing consistent marketing throughout the year.

YOUR EMAIL LIST This is your number one marketing channel, although I know (from reading the Co-Kinetic educational emails) that a lot of therapists actually don’t have email lists and/or aren’t actively building them. My first piece of advice 44

would be to get on with building an email list as soon as possible. There are a number of simple ways you can do this. MailChimp is a great free email marketing service which integrates directly with a lot of online booking systems. I’ve been using the Co-Kinetic Marketing System to post social media that is designed specifically to help you build up your email list, by offering helpful educational content in exchange for filling out a form. And you can also connect this straight to MailChimp too. The following tips will help you get started on building your email list as soon as you put this article down.

1. CREATE AN EARLY REGISTRATION LIST AND PAGE Create an early registration page and sign-up link for your event. This can be done in something like MailChimp and Co-Kinetic also provides pre-built pages for this purpose too, which you can fill in with your own text. There are a number of reasons for doing this, but the main one is that by creating that list you can be 100% certain those people are actually interested in your event. It will help with anticipating numbers, you can create exclusive offers and it creates a clear ‘call to action’ in all of your subsequent marketing material. If you do have an email list you only want to be emailing people who are interested in your event; having an early registration list lets you segment those

clients out, which means you don’t bombard people who aren’t available or interested in the event with emails they don’t want. Once you have a link to your signup page: 1. Contact the people on your email list. Let them know the dates, why you’re running the event and how to register. 2. A few days later send another email to the people who didn’t open the previous email. Keep the content exactly the same, just tweak the subject line to something different to get their attention. 3. Repeat step 2. 4. Repeat step 2… We sent out five separate emails using this exact strategy. Each time 5% of the recipients signed up. And we had only two unsubscribes over the entire email campaign. Turns out people really don’t read their emails, or just keep leaving it until later. So, don’t pester people who DID open all your emails but didn’t sign up. The focus each time is on people who haven’t opened your emails at all. For something like this

PRO TIP ALWAYS send yourself a test

email first and check that every single one of the links is working correctly. The last thing you want is to find out that your sign-up link isn’t working.

Co-Kinetic Journal 2019;80(April):44-46

ENTREPRENEUR THERAPIST

2. GET SOCIAL

3. YOUR WEBSITE

Of course you’re going to want to make the most of your own social media. So here are a few tips to make sure that every post counts, gets good engagement and increases the number of shares and sign-ups.

Super-quick tip – use a WordPress plugin, such as WP Notification Bars, to add a notification bar to the top of your website. You can use this to make an announcement of the event and direct everyone to your sign-up page. Every single website visitor will see this, regardless of whether they are already a client or not. It’s a really powerful and free advertising too.

Don’t forget to include things like your Google My Business page as part of this strategy too: 1. Schedule as many posts as possible in advance. You can just use the built-in option on Facebook to do this. Plan your social media posts and get as many as possible in place, so you can then focus your time on the other things needed to prepare for the event. 2 Make sure EVERY single post contains the sign-up link somewhere – you can mix up the content but have a clear call to action in every post. 3. Post at LEAST once per day. Organic reach is getting lower and lower. Normally less than 10% of your fans will actually get to see a post. So be bold! If you want this event to be a success then increase your normal posting rate. 4. Posts we found that got a lot of traction were: n blurred out versions of the timetable (letting them know they got the full version on sign-up) n introducing the therapists involved n Facebook Live videos or live action promo videos of a therapist delivering a treatment n highlighting any benefits from being on that early registration list. Co-Kinetic.com

4. ENLIST HELP There are two groups of people who you can get to help you promote your event: n therapists/affiliates (ie. other businesses) n your clients.

The Therapists Getting the therapists in your clinic to promote the event is a no brainer, but how do you actually get them to promote it in ways that makes an impact on your sign-ups? And how do you get affiliates from outside of your clinic to get on board with the promotion as well? Make it Easy for Them Use something like Canva to create custom images for each therapist. Replace the text “FREE Gait Assessment available” with “FREE 1:1 Nutrition Consult”, “Spinal Check”, “Sports Massage” – whatever that therapist is offering. It will be much easier for them to promote to their social media network and get behind the project. This also helps to create consistent

branding, giving a professional omnipresent view of your event. Remember that, oddly, because the event is free, people are actually likely to be more sceptical about the value that you are offering, so keeping the branding consistent, clear and smart will help to increase your sign-up rate. You could also give them some examples of what text to post, including a consistent signature leading everyone to your sign-up page. This way you’ll ensure the message is clear – and you don’t just end up with your team posting images with no clear call to action! Be Clear About What You Expect Most therapists have no idea of the challenge of filling an event like this. They worry about being too salesy or pushy, and they don’t want to come across that way on social media too. So reassure them, explain that organic reach on Facebook is superlow and be clear about how often you want them to post. If you want them to post daily, then specify that. If you want them to be promoting the event to every client they see over the next 2 weeks, ask them to. The biggest thing I’ve learnt from

BECAUSE THE EVENT IS FREE, PEOPLE ARE ACTUALLY LIKELY TO BE MORE SCEPTICAL ABOUT THE VALUE THAT YOU ARE OFFERING 45

working with others on an Open Clinic event, is to assume nothing. Remember many therapists have had little, to no exposure on how successful marketing works. Don’t be a dictator but do be clear about how much promotion is going to be needed in order to get the sign-ups that you need. Explain Your ‘Why’ The two strategies above are great, but you’re never going to get buy-in from the team unless they understand WHY you’re running the event. Is it because you want to raise funds for more equipment? Have you recently moved to a new location and are wanting to reach more new clients? Are you trying to get your clinic known as ‘the’ place to go for treatments in the area? Or build an email list that you can work with over the next 12 months? Sit the team down, run a virtual meeting or simply film an explainer video and make sure one of the first things you do is share this with the team. By understanding ‘why’ you’re doing this Open Clinic, it will help them to get excited about it too. And this is the key to getting them 100% onboard with promoting the project.

Ask Your Clients to Help Once the sign-up link has gone live we found this tactic worked extremely well for boosting sign-up numbers. If you have MailChimp create a segment of clients on your list that are 5* rated. This means they have interacted with your emails, opened the content and clicked on links. These are your most active clients in your email database. If you don’t have MailChimp then simply look through your client list (or run a report) to identify your top attending clients. An easy way to do this is simply look for the number of visits and pick the top 10% of clients. Once you have this group of people, you now know who your ‘raving fans’ are. Remember, we are in a fantastic profession – these are loyal clients, who actually care about you and your success. You’ve made massive changes in their lives and they’ll be just as happy to help you, if you ask. 46

So, send your raving fans an email with the subject line “I/We need your help!” And inside explain what you are trying to achieve with this event. Share exactly what you shared with your team or affiliates above, and then just ask them to share the sign-up link with anyone they think would benefit from a session with you. This strategy alone added 5% completely new sign-ups to our list. Just from one email!

5. CREATE YOUR OWN MARKETING MATERIAL I love Canva.com for this – there are thousands of free templates that you can use to create posters or business cards to help promote your event. Keep things simple: event name, what they can expect, date, time and how to sign up. Then you can professionally print these or you can just print them off your own printer. Remember any marketing is better than no marketing. So if you suffer from perfection paralysis, catch yourself. This is Round 1 – next year you can work towards a budget for professional printing. This year, just get distributing: 1. In your own clinic Don’t assume that your clients have read your emails, or fully understand what you are doing. By having posters in prominent places we found that we had more conversations in clinic about the event. Which increased sign-ups. 2. Around your clinic In our case, the office building we are in. We put out posters but also added timetables. Making it easy for the potential clients nearest to us to see what we were offering when. 3. At other events In the last article I spoke about scheduling the date for your event, to fall after any other local events you would normally attend. This means that you can take your posters or print-offs with the sign-up link, to those events. In the next article in this series we’ll focus on how to use and maximise your paid marketing efforts. After that, we’ll progress onto Running your Event,

Selling & Conversions and Reviewing your Results. If you can’t wait then you can listen to Episodes 25–29 of the Massage Therapists’ Business & Marketing Podcast (Further Resources).

FURTHER RESOURCES 1. Episodes 25–29 of the Massage Therapists’ Business & Marketing Podcast by Vicki Marsh. Available at the Massage Therapist Business School https://www. massagetherapistbusinessschool.com/blog/?page=3

RELATED CONTENT he Blueprint for Running a Successful Open Clinic T Event: Part 1 Concept and Planning [Article] https://spxj.nl/2rrhPME The Overwhelming Case for “Try Before You Buy” Conversion Events [Article] https://spxj.nl/2StXxgS How to Generate £3,000 in Revenue in Just 6 Hours – Blizard Physiotherapy Running MOT [Case Study] https://spxj.nl/2wLbRZW 5 Ways to Grow Your Email List [Article] 2 https://spxj.nl/2KdQgCs THE AUTHOR 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.

Co-Kinetic Journal 2019;80(April):44-46

ENTREPRENEUR THERAPIST Matters

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Advice Sheets

HAN DOU T NECK PAIN AND CYCLIN G

THE INJURY

Humans weren’t designed to tensing your were created ride bikes, neck and upper we to when riding. Cycling completelyhave our feet on the Possibly bracing trapezius muscles ground. changes the uneven terrain, yourself on distribution weight through your hurtling along or stabilising muscles and at scary speeds, but also bends yourself due spine, the to poor technique and swaying unnatural position back and neck into from your an pelvis and This too can lengthy periods that is often sustained lower trunk. result in fatigue for of time. Neck developme of these muscles, usually stems pain from cycling nt of muscle from poor spasm and trigger points posture and muscles. Pain painful weak as well as caused by stiffness. neck hyperexte (looking up to see where nsion MANAGEMENT you are going) made worse by positional is REHABILITATIO AND issues on combined the bike, with a lack N of flexibility. Manual therapy techniques stiffness by will reduce THE CAUSE pain and mobilising the cervical well as the Just as you spine, as surroundin have core g soft stabilisers with tissues. lower back, trigger point Massage around your you have stabiliser therapy and release will deep neck deep tissue muscles called relieve flexors around flexibility. Acupunctumuscle spasm and your neck your head improve to hold up. When your re may modality in be an effective neck stabilisers are weak or treatment fatigue quickly trapezius muscle it is left to Physical therapy as well. the (that goes you with appropriat will include providing of your skull from the base to the tip of e stretches flexibility but the shoulder) support your more importantl to maintain to head as you exercises y strengthen lean when these for the deep ing ‘stand-in’ muscles forward. And neck include lots experience fatigue you of chin tucking flexors. These will pain in the can back and sides sit-ups/cru exercises neck. Restore and mini nches with of your balance by your head. get specific keeping the muscles loose It’s best to exercises neck and relaxed from your therapist, as of strengthen through a local physical every individual routine ing and stretching there may Be aware exercises. be other underlyingis different and you may also previous injury pathology subconsciously or (like whiplash) be complicating that could the problem. be

SIT-UP

R Start in a press-up position, and leg in so your bring one left knee is close to your hand. Straight left away, take it back out bring your and then right knee in towards hand, and your right repeat. This exercise is strengthen great for durance and works the whole body. SETS

SETS

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ADV ICE

PROGRESSION

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

Lift one leg off the floor a few inches, the other off and the floor with your knee as shown in the picture. bent Perform a touching your crunch by hand to your sit-up! But foot. This is you can make a tough it easier by your foot closer moving to you, or away This exercise helps to strengthenfrom you to make muscles. the abdominal the exercise harder. muscles and Oblique SETS

Exercise Handouts REPS

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PRODUCED BY:

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Lie on your http://youtu.be/GodaVDAhOYQ side, and form a bridge between your feet and forearms lifting your (by pelvis). This exercise works CLAM abdominal and Oblique the muscles. You Lie on your side, with both knees bent. Keeping your feet together, progress this can exercise by and squeeze your deep abdominal muscles by drawing the belly raising your leg up and holding it in top the air, and button inwards. Open your knees, like a clam, hold, and return to the holding in even lifting the air so your top arm you look like start position. This is a good up and a star fish. SETS strengthening exercise for your REPS gluteal (buttock) and outer thigh/hip Video: muscles. Progress the exercises http://youtu.be/vQKL by opening your knees, like a clam, vMTYA9Q and extend your leg behind you, SUPINE BRIDGE HARD hold, and return to the start position. Lie flat on your back with your arms by your side, and with your SETS REPS Squeeze your knees bent. bottom muscles Video: your back and lift upwards and straighten http://youtu.be/GIEr1JgtdiU leg. Make sure one you maintain lower back) good posture and contract (do not over-arch the deep abdominal your tummy your towards your muscles SUPINE COW STRETCH spine. This abdominal, exercise helps by squeezing lower back, Lie on your back on the floor. gluteal and to strengthen hamstring the SETS muscles. Cross your right knee over your

SETS

PLANK

Rest on your forearms and Hold this position. your toes. Keep good posture, and straight do not let your back too much. arch Progress this exercise by raising one leg and holding Alternate leads it up in the air and then and arms. place it back down. SETS

Video:

Turn your legs outwards, and then lift them off the floor/bed. It’s a great exercise for the lower abdominal muscles, and you will also feel the muscles on the front and inside of your thighs working too.

mins/day

(5 days)

Join friends to make it more enjoyable

1min

SETS

REPS Video: http://youtu.be/4KAS7li6uEM

HIP FLEXION WITH EXTERNAL ROTATION BILATERAL

Video: http://youtu.be/rOeLkhBQgrI

If you are starting out try breaking your daily goal into shorter bouts of 10 minutes at a time

PROGRAMME programm e has specific muscles around exercises your lower to strengthen back and core. It is important to ensure

PROGRESSION SPEED

Standing, cross your legs, and run your arm down the side of your leg. You should feel a stretch in your back, and slightly on the outside of the opposite leg.

SETS

YOUR REHAB ILITATION This exercise

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

Swing your leg to one side, and then the other, in a controlled way. If you feel comfortable, you can speed up. This exercise mobilises a stiff hip joint, and is a good dynamic warm up.

Moderate activities of daily living

Optimal mobility above and golf swing below the that will not lower back is essential over-load the exercises for a ‘safe’ lower back. for the thoracic This includes spine and to protect mobility hips. Core the spine during well as maintain rotational movemen strength is also crucial a good golf posture through ts like the golf swing as the swing.

on each leg. It is important to stretch the uninjured muscles so that both legs reach a similar point of flexibility.

ITB STRETCH

PRODUCED

CORE STRE NGTH

PRODUCED IN ASSOCIATION WITH

LEG SWING SIDE

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10 %

Moderate and vigorous leisure time activity

Reference: Domains of physical activity and all-cause mortality: systematic review and dose-response meta-analysis of cohort studies. http://bit.ly/2S7BXOW

y.com mindandbod 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

MANUA Body L AND.harris www PHYSICA CES FOR 44882 VING RESOUR 01635 TIME-SA

GUIDANCE FOR STRETCHING EXERCISES

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Walking

What Activity Should I Be Doing If I’m Between 18 – 64?

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Type 2 Diabetes

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What Activity Should I Be Doing If I’m Between the Ages of 5 – 17?

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YOUR REHABILITATION PROGRAMME

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What is Moderate Intensity Versus Vigorous Intensity Activity?

If Exercise Was A Pill

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EXERCISE HANDOUT

ILIOTIBIAL BAND STRETCHES This exercise programme has specific exercises to strengthen muscles around upper thigh, buttock and hip area as well as improve balance across your pelvis. In order to achieve proper rehabilitation of your injury it is important to ensure the exercises are performed with good technique. Poor practice may place potential strain on your injury. The following leaflet includes some exercises to help in your rehabilitation.

HAN DOU T

YOUR BRANDING GOES HERE

You Only Get One Chance To Make a First Impression... Int! If you would like to be able to supply your patients with a u o C t I e k a variety of different information leaflets and handouts but So M In February I launched the ability for you to be able to add your brand, to our growing number of Patient Information Resources, at the click of a button. As the saying goes, “creativity is to think more efficiently”, and I’m constantly on the hunt to find ways that I can help you save time and market your business better. And this development is a cracker, because it helps with both, which is presumably the reason why more than 100 people signed up to the service in less than two weeks of launching it, which makes it by far the most popular service I’ve ever provided in 20 years of publishing. As you may (or may not know), all our content subscriptions (ie. Full Site, Physical Therapy or Massage Therapy) include access to the Patient Information Resources. This section consists of: l Exercise Rehabilitation Handouts l Advice Leaflets l Infographics l Cheat Sheets and Posters l Client Newsletters Add the branding upgrade, and you can turn these peer-reviewed pieces of content, into something that looks like you’ve produced it with the help of a professional designer! It’s a great way of not only offering a stand-out quality of service to your existing clients, but also of promoting yourself and your business, in a completely unsalesy way, to people who have not yet had contact with your business. Co-Kinetic.com

don’t know how to start or what to write, we have created more than 120 (and counting) peer-reviewed Patient Information Resources for you. Additionally, you can now easily add your own branding to them, turning them into a unique marketing tool for your business. Discover the different ways these resources can benefit your business. Here are 11 things you can do with this branded content to help you promote your business: 1 Print it (or have it professionally printed) and give to existing clients. 2 Print a range of different leaflets out and put them on literature displays in your waiting room. 3 Send them by email to clients or... 4 Post them to clients you haven’t seen in a while who you don’t have email details for. 5 Share them with local businesses. 6 Share them with other professionals or shops who may have related (but noncompeting) services or products (ideas include sport and fitness shops, health food shops, GP surgeries etc.). 7 If you have a local notice board in your newspaper shop or supermarket, pin some on there so people can take a copy. 8 Distribute them at local events or meetings you attend. 9 Organise a presentation or seminar (our marketing kits include off-the-shelf presentations) and hand them out as supplementary material.

ind places where people stand F and wait around, like train stations or pay-and-go coffee shops – remember if you can add value to the related business, they’re likely to be happy to do stuff in return. Find a nearby gym without a linked therapy service, and give them copies to distribute. In the UK it costs as little £20 for 100 professionally-printed copies, making them an incredibly cost effective marketing tool.

Here are some advantages of using our leaflets we produce: 1. You don’t have to spend time writing them yourself. 2. They are professionally designed making them very eye-catching.

3. Our leaflets cover a wide range of topics and types of content eg. infographics, exercise handouts, advice sheets and customer newsletters. 4. Everything has been peer-reviewed through our usual trusted medical publishing process. 5. Educational leaflets add value to your clients. 6. New leaflets are being added every month. 7. By adding your branding, you get to claim all the credit and customers get to know your business (and always have your contact details to hand).

For more information on adding this branding upgrade to your subscription, visit www.co-kinetic.com/branding 47

Gold Standard Exercise Recommendations for Health What is Moderate Intensity Versus Vigorous Intensity Activity?

If Exercise Was A Pill

Reduce your risk by being more active. Staying physically active reduces your chances of suffering from

Joint and Back Pain

Depression

Dementia

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Cadiovascular Disease

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Vigorous intensity = 7 or 8 think “ Difficulty talking

Moderate intensity = 5 or 6 think “Can talk, but not sing”

Type 2 Diabetes

25% 30% 30% 30% 35% 40% What Activity Should I Be Doing If I’m Between the Ages of 5 – 17? l 60 minutes of moderate to vigorous-intensity physical

activity – every day l > 60 minutes daily will give even better health benefits l Most of the daily physical activity should be aerobic l But should incorporate vigorous - intensity activities that strengthen muscle and bone, at least 3 times per week

What Activity Should I Be Doing If I’m Between 18 – 64? l 150 minutes of moderate-intensity aerobic physical activity each

week, or 75 minutes of vigorous-intensity aerobic physical activity

l Aerobic activity should be performed in bouts

of at least 10 minutes

l 300 minutes of moderate-intensity or 150 of vigorous-intensity

aerobic physical activity brings even greater health benefits l Muscle-strengthening activities should be done involving major muscle groups on 2 or more days a week.

What Activity Should I Be Doing If I’m Over 65 Years of Age? l 150 minutes of moderate-intensity aerobic physical activity each week,

or 75 minutes of vigorous-intensity aerobic physical activity

l Aerobic activity should be performed in bouts of at least 10 minutes l 300 minutes of moderate-intensity or 150 of vigorous-intensity aerobic physical

activity brings even greater health benefits

l Activities that enhance balance and prevent falls on 3 or more days per week l Muscle-strengthening activities should be done involving major muscle groups,

on 2 or more days a week l The goal is to be as physically active as your abilities and conditions allow.

Reference: Global Recommendations on Physical Activity for Health, World Health Organisation 2018

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How Activity Intensity Reduces Your Risk of Dying

22%

Vigorous exercise and sports

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Moderate activities of daily living

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Reference: Domains of physical activity and all-cause mortality: systematic review and dose-response meta-analysis of cohort studies. http://bit.ly/2S7BXOW

First Steps to Being More Active

150 minutes

TIP

mins/day

(7 days)

mins/day

(5 days)

If you are starting out try breaking your daily goal into shorter bouts of 10 minutes at a time Gradually increase the exercise intensity Pick activities you find fun and mix them up

Join friends to make it more enjoyable

1min vigorous intensity

2min moderate intensity

The information contained in this article is intended as general guidance and information only and should not be relied upon as a basis for planning individual medical care or as a substitute for specialist medical advice in each individual case. ©Co-Kinetic 2019

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ADVICE HANDOUT THE INJURY Iliotibial band syndrome (ITBS) has been compared to the feeling of somebody stabbing you in the side of the knee when you run, especially when going downhill. This annoying and painful injury can quickly become crippling if not addressed and corrected. The iliotibial band is a thick piece of connective tissue that runs parallel to your femur (thigh bone) from the outside of your hip to just below your knee. Pain is characteristically felt at the end of the IT band where it attaches to the outside edge of the knee.

ILIOTIBIAL BAND SYNDROME ADVICE FOR RUNNERS Many runners find that as fatigue sets in, their ankles or knees collapse inwards, which in turn pulls on the IT band, forcing it to rub against that bony spot on your knee. This re-enforces the importance of having strong legs to prevent injury. This can be achieved through specific strengthening exercises.

THE SYMPTOMS

THE FIX

nP ain is most frequently felt as a sharp point on the outside of the knee, or (rarely) as sharp pain on the lateral side of the hip. n Commonly, pain occurs after a certain amount of running; not in the first few steps. n While pain generally goes away after stopping activity, it often comes back when running is resumed. n It’s most common in new runners, or after an increase in mileage or hill running.

ITBS can be challenging to treat, but gluteus muscle and hip strengthening are immensely important in both the prevention and treatment processes. A regimen of icing and antiinflammatories will assist in reducing pain. A foam roller can be used to loosen up tight structures as can massage. Physical therapy treatments will work on releasing structures that are shortened and tight movement-based treatment for softtissue injuries will help to break up scar tissue and restore normal function. Strengthening exercises for hip abductors, core and gluteus muscles will be prescribed by your physical therapist along with a stretching programme. Avoid aggressive downhill running, ease off on the volume and intensity of training (or take a complete rest if that is advised and cross train to keep fit).

THE CAUSE The short answer is…lots of things. Most people mistakenly believe that ITBS occurs because of a tight IT band — but the IT band is supposed to be tight to do its job! The source of the problem is almost always weak hip and gluteus muscles. Weak gluteus muscles result in excessive side-shifting or movement of the pelvis which causes your femur (thigh bone) to move abnormally; the outcome being unusual loading of the supportive IT band, ‘pulling’ it away from your knee. Running downhill and always running on the same side of the road are common culprits. Running on the same side of the road close to the pavement can be problem because of the camber of the road which means your pelvis is tilted as one leg is always ‘longer’ angled down into the gutter. This also applies to track/ field running where your inside leg takes shorter strides than your outside leg – again you should run around in both directions to ‘even’ things out and prevent injury. Running at angles puts a lot of stress on the side of the knee and can cause friction between the IT band and the femur. Over-pronation and a leg-length discrepancy can also be contributing factors.

THE PREVENTION Maintaining good soft tissue mobility is essential. Regular stretching and massage as well as foam rolling can help prevent the development of ITBS. Strengthening the gluteus muscles and hip, including your core will provide a more stable pelvis and reduce the ‘tugging’ on your ITB. A little prehab goes a long way to preventing most running injuries, and is less costly and time-consuming to practice healthy than when injured. Always look at your training programme and monitor volume and intensity, as well as excessive downhill routes, too much too soon will cause ITBS. Remember tips like running on different sides of the road and switching directions if running the same routes

frequently or round a track. Have your form assessed for excessive pronation and get advice about orthotics, as they may help prevent an injury. Vary running surfaces as well. Mix hilly runs with flat routes. Try trails and soft surfaces to ease the pounding placed on legs by only running on roads.

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ADVICE HANDOUT

PATELLOFEMORAL PAIN SYNDROME (RUNNER’S KNEE) THE INJURY Runner’s knee, more scientifically called patellofemoral pain syndrome (PFPS) is a condition which affects the cartilage on the underside of the knee cap (patella) and the structures which support it, as it moves up and down over the groove on the femur (thigh bone) when you bend and straighten your knee. The injury happens to both top runners and amateurs alike, with some statistics showing it accounts for nearly 50% of all running injuries.

THE SYMPTOMS n n n n

Tenderness around or behind your knee cap Pain that is aggravated by downhill running Dull pain when running on uneven terrain Pain when you push on the patella bone.

THE CAUSE Injury occurs when there is ‘mal-tracking’ of the patella in the femoral groove and a chronic stimulation of the pain nerves in the surrounding area. The ‘mal-tracking’ may be due to a number of factors such as alignment of your leg, and abnormal muscle forces. Poor strength and flexibility in the hips, hamstrings and quadriceps have all been shown to contribute to this problem. However, training errors are the primary culprit. This can include an accelerated build-up of mileage, as well as excessive high-intensity running or hill work. Worn out or inappropriate footwear is also cited as a possible cause.

THE FIX The first line of treatment for PFPS is rest, along with the use of ice and non-steroidal antiinflammatories (NSAIDs), which may help reduce pain and swelling in the short term. Taping can also facilitate better patella movement and reduce pain, again in the short term.

Research shows that strengthening the hip/ buttock muscles, specifically the hip abductors and the gluteus muscles, can reduce pain in PFPS. Exercises for this may include squats, lunges, crab walking and bridging. Improving flexibility in the leg, especially the hip flexors is essential. Physical therapy is also an important component for reducing pain around the knee and mobilising the joints and soft tissue structures. Remember that cutting back on mileage, or even taking a complete break from running, will be important. A graduated progression back into training can be discussed with your therapist as you work through your rehab programme. Some runners find that uphill running or simulating hills on a treadmill is less painful. Uphill running has the added value of working your glutes. Strong gluteal muscles help control hip and thigh movement, preventing the knee from turning inwards. Cycling, elliptical training and swimming are other ‘knee-friendly’ activities for cross-training.

THE PREVENTION It is important to be proactive with prevention measures, especially if you’ve suffered from runner’s knee in the past. Implementing a regular strength and flexibility routine should be the focus. Strengthening the hips, glutes, quads and hamstrings improves overall stability and helps the kinetic chain function better - reducing load on the knee and aiding support of the joint. Listen to your body and respond at the first sign of discomfort. Runner’s knee is an injury that worsens if you continue to run on it. Building mileage slowly will help ensure you remain healthy. Do not increase your mileage by more than 5-10 percent from one week to the next. Avoiding excessive downhill running is also a good thing to do if you’re hoping to skirt injury.

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