Co-Kinetic Journal Issue 81 - July 2019 by Co-Kinetic

ISSUE 81 JULY 2019 ISSN 2397-138X

ISSUE 72 APRIL

2017

ISSN 2397-138

ISSUE 66/46 OCTOBER 2015

OCTOBE ISSUE 74

R 2017

ISSN 2397-138

ISSUE 67 JANUARY 2016

Formerly

medicine & dyna mics

ISSN 2397-138X

publishe d as....

72SPX01Fro

ntCover.indd

medicine &

dynamics 20/03/2017

ISSUE 66/46 OCTOBER 2015

ISSUE 69 JULY 2016

ISSN 2397-138X

11:54

medicine & dyna mics published on Formerly published

Formerly

d as.... publishe

dd 1

dynamics 19/09/2017

10/12/2015

13:46

67SPX01FrontCover.indd

74CK Front

Cover.indd

as....

medicine & dynamics 66MD01FrontCover_v2.in

& medicine

18/09/2015

11:14

14:45

Formerly

publishe d as....

69SPX01Fro

ntCover.indd

medicine &

dynamics 27/05/2016

published on

66MD01FrontCover_v2.in

dd 1

18/09/2015

14:45

ISSUE 73 JULY 2017 ISSN 2397-138X

ISSUE 75 JANUARY 2018 ISSN 2397-138X

ISSUE 79 JANUARY 2019 ISSN 2397-138X

ISSN 2397-138X APRIL 2017 ISSUE 72

ISSUE 68 AprIL 2016

OCTOBE ISSUE 74

R 2017

ISSN 2397-138

ISSN 2397-138X

PRACTIC AL

RESOURC ES FOR AND MANUAL PHYSICA L THERAPI STS

journal ISSUE 70 OCTOBER 2016 ISSN 2397-138X

Formerly published as....

medicine & dynamics

medicine & dynamics 75CK Front Cover.indd 1

18/12/2017 09:24

73CK Front Cover.indd 1

medicine & dynamics

20/06/2017 09:44

Formerly

published

as....

ics & dynam medicine 20/03/2017

11:54

ISSUE 75 JANUARY 2018 ISSN 2397-138X

ISSUE 77 JULY 2018 ISSUE 79 JANUARY 2019 ISSN 2397-138X

ISSUE

Formerly

80 APRIL

2019

ISSN

2397-1

38X

over.indd

72SPX01FrontC

Formerly published

as....

medicine & dynamics

mics & dyna medicine

14/03/2016

14:37

13:46

68SPX01FrontCover.indd

ISSUE 78 OCTOBE

Cover.indd

d as.... publishe

19/09/2017

74CK Front

ISSN 2397-138

ISSUE 74 OCTOBER 2017 ISSN 2397-138X

Formerly published

R 2018

ISSN 2397-138

as....

APRIL ISSUE 76

2018

ISSN 2397-138

medicine & dynamic s

X 70SPX01FrontCover.indd

06/09/2016

14:54

Formerly published as....

Formerly

publishe d as....

medicine & dynamics

77CK01Fron

Formerly published as....

tCover.indd

hed rly publis Forme

medicine & dynamics 79CK01FrontCover.indd 1

as....

ine & medic

medicine ics & dynamics dynam 19

12/03/20

75CK Front Cover.indd 1 18/12/2017 09:24

17:42

15/06/2018

10/12/2018 11:23

10:10

Formerly published as....

Formerly

publishe d as....

medicine & dynamics

78CK01Fron

tCover.indd

medicine &

dynamics

r.indd

74CK Front Cover.indd 1

rontCove

80CK01F

Formerly 06/09/2018

d as.... publishe

& medicine

14:45

19/09/2017 13:46

dynamics 12/03/2018

76CK Front

ISSUE 4 0 Apr 2014 ISSn 1744-9383

Cover.indd

15:53

ISSUE 60 Apr 2014 ISSN 1471-8138

ISSUE 80 APRIL 2019 ISSN 2397-138X

promoting

best practice excellence in in highlights

manual therapy

n functionAl fAsciAl tAping n Playing hurt

n interPreting research n fascia and anatomy

highlights

sports

n latest research news n research analysis n sports triage medical screening

medicine n the tendinopathy continuum n shoulder impingement

Formerly published as....

medicine & dynamics 80CK01FrontCover.indd 1

12/03/2019 17:42

1999 â&#x20AC;&#x201C; 2019

09:27

20I9

CONFERENCE

HOLIDAY INN, REGENTS PARK, LONDON

OCTOBER 09:00 - 18:00

The Academy, Holiday Inn London Regents Park, Carburton Street, LONDON W1W 5EE

PRESENTERS

MARTIN COLCLOUGH BSC (HONS) MSC OBE Head of Sport Recovery at Help For Heroes Post Traumatic Growth: The Role of Sport in the Recovery of UK Military Veterans JAMES EARLS How should the soft tissue respond during movement? Combining movement and bodywork. DR CHRISTOPHER NORRIS PHD MSC MCSP Integrated manual therapy for the hip and knee DR JAMIE BARKER PHD Loughborough University Wings to Thrive: Developing Resilience and Well-Being in International Disability Footballers

Ticket Prices

TO BOOK:

https://spxj.nl/2Ze9QkP

FULL RATES: Member - £115.00. Student Member - £85.00 (Use member login to book your place) Non-member - £140.00 (Should you subsequently be accepted as an SMA member the £25 joining fee will be waived) SMTO or STO MEMBER - £115.00 (Registration code required) EARLY BIRD RATES: (Limited availability to 30th June): Member - £100.00. Student Member - £75.00

what’s inside PRACTICAL PRACTICAL WAYS TO USE CONTENT TO PROMOTE YOURSELF AND YOUR BUSINESS

PATIENT RESOURCES

The Biopsychosocial Explanation

S URCE NT RESO PATIE

f ycle o The C

Biological (Your Body)

Chemical Breakdown Physical Illness

Being less active

Exercise

tive Nega fear , thinking, future of the ssion depre and mood s swing

Sports Activities

Anxiety

ea Fear list Family Creat ‘no go’ History of things

Society Expectations

Family Dynamic

Socialising and Entertainment

Employment

Isolation

Relationships

Cultural Beliefs

Past Experiences

Sleep ems, probl ess tiredn e and fatigu

Experience and Outings

Trauma

Friendship

Grief

Loneliness

Abuse

can’t

Financial Concerns

Injury

Nurture

Mental Breakdown Depression

Social (Your Environment)

Psychological (Your Mind) ht Weig gain and loss

s, fear Stres ty, anxie and r ange ation frustr

44-49

Age

Nature

Sexual Performance Sleep

THE E OF CYCL NIC CHRO PAIN

General Health Diet

Genetics

Loss of cle s,mus ﬁtnes ness, weak joint stiffness

off Time y , mone work es, worri p onshi relati rns conce

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

PRODUCED BY:

g plannin forRESOURCES TIME-SAVING FOR PHYSICAL AND MANUAL THERAPISTS as a basis upon relied 2019 not be inetic ©Co-K and should al case. tion only informa in each individu ce and advice l guidan st medical d as genera for speciali is intendesubstitute this article or as a ed in l care S tion contain al medica APIST individu THER The informa

ED BY:

PRODUC

TIME-

SAVIN

G RESO

URCE

S FOR

PHYS

ICAL

AND

MAN

50-51

CLIENT RESOURCES

UAL

TWENTY YEARS OF CO-KINETIC

4-7

Annals of Medicine

116 6

BMC Complementary and Alternative Medicine

60 7

134 4

50 0

5 17

Archives of Physical Medicine & Rehabilitation

33 0

LONG-TERM COSTEFFECTIVENESS OF EXERCISE THERAPY AND/OR MANUAL THERAPY FOR HIP OR KNEE OSTEOARTHRITIS: RANDOMIZED CONTROLLED TRIAL AND COMPUTER SIMULATION MODELLING

432 16

Tweets

Facebook posts

640 16

319 10

and Physical

409 6

DISTINCT WORKING EFFECTS OF ACUTE EXERCISE THREE-ARMMEMORY AND EXECUTIVE AND BREAKS IN SITTING FUNCTION EFFECTS , RANDOMISED CROSS-OV ON IN COGNITIONOF EXERCISE WITH ER TRIAL OLDER ADULTS: A AND WITHOUT TO EVALUATE British Journal THE BREAKS of Sports Medicine IN SITTING ON

98 3

455 7

The PDF

TIME-SAVING

MANUAL

THERAPISTS

0 15

ISOMETRIC ACUTE PAIN EXERCISE FOR RELEVANT RELIEF: IS IT MANAGEMEIN TENDINOPATHY NT?

Journal

Produced by:

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

PLATELETA RANDOMIZRICH PLASMA FOR RICH PRP ED CONTROLLED PATELLAR TENDINOPA OR LEUKOCYTE TRIAL THY: -POOR OF LEUKOCYTEJournal of Sports PRP VERSUS SALINE Medicine

American

Mendely readers

AND

Fitness

ARE BALL SETTINGS PITS LOCATED IN PHYSICAL A American SOURCE OF PATHOGENI THERAPY CLINICAL Journal of Infection C MICROORG ANISMS? Control

FOR PHYSICAL

TREATMEN

LOW-CARB PERFORMA OHYDRATE, KETOGENIC DIET SEQUENCE NCE IN EXERCISETRAINED IMPAIRS ANAEROBIC CROSSOVE R TRIAL Journal WOMEN AND EXERCISE of Sports MEN: A RANDOMIZ Medicine ED-

The PDF version of this infographic includes hyperlinks to the individual pieces of research. Click here to access https://spxj.nl/2MgXV41

RESOURCES

Medicine

HOW DOES SURGERY FOR TENDINOPA COMPARE TO SHAM THY? A SYSTEMATI SURGERY Sport & OR PHYSIOTHE Exercise C REVIEW OF RAPY RANDOMIS Medicine ED TRIALS AS A

BMJ Open

Produced by: TIME-SAVING RESOURCES FOR PHYSICAL AND MANUAL THERAPISTS

119

675 14

BENEFICIA ACTIVITY L ASSOCIATIONS OF LOW AND NATIONAL WITH ALL-CAUSE, CARDIOVAS LARGE DOSES COHORT STUDY OF 88,140 CULAR DISEASE OF LEISURE TIME PHYSICAL AND CANCER US ADULTS British MORTALITY Journal :A of Sports

Osteoarthritis and Cartilage

28 15

1306 27

WAKE UP EXERCISE AND SMELL THE COFFEE: META-ANA PERFORMANCE - AN CAFFEINE SUPPLEME LYSES British UMBRELLA REVIEW OF NTATION AND Journal of Sports 21 Medicine PUBLISHED

THE 10 MOS PIECES OF T DISCUSSED RESEAR PHYSICAL CH IN THER (APR - JUN APY 2019)

Journal of Physiotherapy (Australian Physiotherapy Association)

Pain Medicine

409 6

Physiotherapy

33 2

and Science VERSUS STANDING in Sports NATURALLY & Exercise IN

WHAT DOES BEST PRACTICE ELEVEN CONSISTEN CARE GUIDELINE T RECOMMEN FOR MUSCULOS S: SYSTEMATI DATIONS FROM KELETAL PAIN C REVIEW HIGH-QUAL LOOK LIKE? British ITY Journal of Sports CLINICAL PRACTICE Medicine

MASSAGE THERAPY SLIGHTLY DECREASED PAIN INTENSITY AFTER HABITUAL RUNNING, BUT HAD NO EFFECT ON FATIGUE, MOOD OR PHYSICAL PERFORMANCE: A RANDOMISED TRIAL

47 1

PHYSIOTHERAPY BASED ON A BIOBEHAVIORAL APPROACH WITH OR WITHOUT ORTHOPEDIC MANUAL PHYSICAL THERAPY IN THE TREATMENT OF NONSPECIFIC CHRONIC LOW BACK PAIN: A RANDOMIZED CONTROLLED TRIAL

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

Pain (03043959)

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

Chiropractic & Manual Therapies

THE ENERGY COST OF SITTING MAN Medicine

MANUAL THERAPY PREVENTS ONSET OF NOCICEPTOR ACTIVITY, SENSORIMOTOR DYSFUNCTION, AND NEURAL FIBROSIS INDUCED BY A VOLITIONAL REPETITIVE TASK

63 4

THE ACUTE EFFECTS OF JOINT MANIPULATIVE TECHNIQUES ON MARKERS OF AUTONOMIC NERVOUS SYSTEM ACTIVITY: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED SHAM-CONTROLLED TRIALS

62 2

A MANUAL THERAPY AND HOME STRETCHING PROGRAM IN PATIENTS WITH PRIMARY FROZEN SHOULDER CONTRACTURE SYNDROME: A CASE SERIES

Journal of Orthopaedic & Sports Physical Therapy

MANUAL THERAPY FOR THE PEDIATRIC POPULATION: A SYSTEMATIC REVIEW

(APR - JUN 2019)

A RISK-BENEFIT ASSESSMENT STRATEGY TO EXCLUDE CERVICAL ARTERY DISSECTION IN SPINAL MANUAL-THERAPY: A COMPREHENSIVE REVIEW

34-41

YOGA AND BIOMECHANICS: A NEW VIEW OF STRETCHING PART 1

THE 10 MOST DISCUSSED PIECES OF RESEARCH IN MANUAL THERAPY

British of Sports Medicine

535 0

version stories Tweets of this infogr Facebook pieces aphic of resea posts Mendely includes rch. Click readers hyperlinks here to to access https://spx the individual j.nl/30XMYa X News

MANUAL THERAPY & PHYSICAL THERAPY INFOGRAPHICS

16-17

28-33

THE 11RS IN CONCUSSION PART 1: SCREENING

42-43

THE BLUEPRINT FOR RUNNING A SUCCESSFUL OPEN CLINIC EVENT: PART 3 YOUR PAID MARKETING STRATEGY

JOURNAL WATCH

8-15

SHORT

18-27

FEMEROACETABULAR IMPINGEMENT SYNDROME PART 2: MANAGEMENT

TECHNICAL

LONG JULY 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 THOMAS BSC MPhil Art Editor DEBBIE ASHER Sub-Editor ALISON SLEIGH PHD Journal Watch Editor BOB BRAMAH MCSP Subscriptions & Advertising info@co-kinetic.com

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

is published by ISSUE 81 JULY 2019 ISSN 2397-138X

ISSUE

72 APRIL

2017

ISSN 2397-138X

ISSUE 66/46 octoBEr 2015

ISSUE 67 JAnuArY 2016

OCTOBER ISSUE 74

2017

medicine & dynamics

ISSN 2397-138X

Formerly

published

as....

72SPX01FrontCover.indd

medicine

& dynamics

ISSUE 69 JulY 2016

20/03/2017

ISSUE 66/46 octoBEr 2015

ISSN 2397-138X

11:54

medicine & dynamics published on Formerly published

Formerly

published

as....

& dynamics 19/09/2017

10/12/2015

13:46

67SPX01FrontCover.indd

Cover.indd

as....

medicine & dynamics 66MD01FrontCover_v2.indd

medicine

74CK Front

18/09/2015

11:14

14:45

Formerly

published

as....

69SPX01FrontCover.indd

medicine

& dynamics

27/05/2016

published on

66MD01FrontCover_v2.indd

18/09/2015

14:45

ISSUE 73 JULY 2017 ISSN 2397-138X

ISSUE 75 JANUARY 2018 ISSN 2397-138X

ISSUE 79 JANUARY 2019 ISSN 2397-138X

ISSN 2397-138X APRIL 2017 ISSUE 72

ISSUE 68 April 2016

ISSUE

74 OCTOBER

2017

ISSN 2397-138X

PRACTICAL

RESOURCES FOR AND MANUAL PHYSICAL THERAPISTS

journal ISSUE 70 OCTOBER 2016 ISSN 2397-138X

Formerly published as....

medicine & dynamics

medicine & dynamics 75CK Front Cover.indd 1

18/12/2017 09:24

73CK Front Cover.indd 1

medicine & dynamics

20/06/2017 09:44

Formerly

published

as....

medicine

& dynamics 20/03/2017

11:54

ISSUE 75 JANUARY 2018 ISSN 2397-138X

ISSUE 77 JULY 2018 ISSUE 79 JANUARY 2019 ISSN 2397-138X

ISSUE

Formerly

published

80 APRIL

2019

ISSN

1 72SPX01FrontCover.indd

Formerly published

as....

medicine & dynamics

& dynamics 14/03/2016

19/09/2017

14:37

13:46

68SPX01FrontCover.indd

ISSUE

Cover.indd

ISSN 2397-138X

2397-138X

as....

medicine

74CK Front

78 OCTOBER

2018

ISSUE 74 OCTOBER 2017 ISSN 2397-138X

Formerly published ISSN 2397-138X

as....

APRIL ISSUE 76

2018

ISSN 2397-138X

70SPX01FrontCover.indd

medicine & dynamics 1

06/09/2016

Formerly published as....

Formerly

published

medicine & dynamics

as....

77CK01FrontCover.indd

Formerly published as....

Formerly

medicine & dynamics

published

medicine

as....

medicine 79CK01FrontCover.indd 1

& dynamics

75CK Front Cover.indd 1

& dynamics

12/03/2019

18/12/2017 09:24

17:42

15/06/2018

10/12/2018 11:23

10:10

Formerly published as....

Formerly

published

as....

medicine & dynamics

78CK01FrontCover.indd

medicine

& dynamics

74CK Front Cover.indd 1

80CK01FrontCover.indd

Formerly 06/09/2018

published

as....

medicine

14:45

19/09/2017 13:46

& dynamics 12/03/2018

76CK Front

ISSUE 4 0 Apr 2014 ISSn 1744-9383

Cover.indd

15:53

ISSUE 60 Apr 2014 ISSN 1471-8138

ISSUE 80 APRIL 2019 ISSN 2397-138X

promoting

14:54

09:27

Centor Publishing Ltd 88 Nelson Road Wimbledon, SW19 1HX, UK

promoting

best practice excellence in in highlights

manual therapy

n f unctionAl fAsciAl tAping nP laying hurt

n i nterPreting research n f ascia and anatomy

highlights

sports

n l atest research news nr esearch analysis ns ports triage medical screening

medicine nt he tendinopathy continuum n shoulder impingement

Formerly published as....

medicine & dynamics 80CK01FrontCover.indd 1

12/03/2019 17:42

1999 – 2019

https://Co-Kinetic.com

Facebook

https://www.facebook.com/CoKinetic

YouTube

https://www.co-kinetic.com/youtube

Twitter

https://www.twitter.com/sportexjournals

https://www.linkedin.com/company/sportex-net

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.

Tor’s Take on the Last 20 Years of Co-Kinetic r e b i r c s b u S r a e D It’s been quite a journey.

And I’d be lying if I didn’t admit that a lot of it has been incredibly difficult and challenging, both personally and professionally. I started a publishing business at a time when publishing, as an industry, had peaked. And when it began to decline, it did so very quickly and dramatically. There’s one expression that I believe holds true for just about every business out there – if you don’t adapt, you’ll die. Luckily for me, I get bored easily, I HATE routine and I’m always looking to improve on what I’ve done before. It’s an inbuilt driver that I can’t seem to turn off, even if I want to at times. So while we produced our journals, my team also ran courses and conferences, I developed technology for several membership associations, contract published for a couple more, and we licensed our patient information content to much bigger organisations like the UK charity, the British Heart Foundation. These were significant milestones that helped my business to survive financially. It always felt like luck found me, just in the nick of time. But in reality, luck is a

1999

combination of preparation and opportunity, and that really is true. Then about 5 years ago, I hit a wall. I thought I’d got to the end of the road. I’d worked long, long hours to keep the business going. I’d sacrificed countless holidays and I’d worked pretty much every weekend since I’d started the business (I’m still very rarely away from the computer for more than 24 hours at a time). Unfortunately, I had very little to show for it, and I was ready to chuck it all in. Every penny I’d made in profit, I invested back into the business. I was living on income from other work and worst of all I didn’t feel like I was making a difference. All my life, all I’ve ever wanted was to make a difference to people’s lives. When I started my professional life, it was as a physio, solving problems for my patients. Then it became about finding ways to help you solve problems for your patients. But I was doing it through a journal that had basically been superseded, like so many other publications in those 15 years, by the plethora of freely available content on the internet. I couldn’t see a future. I’d ploughed 15 years of life and love into this business, but I was running on empty, both in terms of energy and passion, but also money. So I decided to try one last thing, and see where that took me. And if it didn’t lead somewhere I wanted to go, I resolved to call it quits. I put myself in your hands. I asked more than a 1,000 of you a single, simple question, the answer to which would turn my life around. I asked, “What is the one thing about your business, that keeps you awake at night?” I couldn’t believe how obvious the answer was and more importantly, how many of you gave me exactly the same answer (albeit in a variety of different words). It was simple, “finding new clients”. For 15 years of sportEX, I’d convinced myself I was solving a pain. I was giving you a journal that digested clinical research into practical application, and I was giving you as many tools as I could come up with to help you do that. But the reality was, that wasn’t a real pain. My journal

Co-Kinetic Journal 2019;81(July):4-7

CO-KINETIC MILESTONES

was a nice-to-have resource, but it wasn’t a MUST HAVE resource. My journal might have helped you do your job a bit better and/or more quickly, but it didn’t fundamentally change your business, or your life, or the lives of the people around you. And if I was going to move forward with passion and commitment for my business, then that was the ONLY thing I was interested in doing. The exciting thing for me, is that I love marketing. After I left physio, but before I started sportEX, I had a job in marketing. I loved the combination of analysis and strategy with creativity. I loved science but I also did Art A-level. And guess what, marketing is a perfect blend of art and science. I also shared the dread, that it turns out a large number of you share (in no doubt related to the fact I also started out life as a healthcare professional), of coming across as being salesy while promoting my business. So for the previous 3 years, I’d been using a strategy called content marketing, to help me promote sportEX. For those who are unfamiliar with the term content marketing, it’s a way of using educational content, to promote you, your business and your services, without resorting to any kind of sales pitch. The answer was suddenly so obvious. I would direct the 15 years of experience I’d gained in publishing a high-quality peer-reviewed clinical journal, into producing educational content for patients, that you could use to promote your own businesses. I could have just developed social media content and built a viable subscription out of that, but as I said before, the only future for me in this business, was to build a solution that could genuinely change your business and, through that, change lives. So I took it a stage further and built a whole strategy that enabled you to collect new leads at the top of the marketing funnel and take them all the way through to converting them into paying clients, in the very least salesy way possible. I turned it into an interactive Blueprint so I could share it with everyone, whether they subscribed to Co-Kinetic or not. You can find it at this link: https://co-kinetic.com/blueprint. I then created the content and built the technology that would allow even the most technophobic person to execute the Blueprint. At last, I had a proper problem to solve, and I already had all the skills, experience and team in place that I needed to deliver a solution to that problem. And in a nutshell, turning that into reality has been the focus of the last 5 years. Is it working? Well let’s put it this way, 61% of my turnover now comes from my marketing and business growth subscriptions, the first of which I launched just 18 months ago. Only 39% of my turnover comes from subscriptions I’ve been building for 20 years. Even more importantly, and I don’t even know how to put this into words without it sounding naff … I’m filled with more energy and passion for what I do now, than I was when I started out as a 28-year-old, first-time business owner 20 years ago. That’s what can happen when you open your ears to your customers and find a really genuinely painful problem Co-Kinetic.com

to solve. It took me a long, long time to learn that lesson, but the important thing (or so people keep telling me), is that I got there eventually. It took me right to the edge of my own personal resilience, and it took my business right to the edge of its life. It’s been a tough old journey, but at last I’ve found my purpose, which is help you guys to build the businesses that can support your dreams, in a way that you can be comfortable with.

So what lessons have I learnt 20 years on?

1. To listen to my customers, some may not always be fair (fortunately not many), but as a collective you’re always right and you have lead me to where I needed to go, once I’d learnt to relinquish control, and let myself be led there (and that last bit was hard!) 2. Look after your customers from day 1. Loyalty only works if it’s a two-way street. I have always, and I will always, endeavour to treat each of you, in the way I would want the most exceptional business out there, to treat me. 3. Don’t stop digging until you’ve found the most painful pain that your customers are suffering, and then dig some more. The greater the pain, the more successful your solution will be. The same goes for patients in a more literal sense. 4. I sure as hell have learnt the true meaning of resilience! 5. To my dearly departed Dad who taught me a lot about what’s important in life and who ran businesses much bigger than mine – I think at last I’ve figured out how to build a profitable business with absolute honour and integrity, without compromising success. 6. And lastly but probably most importantly, as the saying on my favourite t-shirt brand goes, “do what you love, and love what you do”.

Thank you for being here with me on this journey. My greatest hope is that the resources I produce and the technology I create, help to transform part of your journey too. Very warm wishes

tor

2019

? r Swnim g Sinkgo n ti and Preve Treatin Injuries Swimming

world. rts in the ds. even pon popular spo the most , rivers and of is one of s, streams not short Swimming er, we’re , pools, lake ace is wat in the sea We swim Earth’s surf the of n 70% And give likely to most are s. that the injuries opportunitie

explore efforts. ct’ swimming d a ‘low-impa sink your r is considere wimming that the wate lder to the fact The Shou even a sport due ntage of invested a large perce for If you’ve time supports exactly amount of moderate and weight. And in the ming up your body used ng traini swim lane line, n it’s often that reaso black es to joints down that on of injuri you will have rehabilitati aring ie. of it’s likely that by weightbe affected some form ankles. red and s unte knee enco n that for back, hips, lder.’ Give of if you swim mer’s shou n, hundreds ‘swim rm etitio However, perfo in comp is be annually tness, or se injury it should swimmers general fi g an overu rotations ful of work s of arm developin and force this type thousand the risk of repetitive learn that s on use of the s as well surprise to lot of stres no a high beca revolution s lder ency place level in the shou joint. and frequ nature of to hold you muscles and no surprise, the back, lder on s shou as the as stres ably come suffer most r. It will prob swimmers the wate lder is the of regular does mer’s shou In fact, 84% ming. It is that swim es. So, what injury in swim for a number of se type injuri shouldn’t common from overu term you? You ng or around a blanket mean to d in and basically ce your traini all of this ne can be injure one arm should redu g things that face it, anyo swim? You joint. Durin ion sport? Let’s head in the shoulder is in a posit the their change your lder have , the shou ared to tures) cipating revolution hing struc who is prep tially parti ent (pinc by hours, essen doing it and of impingem time. Multiply that water for must love their the ry sport, m and it’s to manage for 25% of in a solita annu able per be es . strok want to will be some a million nue to swim therefore that there shed and still conti ming - whether surprising ly squa risk the hard injury to damage fits of swim ical activity, The bene cumulative and phys . ral fitness just to e it’s an injury structures etitions, or it’s for gene re you assum rfly e to win comp stress relief - far And befo tyle and butte the desir for affects frees has shown that quiet place that only find your rch injury. all , the resea the risk of together on across swimmers outweigh we’ve put in mind, ge, injury is comm of swimming With this you mana shoulder level or help to rces any age te! injuries strokes, at a set of resou n’t discrimina swimming prevent, n. It does with all yet r etitio that comp or bette the fact be due to power r. This may 0% of the altogethe een 50–9 RIES strokes betw THE INJU SWIM and SINK OR deep end in at the So, let’s dive

01/05/2019

Swimming

19:00

1 tter.indd

Newsle

1999 Co-Kinetic JULY 1999

Launch of sportEX medicine journal – written for sports medicine doctors and sports physiotherapists, focusing on musculoskeletal injury and exercise medicine. Packed with practical tools like photocopiable patient leaflets to help you do your job more effectively.

JUNE 2009

JULY 2004

With the membership of the SMA 2007 growing healthily, we launched nce re fe n co our third title, sportEX dynamics september journal, focusing specifically on 14-16 2007 sports massage/manual therapy. confprogcove

30/8/07

6:06 pm

Page 2

5th

1st

us Bedford camp Bedfordshire University of s age and sport sports mass ilitation Injury rehab

FEBRUARY 2003

SEPTEMBER 2007

Following Government funding cuts we took on the management of the Sports Massage Association (SMA) and grew it from 130 to 900 members in 2 years.

July 1999

Ran our biggest and most ambitious sportEX/SMA conference featuring 6 international speakers, and 350 attendees. Sadly this was to be our last conference, as our spectacular conference organizer Katie James, retired to motherhood, and was literally irreplaceable.

SEPTEMBER 2003

Organised and ran the first ever UK conference on sports massage as a joint initiative between sportEX and the Sports Massage Association.

4:48 pm

14/6/06

1 page SMA conf

WITH ONJUNCTION PORTEX IN C SOCIATION HOSTED BY S MASSAGE AS THE SPORTS

RS GUEST SPEAKE INCLUDE OW & LEON CHAIT RS THOMAS MYE

22nd-23rd September 2006 Loughborough

University, Leicestershire

PROGRAMME CONFERENCE SPEAKERS FRIDAY 08.30-09.15

Tea, coffee and Registration

09.15-09.30 09.30-11.00 11.00-11.30 11.30-13.00 13.00-14.00 14.00-15.00 15.00-15.30 15.30-17.00

a networking be holding ■ We will evening at

juice -

Introduction Thomas A Revolution Myers Anatomy Trains: Patterning in Soft-Tissue juice Tea, coffee and Liz Holey Manipulation Connective Tissue Lunch Warren Hutson manual therapy Cycling and juice Tea, coffee and Thomas Myers Visual Bodyreading: in Standing Assessment

juice Tea, coffee and and Manual Assessment Muscular 09.00-11.00 Treatment of associated Dysfunction Disorders with Breathing juice Tea, coffee and 11.00-11.30 of a Live assessment 11.30-12.30 series of patients

08.30-09.00

12.30-13.30 13.30-14.30 14.30-15.00 15.00-17.00

Friday in dinner on the Friendly Hotel at the Quality . You can book will Loughborough

numbers any time however people and 200 be limited to first first come, will be on a £30 The cost is served basis. person. is

per for the conference ■ Payment of booking required at

the time

charge a £3 handling ■ There is on credit made for bookings for is no charge card ( there by payments made debit card) .

SPEAKERS

SATURDAY

Lunch

Tissue Repair

Dr Leon Chaitow

and Healing

juice Tea, coffee and Integrated Neuromuscular (INIT) Inhibition Technique

TO BOOK

Multipanel disciplinary inc. Dr Chaitow

DELEGATE FEES sportEX subscribers and OSCA) SMA members BASRaT, STO and of (inc. members VAT) - £240 ( inc. subscribers Non sportEX VAT) - £260 ( inc.

Prof Eyal Lederman Dr Leon Chaitow

please a subscriber t - if you are prices the discounted WEB: www.sportex.ne in, to access 8404 8261 ensure you log 3312 FAX: 020 Road, Wimbledon, so for safety if mail, TEL: 020 8287 86-88 Nelson (last resort!): experience problems receiving from us within SNAIL MAIL to acknowledgement * we continue - however we do not receive SW19 1HX, UK subs@sportex.net booking and book.

Y IMAGE COURTES

Journal

Blood pressure Nordic walking Body image

PluS all the latest news

Produced in with association

OF PRIMAL

PICTURES

Tor coordinated the strategic planning and development of a brand new elearning platform and content strategy for YMCAFit, and their awarding body, Central YMCA Qualifications.

SEPTEMBER 2006

JANUARY 2001

September l issue 14

SEPTEMBER 2008–2009

Page 1

IAL IX MYOFASCM ATR

THE

to emailing post your phone or by us by telephone you wish to contact us via or contacting 7-10 days, please using the website recommend would strongly

Launch of a new title, sportEX health, focusing on exercise medicine, exercise prescription and GP referral. We published sportEX health for 10 years from Jan 2001-July 2011.

lineup International including soft 2 x Australian sts tissue therapi physical 4 x American letic trainers therapists/ath therapist Canadian athletic

We successfully tendered to become the publisher for the Register of Exercise Professionals (REPs) journal which we published from Sept 2009 through to July 2014. During this time the journal circulation nearly doubled from 30,000 to 55,000.

Ran our most successful softtissue conference to date, featuring Tom Myers, founder of Anatomy Trains and the world-renowned Leon Chaitow. We called it the Myofascial Matrix and had just over 400 paying delegates.

SEPTEMBER 2010–2012

Following on from the success of the YMCA elearning project, we built our own elearning system for sportEX, offering certificated SCORM-compliant quizzes that subscribers could use for their professional development. We also launched an iPad and Android mobile app for the journals.

Co-Kinetic Journal 2019;81(July):4-7

CO-KINETIC MILESTONES

Milestones 2019 JULY 2016

In response to results from a 1,000-strong survey seeking to identify the most difficult challenge that our subscribers were facing, we turned our publishing expertise towards creating educational marketing content our subscribers could use to market their businesses and get new clients. We began creating content marketing ‘kits’ around specific clinical topics.

APRIL 2015

During 2014, Tor developed a purpose-built contentmanagement system, that was equipped to thrive under the pressures of modern-day publishing. We transitioned 16 years of content and 2,500 customers and subscriptions onto this new platform, which went live in April 2015.

JANUARY 2016

We consolidated sportEX medicine and sportEX dynamics into one Co-Kinetic journal and expanded our content range to include advice on marketing and growing a physical therapy business.

ADV ICE

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 tissues. stabilisers with trigger lower back, Massage around your point therapy you have stabiliser and deep tissue release will deep neck muscles called relieve flexors around flexibility. Acupunctumuscle spasm and your neck your head improve to up. When your hold re may be modality in neck stabilisers are weak or an effective 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 flexors. include experience fatigue you lots of chin pain in the can tucking exercises These will back and sides sit-ups/cru 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

PREVENTI ON BODY CONDIT IONING

The information

PRODUCED BY:

contained

n The neck TIPS muscles scapular (shoulder work together with the girdle) stabilising including the muscles, middle and lower trapezius muscles and the serratus anterior muscle. Strengthen ing these will also help off-load upper trapezius, the levator scapular neck muscles. Exercises could and anterior type actions with an emphasis include rowingscapular back on pulling the and together, as well as ups and many push other balls and resistance activities using Swiss bands. n Your physical therapist can provide you a rehab programm with pain and preferably e to manage your neck prevent it. They offer advice can also regarding your ergonomics your daily chores in and work. This is particularly important if you sit for hours at a computer or

driving, or if you are involved and lifting/carry in manual labour ing, as these aggravating could all be your neck pain. Small changes how you carry in out your work can make a and daily chores big difference in neck posture and subsequen t pain.

BIKE SET UP

TIPS n Change your posture on the bike. reaching too If you’re far forward, or your handlebars are too low, shorten the stem to shorten your reach. Raise your bars and riding upright will more reduce the strain you’re your back and putting on neck. your hand positions Don’t forget to change at regular intervals, sit up on the and bike to stretch, your neck and straightenin g out back to vary the loads on different muscle the groups.

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

Physio117

TIME

-SAV INGinfo@physio journ RESO URCE al 43225 117.co.uk 07754 AND

S FOR PHYS 6MAN UAL THER www.physi ICAL APIS TS co.uk o117.

JANUARY 2019

In a bid to help ALL our subscribers to promote themselves more professionally and more widely, we added in the ability to rebrand all our patient-facing content like leaflets and handouts. In just 5 months, more than 20% of our customers have signed up to this upgrade.

lores Campaign Exp This Month’s Managing Ways of

Chr nic Pain

’S THIS MONTH CAMPAIGN

Explores

at How to Tre t and Preven Injuries ing imm Sw S ABOUT OUR

FOR DETAIL RCES CONTACT US LATEST RESOU EVENTS AND

NOVEMBER 2017

JULY 2015

With the new website live and 16 years of publishing under the sportEX brand, it was time for a new look that reflected the business we’d grown into. Based on the principles of collaboration, a cooperative approach to content creation, and a desire to build a business that worked as a virtuous circle for everyone involved, we developed the Co-Kinetic brand.

Co-Kinetic.com

With uptake to the new patient-focused marketing content gathering momentum, it quickly became clear that technology skills (or the lack of) were preventing people from taking full advantage of this content to really grow their businesses. So Tor developed a technophobe-friendly marketing platform built into Co-Kinetic which allowed ANYONE, regardless of their technology skills, to implement a full, client-generating, businessbuilding marketing strategy.

June 2019 JUNE 2019

After 16 months of testing and improving the bigger marketing platform, we have just launched a simpler, entry -level marketing solution, designed specifically to help you build engagement on your social networks and use them to build your email list, thereby turning your social networks into a dynamic business growth tool. This new subscription is called Done-For -You Social Media 7

CLICK ON RESEARCH TITLES TO GO TO ABSTRACT SILK FIBROIN SCAFFOLDS FOR COMMON CARTILAGE INJURIES: POSSIBILITIES FOR FUTURE CLINICAL APPLICATIONS. Farokhi M, Mottaghitalab F, Fatahi Y et al. European Polymer Journal 2019;115:251–267

USE OF TRADITIONAL AND COMPLEMENTARY MEDICINE FOR MUSCULOSKELETAL DISEASES. Kavadar G, Eroğlu Demir S, Aytekin E et al. Turkish Journal of Medical Sciences 2019;49(3):doi:10.3906/sag-1509-71. No.21 OPEN

This review highlights the investigations on silk-based biomaterials for cartilage tissue engineering. Traumatic injury in weight-bearing articular cartilage (eg. hip, ankle and knee) causes problems that may also affect the surrounding ligaments and meniscus. For example, 16–40% of patients with severe articular cartilage trauma suffer from a rupture of the anterior cruciate ligament. In addition osteochondral defects (OCDs) are usually associated with subchondral bone and articular cartilage lesions as some consequences of ageing, trauma or disease. OCDs commonly have a slow progression causing long-term disability, pain and joint failure. Due to the avascular nature of the cartilage matrix, undifferentiated mesenchymal stem cells, which are the starting point of cartilage development, cannot be transported from blood vessels to injured cartilage, thus reducing the self-healing ability. Other tissue engineering protocols are briefly discussed with more detail being given to silk fibroin which is a potent and advanced biomaterial for regenerating both soft and hard tissues. Fibroin scaffolds possess superior mechanical strength, suitable bioactivity, elasticity, degradability, and tailorable chemical structure. Owing to the important properties as natural biomaterials, the fabrications of various types of scaffolds/matrices for regenerating the tissues like cartilage for regeneration and repairing the defects are possible.

Co-Kinetic comment If you deal with athletes (or the general population) who suffer from damaged articular cartilage this paper is a must-read not just because of its review of the scaffolding method but because of the way it explains what is going on with the damaged tissue. Oh and, yes it is natural silk made by silk worms. As a bonus there is a chapter on using a similar technique for regenerating damaged intervertebral discs. Basically the scaffolding gives tissue an anchor on which to grow, usually achieved by removing some undamaged cells and growing them on the scaffold. If you want more information on this try the paper by Chan BP and Leong KW, ‘Scaffolding in tissue engineering’ in European Spine Journal 2008;doi:10.1007/s00586-008-0745-3. 8

OPEN

Data for this study came from a self-administered questionnaire completed by 839 patients (592 female, 247 male; mean age 48.9±13.0 years), who attended the physical therapy and rehabilitation units of three public hospitals in Turkey between September 2014 and March 2015. There was no significant statistical difference between users and none users of traditional and complementary medicine (TCM) in terms of age, gender, body mass index, socioeconomic status, or educational level. The disease duration of TCM users was significantly higher than that of non-users. Of TCM users, 73.4% had tried only one method and 21.9% had used two methods. The most commonly used TCM methods were balneotherapy (mineral water bath) (31%), herbal therapies (30%), wet cupping (22.2%), and massage-manipulation methods (21.2%). Of TCM users, 75.1% were satisfied with their treatment.

EFFECTIVENESS OF KINESIO TAPING ON BALANCE AND FUNCTIONAL PERFORMANCE IN SUBJECTS WITH PLANTAR FASCIITIS. Kirthika VS, Sudhakar S, Padmanabhan K et al. Research Journal of Pharmacy and Technology 2018;11(10):4671–4674 Forty subjects of both sexes aged between 40 and 60 years with a 6-month history of plantar fasciitis took part in the study. They were randomly allocated into a taping group (n=20) who received the application of Kinesio tape (K-tape), or a control group (n=20) given calf stretching

exercises. Both were treated over a 2-week period. The outcome measures used were Foot and Ankle Ability Measure and Star Excursion Balance Test. The K-tape group had a significant improvement in functional performance and dynamic balance when compared to the control group.

Between 2017 and 2018, rock climbers on rock climbing forums and at local gyms around Sacramento, CA, USA, were queried using an online questionnaire form. Of the 237 who ended up as patients, 89.03% of them were aged between 19 and 35 years with 47.68% between 19 and 26 and 41.35% between 27 and 35 years. The average age of the climbers were 27.4 years. The surgical cohort was older at an average age of 29 years compared with the non-operative group at 27.2 years. Of the patients, 196 (82.70%) were male and 41 (17.30%) were female. Average years of climbing experience was 4.3 years (range 0–15 years), with 20% under 1 year, 37%

at 1–3 years, 14% at 3–5 years, 16% at 5–8 years and 8.5% at 9–15 years. The group climbed on average YDS 5.11b and bouldered between Hueco grades V4 and 5 (can climbers please explain this to the rest of us). There were 432 injuries in 237 patients. In order of decreasing injury type there were 181 (41.9%) hand and elbow, (19.9%) foot and ankle, 75 (17.3%) shoulder, 32 (7.4%) knee, 16 (3.7%) spine, 12 (2.8%) hip, and 30 (6.9%) other. Non-operative patients elicited a similar injury distribution at 168 (44.4%) hand and elbow, 69 (18.3%) foot and ankle, 64 (16.9%) shoulder, 28 (7.1%) knee, 12 (3.1%) spine, 11 (2.9%) hip and 27 (7.1%) other injuries. The

Co-Kinetic Journal 2019;81(July):8-15

RESEARCH INTO PRACTICE

Journal Watch SOFT TISSUE AND BONY INJURIES ATTRIBUTED TO THE PRACTICE OF YOGA: A BIOMECHANICAL ANALYSIS AND IMPLICATIONS FOR MANAGEMENT. Lee M, Huntoon EA, Sinaki M. Mayo Clinic Proceedings 2019;94(3):424–431

Co-Kinetic comment Before the scientists among you turn your noses up at this study, note that the main reason given for using TCM was a dissatisfaction with more conventional medicine and that 75% of the participants were satisfied with the TCM treatment. Never dismiss the power of believing in something.

Co-Kinetic comment Ok, K-tape works. What would happen if you combined the tape and exercise?

The medical records of patients at the Mayo musculoskeletal clinic with injuries that were primarily caused by yoga between January 1, 2006, through December 31, 2018, were analysed. Injuries were categorised into three groups: (1) soft tissue injury, (2) axial non-bony injury, and (3) bony injury. Patients underwent evaluation and were counselled to modify exercise activity. A total of 89 patients were included in the study. Within the soft tissue group, 66 patients (74.2%) had mechanical myofascial pain due to overuse. Rotator cuff injury was seen in 6 (6.7%), and trochanteric bursopathy was observed in 1 (1.1%). In the axial group, exacerbation of pain in degenerative joint disease [46 patients (51.7%0)] and facet arthropathy [n=34 (38.2%)] were observed. Radiculopathy was seen in 5 patients (5.6%). Within the bony injury category, kyphoscoliosis was seen on imaging in 15 patients (16.9%) Spondylolisthesis was present in 15 patients

(16.9%). Anterior wedging was seen in 16 (18.0%), and compression fractures were present in 13 (14.6%). The poses that were most commonly identified as causing the injuries involved hyperflexion and hyperextension of the spine. The authors correlated the kinesiologic effect of such exercises on specific musculoskeletal structures.

Co-Kinetic comment Bet you didn’t associate yoga with injuries. In truth a large proportion of this lot may have had them before the yoga, and made them worse by doing it. The study does highlight the dangers of participants with osteopenia or osteoporosis being at higher risk of compression fractures or deformities and thus they would benefit from avoiding extreme spinal flexion. Bottom line is screen your patients before you recommend any exercise.

ROCK CLIMBING INJURIES AND TIME TO RETURN TO SPORT IN THE RECREATIONAL CLIMBER. Lum ZC, Park L. Journal of Orthopaedics 2019;16(4):361–363 operative group had more foot and ankle injuries than hand and elbow. Their injuries listed consisted of 17 (31.5%) foot and ankle, 13 (28.1%) hand and elbow, 11 (20.3%) shoulder, 4 (9.3%) knee, 4 (7.4%) spine, 1 (1.9%) hip and 3 (5.5%) other. 154 (66%) patients underwent no treatment, 49 (21%) underwent formal physical or occupational therapy, 26 (11%) underwent surgery. Of those who underwent surgery, 24/26 (92%) were satisfied. Recovery back to preinjury level took on average 4.4 months (range 0–5 years). Non-operative patients

Co-Kinetic.com

recovered on average after 3.9 months, while surgical patients took 9.1 months on average to return to their preinjury level. Of the group, 8/27 (30%) of surgical patients were considered to be still recovering and, thus, not at their preinjury level, 5/210 (2%) of nonoperative patients were considered to have never recovered and 38/210 (18%) were considered to be still recovering. Return to same level or better occurred in 80% of non-surgical patients and 70% of surgical patients.

Co-Kinetic comment Understatement of the year so far goes to the authors of this paper. ‘Injuries from falls or ligament/tendon involvement is a frequent injury pattern in rock climbing’. It is not the climbing, it’s the falling. Before this paper, not much is known about rock climbing injury. This may change soon because the International Olympic Committee want greater youth involvement so it will be an Olympic Sport in at Tokyo 2020. There will be three disciplines; sport, bouldering, and speed with the medals awarded for the combined results of the three. Karate, skateboarding and surfing are in as well so expect studies on them soon.

A META-ANALYSIS OF THE EFFECTS OF FOAM ROLLING ON PERFORMANCE AND RECOVERY. Wiewelhove T, Döweling A, Schneider C et al. Frontiers in Physiology 2019;doi:https://doi.org/10.3389/fphys.2019.00376 The objective of this meta-analysis was to compare the effects of foam rolling applied before (prerolling as a warm-up activity) and after (post-rolling as a recovery strategy). Twenty-one studies were located that met the inclusion criteria. Fourteen studies used pre-rolling, seven post. Pre-rolling resulted in a small improvement in sprint performance (+0.7%) and flexibility (+4.0%), whereas the effect on jump (−1.9%), and strength performance (+1.8%) was negligible. Post-rolling slightly attenuated exercise-induced decreases in sprint (+3.1%) and strength performance (+3.9 %). It also reduced muscle pain perception (+6.0%), whereas its effect on jump performance (−0.2%) was trivial. Of the twenty-one studies, fourteen used foam rollers, whereas the other seven used roller massage bars/sticks. A tendency was found for foam rollers to offer larger effects on the recovery of strength performance (+5.6% vs −0.1%) than roller massagers. The differences in the effects between foam rolling devices in terms of pre-rolling did not seem to be of practical relevance (overall performance: +2.7% vs +0.4%, flexibility: +5.0% vs +1.6%). Overall, it was determined that the effects of foam rolling on performance

OPEN

Co-Kinetic comment Every little helps so a very low percentage increase is still an increase. The question is whether or not the underlying reason is physiological or psychological and whether or not it is worth the cost of the roller and the effort involved? Can someone answer this please?

USING PRESSURE MASSAGE FOR ACHILLES TENDINOPATHY. A SINGLE-BLIND, RANDOMIZED CONTROLLED TRIAL COMPARING A NOVEL TREATMENT VERSUS AN ECCENTRIC EXERCISE PROTOCOL. Stefansson SH, Brandsson S, Langberg H et al. The Orthopaedic Journal of Sports Medicine 2019;7(3):doi:10.1177/2325967119834284 A total of 60 patients with Achilles tendinopathy (AT) were randomised into three groups. Group 1 underwent an eccentric exercise protocol for 12 weeks in which patients stood on a step, lifted up onto their toes, put their weight on their injured leg, and slowly lowered their heel as far as possible until a maximal stretch was felt. The protocol was performed with both straight knee and bent knee. As pain decreased, extra weight was added, 5kg at a time. If the patient was painfree for the full 15 repetitions for 3 sets, another 5kg was added for the next phase, and so on. Group 2 underwent pressure massage, with a physical therapist twice a week (2 or 3 days between treatments) for 6 weeks and once a week for 6 weeks. The therapist used his or her knee to put pressure on the soleus muscle at three different locations. Pressure was held until pain

and recovery are rather minor and partly negligible, but can be relevant in some cases (eg. to increase sprint performance and flexibility or to reduce muscle pain sensation). Evidence seems to justify the widespread use of foam rolling as a warm-up activity rather than a recovery tool.

started to decrease and the muscle started to relax but not for more than 60s. The patient’s pain tolerance was used to control the amount of pressure; with this technique, the patient should always be able to tolerate the pain. If the patient could not tolerate the pressure (ie. it was too painful), pressure was removed, and the patient was allowed to recover before starting the treatment again with less pressure. Group 3 underwent pressure massage and an eccentric exercise protocol for 12 weeks. Patients were evaluated before treatment and after 4, 8, 12, and 24 weeks with the Icelandic version of the Victorian Institute of Sports Assessment–Achilles questionnaire (VISA-A-IS). The results showed that all groups improved when evaluated with VISA-A-IS scores. The pressure massage group improved significantly more than the eccentric exercise

group at week 4, which was the only between-group difference. Ankle ROM increased significantly over time (ROM bent knee and ROM straight knee), but no significant difference was found between groups. No significant difference was found in evaluations of pain pressure threshold or US scan measurements. In conclusion pressure massage is a useful treatment for AT. Compared with eccentric exercise treatment, pressure massage gives similar results. Combining the treatments did not improve the outcome.

Co-Kinetic comment The study reports that the success rate for eccentric exercises in AT is reported to range from 60 to 90% so maybe using the pressure massage will cover the rest.

Co-Kinetic Journal 2019;81(July):8-15

RESEARCH INTO PRACTICE

The parts of this study likely to be of the greatest interest to readers of Co-Kinetic involve a review of evidence for the efficacy of massage in sport and pain relief. Space prevents us from presenting the full references for each paper in each section so we will summarise.

Sports massage In a study on a long-distance Ironman triathlon race, 74 athletes were massaged for their primary complaint of pain in the quadriceps. Although the massage group had significantly lower pain based on digital pressure algometry, no differences were noted between the massage and the control group on ROM. ROM seems to increase only when the hamstrings are massaged along with the quadriceps, at least in those with knee pain. In another study massage therapy led to better sleep and less muscle tightness. The improved sleep is consistent with previous massage therapy data showing a greater proportion of time spent in deep sleep. More deep sleep leads to less substance P (a peptide that causes pain) being emitted. This, in turn, leads to less pain.

Massage for pain reduction In a meta-analysis on 67 studies on massage therapy for pain management in general, massage therapy reduced pain as compared to sham controls and no treatment controls. In addition, the massage therapy groups as compared to the control groups had lower anxiety, improved mood and better healthâ&#x20AC;&#x201C; related quality of life. Other studies have focused on pain in different body parts and joints. In a systematic review on pain in different joints, 26 RCTs including 2,165 participants showed mixed results. Massage reduced pain in the short term for shoulder pain and osteoarthritis of the knee but not for neck pain or low back pain. Longterm function improved not only for

Co-Kinetic.com

SOCIAL TOUCH, CT TOUCH AND MASSAGE THERAPY: A NARRATIVE REVIEW. Field T. Developmental Review 2019;51:123â&#x20AC;&#x201C;145 individuals with shoulder pain and knee arthritis but also for those with low back pain. When massage therapy was compared to joint manipulation, both forms of moderate pressure stimulation were effective. In a comparison between massage therapy and physical therapy for chronic low back pain, massage therapy participants had a greater decrease in pain intensity and disability, perhaps because the massage therapy was less strenuous than the physical therapy. In another study on 104 patients with chronic low back pain, those who received massage therapy showed less pain and disability after 12 weeks of the therapy. Surprisingly, 75% still showed clinical improvement at 24 weeks. A meta-analysis study has suggested that although massage therapy has reduced low back pain in the short-run, the effects disappeared at follow-up. These results are not surprising inasmuch as pain reduction would not be expected after the massage therapy had been discontinued any more than diet, exercise and drug effects would be expected to continue once the practice had been discontinued. In a knee pain study, Chinese massage (moderate pressure massage) was given three times per week for 2 weeks. At the end of the 2-week period, knee pain was significantly reduced. In contrast to other knee pain studies that exclusively massaged the participantsâ&#x20AC;&#x2122; quadriceps muscles, a study on moderate pressure massage for both the quadriceps and hamstrings yielded not only reduced pain but also increased range of motion. For a study on upper limb pain participants were randomly assigned to a moderate pressure massage therapy or a light pressure massage therapy group. At the end of the first and last sessions, the moderate pressure massage group

experienced less pain. By the end of the study, the moderate pressure massage group not only had a greater decrease in pain but also greater ROM in their upper joints including their elbows and shoulders. In a meta-analysis on shoulder massage studies including 237 participants, the effect sizes suggested a significant reduction in pain and increased ROM, especially flexion and abduction of the shoulder following massage. In a randomised controlled study on neck pain, participants were provided weekly moderate pressure massages and were taught the massage and asked to practice it on a daily basis to reduce neck pain. By the end of the study, the massage group versus the wait-list control group was showing greater increases in ROM and greater decreases in ROM-associated pain. A meta-analysis conducted on massage versus inactive therapies yielded similar results. However, when massage therapy was compared to aqua therapy, massage therapy did not yield better effects for neck pain. A different research group reported a meta-analysis that further confirmed that massage therapy was not more effective than active controls. The active controls, however, were provided similar moderate pressure stimulation, so they would be expected to experience similar effects. These results, like those from other studies, suggest that treatment comparisons are more valid than comparing massage therapy with inactive or wait-list controls.

OPEN

Co-Kinetic comment This review by the queen of massage research, Tiffany Field, covers the three topics in the title. The first two, Social and CT Touch, are of interest to those in the massage industry. It is a touch therapy after all. The section we have summarised is only a small part of this work. If you use any hands-on therapy and need to quote evidence back at the doubters who believe that physical therapy should be exercise alone you must get hold of this paper.

MANUAL THERAPY FOR THE PAEDIATRIC POPULATION: A SYSTEMATIC REVIEW. Prevost CP, Gleberzon B, Carleo B et al. BMC Complementary and Alternative Medicine 2019;19(1):60 A search of the usual databases came up with 3,563 articles, of which 50 met the inclusion criteria and one of these involved children under the age of 18 years treated with manual therapy. There is a statistic quoted from another paper which suggests that most of the paediatric population being treated with manual therapy are in the 12–18-year-old age group and have back or neck pain. Of the 50 papers, 32 were RCTs and 18 were observational studies. From a long list of medical conditions the conclusion was that there was moderate-positive overall assessment for three conditions: low back pain, pulled elbow, and premature infants.

Co-Kinetic comment Take what is offered. Manual therapy in one of its forms is effective for three conditions. The big question is why would you use it for some of the others, eg. infantile colic and sub-optimal breast feeding? One positive was that adverse events were uncommon. A big negative is that the authors class manual therapy as a complementary and alternative medicine. No it is not.

RESPIRATORY EXCHANGE RATIO IN AEROBIC EXERCISE ON TREADMILL VERSUS CYCLE ERGOMETER AT SIMILAR PERCEIVED EXERTION. OPEN Sharma P, Tiwari S, Verma D et al. National Journal of Physiology, Pharmacy and Pharmacology 2018;8(6):872–877 In this study, 16 sixteen males with normal BMI performed 30min of continuous moderate intensity on a treadmill (TM) and cycle ergometer (CE) at a rate of perceived exertion of 13. Systolic blood pressure (SBP) and diastolic blood pressure (DBP), heart rate (HR), and pulse pressure (PP) were analysed just before and after the exercise trial. Respiratory exchange ratio (RER) was estimated during the last 2min of exercise. HR after TM (136±10) tended to be higher than CE (132±9), while changes in SBP, DBP, and PP were non-significant. RER was non-significantly higher in CE (0.89±0.05) than TM (0.91±0.06). Oxygen consumption was significantly higher in TM (1.11±0.17L/min) than CE (1.03±0.16L/min).

Co-Kinetic comment This is a fine example of

A retrospective chart review over a 6-year period found 6,593 overuse injuries in children aged 5–18 years (mean age 13.4 years). The injuries were gradual-onset in nature, caused by repeated microtrauma without a single identifiable acute event during sports participation. Males presented with a greater proportion of apophysis, physis, and articular cartilage injuries. Females presented with greater bone, tendon, and ‘other’ injuries. Children <9 years of age demonstrated apophysis and physis injuries. Conversely, children older than 15 years of age presented with tendon, bone, bursa, and other overuse injuries. The most frequent overuse diagnosis was patellofemoral pain syndrome (20.4%), followed by tibia tubercle apophysitis (11.8%), calcaneal apophysitis (10.7%), rotator cuff tendonitis (5.6%), and iliac crest apophysitis. Patellofemoral pain

why you have to be very careful about drawing conclusions from published research. At first it appears that the subjects used more energy on the treadmill. However, it is a very small sample size and if you turn to the study limitation section the authors admit that the lack of VO2 max measurement was because of the non-compliance of participants. Mouth breathing through a face mask caused discomfort to them and, hence, metabolic data were only collected during the last 2min of the exercise trial. Additionally, participants were asked to maintain a 1-day food diary but this was not monitored. The authors state that the effects of these limitations on the study data are unclear and require further studies. This raises the question of why they didn’t wait for those studies before they published.

AGE AND SEX DIFFERENCES IN OVERUSE INJURIES PRESENTING TO PEDIATRIC SPORTS MEDICINE CLINICS. Valasek AE, Young JA, Huang L et al. Clinical Pediatrics 2019;58(7):770–777 syndrome was the top diagnosis in females (n=971, 26.3%). Tibia tubercle apophysitis was the top diagnosis in males (n=464, 16.0%). Overall track and field/cross country were the most common sports in which overuse injuries were reported (18.1%), followed by baseball/softball (15.0 %) and soccer (14.1%). Males reported more overuse injuries in baseball (21.3%) than other sports. Females sustained the majority of overuse injuries during participation in track and field/cross country (19.1%) than in other sports. Although early sports specialisation was not evaluated in this cohort, >80% of this paediatric cohort continued their sports participation despite pain and

injury before clinical presentation.

Co-Kinetic comment Although sport specialisation is not directly addressed here it is clear that it is an underlying issue. A number of USA medical authorities position statements on sports specialisation are quoted in this paper. They all say that early specialisation is not good for child physical development. The most shocking finding in this paper is that a significant number of kids are playing on while in pain. The young athlete should not have to make this decision for themselves. Their parents, coaches and team medical staff should be preventing it.

Co-Kinetic Journal 2019;81(July):8-15

RESEARCH INTO PRACTICE

PAIN ON THE PLANTAR SURFACE OF THE FOOT. Gutteck N, Schilde S, Delank KS. Deutsches Arzteblatt International 2019;116(6):83–88 OPEN

This is a literature search of PubMed using the terms, ‘metatarsalgia’, ‘transfer metatarsalgia,’ ‘Morton neuroma’, ‘Freiberg disease’, ‘Freiberg’s infraction’, ‘plantar fasciitis’, ‘plantar spur’ and ‘heel pain’. Patients complain of pain in the medial plantar part of the heel. The pain often occurs when they take the first steps after getting out of bed in the morning or following a period of inactivity. After initial improvement, the pain worsens in the course of the day. One systematic review of eight studies with a total of 3,500 patients found a prevalence of 5.2 to 17.5% in active runners. Causes are multifactorial. One is a mechanical overloading reaction to multiple instances of micro-trauma (upping training mileage prior to charity runs and wearing unsuitable footwear are classic reasons). The risk factors are thought to be shortening

of the calf muscles, being overweight, long periods of employment in nonsedentary occupations, and deformities of the foot. In a retrospective study, 17.2% of the radiographs showed no abnormality. A plantar heel spur was present in 59.5% of cases, and 46.5% of the patients had an Achilles heel spur. There is no consensus on the diagnostic power of other imaging modalities (magnetic resonance imaging and sonography). In 90–95% of cases, conservative treatment (eg. stretching exercises, fascia training, ultrasound therapy, glucocorticoid injections, radiotherapy, shoe inserts, and shock-wave therapy) results in relief of pain within 1 year. If all else fails, continuing pain is an indication for surgical treatment by plantar fasciotomy and/or calf muscle release. In metatarsalgia, a directed diagnostic work-up to find the cause is mandatory, including a search for excessive mechanical stress due to abnormal foot posture, neuropathic pain, rheumatoid arthritis, aseptic

bony necrosis, or malignant disease; imaging studies and pedobarography (study of pressure fields acting between the plantar surface of the foot and a supporting surface) are needed. Nonsteroidal antirheumatic drugs (NSARD) may be helpful in the acute stage although one study found that their use together with a stretching programme was only slightly better than placebo.

Co-Kinetic comment This turned up via Europe PMC which is a database that claims to have 5 million more abstracts than PubMed. Happy reading. By the way, at the time of writing, Journal watch has brought you research from 287 journal titles over the last 10 years. That’s titles, not editions. Is it time that sports physical therapy and science called a halt to this deluge and went for quality over quantity? This paper comes into the quality section. It is one of those ‘everything you need to know articles’ that we love.

EFFECT OF MANUAL PHYSIOTHERAPY IN HOMOGENEOUS INDIVIDUALS WITH SUBACROMIAL SHOULDER IMPINGEMENT: A RANDOMIZED CONTROLLED TRIAL. Land H, Gordon S, Watt K. Physiotherapy Research International 2019;24(2):1768 In this study were 60 participants aged between 40 and 60 years who had tested positive for a minimum of three out of five subacromial impingement tests. Possible tests were, Hawkins Kennedy, Neer, external rotation resistance test, rotator cuff tendon palpation; horizontal (cross-body) adduction, painful arc, drop arm test, and speed test. They also had to have catching or aching pain without appreciable joint stiffness, pain at the anterior or antero-lateral shoulder and a history of insidious onset without trauma. They were randomly allocated to one of three groups. Treatment duration was 12 consecutive weeks consisting of nine treatments over 6 weeks, followed by 6 weeks when one home exercise was performed daily. Group 1: an active control group, which received ultrasound for 6 weeks at 1MHz, 50% pulsed, 0.5Wcm2 for 8min directed at the sub-acromial area while lying in supine. Group 2: an intervention group, which received treatment to the upper thoracic levels for 6 weeks along with daily thoracic home exercise performed for the entire 12-week period. Treatment was transverse mobilisations (T1–T6), grade 3, performed from the side of the painful shoulder, costovertebral mobilisations (T1–T6), grade 3, on the side of the painful shoulder. The total session time was 20min. The home exercise programme was passive thoracic extension localised to the area of treatment by participants lying in supine on a rolled towel positioned longitudinally along the Co-Kinetic.com

thoracic spine for 5min, twice a day. Group 3: an intervention group, which received treatment to the soft tissues of the posterior shoulder for 6 weeks along with a daily posterior shoulder home stretch performed for the entire 12-week period. This was massage along the length of infraspinatus and teres minor, performed for 15min with the participant lying on the nonsymptomatic side with the painful shoulder supported in elevation. This was followed by anteroposterior glenohumeral mobilisations, grade 3, for approximately 2min. The total session time was 20min. The participant was instructed to perform a passive cross adduction stretch in standing, twice for the count of 20, two times during the day. Compliance with the exercise was monitored via an exercise diary. Data was collected at baseline, 3, 6, 9, and 12 weeks. No differences were identified between groups at baseline. Upper thoracic and posterior shoulder interventions, with a targeted home exercise, both significantly decreased pain and increased function scores and increased posterior shoulder range compared with active control at 12 weeks, and 6 months following cessation of the trial.

Co-Kinetic comment This is an excellent piece of work. The condition is well described and the treatments given in sufficient detail (with pictures) to allow clinicians to have a go. It is also realistic in that it uses combined treatments rather than isolating just one which is great for experiments but rarely much help for the sufferer. Good effort. 13

DOES PAIN-INDUCING MASSAGE PRODUCE PAIN SENSITIVITY CHANGES SIMILAR TO A CONDITIONED PAIN MODULATION PARADIGM? A DOUBLE-BLINDED RANDOMIZED CONTROLLED TRIAL. Wilson A, Riley J, Bishop M et al. The Journal of Pain 2019;20(4)Suppl:S50 This is about trying to discover the mechanisms of pain inhibitory systems. The conditioned pain modulation paradigm is a way to study the endogenous pain inhibition ability of the subject. Fifty healthy participants [68% female, mean age 22 years (SD=4.72)] were randomly assigned to four 1min exposures to a cold pressor to the hand, a pain-inducing massage (PIM) or a pain-free massage (PFM) to the neck. Pressure pain thresholds (PPT) were assessed on the contralateral foot before and after each intervention period. Cold pressor pain ratings exceeded PIM pain reports and both exceeded the PFM. Cold pressor resulted in increased PPT compared to PFM after 1, 2, and 3min but not following the 4th minute. PIM resulted in higher PPT compared to PFM after 3 and 4min. PIM and cold pressor did not

After a 10km run, 78 runners aged 18–60 years, were randomly allocated to an experimental group who received massage therapy to the quadriceps muscle aimed at recovery after sporting activity, and the control group received sham hip and knee joint mobilisations. The massage was described as 1min of superficial effleurage, in which the therapist slid both hands in the direction of the muscle fibres from distal to proximal with a gentle pressure on the thigh; 3min of deep effleurage, in which the therapist performed the same movement but applied more pressure to the thigh; 3min of petrissage, in which the therapist used the entire surface of the palm of the hands to compress and lift the tissue sequentially; 1min of tapotement, in which the therapist agitated the tissues of the thigh with cupped hands; and 2min of superficial effleurage to finish the intervention. Hypoallergenic skin oil 14

differ at any time point. Pearson correlation revealed that greater intervention-related pain was associated with increases in PPT. Although PIM resulted in less selfreported pain than a cold pressor task, both resulted in a similar magnitude of the conditioned pain modulation suggesting shared underlying mechanisms.

Co-Kinetic comment This edition of the journal contained abstracts presented at a recent conference so we do not have the full details of the work but basically what it is suggesting is that pain does indeed inhibit pain and therefore it is using the same inhibitory pathway.

THE EPIDEMIOLOGY AND MANAGEMENT OF EXERTIONAL HEAT ILLNESSES IN HIGH SCHOOL SPORTS DURING THE 2012/132016/17 ACADEMIC YEARS. Kerr ZY, Yeargin SW, Hosokawa Y et al. Journal of Sport Rehabilitation 2019;doi:10.1123/jsr.2018-0364 This report was compiled from data collected by athletic trainers working in high school sports in the United States. Overall, 300 exertional heat illness (EHI) were reported, for an overall rate of 0.13/10,000 athlete exposures (AE). Of these, 44.3% occurred in American football preseason practices; 20.7% occurred in American football preseason practices with a registered air temperature ≥90°F and ≥1 hour into practice. The EHI rate was higher in American football than all other sports. However, girls’ cross country had the highest competition EHI rate (1.18/10,000AE). The EHI rate was higher in the South US census region than all other US census regions. Common EHI management strategies included: having medical staff on-site at the onset of EHI (92.7%); removing athlete from play (85.0%); and giving athlete fluids via the mouth (77.7%).

Co-Kinetic comment This is a bit stating the obvious but the rates were highest in hot states, in the summer and for a sport in which the athletes wear a lot of protective equipment. However, the take-home message is that even though the incidence is small, heat illness occurs. Be prepared for it.

MASSAGE THERAPY SLIGHTLY DECREASED PAIN INTENSITY AFTER HABITUAL RUNNING, BUT HAD NO EFFECT ON FATIGUE, MOOD OR PHYSICAL PERFORMANCE: A RANDOMISED TRIAL. Bender PU, Medeiros da Luz C, Feldkircher JM et al. Journal of Physiotherapy Volume 2019;65(2):75–80 was used to reduce friction between the therapist’s hands and the participant’s skin. The control group received sham hip and knee joint mobilisations from the same therapist. The mobilisations served no therapeutic purpose and were applied only to promote a feeling of slight pressure on the skin without proper joint mobilisation. The participants were in supine with the knee flexed at 90°. For sham hip joint mobilisation, a belt was placed on the participant’s inguinal region and around the therapist’s lumbar region. For sham knee joint mobilisation, a belt was placed around the proximal region of the participant’s tibia and around the therapist’s lumbar region. From these positions, the therapist projected his/

her body in order to move away from the participants, producing a slight and oscillatory pressure on the skin for 5min in each mobilisation. Outcome measures were taken before and after treatment and the results showed that the massage group had significantly lower scores than the control group on the numerical rating scale for pain by 0.7 points. There were no significant between-group differences for any of the other outcome measures, which included perceived fatigue, flexibility, strength or jump performance.

OPEN

Co-Kinetic comment The intervention techniques are well described but there is also an embedded video of the massage which is a great idea. Even better is the rock music that goes with it. Co-Kinetic Journal 2019;81(July):8-15

RESEARCH INTO PRACTICE

In a crossover design with a 3-day washout period, 16 male basketball players (mean age 20.13±1.31 years) were randomly allocated into two groups. Both underwent 20min of basketball-playing simulation after which they were assessed on heart rate variability (HRV), and a group of physical fitness tests (sit and reach, grip, back and leg strength). This was followed by either a 10min Thai massage or, if in the control group, ‘regular passive rest’. This was not further described. The massage consisted of Thai traditional and effleurage massage techniques applied throughout the body of the participants [including biceps and triceps (arms), deltoid (shoulders), latissimus dorsi, thoraco-lumbar fascia, trapezius (back)], and stretching muscles which consisted of hamstrings, rectus femoris, arms and back. They were assessed again immediately after the interventions. The results showed that HRV and the physical fitness tests were significantly increased in both groups and heart rate decreased. There was a difference in the two groups on various HRV parameters but with no significant difference between groups. There was

THE ACUTE EFFECT OF TRADITIONAL THAI MASSAGE ON RECOVERY FROM FATIGUE IN BASKETBALL PLAYERS. Kaesaman N, Eungpinichpong W. International Journal of GEOMATE 2019;16(55):53–58 also a post-treatment questionnaire measuring the level of relaxation and satisfaction that the participants felt. This is not further described and the only result mentioned is a quote in the discussion, ‘the basketball players significantly noticed the mental and muscle tension, refreshment and power boost to play more effectively in another half of the game’.

Co-Kinetic comment Traditional Thai massage differs from the more usual Swedish massage used in sport in that there is an emphasis on firm acupressure and deep stretches. That is very much a simplification so please – no angry letters from devotees. Here, there appears to be a mixture of both because effleurage is mentioned. The rationale behind the time scale of 10min was that it was a recovery strategy to be used at half time which is a great idea but they seem to pack a lot into those 10min. Overall this is positive for using massage as a recovery

THE MANAGEMENT OF SHOULDER IMPINGEMENT AND RELATED DISORDERS: A SYSTEMATIC REVIEW ON DIAGNOSTIC ACCURACY OF PHYSICAL TESTS AND MANUAL THERAPY EFFICACY. Innocenti T, Ristori D, Miele S et al. Journal of Bodywork and Movement Therapies 2018;doi:https://doi.org/10.1016/j.jbmt.2018.08.002 A systematic search of four databases was conducted, including RCTs and cross-sectional studies. Cochrane Risk of Bias and QUADAS-2 were adopted for critical appraisal and a narrative synthesis was undertaken. Six RCTs and two cross-sectional studies were appraised. Studies presented low to moderate risk of bias. The conclusion was that there is a lack of evidence to support the mechanical construct guiding the choice of physical tests for diagnosis of impingement. Manual techniques appear to yield better results than placebo and ultrasounds, but not better than exercise therapy alone. Discrepancy between the goal of assessment strategies and the relative proposed treatments were present together with high heterogeneity in terms of selection of patients, type of endpoints and follow-ups.

Co-Kinetic comment Confused? It appears that the more we know the less we know. No diagnostic tests stands out. No treatment is top of the pack. Exercises are OK as long as people do them. Pick two or three tests that work for you. Mix up some manual therapy and exercise. Above all don’t give up just because the evidence is inconclusive.

Co-Kinetic.com

strategy in a short time period but so was the passive rest. Without more details of the questionnaire it is difficult to agree with their final conclusion that Thai massage ‘has a more acute effect on the recovery of basketball players than the passive rest’ unless you are a cardiologist who can interpret the statistics that make up the various parameters of HRV. One parameter of HRV is RMSSD, which is mentioned in the results of this study but not explained. An internet search reveals that it is the square root of the mean squared difference between adjacent normal to normal intervals. Call the cardiologist.

OPEN

HAND AND WRIST INJURIES RELATED TO MOTOCROSS INJURIES: 5 YEAR SERIES. Singh R, Chojnowski A, Hay S. The Journal of Hand Surgery (Asian-Pacific Volume) 2019;24(01):60–64 A total of 615 injuries involving motocross riders were reported at a UK regional trauma unit between 2010 and 2015. There were 240 patients with 265 hand and wrist injuries. Most of the injuries were sustained in male patients. The age range of the patients was from 4 to 78 years, with most injuries occurring during the spring and summer months. A total of 96 (40%) patients required operative treatment. The most common injury pattern was distal radius fractures (n=53, 20%), followed by metacarpal fractures (n=38, 14%) and phalangeal fractures (n=36, 13.5%). The number of annual tournaments, racers and subsequent hand and wrist related injuries and operative requirements have quadrupled over the past 5 years.

Co-Kinetic comment This paper describes motocross as ‘an increasing fashionable sport’. Does that mean that it is attracting inexperienced riders who are contributing to their own downfall? The age group of 4–78 years may suggest so. Is the protective equipment sufficient? Are the courses safe enough? These are certainly all questions for further research if any one fancies it. 15

THE 10 MOST DISCUSSED PIECES OF RESEARCH IN PHYSICAL THERAPY (APR - JUN 2019)

THE ENERGY COST OF SITTING VERSUS STANDING NATURALLY IN MAN Medicine and Science in Sports & Exercise

409 6

WHAT DOES BEST PRACTICE CARE FOR MUSCULOSKELETAL PAIN LOOK LIKE? ELEVEN CONSISTENT RECOMMENDATIONS FROM HIGH-QUALITY CLINICAL PRACTICE GUIDELINES: SYSTEMATIC REVIEW British Journal of Sports Medicine

1306 27

119

WAKE UP AND SMELL THE COFFEE: CAFFEINE SUPPLEMENTATION AND EXERCISE PERFORMANCE - AN UMBRELLA REVIEW OF 21 PUBLISHED META-ANALYSES British Journal of Sports Medicine

675 14

BENEFICIAL ASSOCIATIONS OF LOW AND LARGE DOSES OF LEISURE TIME PHYSICAL ACTIVITY WITH ALL-CAUSE, CARDIOVASCULAR DISEASE AND CANCER MORTALITY: A NATIONAL COHORT STUDY OF 88,140 US ADULTS British Journal of Sports Medicine

432 16

HOW DOES SURGERY COMPARE TO SHAM SURGERY OR PHYSIOTHERAPY AS A TREATMENT FOR TENDINOPATHY? A SYSTEMATIC REVIEW OF RANDOMISED TRIALS BMJ Open Sport & Exercise Medicine

640 16

LOW-CARBOHYDRATE, KETOGENIC DIET IMPAIRS ANAEROBIC EXERCISE PERFORMANCE IN EXERCISE-TRAINED WOMEN AND MEN: A RANDOMIZEDSEQUENCE CROSSOVER TRIAL Journal of Sports Medicine and Physical Fitness

319 10

ARE BALL PITS LOCATED IN PHYSICAL THERAPY CLINICAL SETTINGS A SOURCE OF PATHOGENIC MICROORGANISMS? American Journal of Infection Control

409 6

DISTINCT EFFECTS OF ACUTE EXERCISE AND BREAKS IN SITTING ON WORKING MEMORY AND EXECUTIVE FUNCTION IN OLDER ADULTS: A THREE-ARM, RANDOMISED CROSS-OVER TRIAL TO EVALUATE THE EFFECTS OF EXERCISE WITH AND WITHOUT BREAKS IN SITTING ON COGNITION British Journal of Sports Medicine

98 3

PLATELET-RICH PLASMA FOR PATELLAR TENDINOPATHY: A RANDOMIZED CONTROLLED TRIAL OF LEUKOCYTERICH PRP OR LEUKOCYTE-POOR PRP VERSUS SALINE American Journal of Sports Medicine

455 7

ISOMETRIC EXERCISE FOR ACUTE PAIN RELIEF: IS IT RELEVANT IN TENDINOPATHY MANAGEMENT? British

Journal of Sports Medicine

0 15 Produced by: TIME-SAVING RESOURCES FOR PHYSICAL AND MANUAL THERAPISTS

News stories

Tweets

Facebook posts

535 0

Mendely readers

The PDF version of this infographic includes hyperlinks to the individual pieces of research. Click here to access https://spxj.nl/30XMYaX

THE 10 MOST DISCUSSED PIECES OF RESEARCH IN MANUAL THERAPY

Annals of Medicine

116 6

BMC Complementary and Alternative Medicine

60 7

134 4

50 0

5 7

PHYSIOTHERAPY BASED ON A BIOBEHAVIORAL APPROACH WITH OR WITHOUT ORTHOPEDIC MANUAL PHYSICAL THERAPY IN THE TREATMENT OF NONSPECIFIC CHRONIC LOW BACK PAIN: A RANDOMIZED CONTROLLED TRIAL Pain Medicine

33 0

MASSAGE THERAPY SLIGHTLY DECREASED PAIN INTENSITY AFTER HABITUAL RUNNING, BUT HAD NO EFFECT ON FATIGUE, MOOD OR PHYSICAL PERFORMANCE: A RANDOMISED TRIAL

Journal of Physiotherapy (Australian Physiotherapy Association)

33 2

Physiotherapy

47 1

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

Archives of Physical Medicine & Rehabilitation

MANUAL THERAPY PREVENTS ONSET OF NOCICEPTOR ACTIVITY, SENSORIMOTOR DYSFUNCTION, AND NEURAL FIBROSIS INDUCED BY A VOLITIONAL REPETITIVE TASK

63 4

Chiropractic & Manual Therapies

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

Pain (03043959)

THE ACUTE EFFECTS OF JOINT MANIPULATIVE TECHNIQUES ON MARKERS OF AUTONOMIC NERVOUS SYSTEM ACTIVITY: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED SHAM-CONTROLLED TRIALS

62 2

A MANUAL THERAPY AND HOME STRETCHING PROGRAM IN PATIENTS WITH PRIMARY FROZEN SHOULDER CONTRACTURE SYNDROME: A CASE SERIES

Journal of Orthopaedic & Sports Physical Therapy

MANUAL THERAPY FOR THE PEDIATRIC POPULATION: A SYSTEMATIC REVIEW

A RISK-BENEFIT ASSESSMENT STRATEGY TO EXCLUDE CERVICAL ARTERY DISSECTION IN SPINAL MANUAL-THERAPY: A COMPREHENSIVE REVIEW

(APR - JUN 2019)

LONG-TERM COSTEFFECTIVENESS OF EXERCISE THERAPY AND/ORÂ MANUAL THERAPY FOR HIP OR KNEE OSTEOARTHRITIS: RANDOMIZED CONTROLLED TRIAL AND COMPUTER SIMULATION MODELLING

Osteoarthritis and Cartilage

28 15

Tweets

Produced by: TIME-SAVING RESOURCES FOR PHYSICAL AND MANUAL THERAPISTS

Facebook posts

Mendely readers

The PDF version of this infographic includes hyperlinks to the individual pieces of research. Click here to access https://spxj.nl/2MgXV41

Femoroacetabular Impingement Syndrome Part 2: Management

Part 1 of this article described the hip morphology associated with femoroacetabular impingement (FAI) and how to accurately identify FAI syndrome (FAIS) using the triad of symptoms, clinical signs and imaging findings. This article, Part 2, moves on to discuss treatment of FAIS. The current literature and evidence is clarified, allowing you to prescribe exercises for conservative management and, if necessary, to know when and how to discuss progression to surgery and its potential outcomes, enabling the patient to participate in a shared decision-making process. Read this article online https://spxj.nl/2HMSdms HIP | LOWER LIMB | 19-07-COKINETIC FORMATS WEB MOBILE PRINT 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) syndrome (FAIS) is a motionrelated clinical hip disorder with a triad of symptoms, clinical signs and imaging findings (1). It represents a symptomatic premature contact between the proximal femur and the acetabulum. Typically, the morphology of the hip exhibits shapes that predispose it to impingement, often described with the terms cam and pincer morphology. The epidemiology of cam and pincer morphology is not well defined but may be present in 30% of the general population. Not all patients with cam and/or pincer morphology develop FAIS, but the treatment of those who do is controversial. Being able to accurately identify the clinical signs and symptoms and combine them with the imaging findings is the first step, which has been discussed along with the morphology of FAIS in Part 1 of this article. If you have missed it (or need a refresher) you can find it at this link: https://spxj.nl/2YDNEjI. So, now that you understand what is going on inside the patient’s hip and you can correctly diagnose it – what do you do with it? The most appropriate management for patients with FAIS is a subject of much debate in sports medicine and orthopaedics. Over the past 10 years, increasing numbers of patients have been treated for FAIS with shape changing surgery, most frequently through hip arthroscopy. Surgery has been shown to provide improvements in patient symptoms,

although patient expectations are not always met (2*). The recent Warwick Consensus Meeting proposed three main treatment approaches for patients with FAIS: conservative care, physiotherapy-led rehabilitation and hip surgery. Most of the ongoing research focuses on investigating the effectiveness of hip surgery for FAIS. Such studies – even if highly relevant – provide little information on non-surgical protocols for managing patients with a diagnosis of FAIS who are not yet candidates for hip surgery (3). The criteria for diagnosis clearly describes a triad of symptoms, clinical signs and imaging findings (Fig. 1). In contrast, appropriate treatment of FAIS could be described as a little vague and far reaching (3,4*).

What is the Appropriate Treatment of FAIS According to the Warwick Agreement (4*)?

FAIS can be treated by conservative care, rehabilitation or surgery. Conservative care may involve education, watchful waiting, and lifestyle and activity modification. Physiotherapy-led rehabilitation aims to improve hip stability, neuromuscular control, strength, range of motion and movement patterns. Surgery, either open or arthroscopic, aims to improve the hip morphology and repair damaged tissue. Good management of the variety of patients with FAIS requires the availability of all of these Co-Kinetic Journal 2019;81(July):18-27

PHYSICAL THERAPY

approaches. Besides the level of hip joint damage, which might favour the surgical option for patients with early stages of chondral lesion and severe morphologies, the failure of nonsurgical management is frequently considered the most important indication for hip surgery (Link 1)(5). Despite this, optimal non-surgical management is not known, so where do you define ‘the failure point’? Non-surgical management for patients with FAIS should probably include a combination of conservative care, that is, education, activity and lifestyle modification, physiotherapy-led rehabilitation, and, if also required, the use of oral analgesics (1,3). However, the failure of non-surgical management as an indication for hip surgery has been poorly reported in previous studies (6*). Studies have not clarified

Sy mp cli tom ck in st g, giv iffn in

Diagnostic hip injections to confirm hip as source of pain

whether non-surgical treatments were attempted and failed before surgery. In addition to this, some studies have stated non-surgical management failure was a criterium for surgical intervention but were unclear in describing what the prior management protocols were that failed (6*). FAIS is an important condition that can be managed by physiotherapists, together with other health professionals. ‘Failed conservative care’ is a reason for surgery being introduced into the shared decisionmaking process with the patient. Two recent landmark randomised controlled trials (RCTs) have brought new data

al signs consistent with Clinic yndrome (eg. restricted FAI s ROM or positive impingement test)

symptoms, s ig d of Tria adiological featu ns r res d an

DIAGNOSIS Femoroacetabular Impingement Syndrome Treatment options

Conservative care

Ra dio of logi c c pla mor am al o in rad pho iog r

s ng di r fin ince n rp yo g lo phs a

in pa ip g h n f i s o atch r c so es ay w g

THE MOST APPROPRIATE MANAGEMENT FOR PATIENTS WITH FAIS IS A SUBJECT OF MUCH DEBATE

Additional cross sectional imaging if indicated (eg. CT or MRI

Arthroscopic surgery Surgery Open surgery

Physiotherapy-led rehabilitation

Figure 1: Pathway for the management of femoroacetabular impingement (FAI) syndrome. Reproduced with permission from 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 (4*).

Co-Kinetic.com

to that patient-centred discussion, which can involve the questions: Would you consider surgery for this condition? What is the likelihood that your impairments will be appreciably improved with arthroscopic hip surgery followed by rehabilitation? (7*,8). As clinicians delivering exercise therapy, we need to reflect on the question: Are we providing high-quality, outcomedriven, exercise therapy programmes to these patients? (9). Contemporary exercise therapy should be informed by the patient’s needs and preferences, and address patient-specific impairments. Specific hip-related impairments in FAIS include hip muscle weakness, particularly hip adductors; lower trunk strength bilaterally; poor dynamic singleleg balance; and lower functional task performance in non-operative, preoperative and postoperative groups (10). None of these impairments can be corrected by surgery alone. These impairments could be best addressed with graded exercises (9,10*).

To Cut or Not to Cut, that is the Question

Most ongoing RCTs evaluating treatments for FAIS compare surgical with non-surgical management options (5). The main purpose of these studies is to evaluate the effectiveness of hip surgery, using non-surgical protocols as control treatments. The problem with this is that firstly; only patients with FAIS who already have a surgical indication would be included in these studies. Ethically, these are the only patients who would accept to be included in a trial where one treatment arm is surgery (3). Based on the available evidence, it seems that non-surgical and surgical management of FAIS should be sequential rather than parallel treatment options. In fact, when patients are deemed to fulfil the criteria for hip surgery, non-surgical management should have already been attempted and failed (2*). In addition, patients who have not yet 19

FAIS CAN BE TREATED BY CONSERVATIVE CARE, REHABILITATION OR SURGERY … AND GOOD MANAGEMENT OF FAIS PATIENTS REQUIRES THE AVAILABILITY OF ALL OF THESE APPROACHES attempted non-surgical management options may prove to not actually need hip surgery, at least in the short term, if they undertake a trial of high quality and efficacious rehabilitation first (2*). ‘Doc, will this surgery allow me to return to sport?’ is a question that every athlete asks when considering surgery as a treatment option. Whether such surgery permits successful return to sport (RTS) is unclear. ‘Successful’ RTS has at least three elements: 1. playing the sport again (at any level); 2. playing the sport again at the previous level of competition [ie. National Collegiate Athletic Association (NCAA) or professional league]; and 3. performing at a previous level using objective sports performance criteria relevant to the sport (ie. world ranking in tennis) (11*). So, where does the research stand regarding surgery as an option for FAIS management? The short of it is: l Time taken to RTS post-surgery is on average 7±2.6 months (11*). l Criteria for readiness to RTS is unspecified; seemingly based on time elapsed since surgery (11*). l Reporting players’ post-surgery athletic performance is usually based on a pre/post-surgery comparison. For example increased running mileage, distance to greens in golf, or improvement in time/week a sport can be performed. Actual performance in sporting competition is not reported (11*). l RTS rate is on average 91% postsurgery; however, only 74% return to the pre-injury level (11*). l More than two-thirds of the patients are satisfied after surgery. Nevertheless, average scores from patients indicate residual mild hip pain and/or activities of daily living (ADL) and sport function lower than their healthy counterparts after hip arthroscopy (12*). 20

l 89% of patients return to some sort of physical activity. Only 50% return to their pre-injury sport of which 21.4% to the same and 28.3% to lower performance-levels (13). l 39% return to participation in a different sport, whereas 11% do not return to any form of physical activity (13). l Hip arthroscopy may be clinically more effective at improving hiprelated quality-of-life scores than Personalised Hip Therapy in FAI patients, but is definitely not more cost-effective (14*). l Outcomes of surgery are reduced in patients over the age of 40 years and in the presence of hip osteoarthritis and cartilage damage. On average, 9 out of 10 athletes RTS after surgery for FAIS (11*). This can be considered one level of ‘success’. However, 2–3 out of 10 athletes failed to return to their pre-injury level of competition after surgery. This should be discussed with athletes as part of a preoperative shared decision-making (11*). Returning to competitive sport at a high level is often a factor that makes athletes consider surgery, so capacity to return to play at a previous competition level warrants specific discussion between the surgeon and the athlete. Going beyond merely the ‘level of competition’ to the ‘capacity for best ever performance’ is another important consideration for patients, yet very rarely do studies compare sporting performance before and after FAI surgery (11*). The fact that a proportion of players are restricted in their ability to participate in sport post-surgery is concerning (11*). Athletes typically choose surgery for pain relief and RTS pre-injury level. Of additional concern is the lack of criteria used to determine RTS beyond post-surgical time. Studies have shown that passive range of motion (PROM) improved;

patients generally reported fewer symptoms and felt satisfied with the surgical procedure. However, rarely do you hear about surgical complications, failures, or career longevity. Given that one in four athletes do not return to their pre-injury level of sport competition, the high level of reported satisfaction and significant improvement in pre-surgical to post-surgical PROMs suggests that athletes’ decision-making may be based on limited information (11*). Players may be anticipating successful RTS/RTS pre-injury level, and they may overestimate their satisfaction in relation to sport performance postsurgery (11*). Since FAIS was thought to be caused primarily by structural hip abnormalities, surgery –whether open or arthroscopic – was considered to be the main treatment (15). Nevertheless, dynamic hip joint instability, defined as excessive femoral head translation relative to the acetabulum during daily and sports activities, may also contribute to the FAI pathomechanism (15). Indeed, this may lead to mechanical overloading of the hip joint structures and pain. Managing dynamic hip joint instability has often been overlooked in terms of treatment options for FAIS (15). It is understood that abnormalities in the osseous and inert hip structures, which are commonly treated with hip surgery, might not be the only determinants of hip pain in patients with FAI. Abnormal morphology provides a simple construct that lends itself well to the idea of surgical correction. However, the high prevalence of abnormal morphological findings in asymptomatic individuals suggests the problem is more complex (16*).

Non-Surgical Treatment Options

At present, it is not clear what comprises the best non-surgical management for FAIS and, also, which patients could benefit the most from non-surgical protocols. So far, a single non-surgical protocol (ie. Personalised Hip Therapy) has been proposed (7*). This protocol consists of conservative care and Co-Kinetic Journal 2019;81(July):18-27

PHYSICAL THERAPY

an exercise-based hip programme. It was developed based on the available literature, Delphi consensus and feedback from experienced physiotherapists. In addition to this, a rationale has been provided in support of the potential effectiveness of an active training therapy for the non-surgical management of FAIS, which includes hip and lower limb muscle strengthening, core stability and postural balance exercises (16*,17). It has been hypothesised that improving dynamic stability of the femoroacetabular hip joint as a result of active neuromuscular training may lessen the mechanical loads on the hip joint structures and reduce the symptoms in some patients. In contrast, it is more difficult to develop a plausible rationale for explaining how passive physical therapies alone, such as manual therapy (massage, mobilisation and stretching) might act on the hip joint biomechanics so as to reduce the symptoms. So let’s consider these management protocols in more detail.

1. Personalised Hip Therapy Protocol

It has been suggested that clinicians should be cautious in the use of surgery for FAIS and that non-operative approaches should be considered. Patients with FAIS have altered hip muscle strength, range of motion (ROM) and gait biomechanics, and these offer potential targets for treatment through physiotherapy (2*). Although many authors recognise the likely value of non-operative or conservative care, there is very little published guidance and evidence on how this care should be delivered (2*). A recent study has aimed to develop a physiotherapist-led non-operative treatment protocol for patients with FAIS that could be compared with arthroscopic surgery in a large pragmatic RCT (2*,7*). Systematic reviews, Delphi consensus, relevant literature and the experiences of physiotherapists treating patients with FAIS were all compiled to draw up and agree upon a treatment protocol, referred to as Personalised Hip Therapy (PHT) (2*). This PHT protocol could provide guidance to clinicians Co-Kinetic.com

and researchers in an area where evidence is limited. Exercise is an effective treatment for many types of musculoskeletal pain. PHT has many similarities to other non-operative treatment regimens including the European League against Rheumatism (EULAR) and Osteoarthritis Research Society International (OARSI) guidelines on hip and knee osteoarthritis. These also recommend a comprehensive assessment, education, lifestyle modification and exercise-based programme. PHT includes an exercise-based programme that aims to improve deficiencies in hip function (including muscle weaknesses and ROM) that have been highlighted in FAIS (1,2*). Through an individualised exercisebased programme, physiotherapists using PHT are able to target these deficiencies. Where conservative treatment of FAIS is advocated, PHT gives clinicians a protocol for content and delivery. The results from the first RCT using PHT (7*) showed a 14% improvement in hip-related quality of life over a 12-month period. However, hip arthroscopy led to a greater improvement than did PHT, and this difference was clinically significant. The most common reason for low outcome (poorer than expected results) of PHT was that 72% of participants did not receive the minimum of six therapy sessions. Other reasons included no progression of exercises by the physiotherapist in 23% of the cases and patients not complying with the exercise programme. Questions need to be raised regarding the efficacy of only having six sessions or less over a 12-month period and the compliance of patients with home programmes and progression of exercises over time to ensure the best outcomes. Table 1 shows a summary of the PHT protocol (2*,7*). For more detail see the Personalised Hip Therapy manual for physiotherapists (Link 2) as well as the exercise programme (Link 3) conducted during the study (2*). In another recent RCT by Mansell et al. to determine the comparative effectiveness of surgery and physical

therapy for FAIS (8), statistically significant improvements were seen in both groups. Patients received 12 sessions of supervised physiotherapy over 6 weeks. However, at 2 years there was no difference between the surgical and physiotherapy group, and most patients reported little to no change in their quality of life at that time (8). We must question whether the non-surgical treatment programmes evaluated in the recent RCTs discussed above (7*,8), included the type, dose and progression of exercises needed to generate a meaningful change in strength and function. Results showed that physiotherapist-led groups did have improvement (approx. 14% in both studies) (7*,8); however, patients still remained ‘impaired’ at the conclusion of the programmes (hip-related quality-of-life scores on average were 45–49 points out of 100) (7*,8). So then what constitutes optimal non-surgical care for patients, or best post-surgical rehabilitation and contemporary, effective RTS for FAIS patients? Looking at the most recent RCTs (7*,8) what could be identified or changed to make your clinical practice

ON AVERAGE, 9 OUT OF 10 ATHLETES RETURN TO SPORT AFTER SURGERY FOR FAIS, BUT 1 IN 4 FAILED TO RETURN TO THEIR PRE-INJURY LEVEL OF COMPETITION

TABLE 1: Personalised Hip Therapy summary [Reproduced with permission from Wall PD et al. Personalised Hip Therapy: development of a non-operative protocol to treat femoroacetabular impingement syndrome in the FASHIoN randomised controlled trial (2).]

FOUR CORE COMPONENTS

1. Patient Education and advice l Advice about relative rest. In particular, relative rest in a specific l Education about FAI and available treatments. ROM where pain in that particular ROM is likely to represent l Advice about posture, gait and lifestyle behaviour modifications ongoing impingement. Specific activity/sport technique advice to try to avoid FAI. and modification. l Advice about activities of daily living to try to avoid FAI (reducing/ avoiding deep flexion, adduction and internal rotation of the hip). 2. Patient Assessment l History. To include: history of presenting complaint, relieving and aggravating factors, past medical history, medications, previous treatments, social history including occupation, patient’s concerns, fears and beliefs, patients individual requirements and expectations.

l Examination. Determine pain-free, passive ROM in the hip, determine the strength of motion in the hip in flexion, extension, abduction, adduction, internal and external rotation and impingement testing.

3. Help with Pain Relief l Advice about anti-inflammatory medication for 2 to 4 weeks. l Advice about simple analgesics if they do not respond well to anti-inflammatory medication.

l Engagement in, and adherence to, a personalised exercise programme.

4. Exercise-based hip programme l An exercise programme that is individualised, progressive and supervised. l A phased exercise programme that begins with muscle control work, and progresses to stretching and strengthening with increasing ROM and resistance. l Muscle control/stability exercise (targeting pelvic and hip stabilisation, gluteal and abdominal muscles). l Strengthening/resistance exercise firstly in available range (painfree ROM), and targets: gluteus maximus, short external rotators, gluteus medius, abdominal muscles, lower limb in general.

l Stretching exercise to improve hip external rotation and abduction in extension and flexion (but not vigorous stretching – no painful hard end stretches). Other muscles to be targeted if relevant for the patient include iliopsoas, hip flexors and rotators. l Exercise progression in terms of intensity and difficulty, gradually progressing to activity or sport-specific exercise where relevant. l A personalised and written exercise prescription that is progressed and revised over treatment session. l Encourage motivation and adherence through the use of a patient exercise diary to review progress. l Patients to have access to resistance bands, exercise balls and exercise mats.

PROTOCOL EXCLUSIONS

DELIVERY OF CARE

ADDITIONAL OPTIONAL COMPONENTS

The following can be included in the patient’s care if the treating physiotherapist feels it is appropriate l Manual therapy hip joint mobilisations. Eg. distraction, distraction with AP glides, trigger point work. l Hip joint injection. Potentially useful for patients who do not improve with ‘core’ treatment. Maximum of one steroid hip injection allowed. l Orthotics patients can be assessed for biomechanical abnormalities and either have these corrected by the treating physiotherapist or the patient can be referred to allied healthcare professionals such as a podiatrist for custom-made insoles, etc.

l Taping. Taping techniques such as taping the thigh into external rotation and abduction to help with postural modification/ reminding. l Group-based treatments. The core programme can be supplemented by but must NOT be substituted with groupbased treatment. l Treatment of additional pathology/symptoms. Physiotherapists are free to treat any additional pathology or symptoms that they feel are exacerbating a patient’s FAI. Examples of this might include treating co-existing low back pain.

l The maximum total number of contacts with the physiotherapist l Care provided over at least 12 weeks. is 10 including the optional further booster sessions. l A minimum of 6 ‘contacts’ with the physiotherapist over 12 weeks. l Care provided by the same physiotherapist throughout where l Ideally, all 6 contacts are face-to-face but at least 3 should be possible. face-to-face. Others can be via telephone/email support where l Assessment between treatment session will be done by: that is needed due to geographical distance. subjective assessment, objective assessment and exercise l Further ‘booster’ follow-ups can be arranged between 12 weeks adherence. and 6 months. l Forceful manual techniques. Forceful manual techniques in restricted ROM (grade 5 mobilisations, or forceful stretching). No painful hard end stretches. l Student or technical instructor care. Care should not be delivered by a student or technical instructor.

l Hydrotherapy. Patients should not have hydrotherapy as part of their treatment. l Acupuncture. Patients should not have acupuncture as part of their treatment. l Electrotherapy. Patients should not have electrotherapy as part of their treatment.

AP, anteroposterior; FAI, femoroacetabular impingement; ROM, range of motion 22

Co-Kinetic Journal 2019;81(July):18-27

PHYSICAL THERAPY

outcomes more effective? l The initial design of both studies dates back to 2012 and may not represent current best practice. l Mansell et al. only performed exercises for 6 weeks comprising mostly of mobility and therapeutic motor control exercises (8). The UK FASHIoN study (7*), which includes PHT, was developed to comply with National Health Service requirements and, therefore, the majority of patients attended less than 8 physiotherapy-led sessions, an average of 5 physiotherapy-led sessions over 12â&#x20AC;&#x201C;24 weeks. There is no information about whether additional home-based exercises were performed. This dose (on average biweekly or monthly visits) would be considered insufficient to resolve muscle strength and activity impairments (9,18). The prescription of primarily non-functional, low-load exercises is likely to be of insufficient stimulus to address the deficits in strength and functional performance that are known to exist in patients with FAIS (18). Knowledge regarding optimal exercise interventions has grown over the past 7â&#x20AC;&#x2030;years. These exercise protocols should form a good baseline for managing FAIS patients but would need to be updated in intensity, frequency and duration as well as load progression to be considered current best practice (9). l It has been said that patients with FAI should be seen over a longer period of time, more than just 2â&#x20AC;&#x201C;3 weeks, and more frequently (19*). The duration of care is based on theory that suggests that physiological changes in muscle occur after a 12-week programme of exercise (2*). This may cause challenges and require protocol changes as some national health systems only allow three or four physiotherapy contacts for musculoskeletal pain. Evidence suggests that better outcomes are achieved from exercise-based regimes when they are supervised and the contact between the supervisor and patient is increased (2*). In order to allow more contact between physiotherapists and Co-Kinetic.com

their patients, possibly telephone and email contacts would suffice allowing progress to exercise programmes and to support patient adherence. Ideally an FAIS protocol should be delivered over a 12-week period and a minimum of six treatment sessions, of which at least three should be face to face. The treatment sessions with physiotherapists can be supplemented by patients continuing their individualised exercise programme at home. l Post-surgical outcomes might be enhanced if postoperative rehabilitation programmes were targeted to individualised impairments, contained exercisebased interventions that were adequately progressed and included relevant strategies to facilitate RTS. Professionals delivering exercise therapy need to step up to the challenge of designing and testing such high-quality postoperative rehabilitation programmes (9). l The postoperative rehabilitation programmes from the most recent RCTs (7*,8) were not described. The studies indicated that (1) post-arthroscopy patients with FAIS have impairments in activities, function and quality of life; and (2) improvements in these impairments did occur, but were less encouraging than originally anticipated. The quality of the physiotherapy-led post-surgery rehabilitation needs to be enhanced (9). l RTS or activity was not documented (8) or only considered when it was felt to be appropriate by the treating physiotherapist, with an unclear description of how RTS was achieved (7). Rehabilitation programmes must incorporate relevant strategies from the treatment onset to facilitate successful RTS (20*). Granted, current best practice enabling successful RTS for athletes with hip pain remains unclear (9). In the most recent trial published in 2019 by Palmer et al., trial patients with symptomatic FAI experienced a greater improvement in symptoms with arthroscopic hip surgery than with

physiotherapy and activity modification 8 months post-randomisation (21*). The 10-point mean difference in activities of daily living on the hip outcome score (HOS ADL) between groups was greater than the prespecified minimum clinically important difference of 9 points (21*). Overall, 51% of participants randomised to arthroscopic surgery and 32% randomised to a programme of physiotherapy and activity modification reported an improvement in HOS ADL of at least 9 points (minimum detectable change and a clinically important change within an individual). In addition, 48% of participants in the arthroscopic surgery group and 19% in the physiotherapy programme group achieved the patient acceptable symptomatic state (PASS) after treatment (21*). Physiotherapists of different seniority and trained in the study protocol delivered the physiotherapy programme, with a maximum of eight sessions. Little evidence exists to guide the development of an optimal physiotherapy protocol which could be a limiting factor in all these RCTs. It could be that a greater number and frequency of physiotherapy sessions with only senior specialist physiotherapists might improve outcomes. To muddy the waters further, patients having had surgery also received physiotherapy but with different objectives, making it difficult to compare. l The focus of physiotherapy for the treatment of symptomatic FAI (ie. FAIS) (through a randomised study intervention) was to improve pain and function. The principal elements of the programme started with activity and movement modification, followed by muscle strengthening and segmental stabilisation, and finally optimisation of functional movements with sensory motor training and return to activity according to patient goals. This physiotherapy package was delivered over a median of six sessions (21*). l The focus of physiotherapy post-arthroscopic surgery was to maintain ROM and guide return to activity. Patients were advised 23

THE PERSONALISED HIP THERAPY PROTOCOL INCLUDES AN EXERCISE-BASED PROGRAMME THAT AIMS TO IMPROVE DEFICIENCIES IN HIP FUNCTION THAT HAVE BEEN HIGHLIGHTED IN FAIS to commence active ROM and isometric exercises the day after surgery, progressing to stretches and static bicycle exercise (no resistance) within a week. Strengthening exercises

Video 1: Mobility Exercises | Femoroacetabular Impingement (FAI) (Courtesy of YouTube user Physiotutors) https://youtu.be/jnNzUXL59F4

and low impact activities were introduced after 3 weeks, usually under physiotherapist guidance, and impact exercise was permitted after 6 weeks, with sport-specific rehabilitation when appropriate. This physiotherapy package was delivered over a median of four sessions (21*). This trial did not capture patients with minimally symptomatic FAI, a condition that is typically diagnosed and treated in primary care. Instead it looked at patients who are referred to secondary or tertiary care with more severe or prolonged symptoms. Given the potential complications of surgery and observed clinical improvement with the physiotherapy programme, it is recommended that physiotherapy be a first-line treatment. If symptoms continue then the likelihood of symptom improvement with arthroscopic surgery should be considered (21*).

2. Dynamic Hip Stability Protocol

Video 2: Pelvic Control Exercises | Femoroacetabular Impingement (FAI) (Courtesy of YouTube user Physiotutors) https://youtu.be/fT_to88kskw

Video 3: Strengthening Exercises | Femoroacetabular Impingement (FAI) ) (Courtesy of YouTube user Physiotutors) https://youtu.be/k_PQIM6_o7Y 24

Skeletal muscles support, control and create movement about the hip joint. They ensure dynamic stability of the hip, pelvis and trunk. Neuromechanical structures include nociceptors and mechanoreceptors, which provide hip joint pain sensation and proprioception, respectively. They are found in several hip joint structures including the acetabular labrum. Hip muscle weakness is common in patients with symptomatic FAI and deep hip muscles could potentially be most affected because of their proximity to the painful, damaged and/or inflamed inert hip structures (1). Besides being primary movers for hip flexion, external rotation and abduction, the deep hip muscles are also key muscles for ensuring dynamic stability of the femoroacetabular joint. In order to compensate for such deep hip muscle weakness and

the resultant joint instability during functional activities, secondary movers may thus be overactivated (15). This may lead to anterior gliding of the femoral head into the acetabulum and exaggerated anterior mechanical hip joint loading (15). Accordingly, repeated mechanical loading, potentially enhanced by the presence of FAI-related bony deformities, may result in structural acetabular labrum alterations over time. Based on the biochemical pain model proposed for tendinopathies (9*), it is believed that pain experienced by patients with FAI may already result from repeated mechanical loading of the acetabular labrum before structural damage occurs. Indeed, repeated mechanical loading of the labrum may lead to the upregulation of its nociceptive receptors through the production of nociceptive neurotransmitters (eg. substance P) (Link 4)(19*). The suggested management of muscular, proprioceptive and nociceptive hip dysfunctions could consist of active physical therapy aimed at improving hip neuromuscular function (15). The protocol should include hip-specific and functional lower limb strengthening, as well as core stability and postural balance exercises (17). See Videos 1, 2 and 3 (from PhysiotutorsÂŽ) for ideas on strengthening the hip, lower lumbar/ pelvis and core to improve FAI symptoms. In particular, strengthening the deep hip external rotator, flexor and abductor muscles has the potential to improve dynamic stability of the femoroacetabular joint and to minimise anterior gliding of the femoral head into the acetabulum (15). This would reduce the anterior mechanical loading of the acetabular labrum and downregulate nociceptor activity (15,19*). This mechanism may also be effective if the labrum already has structural damage (19*). Moreover, progressive strength training might reduce hip joint inflammation, which is common in patients with FAI (15). A recent case series illustrated a clinical reasoning process used to prioritise patientsâ&#x20AC;&#x2122; treatment along a continuum of neuromuscular control and mobility (Link 5)(16*). The results had positive outcomes Co-Kinetic Journal 2019;81(July):18-27

PHYSICAL THERAPY

for conservative, specifically physiotherapy management of FAIS patients. The treatment approach also illustrates successful management of potential surgical candidates that elected to forgo surgery after satisfactory completion of conservative management (16*). It is anticipated that the proposed non-surgical interventions discussed above will probably not be successful in reducing hip pain in all patients with FAIS. Symptomatic FAI is the result of abnormalities at multiple and interconnected hip structures. Some patients with FAIS might indeed be able to cope with FAI-related bony deformities and hip pathologies through improved dynamic hip joint stability, while others may not (15).

Conclusion

Treatment interventions should aim to address the patient’s specific impairments, such as reduced strength, ROM or functional performance. 1. Education. Teach the patient about their condition and that surgery is not always required. Instead, changes to a patient’s movement patterns, daily activities and hip joint loading may reduce their symptoms. Reassure patients that flare-ups are normal and will settle with time. Patients may have some symptoms with activity; however, this does not equate to further damage. Guide the patient during exercise by using the traffic-light system of pain. The aim is to empower the patient, so they become less fearful of activity. 2. Strength. Strength can be measured in clinical practice with a hand held dynamometer. Patients with FAI have impaired hip muscle strength, specifically hip adduction, abduction and extension. Patients with FAI may also present with reduced trunk muscle endurance which may increase hip joint loading. Exercises should be prescribed to target these muscle groups. 3. Functional tasks. Patients may present with impaired function and endurance during tasks such as hopping, landing, squatting and singleleg squatting. These can be addressed by incorporating functional and plyometric training into rehabilitation. Co-Kinetic.com

4. Cardiovascular training. A progressive cardiovascular training programme should be prescribed to improve fitness and load tolerance in patients with FAI. 5. ROM. FAI includes a large biological component and manual therapy should be used as an adjunct to exercise therapy. Techniques targeting iliopsoas, glute med, piriformis, lumbopelvic area and hip adductors can help to reduce pain and improve range of movement in patients with FAI. Joint mobilisations and manual traction techniques may provide patients with short-term relief and improve exercise compliance. 6. When to refer for a surgical opinion. All patients should try a period of conservative management for at least 3 months before considering a surgical opinion. Ensure that patients have been provided with the best quality conservative management before onward referral. If there is no improvement in 3 months and the patient has been exposed to the best quality conservative management then consider other options. Referral for a surgical opinion should be a shared decision with the patient. Provide the patient with a realistic view of the outcome of surgery, recovery timescales and the likelihood of achieving their goals of returning to sport or other activities. 7. What about patients concerned with osteoarthritis (OA)? Patients with a cam morphology are 10 times more likely to develop hip OA, but only 5% of them go on to develop OA. There is no evidence that prophylactic surgery is beneficial in patients with hip pain. To reduce the risk of developing OA, advise patients to maintain a healthy bodyweight, keep their muscles strong and continue to perform weight bearing physical activity. Greater research is required into

the effectiveness of non-surgical management options for patients with FAIS. Besides identifying the optimal non-surgical protocols for FAIS, this would also allow the detection of patients who may best benefit from these protocols, and those who would be the best candidates for hip surgery. In addition, better understanding of effective non-surgical management for FAIS would provide clarity around surgical indications and improve decision-making specific to the diagnosis of FAIS. Clinicians providing contemporary exercise therapy must rise to the challenge in optimising the management of FAIS. How do we best develop, test and implement high-quality, high-value exercise-based interventions for patients with FAIS in both non-operative and postoperative scenarios? (9). Such trials are under way (so keep your eyes and ears open for results in the future). These studies include: 1. ‘The physiotherapy for Femoroacetabular Impingement Rehabilitation STudy (PhysioFIRST): A participant and assessor blinded randomised controlled trial of physiotherapy to reduce pain and improve function for hip impingement’ (https://spxj.nl/2W79RcD); 2. ‘Femoroacetabular Impingement (FAI): The Effectiveness of Physical Therapy’ (https://spxj.nl/2wb2WjX); 3. ‘Muscular and Functional Performance in FAIS Patients’ (https://spxj.nl/2HJxa2D); and 4. ‘Movement Pattern Training in People With Intra-articular, Prearthritic Hip Disorders’ (https://spxj.nl/2LTc6w4). Ultimately, it is believed that carefully considering the types of exercises and protocols discussed above, tailoring to your patients’ needs, and bearing in mind factors like quality of the exercise,

TREATMENT INTERVENTIONS SHOULD ADDRESS THE PATIENT’S SPECIFIC IMPAIRMENTS, SUCH AS REDUCED STRENGTH, ROM OR FUNCTIONAL PERFORMANCE 25

supervision, progression, exercise intensity, and duration for example will lead to improved outcomes; and assist patients and clinicians in making an informed, shared decisions to deliver the most appropriate and effective care. References

1. 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 2. Wall PD, Dickenson EJ, Robinson D et al. Personalised hip therapy: development of a non-operative protocol to treat femoroacetabular impingement syndrome in the FASHIoN randomised controlled trial. British Journal of Sports Medicine 2016;50:1217–1223 Open access https://spxj.nl/2Q9DsfO 3. Casartelli NC, Bizzini M, Kemp J et al. What treatment options exist for patients with femoroacetabular impingement syndrome but without surgical indication? British Journal of Sports Medicine 2018;52:552–553. 4. 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 5. Khan M, Bedi A, Fu F et al. New perspectives on femoroacetabular impingement syndrome. Nature Reviews. Rheumatology 2016;12:303–310. 6. Peters S, Laing A, Emerson C et al. Surgical criteria for femoroacetabular impingement syndrome: a scoping review.

British Journal of Sports Medicine 2017;51(22):1605–1610 Open access https://spxj.nl/2WPSOJa 7. Griffin DR, Dickenson EJ, Wall PDH et al. Hip arthroscopy versus best conservative care for the treatment of femoroacetabular impingement syndrome (UK FASHIoN): a multicentre randomised controlled trial. Lancet 2018;391 (10136):2225–2235 Open access https://spxj.nl/30xfFLF 8. Mansell NS, Rhon DI, Meyer J et al. Arthroscopic surgery or physical therapy for patients with femoroacetabular impingement syndrome: a randomized controlled trial with 2-year follow-up. American Journal of Sports Medicine 2018;46:1306–1314 9. Kemp JL, King MG, Barton C et al. Is exercise therapy for femoroacetabular impingement in or out of fashion? We need to talk about current best practice for the non-surgical management of FAI syndrome. British Journal of Sports Medicine 2019;pii:bjsports-2018-100173 10. 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(19):1180 Open access https://spxj.nl/2toJO0o 11. Reiman MP, Peters S, Sylvain J et al. Femoroacetabular impingement surgery allows 74% of athletes to return to the same competitive level of sports participation but their level of performance remains unreported: a systematic review with metaanalysis. British Journal of Sports Medicine 2018;52(15):972–981 Open access https://spxj.nl/2VMJSaO 12. Kierkegaard S, Langeskov-Christensen M, Lund B et al. Pain, activities of daily living and sport function at different time points after hip arthroscopy in patients with femoroacetabular impingement: a

LINK 1: See Figure 4. Diagnostic approach to guide surgical and conservative management of femoroacetabular impingement (FAI) from Khan et al. Link 1: New perspectives on femoroacetabular impingement syndrome. Nat Rev Rheumatol 2016;12:303–310 (5). https://spxj.nl/2HsBpAY LINK 2: Personalised Hip Therapy: The Manual, supplementary file D from Wall PD et al. Personalised hip therapy: development of a non-operative protocol to treat femoroacetabular impingement syndrome in the FASHIoN randomised controlled trial. Brit J Sports Med 2016;50:1217– 1223. https://spxj.nl/2Q9DsfO LINK 3: Personalised Hip Therapy Core Exercises, supplementary file C from Wall PD et al. Personalised hip therapy: development of a non-operative protocol to treat femoroacetabular impingement syndrome in the FASHIoN randomised controlled trial. Brit J Sports Med 2016;50:1217– 1223. https://spxj.nl/2Q9DsfO LINK 4: See Figure 1: A proposed cycle of FAIS and ALTs from Narveson JR et al. Conservative treatment continuum for managing femoroacetabular impingement syndrome and acetabular labral tears in surgical candidates: a case series. Int J Sports Phys Ther 2018;13(6):1032–1048. https://spxj.nl/2Maorwf LINK 5: See Table 1 from Narveson JR et al. Conservative treatment continuum for managing femoroacetabular impingement syndrome and acetabular labral tears in surgical candidates: a case series. Int J Sports Phys Ther 2018;13(6):1032–1048. https://spxj.nl/2Maorwf

systematic review with meta-analysis. British Journal of Sports Medicine 2017;51(7):572–579 Open access https://spxj.nl/2Ewm3tt 13. Wörner T, Thorborg K, Stålman A et al. 5 Return to sport and psychological readiness following hip arthroscopy. A cross-sectional study covering return-rates 3–39 months after femoroacetabular impingement surgery. British Journal of Sports Medicine 2018;52(Suppl 1):A2 14. Øiestad BE. Critically appraised paper: Hip arthroscopy is more effective than personalised hip therapy for improving hip-related quality of life in patients with femoroacetabular impingement syndrome [synopsis]. Journal of Physiotherapy 2019;65(1):51 Open access https://spxj.nl/2LVyCog 15. Casartelli NC, Maffiuletti NA, Bizzini M et al. The management of symptomatic femoroacetabular impingement: what is the rationale for non-surgical treatment? British Journal of Sports Medicine 2016;50(9):511– 512 16. Narveson JR, Haberl MD, Nathan Vannatta C, Rhon DI. Conservative treatment continuum for managing femoroacetabular impingement syndrome and acetabular labral tears in surgical candidates: a case series. International Journal of Sports Physical Therapy 2018;13(6):1032–1048 Open access https://spxj.nl/2Maorwf 17. Terrell S, Lynch J. Exploring nonoperative exercise interventions for individuals with femoroacetabular impingement. ACSM’s Health & Fitness Journal 2019;23(1):22–30 18. American College of Sports Medicine. ACSM’s guidelines for exercise testing and prescription, 10th edn. Wolters Kluwer Health 2017 (Print £34.50 Kindle £32.39). Buy from Amazon (https://spxj.nl/2QdSwJw) 19. Khan KM, Cook JL, Maffulli N et al. Where is the pain coming from in tendinopathy? It may be biochemical, not only structural, in origin. British Journal of Sports Medicine 2000;34(2):81–83 Open access https://amzn.to/2M9L57A 20. Ardern CL, Glasgow P, Schneiders A et al. 2016 consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern. British Journal of Sports Medicine 2016;50:853–864 Open access https://spxj.nl/2WV4ytE 21. Palmer AJR, Ayyar Gupta V, Fernquest S et al. Arthroscopic hip surgery compared with physiotherapy and activity modification for the treatment of symptomatic femoroacetabular impingement: multicentre randomised controlled trial. BMJ 2019;364:l185 Open access https://spxj.nl/2HROKSv.

Co-Kinetic Journal 2019;81(July):18-27

PHYSICAL THERAPY

KEY POINTS

lT he treatment of femoroacetabular impingement syndrome (FAIS) remains controversial – physiotherapy and surgery can both improve symptoms but it is uncertain which treatment is superior. lR ecent randomised controlled trials indicate that arthroscopic hip surgery may be superior to physiotherapy and active modification at improving patient symptoms in the shorter term. l I n the long term it appears that both physiotherapy and arthroscopic surgery give similar results at improving activities of daily living for FAI patients. lN ot all patients benefit from surgery. The decision to operate needs to be collaborative, including the patient, and with full disclosure about the recovery times and return-to-sport (RTS) queries. lT here is no clear protocol for best non-operative management for FAIS. Although it should include exercises specific to the patient’s needs, appropriate intensity and frequency, progression, at least 12 weeks of contact with the patient. lR ehabilitation should focus on hip joint stabilising and strengthening exercises, pelvic and core control, lower trunk stability, neuromuscular control, functional performance. lM anual therapy can be used as an adjunct to exercise therapy to reduce pain and improve mobility. lT here is no clear criteria for RTS for FAI patients postsurgery or post-injury.

RELATED CONTENT

lF emoroacetabular Impingement Syndrome Part 1: Diagnosis and Morphology [Article] https://spxj.nl/2YDNEjI lF emoroacetabular Impingement (FAI): Management Techniques Using Postural Restoration: Part 1 [Article] http://spxj.nl/1AhmF0n l Femoroacetabular Impingement (FAI): Management Techniques Using Postural Restoration: Part 2 [Article] http://spxj.nl/2zziL80 l Femoroacetabular Impingement: Mechanisms, Diagnosis and Treatment Options using Postural Restoration®: Part 3 [Article] http://spxj.nl/2zzYJug l Hip Impingement Redefined: Symptoms, Diagnosis, Treatment and Rehabilitation [Video] https://spxj.nl/2X7KDZ0

DISCUSSIONS

l Having reviewed the most recent exercise protocols for FAIS from the current RCTs, would you consider using them as a baseline programme in your practice? l W hat specific exercises do you use when treating patients with FAIS? l W hat would be your point or time frame to consider conservative management ‘a failure’ and refer for surgery?

Want to share on Twitter? Here are some suggestions

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

Tweet this: FAIS can be treated by conservative care, physiotherapistled rehabilitation or surgery https://spxj.nl/2HMSdms Tweet this: FAIS often includes muscle impairments that cannot be corrected by surgery alone https://spxj.nl/2HMSdms Tweet this: Non-surgical and surgical management of FAIS should be sequential, not parallel, treatment options https://spxj.nl/2HMSdms Tweet this: Managing dynamic hip joint instability has often been overlooked as a treatment option for FAIS https://spxj.nl/2HMSdms Tweet this: An FAIS therapy protocol should be delivered over a 12-week period https://spxj.nl/2HMSdms Tweet this: Progressive strength training might reduce hip joint inflammation, which is common in FAI patients https://spxj.nl/2HMSdms

HEAD | CONCUSSION | 19-07-COKINETIC FORMATS WEB MOBILE

All references marked with an asterisk are open access and links are provided in the reference list By Kathryn Thomas BSc MPhil Can’t see 11 Rs in Concussion? Well, maybe that’s just the point. Concussion often isn’t that obvious to ‘see’ especially in fast moving sports with high-pressure situations. If you don’t know exactly what to look for or how to identify it, you won’t recognise the concussion and respond appropriately. Maybe you feel this has been discussed before and are aware of what to do; however, the science behind sportrelated concussion (SRC) is constantly evolving, individual management and return-to-play decisions remain in the realm of your clinical judgement and knowledge. Keeping up to date is a ‘nobrainer’. This article summarises what is known about SRC and provides you with tools to make you more confident in handling a situation and rehabilitating a patient following SRC. We have published previously, for your reference, a paper on concussion based on past consensus statements [see “Concussion in Sport: Putting the Guidelines into Action” (http://spxj.nl/2CpEeNh) by Dr Sarah Morton MBBS]. However, since then the guidelines were updated at the 5th International Conference on Concussion in Berlin 2016 (Link 1)(1*), which took in approximately 60,000 published articles and expert panels of professionals, including 10 sports organisations (American football, Australian football, basketball, cricket, equestrian sports, football/soccer, ice hockey, rugby league, rugby union and skiing) and 11 sport governing bodies/federations [Australian Football League, Gaelic Athletics Association, International Ice Hockey Federation, International Ski Federation, National Hockey League, Hockey Canada, National College Athletics Association, National Football League (NFL), National Rugby League, World Rugby and the English Football Association; Cricket (England and Wales Cricket Board and International Cricketers Association) and the 28

THE 11 Rs IN CONCUSSION PART 1: Screening Concussion in sport can be challenging to identify but it is crucial that it is not missed. This article, Part 1 of 2, discusses what you need to know so that you can identify sport-related concussion using appropriate sideline evaluation tools, with links provided for easy download. In addition, the guidelines around mandatory and discretionary signs of concussion and the appropriate actions are described enabling you to be able make the all-important decision regarding removal of the player or allowing them to play on. Read this article online https://spxj.nl/2WDJGu4 International Basketball Federation] attended as observers. It will be beneficial for you to read this article and download the tools available to assist in your diagnosis and management of concussion. This information pertains to all SRC identification and management but because certain sports may have different rulings, etc, we have included the links here where specific recommendations/rule changes have been made regarding NFL (Link 2) (2*) and combat sports (Link 3)(3*). If you work specifically with teams or athletes involved in these sports it may be worthwhile looking over additional sports-specific information.

Quick Refresher on the Pathophysiology of Concussion

The pathophysiology of concussion is not completely understood but has been characterised as force delivered to the brain causing disruptive stretching of neuronal cell membranes and axons

resulting in a complex cascade of ionic, metabolic and pathophysiological events. Current understanding of the pathophysiology of concussion is primarily based on animal models that have limitations when extrapolated to humans. It appears that stress applied to the neuron

THE PATHOPHYSIOLOGY OF CONCUSSION HAS BEEN CHARACTERISED AS FORCE DELIVERED TO THE BRAIN CAUSING DISRUPTIVE STRETCHING OF NEURONAL CELL MEMBRANES AND AXONS RESULTING IN A COMPLEX CASCADE OF IONIC, METABOLIC AND PATHOPHYSIOLOGICAL EVENTS Co-Kinetic Journal 2019;81(July):28-33

PHYSICAL THERAPY

causes changes in intracellular ion concentrations, indiscriminate release of neurotransmitters, mitochondrial dysfunction leading to the production of reactive oxygen species, and increased utilisation of glucose to restore sodium and potassium balance. The increased glucose uptake combined with the injury-related decrease in resting cerebral blood flow creates an energy mismatch. Inflammatory cell activation, axonal degeneration and altered plasticity may occur in the subacute and chronic stages of concussion. Animal and human studies support the concept of increased brain vulnerability following an initial injury to a second brain tissue insult that can result in worsening cellular metabolic changes and more significant deficits (4*). The Concussion In Sports Group (CISG) have identified the 11 Rs of SRC, to help provide a logical flow to clinical concussion management (1*), which are: 1 Recognise 2 Remove 3 Re-evaluate 4 Rest 5 Rehabilitation 6 Refer 7 Recover 8 Return to sport 9 Reconsider 10 Residual effects and sequelae 11 Risk reduction. A handy infographic that accompanies the Consensus Statement on Concussion in Sport is available to purchase from the British Journal of Sports Medicine (Fig. 1).

1. Recognise

The actual definition of concussion in sport still attracts some debate. Often the term mild traumatic brain injury (mTBI) is used interchangeably with concussion; however, this term is vague and not based on validated criteria in this context. One key unresolved issue is whether concussion is part of a TBI spectrum associated with lesser degrees of diffuse structural change than are seen in severe TBI, or whether the concussive injury is the result of reversible physiological changes. Therefore, the CISG agree upon the following definition specific to concussion in sport (1*): Co-Kinetic.com

“Sport related concussion is a traumatic brain injury induced by biomechanical forces. Several common features that may be utilised in clinically defining the nature of a concussive head injury include: l SRC may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head. l SRC typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. However, in some cases, signs and symptoms evolve over a number of minutes to hours. l SRC may result in neuropathological changes, but the acute clinical signs and symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies. l SRC results in a range of clinical signs and symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive features typically follows a sequential course. However, in some cases symptoms may be prolonged.

Figure. 1: Infographic summarising the Consensus Statement on Concussion in Sport. (Available to purchase from: McCrory P et al. Infographic: Consensus statement on concussion in sport. BJSM2017; 51(21): 1557–1558 https://spxj.nl/2VJr0F0)

assessment is the rapid screening for a suspected SRC, rather than the definitive diagnosis of head injury. Players manifesting clear on-field signs of SRC (eg. loss of consciousness, tonic posturing, balance disturbance) should immediately be removed from sporting participation. Players with a suspected SRC following a significant head impact or with symptoms can proceed to sideline screening using appropriate assessment tools, such as the Sport Concussion Assessment Tool – 5th Edition (SCAT5). Both groups can then proceed to a more thorough diagnostic evaluation, which should be performed in a distraction-free environment (eg. locker room, medical room) rather than on the sideline. Evolving and delayedonset symptoms of SRC are well documented and highlight the need to consider follow-up serial evaluation after a suspected SRC regardless of a negative sideline screening test or normal early evaluation (1*).

The clinical signs and symptoms cannot be explained by drug, alcohol, or medication use, other injuries (such as cervical injuries, peripheral vestibular dysfunction, etc) or other comorbidities (eg. psychological factors or coexisting medical conditions).”

Sideline Evaluation

SRC is an evolving injury in the acute phase, with rapidly changing clinical signs and symptoms, which may reflect the underlying physiological injury in the brain. SRC is considered to be among the most complex injuries in sports medicine to diagnose, assess and manage. The majority of SRCs occur without loss of consciousness or frank neurological signs. In all suspected cases of concussion, the individual should be removed from the playing field and assessed by a physician or licensed healthcare provider (1*). A key concept in sideline

SPORT-RELATED CONCUSSION (SRC) IS CONSIDERED TO BE AMONG THE MOST COMPLEX INJURIES IN SPORTS MEDICINE TO DIAGNOSE, ASSESS AND MANAGE 29

The recognition of suspected SRC is, therefore, best approached using multidimensional testing. The SCAT5 currently represents the most wellestablished and rigorously developed instrument available for sideline assessment of adults and children older

than 13 years (Link 4). For younger children between 5 and 12 years the Child SCAT5 is recommended (Link 5). The Concussion Recognition Tool (CRT) can also be used in identifying concussion across all ages (Link 6). The NFL have their own Concussion Game

Table 1: Mandatory signs of concussion and appropriate action

Reproduced with permission from Patricios JS, Ardern CL, Hislop MD, et al. Implementation of the 2017 Berlin Concussion in Sport Group Consensus Statement in contact and collision sports: a joint position statement from 11 national and international sports organisations. British Journal of Sports Medicine 2018;52:635–641 (6) Signs

Action

Loss of consciousness

Remove the athlete from the field of play.

Lying motionless for >5s*

In some codes (eg. AFL, NRL, NFL, WR), the athlete may not return to the game once removed for a mandatory sign (referred to as ‘no-go’ criteria in the NFL). In other codes, a mandatory sign results in a mandatory assessment conducted in a distraction-free environment to determine whether to allow the player to return to the field of play.

Confusion/disorientation Amnesia Vacant look Motor incoordination Tonic posturing Impact seizure Ataxia

*NRL and AFL use >1s as a discretionary sign for an off-field assessment. AFL, Australian Football League; NFL, National Football League; NRL, National Rugby League; WR, World Rugby.

Table 2: Discretionary signs of concussion and appropriate action Reproduced with permission from Patricios JS, Ardern CL, Hislop MD, et al. Implementation of the 2017 Berlin Concussion in Sport Group Consensus Statement in contact and collision sports: a joint position statement from 11 national and international sports organisations. British Journal of Sports Medicine 2018;52:635–641 (6) Signs

Action

Clutching the head* Being slow to get up*

Further evaluation is required. The athlete should:

Suspected facial fracture

1. be removed from the arena,

Possible ataxia

2. undergo an evaluation in a distraction-free environment; and

Behaviour change† Other clinical suspicion

3. only return to sport if the signs are determined to have been from a cause other than concussion (ie. the diagnosis of concussion is ruled out).

*NHL discretionary signs slow to get up or clutching the head do not require removal from play. The clinician should exercise his or her medical judgement regarding whether to remove the player for an acute evaluation. †Some codes such as NRL, AFL and WR consider this a definitive removal criterion. AFL, Australian Football League; NHL, National Hockey League; NRL, National Rugby League; WR, World Rugby.

Day Checklist (Link 7)(2*). The SCAT is useful immediately after injury in differentiating concussed from non-concussed athletes, but its utility appears to decrease significantly 3–5 days after injury. The symptom checklist, however, does demonstrate clinical utility in tracking recovery. Baseline testing may be useful, but is not necessary for interpreting post-injury scores. If used, clinicians must strive to replicate baseline testing conditions. Additional tests that may add to the clinical value of the SCAT tool include clinical reaction time, gait/ balance assessment, video-observable signs and oculomotor screening (1). The addition of sideline video review offers a promising approach to improving identification and evaluation of significant head-impact events (1*). Video review has rapidly become an important tool in professional sports for the identification of brief early signs of a possible concussion. Currently, however, there is little consistency across sporting codes regarding the definition and interpretation of the video signs (5). Video review can assist sideline physicians in identifying possible concussions which may otherwise not be detected. Video signs with more than 90% agreement of possible concussion include (2*): l lying motionless l motor incoordination/ataxia/ staggering gait/stumbles/stagger l no protective action – floppy l no protective action – tonic l cervical hypotonia l impact seizure/convulsion l tonic posturing l blank/vacant look.

Symptoms and Signs of Acute SRC

Recognising and evaluating SRC in the adult athlete on the field is a challenging responsibility: performing this task often involves a rapid assessment in the midst of competition with a time constraint and the athlete eager to play. The sideline evaluation is based on recognition of injury, assessment of symptoms, cognitive and cranial nerve function, and balance (1*). Because SRC is often an evolving injury, and signs and symptoms may be delayed, erring on the side of caution (ie. keeping an athlete out of participation when there is any suspicion Co-Kinetic Journal 2019;81(July):28-33

PHYSICAL THERAPY

of injury) is important (1*). The suspected diagnosis of SRC can include one or more of the following clinical domains (1*): l symptoms: somatic (eg. headache), cognitive (eg. feeling like in a fog) and/or emotional symptoms (eg. lability) l physical signs (eg. loss of consciousness, amnesia, neurological deficit) l balance impairment (eg. gait unsteadiness) l behavioural changes (eg. irritability) l cognitive impairment (eg. slowed reaction times) l sleep/wake disturbance (eg. somnolence, drowsiness). Mandatory and discretionary signs of concussion and appropriate actions are detailed in Tables 1 and 2, respectively (6*).

2. Remove

The following steps should be taken when a player shows any symptoms or signs of an SRC (1*). 1. The player should be evaluated and particular attention should be given to excluding a cervical spine injury. 2. The appropriate disposition of the player must be determined in a timely manner. If no healthcare provider is available, the player should be safely

removed from practice or play and urgent referral to a physician arranged. 3. Once the first aid issues are addressed, an assessment of the concussive injury should be made using the SCAT5 or other sideline assessment tools. 4. The player should not be left alone after the injury, and serial monitoring for deterioration is essential over the initial few hours after injury. 5. A player with diagnosed SRC should not be allowed to return to play on the day of injury. When a concussion is suspected, the athlete should be removed from the sporting environment and a multimodal assessment should be conducted in a standardised fashion (eg. the SCAT5). Completing the SCAT alone typically takes 10 minutes, and so sporting disciplines should allow adequate time and facilities both on and off the field for all injured athletes. In some sports, this may require rule changes to allow an appropriate off-field medical assessment to occur without affecting the flow of the game or unduly penalising the injured player’s team. The final determination regarding SRC diagnosis and/or fitness to play is a medical decision based on clinical judgement (1*). Team physicians often insist on having the sole decision-making

IN ALL SUSPECTED CASES OF CONCUSSION, THE INDIVIDUAL SHOULD BE REMOVED FROM THE PLAYING FIELD AND ASSESSED BY A PHYSICIAN OR LICENSED HEALTHCARE PROVIDER responsibility in removing a player with suspected SRC from play. This is frequently met with resistance from other concerned parties, including the coach and the athlete (7). The decisionmaking process in concussion can be made difficult because of (7): 1. lack of visible signs 2. lack of diagnostic criteria 3. c ompromised decision-making ability – field side, time restraints 4. c onflict of interest – situational pressure and bias. Shared decision-making is a proven method to navigate medical decisions at an individual doctor–patient level. A three level approach has been proposed for SRC care at Organisational, Coach and Athlete levels, which has been called ‘OCAsion’ decision-making (Table 3)(7). What happens in a recreational

Table 3: Three level “OCAsion” decision making in sport-related concussion

Reproduced with permission from Holtzhausen L, Dijkstra HP, Patricios J. Shared decision-making in sports concussion: rise to the ‘OCAsion’ to take the heat out of on-field decision-making. British Journal of Sports Medicine 2019;53:590–592 (7). Decision outcome

Level

Team talk

Option talk

Level 1: (O) Organisational level (World Rugby, FIFA, national federation, football club or league)

l Team: inclusive group of decision makers l Time: initial action of the process l Talk: educate

Towards evidenceDiscuss biases, (as based policy discussed in text) risk/ benefit, consider options from all team members

Concussion policy to facilitate levels 2 and 3 shared decision-making

Level 2: (C) Coach/operational level (team management, coaching and medical staff)

l Team: coaching and technical staff; senior medical staff l Time: preseason (after conclusion of level 1) l Talk: educate and describe policy

Discuss biases Consider ways of implementing policy

Towards an implementation/ operational plan

Implementation/ operational plan in place before the start of a season/competition

Level 3: (A) Athlete/team level (team physician, team and individual athletes

l Team: athletes (team); team medical staff, coach l Time: preseason (after conclusion of level 2) l Talk: group education; individual baseline sessions

Balanced education Discuss medical and sport risk/benefit ratios Scenario setting

Towards a group and individual decision to adopt the implementation/ operational plan

Player written consent on shared decision before the start of a season/ competition

Co-Kinetic.com

Decision talk

A KEY CONCEPT IN SIDELINE ASSESSMENT IS THE RAPID SCREENING FOR A SUSPECTED SRC, RATHER THAN THE DEFINITIVE DIAGNOSIS OF HEAD INJURY

setting where specialist support may be absent? At community level, across all codes, CRT5 should be used to identify situations where athletes should be removed from sport because of possible concussion (1*,6*). Any suspicion of concussion should result in the athlete being removed from the playing area (this may be the responsibility of a coach, teacher or parent) and should not return to sport until an appropriate medical evaluation has been completed. As for the standard head-and-neck injury protocol, attention should also be focused on appropriate management of potential cervical spine, maxillofacial and airway injuries (6*). Bearing this in mind, another area of importance, discussed later in the article, is the role of educating and sharing concussion knowledge with persons outside of the medical profession. Handling a patient with suspected head injury and/or concussion in the correct manner could avoid catastrophic injury.

3. Re-Evaluate

The athlete may be evaluated in the emergency room or doctor’s office as a point of first contact after injury or may have been referred from another care provider. In addition to the points outlined above, the key features of follow-up examination should encompass (1*): 1. A medical assessment including a 32

comprehensive history and detailed neurological examination including a thorough assessment of mental status, cognitive functioning, sleep/ wake disturbance, ocular function, vestibular function, gait and balance. 2. Determination of the clinical status of the patient, including whether there has been improvement or deterioration since the time of injury. This may involve seeking additional information from parents, coaches, teammates and eyewitnesses to the injury. 3. Determination of the need for emergent neuroimaging to exclude a more severe brain injury (eg. structural abnormality). Neuropsychological assessment (NP) is a ‘cornerstone’ of SRC management. Neuropsychologists are uniquely qualified to interpret NP tests and can play an important role within the context of a multifaceted, multimodal and multidisciplinary approach to managing SRC (1*). Concussion investigations are still under scrutiny; advanced neuroimaging, fluid biomarkers and genetic testing are important research tools, but require further validation to determine their ultimate clinical utility in evaluation of SRC (1*).

A Final Thought

The recognition of heterogeneity among concussion presentations has led to the concept of ‘clinical profiles’ (Link 8) or ‘clinical domains’ with the potential for more specific prognostic value and targeted treatment (4*). It must be stressed that this is an emerging concept and does not represent clinical standards or norms but may serve to facilitate individualised patient management. It highlights the complexity of SRC and although time frames and guidelines are important it stresses the individual nature of dealing with each patient and each concussion (4*). The diverse symptoms and functional impairments of SRC are variously categorised with overlapping symptom clinical profiles that may include cognitive, affective (anxiety/ mood), fatigue, migraine/headache, vestibular and ocular. Research how clinical profiles fit into the clinical care of SRC is ongoing (4*). Recognising a concussion may be

the most important part of concussion management! ‘Seeing’ it, diagnosing it and removing the player from the sport is the first and safest step one can take in ensuring good outcomes for the individual. Print out and carry concussion tools with you to aid in your assessment on field or in your practice. And don’t be shy to refer a patient for specialist assessment, even if there is resistance from the individual or family – they will thank you later when they recover sooner and without risk or secondary complications. In this Part 1 of the 11 Rs of Concussion we have dealt with the first 3 Rs including recognising, removing and re-evaluating the patient. Look out for Part 2 of this Concussion article that will detail management of concussion: rehabilitation exercises, return to sport/ school protocols and prevention. References

1. McCrory P, Meeuwisse W, Dvorak J et al. Consensus statement on concussion in sport— the 5th international conference on concussion in sport held in Berlin, October 2016. British Journal of Sports Medicine 2017;51:838– 847 Open access https://spxj.nl/2wcanqT 2. Ellenbogen RG, Batjer H, Cardenas J et al. National Football League Head, Neck and Spine Committee’s Concussion Diagnosis and Management Protocol: 2017–18 season. British Journal of Sports Medicine 2018;52:894–902 Open access https://spxj.nl/2YJDjmt 3. Neidecker J, Sethi NK, Taylor R et al. Concussion management in combat sports: consensus statement from the Association of Ringside Physicians. British Journal of Sports Medicine 2019;53(6):328–333 Open access https://spxj.nl/2HLNnEM 4. Harmon KG, Clugston JR, Dec K et al. American Medical Society for Sports Medicine position statement on concussion in sport. British Journal of Sports Medicine 2019;53:213–225 Open access https://spxj.nl/30L2O8W 5. Davis GA, Makdissi M, Bloomfield P et al. International consensus definitions of video signs of concussion in professional sports. British Journal of Sports Medicine 2019;doi:10.1136/bjsports-2019-100628 6. Patricios JS, Ardern CL, Hislop MD et al. Implementation of the 2017 Berlin Concussion in Sport Group Consensus Statement in contact and collision sports: a joint position statement from 11 national and international sports organisations. British Journal of Sports Medicine 2018;52:635–641 Open access https://spxj.nl/2EtsrRZ 7. Holtzhausen L, Dijkstra HP, Patricios J. Shared decision-making in sports concussion: rise to the ‘OCAsion’ to take the heat out of on-field decision-making. British Journal of Sports Medicine 2019;53:590–592. Co-Kinetic Journal 2019;81(July):28-33

PHYSICAL THERAPY

KEY POINTS

lT he 11 Rs of sport-related concussion (SRC) provide a logical flow to clinical concussion management, being: Recognise; Remove; Re-evaluate; Rest; Rehabilitation; Refer; Recover; Return to sport; Reconsider; Residual effects and sequelae; Risk reduction. lA key concept in sideline assessment is the rapid screening for a suspected SRC, rather than the definitive diagnosis of head injury. lU sing tools including SCAT5, CRT5, Child SCAT can aid in early detection of a concussion. lW hen a concussion is suspected, the athlete should be removed from the sporting environment and a multimodal assessment should be conducted in a standardised fashion. lT he sideline evaluation is based on recognition of injury, assessment of symptoms, cognitive and cranial nerve function, and balance. lS RC is often an evolving injury, and signs and symptoms may be delayed, erring on the side of caution is always safest choice. lN europsychological testing is still the cornerstone of SRC management and should be performed/interpreted by a neuropsychologist. lT he decision-making process in concussion can be difficult due to lack of visible signs, lack of diagnostic criteria, compromised decision-making ability: field-side distractions, time restraints, and conflict of interest – situational pressure and bias.

LINK 1: McCrory P, Meeuwisse W, Dvorak J et al. Consensus statement on concussion in sport – the 5th international conference on concussion in sport held in Berlin, October 2016 British Journal of Sports Medicine 2017;51:838–847 (1) https://spxj.nl/2wcanqT LINK 2: Ellenbogen RG, Batjer H, Cardenas J et al. National Football League Head, Neck and Spine Committee’s Concussion Diagnosis and Management Protocol: 2017–18 season. British Journal of Sports Medicine 2018;52:894–902 https://spxj.nl/2YJDjmt LINK 3: Neidecker J, Sethi NK, Taylor R et al. Concussion management in combat sports: consensus statement from the Association of Ringside Physicians. British Journal of Sports Medicine 2019;53(6):328–333 https://spxj.nl/2HLNnEM LINK 4: Downloadable Sport Concussion Assessment Tool – 5th Edition (SCAT5) https://spxj.nl/2HLovwP LINK 5: Downloadable Child SCAT5 https://spxj.nl/2EBAhJB LINK 6: Downloadable Concussion Recognition Tool (CRT) https://spxj.nl/2wahtMI LINK 7: See Figure 1: National Football League Concussion Game Day Checklist https://spxj.nl/2wmKNQp from Ellenbogen RG, Batjer H, Cardenas J et al. National Football League Head, Neck and Spine Committee’s Concussion Diagnosis and Management Protocol: 2017–18 season. British Journal of Sports Medicine 2018;52:894–902 (2) https://spxj.nl/2YJDjmt LINK 8: Figure 1: Overlapping clinical profiles: an emerging concept to facilitate individualised management after sport-related concussion. Most patients have features of multiple profiles. https://spxj.nl/2JRp2Qy From Harmon KG, Clugston JR, Dec K et al. American Medical Society for Sports Medicine position statement on concussion in sport. British Journal of Sports Medicine 2019;53:213–225 (4) https://spxj.nl/30L2O8W

RELATED CONTENT

lC oncussion in Sport: Putting the Guidelines into Action [Article] http://spxj.nl/2CpEeNh

Want to share on Twitter? DISCUSSIONS

l What tools do you find most effective in assessing an individual with suspected concussion? lD o you feel that the sporting codes that you are involved in provide ample time and support to allow appropriate decision-making during suspected concussion without disadvantaging the player or team? l I n your dealings with concussion patients, do you find resistance in removing them from the field of play or stopping their activity due to a perception that concussion is ‘not that serious’, just a ‘ding on the head’?

Co-Kinetic.com

Here are some suggestions

Tweet this: Most sport-related concussions occur without loss of consciousness https://spxj.nl/2WDJGu4 Tweet this: Video review can assist sideline physicians in identifying possible concussion https://spxj.nl/2WDJGu4 Tweet this: Sport-related concussion is often an evolving injury, so erring on the side of caution is important https://spxj.nl/2WDJGu4 Tweet this: Neuropsychological assessment is a ‘cornerstone’ of the management of sport-related concussion https://spxj.nl/2WDJGu4 33

YOGA AND BIOMECHANICS: A New View of Stretching Part 1 All references marked with an asterisk are open access and links are provided in the reference list

Select any yoga posture to analyse in the context of load and you will easily identify, in addition to the compressive loading on bones and cartilage, the tensile loading on the soft musculoskeletal tissues. In other words, most of the positions we place our bodies in to accommodate the shapes of yoga asana require some stretch and flexibility. Perhaps it is this reason that leads the public to associate yoga with stretching, much to the dismay of many teachers. There appears to be a divide within the yoga community – some ardently refute that yoga is stretching, while others seem to enthusiastically connect the two. My intention is not to defend either position, but to offer an alternative view of stretching so that we may move beyond the disparity and come together to have a fresh conversation on what it means to put tissues under tension. In order to achieve this, we will need to define some terms – a lot of terms. I find that many conversations I have out in the world about stretching are inconclusive because we are all speaking the same words but with different definitions. Just recently a colleague, who is also a yoga educator, asked me a seemingly simple question about the best way to stretch tendons. My first answer did not satisfy her

How often do you encounter a patient with ‘tightness’ in parts of their musculoskeletal system and encourage stretching to ‘loosen’ it and improve flexibility and range of motion? How often do we ourselves practise yoga to stretch and improve our own flexibility? We use these terms glibly, because, well, everyone knows what ‘stretching’ means, right? And the answer to that question, is actually, probably not! This article is Part 1 of two, which will really get you thinking about what exactly you mean when you use the word ‘stretch’ and will allow you to do the right kind of stretches for the best result depending on the desired outcome. This article has been extracted from chapter 2 of the author’s book Yoga and Biomechanics: Stretching Redefined. Read this article online https://spxj.nl/2KAQEd8 By Jules Mitchell MS, CMT, ERYT500 because she was invested in what she had already learned about the topic through her previous yoga studies. Not until we started breaking down all the components of the question for clarity and defined all the terms until we were certain we understood each other, did we make progress. At this point, we rephrased the question altogether to ask about the best way to load tendons and the discussion became

quite enriching. In this article we will learn about stretching and how it may or may not be a part of yoga (Thought Provoker 1). Through a careful exploration into stretching, not just whether it improves flexibility, but some of the possible mechanisms at work, we can deconstruct many stretching sound bites commonly recited in class.

YOGA | STRETCHING |19-07-COKINETIC FORMATS WEB MOBILE PRINT

SOME YOGA TEACHERS ARDENTLY REFUTE THAT YOGA IS STRETCHING, WHILE OTHERS SEEM TO ENTHUSIASTICALLY CONNECT THE TWO 34

Co-Kinetic Journal 2019;81(July):34-41

MANUAL THERAPY

Thought Provoker 1: What is Stretching? Have you ever stopped to ponder what stretching means exactly? Could you explain what stretching does, how it works, and why we do it? Could you go further and define precisely what words like mobile, flexible, tight, loose, lengthen, release, resistance, etc., mean? Take a few moments to ponder what structures are involved, what mechanism is contributing to your explanation (ie. how it works), and how confident you would be explaining it to a room full of exercise scientists. I encourage you to do this because it was this self-imposed exercise that led me to many of the conclusions I will present to you. I first had to become uncomfortably aware of the fact that I was using words without a clear understanding of what they meant.

Conventional Stretching

Stretching is widely accepted as an essential practice for maintaining physical activity. The general population overwhelmingly believes that stretching is good. Some commonly associated benefits may include improved athletic performance, injury prevention and, of course, flexibility. If you can reach your toes, although you probably have not acquired any sort of special skill resulting from it, you may have been the subject of ‘flexibility envy’ on more than one occasion. Culturally, stretching is promoted ubiquitously. My grade school physical education teacher led us through stretches before sending us off to run laps, a practice which continued through my high school soccer years. Commercial gyms provide stretching areas, some community racing events provide organised stretching often alongside the massage services, and stretching related products are sold everywhere.

For a more formal assessment of the benefits of stretching we turn to a governing body for health and fitness, the American College of Sports Medicine (ACSM). Founded in 1954, the ACSM is ‘the largest sports medicine and exercise science organisation in the world. With more than 50,000 members and certified professionals worldwide, ACSM is dedicated to advancing and integrating scientific research to provide educational and practical applications of exercise science and sports medicine’ (1*). Every several years the ACSM publishes a series of position statements. These in-depth reviews of current research in exercise and sport science serve as the gold standard for exercise recommendations in different populations. For the general population, they have selected five components of fitness (Table 1) (2*). Flexibility is one of the components of fitness, as is neuromuscular training. Interestingly, yoga falls under the mind–body category, not the flexibility category (although they do reference yoga in the flexibility guidelines). Yet, the number one reason the consumer chooses yoga is to become flexible (followed by stress relief, general fitness, improvements in general health, and physical fitness), as reported in the 2016 Yoga in America study conducted by Yoga Journal

Table 1: Components of fitness Component

Example activity

Cardiovascular Running Strength Weightlifting Body mass index (BMI)

Measure of body fat percentage

Flexibility Stretching Neuromuscular fitness

Qi gong, yoga

magazine (Thought Provoker 2)(3*). Note the difference between the sport science and consumer impressions of yoga.

Thought Provoker 2: Yoga and Flexibility For the 35 million people in the US practising yoga in 2016, it is the desire to attain flexibility that is bringing them to their mats. Additionally, flexibility is what keeps them coming back, as it has been reported as the number one motivation to continue practising. If yoga and conventional stretching are not related, as many argue, then perhaps yoga has a serious publicity problem. What are your thoughts on yoga, stretching, and flexibility? What role do the mainstream media, social media, and the leaders in your own yoga community play in perceptions about yoga? If a yoga student wants to improve her flexibility, what responsibility does the yoga teacher have to either meet the demand or change her perception? The ACSM classifies the activity of stretching as flexibility training. They clearly define five different approaches to achieving greater range of motion (ROM). Surprisingly, the ACSM guidelines for how to stretch and the reported benefits are somewhat underwhelming. In the 25-page position stand offering exercise guidelines, less than one page is dedicated to stretching. A full-body stretching routine can be completed in under 10 minutes and 2–3 days per week should suffice (2*). In the absence of a detailed and compelling argument for more than 20–30 minutes a week, tradition appears to be the driving force for the promotion of stretching.

Types of Stretching

Here, we will review in detail

Co-Kinetic.com

MANY CONVERSATIONS ABOUT STRETCHING ARE INCONCLUSIVE BECAUSE WE ARE ALL SPEAKING THE SAME WORDS BUT WITH DIFFERENT DEFINITIONS each type of stretching to highlight that not all stretching is the same. Just as compressive loads can vary in magnitude, rate, and time parameters, so can tensile loads. The purpose, at this time, is not to value one type of stretching over others, but to clearly outline the similarities and differences. Later, when we examine how different loading modes and parameters affect muscle and connective tissue, you will be able to determine which type of stretching satisfies a specific outcome. A mantra to which I adhere is that there is no right way to teach a yoga pose or sequence a class, as long as you can provide sound reasoning for your methods.

Ballistic Stretching

The first type of stretching, ballistic stretching, is characterised by bouncing repeatedly into a stretch. I am always reminded of the type of stretching we did in physical education class in elementary school before running a few laps; we would sit on the grass, stretch one leg out, bend the opposite leg in, and bounce repeatedly while reaching for our toes. The process looks very Jane Fonda and very 1980s. This technique fell out of fashion for some time; rumours told us bouncing was unsafe and would lead to injury. Lack of evidence has weakened this position and while it is now more acceptable to bounce and stretch, it is still not something we see very often. I expect someone will soon discover this untapped market, develop a system of ballistic stretching reinforced by several optimistic claims of superiority, trademark the brand, train others to teach it, charge them an annual licensing fee to be associated with the brand, and further monetise it by manufacturing widgets necessary to achieve the greatest benefits. Sound about right?

Dynamic Stretching

Figure. 1: Legs-Upthe-Wall Pose or a passive stretch supported by the wall

Figure 2: Upward Extended Feet Pose (supine double leg raise) or an active stretch held with agonist contraction

Dynamic stretching, also called slow movement stretching, is characterised by repetitive slow movements that progressively increase in range. You may relate this to joint rotations such as full shoulder circles or ankle rolls, for example. Qualities of dynamic stretching appear in the Vinyasa style of yoga where classes are often sequenced to progressively increase oneâ&#x20AC;&#x2122;s range through repetition. For example, Plank Pose becomes Downward-Facing Dog Pose becomes Handstand, eventually. Or Side Angle Pose becomes Bound Side Angle Pose, which then becomes Bird of Paradise. While these configurations are far more complex than the basic and isolated joint rotations characteristic of dynamic stretching, the underlying concept is still there. Incidentally, the currently preferred (because ideas change as research progresses) method of presport or pre-activity stretching among coaches and athletes is dynamic stretching (for reasons we will discuss ahead).

Static Stretching

Static stretching encompasses a larger range of stretching styles than the previous two and is considered either active or passive. Both types of static stretching consist of holding a stretched position for a specified amount of time. The most common durations you will find in the literature are 15-second increments up to 60 seconds, but you will certainly see others, and sometimes, although rarely, upwards of 5 minutes. If you consider the average slow-breathing yoga practitioner takes approximately 12 breaths per minute, each breath would last about 5 seconds; therefore holding a yoga posture for five breaths approximates a 25-second static stretch. The category of static stretch depends on the nature of the pose. Static stretching is most often done passively. Passive stretching requires an external force to hold the stretch. Legs-Up-the-Wall Pose, although not a pose with a central purpose of stretching the hamstrings, is technically a static passive stretch because the wall provides the support for the position (Fig. 1). Reclining Hand-to-Big-Toe Pose with the index and middle finger hooking the big toes or supported with a belt is a passive stretch because the arm is holding the leg in hip flexion to stretch the hamstring. Because of the ubiquity of passive stretching in the flexibility research, many papers use the terms static stretching synonymously with static passive stretching. It is prudent, therefore, to read the methods section of any paper on static stretching to reveal exactly what type of stretching the intervention entailed.

Active Stretching

In contrast, active stretching, according to ACSM, recruits the opposing muscle group to hold the position. By this description, the active muscle is the prime mover (agonist) and the target muscle being stretched is the opposing one (antagonist). The active version of Supported Legs-Up-the-Wall Pose is Supine Double Leg Raise Pose (Fig. 2) and of Reclining Hand-to-Big-Toe Pose is a hands-free, prop-free, unsupported expression of the same pose. In both, the absence of any external support Co-Kinetic Journal 2019;81(July):34-41

MANUAL THERAPY

recruits the agonist hip flexor group to hold the position, stretching the targeted antagonist hamstring group. The active stretching category is the only section in the ACSM flexibility guidelines which refers to yoga. Arguably, any standing pose in yoga held statically is an active stretch across one or more joints, as is any arm balance, inversion, or seated posture as long it recruits agonist muscle contractions. In some seated postures, however, the distinction between active and passive stretches may be somewhat ambiguous. For example, in Seated Forward Bend Pose, one individual may effortlessly rest her trunk on her thighs and the pose would be passive (Fig. 3). In another person, the trunk may deviate backwards, perhaps due to the lack of a hip hinge, and the pose would be active as she works against gravity to maintain a forward leaning position (Fig. 4). Brace the back against a wall, however, and it would become passive again (Fig. 5). Therefore, the same pose may be active for one student and passive for another, determined by the source of force (ie. internal, external). An active stretch requires internal force production on the part of the student to hold the position whereas a passive stretch is supported by any external force, including gravity.

Proprioceptive Neuromuscular Facilitation

The fifth and final approach to stretching recognised by ACSM is proprioceptive neuromuscular facilitation (PNF), or as manual therapists often call it, muscle energy technique (MET). The stretching applications of this technique vary, mostly combining some aspect of isometric contractions with passive stretches through a given ROM. The most recognised method is probably the contract–relax method, where a partner takes a subject to the endrange stretch of a target muscle, the subject then isometrically contracts the target muscle against the partner’s resistance for a period of time (usually around 6–10 seconds), after which the subject relaxes, and the partner passively stretches the target Co-Kinetic.com

muscle further. What is unique about contract–relax is the emphasis on the contraction of the target, or stretched, muscle instead of the opposing muscle. Although used more by athletic trainers and manual therapists than yoga teachers, PNF techniques are widely accepted as an effective method of ROM training. Moreover, the immediate, albeit temporary gains in ROM make PNF an easily demonstrable technique susceptible to exaggerated claims about its benefits. Rife with assertions about the role of muscle reflex activation in flexibility, plenty of misinformation circulates around PNF. For this reason, moving forward, we will focus on the isometric component and refer to PNF and MET stretching as isometric stretches, where the target muscle is isometrically contracted for some period of time at end range. Isometric stretching is, therefore, distinct from active stretching and also from resistance stretching.

isometrically pause briefly at the shortened range, and then in a slow and controlled manner, lengthen the muscle with the resistance still applied. Unlike isometric stretching, this method is less about a contraction

Figure 3: Seated Forward Bend Pose, passive, supported by gravity

Figure 4: Seated Forward Bend Pose, active, working against gravity

Figure 5: Seated Forward Bend Pose, passive, supported by a wall with some gravitational assistance

Resistance Stretching

Resistance stretching, although not identified by the ACSM, is a method of stretching using eccentric contractions. Most often performed with a partner, an inanimate external weight can also be used to apply resistance. The subject will warm-up the muscle with a few resisted concentric contractions,

NOT ALL STRETCHING IS THE SAME

Table 2: Types of stretching Flexibility exercise

Descriptions

Example

Ballistic

Bouncing stretches using momentum to increase range

Jane Fonda workouts

Dynamic

Slow movements gradually increasing in range

Joint circles

Static passive

Holding position using support

Legs-Up-the-Wall Pose

Static active

Holding position using opposing muscle

Supine Double Leg Raise

Stretch involving some Proprioceptive neuromuscular facilitation combination of isometric contractions and passive stretching Resistance stretching

Slow, controlled eccentric lengthening against resistance

Contract–relax (isometrically contracting target muscle at end range followed by a deeper passive stretch) A partner-assisted stretch where the person being stretched tries to concentrically contract against the partner’s efforts to lengthen the muscle

RESISTANCE STRETCHING IS A METHOD OF STRETCHING USING ECCENTRIC CONTRACTIONS

Torque/Force

at end range, and more about a loaded controlled eccentric contraction through the entire range. Extreme ranges are usually avoided because the stretch ends when the subject loses the ability to effectively control the joint position, regardless of the subject’s available passive range. Resistance stretching is not well represented in the literature, presumably because it is not commonly identified as a stretching method. Eccentric training has been extremely well studied, especially in recent years and, therefore, the eccentric training research will inform us about the effects of this particular method of tensile loading. With so many options available, it becomes apparent why definitions are needed in a conversation about stretching. Clarification of variables is required when speaking of specific outcomes. For example, resistance stretching might essentially be eccentric loading, but it’s a relatively low load eccentric contraction when compared with the types of eccentric loading used as an intervention in a study. Static stretching can be active or passive, and not all stretching types suggest the stretched muscle must be relaxed as is often assumed. Now that we have identified the different ways in which we can stretch (Table 2), we turn to a discussion on all the reasons why we are supposed to stretch and

Before stretching

After stretching

Range of Motion Figure 6: A decrease in passive resistance torque after stretching

whether or not those reasons are satisfied by the method.

Why We Stretch

Surprisingly, the bulk of the research on the effects of stretching is relatively new. In the last 10–20 years, when papers on the subject were first published, the data on static stretching began to reveal that influences on performance, injury prevention, and ROM may not be as positive as we originally assumed. This discovery caused a reversal of opinion in many fitness circles and, in some cases, stretching was even vilified. Fortunately, continued research has shown that those conclusions may have also been premature. There is still much we do not understand and, for now, the conclusions lie somewhere in the middle – stretching is sometimes good, but not that good, and when good, only under certain conditions. What the body of literature lacks in tenure, reliability, validity and reproducibility it makes up for in volume. Literally hundreds of papers set out to determine once and for all why we should or should not stretch. It can be quite dizzying as they examine multiple types of stretching of varying dosages against different controls on diverse populations. Fortunately, a recent collaboration between the top stretching researchers produced a systematic review summarising the results of the high-quality RCTs published to date (4*). My book Yoga Biomechanics: Stretching Redefined sets out to explore how tissues behave under tension beyond the constraints of conventional stretching. We will rely on this current and high-quality review to provide us with a condensed, yet focused, summary of stretching outcomes so that we may move on to explore other biomechanical principles and how they fit into yoga asana. Regarding sports performance, the researchers assembled the data into multiple configurations to establish various relationships. To begin, all types of stretching were evaluated for acute influences on overall performance (whichever specific performance outcome was being measured in any given paper). Acute effects of stretching refers to the results

immediately (usually within 1 hour) after a stretching bout. Stretches under 60 seconds resulted in an average decrease in performance by 1.1% and stretches over 60 seconds decreased performance by 4.6%. Whereas both results had a negative impact, the evidence may only have clinical significance in highly competitive situations like training for the Olympics. The results may not be compelling enough to advise a recreational athlete who enjoys his stretching routine before his sport, and who feels better because of it, to forgo it. When the same data were rearranged to divide performance into the categories strength and power, the numbers told a different story. The acute effects of stretching resulted in a 4.8% deficit in strength, but only a 1.3% deficit in power-speed. The caveat here is that the duration of the stretches in the strength data was longer and we have no way of determining if time in the stretch was a factor in the greater deficit. The variable, strength, is measured by how much weight someone can move, power is measured by the speed at which one can move said weight. Power has a time component to it, strength does not. This is discussed further in chapter 3 of the book Yoga Biomechanics: Stretching Redefined. Arranged by type of stretch, static stretching diminished overall performance by 3.7% and PNF by 4.4%, but dynamic stretching improved performance by 1.3%. Anyone familiar with the literature expects dynamic stretching to improve performance as it has been the recommended preactivity stretching method for roughly the last decade. ACSM suggests engaging in static stretching or PNF either post-activity or entirely separate from the activity or sport. Static stretching affected tasks requiring short-range performance negatively by 10.2% but positively by 2.2% in tasks requiring long-range performance. It seems that specificity, as should be expected, applies again – end-range training improves endrange performance. Concerning injury, the acute effects of static stretching or PNF seem to slightly reduce injury frequency in Co-Kinetic Journal 2019;81(July):34-41

MANUAL THERAPY

muscle injuries relating to sprintingtype activities but not endurance sports. For overuse injuries and other ‘all-cause’ injuries, stretching did not appear to have any effect. In any case, there appeared to be no adverse effects from pre-activity static stretching, rendering the intervention harmless but only somewhat beneficial, and sometimes even slightly detrimental, depending on the performance goals. The authors examined dozens of other configurations in addition to the few I selected above. Among the many outcome variables they examined, those I have highlighted tell us enough of the story for our purposes here. I mention this for full transparency, so it does not seem I am cherry-picking data to support my own opinions. I encourage you to read the paper in its entirety if the subject matter intrigues you (4*). As per our discussion on why we stretch, it appears the evidence does not hold up to the popular consumer belief about performance and injury prevention. One issue with measuring performance and injury prevention as primary outcomes, however, is that there are any number of internal factors and external environmental conditions that could influence outcomes. This complicates study design for the long-term effects of stretching on performance. If the subjects continue to train, any long-term benefits could be a result of the actual training. If subjects discontinue training, we would expect to see deficits and injuries, but I’m not aware of any studies looking at the effects of stretching on injury occurrences in sedentary populations as that would seem irrelevant. I’m also unaware of any studies designed to test whether stretching causes injuries because that is not the theory sports scientists are striving to validate. The emerging yoga narrative about the stretching injuries that yoga may cause is discussed in subsequent chapters in the book Yoga Biomechanics. We must first exhaust our investigation of conventional stretching and how the body responds and adapts to it.

Passive Resistance Torque

Torque, as you may recall, is the word Co-Kinetic.com

for a rotational force. In ROM research, when a subject’s limb is passively moved into a stretch, a torque occurs within the joint space, measurable by a torque meter. Passive resistance torque (PRT) is the measurement of resistance against a joint rotation (Fig. 6). The deformation behaviour of the soft tissue crossing the joint as it is stretched contributes to this resistance. Imagine practising yoga in stretchy yoga pants versus jeans. The jeans contribute greater resistance than the stretchy pants, thereby limiting ROM. Now imagine those jeans developed less resistance after several stretches. We could call that a decrease in PRT. The word passive implies that the movement is not initiated through an internal force, but is achieved through the application of an external force. In a biomechanics lab, this is usually a rig with a pulley. A goniometer measures joint angle and a dynamometer measures the torque. A subject with less PRT responds with less resistance than a subject with greater PRT. Research shows acute stretching reduces PRT, thereby increasing ROM. In the early years of flexibility research, Magnusson published what is today considered a classic paper. His work established some of the testing protocols of the time, before technological advancements in ultrasound became the measurement tools of choice. One of his discoveries was that the acute changes in PRT were fleeting, lasting only about an hour. The subjects had decreased PRT with 5×90-second stretches, spaced 30 seconds apart. PRT returned to baseline in a follow-up test, 1 hour later (5). His work has been replicated, and also refuted, by many over the years, including himself. Chronic stretching has also been shown to reduce PRT. A 4-week protocol of 2×60-second stretches twice per day resulted in a decline of PRT at the end of the intervention. Final PRT measurements were taken 24 hours after the last stretching dose, indicating that reductions in PRT last more than an hour when stretching is consistently performed. No followup test was conducted in the weeks or months after the daily stretching protocol, providing no indication of the

lasting duration of change (6). Finally, long-held stretches also have an acute effect on PRT. Subjects held a passive stretch for 1, 2, 3, 4, and 5 minutes. After 1 minute, PRT was not yet significantly lower than baseline, but every additional minute thereafter, it was. The 4- and 5-minute stretches resulted in significantly lower PRT than the 1-minute. Moreover, the 5-minute stretch was significantly lower in PRT than the 2-minute one (7). We can conclude that in men averaging 20 years of age, a 5-minute static stretch should reduce passive resistance in ankle dorsiflexion more than a 2-minute stretch will. In sports science, it is a long-held belief that diminishing returns do not warrant holding a stretch longer than about 30–60 seconds (which is still the ACSM recommendation). This paper suggests that changes might continue to occur 3–5 minutes into the stretch, which is interesting because certain types of yoga are characterised by long-held stretches, although their practice is only anecdotally supported. I must note here, we cannot extrapolate these results to just any yoga posture, or even to all other joints or populations because those variables were not accounted for in this particular study. The significance of PRT is that we see changes in mechanical properties in response to various static stretching parameters. Some changes are temporary, some are longer lasting. The mechanical properties and their influencing factors are discussed further in subsequent chapters of the book Yoga Biomechanics. For now, we will consider possible neural adaptations to stretching.

Stretch Tolerance

Stretch tolerance describes the limit to which an individual can ‘tolerate’ the discomfort associated with a deepening stretch. A purely ‘sensory’ theory, its basis lies in an individual

NOT ALL STRETCHING TYPES SUGGEST THE STRETCHED MUSCLE MUST BE RELAXED 39

Thought Provoker 3: Tightness How do you explain the feeling of tightness that compels people to stretch? Do you think tightness is a function of mechanical tissue properties or a sensory experience? How can you determine if a muscle is tight; would it require a laboratory setting? Does this method of measurement support your explanation of tight? adapting to and becoming less sensitised to what most consider the painful experience associated with stretching, or finding the sensation becoming less offensive, or more tolerable, after repeated exposure. The theory emerged because all human trials measuring end ROM will always stop at an individual’s tolerance. Unlike animal studies where tissues can be extracted and mechanical limits tested ex vivo, ROM studies on humans are limited by the subject’s request to stop the stretch in the presence of pain and discomfort. The main premise of the sensory theory is that changes in ROM are not due to alterations in tissue properties, but in sensory tolerance. In the early years of flexibility research, Magnusson, again, published a second classic paper. This time, he looked at the effects of a 3-week stretching intervention on tissue properties as opposed to those immediately following a stretch. His testing protocols were twofold. One measured PRT at a predetermined range assessed by the sensation of tightness. The other was similar but progressed into a painful range. Yoga teachers may understand this distinction via the popular cue – to enter the pose ‘to the point of discomfort but not to the point of pain.’ After the completion of the intervention, the investigators found no alterations in tissue properties, concluding tolerance to be the mechanism of change in ROM (8*). Note, Magnusson published both the previously cited paper on the transient changes in tissue properties in response to acute stretching and this paper on the absence of tissue property changes in response to chronic stretching in the same year. It was an important year for 40

stretching science. These papers launched a debate among the mechanical and sensory theorists, and the subsequent publication of multiple papers defending either position or both. Magnusson continued to publish, and 14 years later coauthored a perspective paper proposing that the sensory theory explains the inconsistencies across the literature resulting from the challenges posed in attempts to control for all variables (9*). In spite of these methodological challenges, today, the evidence is compelling enough for us to validate both theories concurrently, but there is still much we do not know (Thought Provoker 3). For example, we do not understand the neurophysiology behind tolerance and how it is regulated in the nervous system. We do have some limited research on the topic of anaesthesia and ROM. Subjects undergoing knee surgery were tested on the ‘healthy leg’ (ie. the leg not operated on). ROM during a passive hamstring stretch was tested pre , intra , and postoperatively. The aim was to compare four variables: spinal anaesthesia, general anaesthesia, a nerve blocker, and an epidural. In all cases, the intra-operative ROM was significantly greater than the pre- and postoperative measurements, which did not change significantly. The spinal anaesthesia resulted in the greatest increase in ROM, suggesting neural regulation of stretching may occur at the level of the spinal cord (10). In another study focusing on the role of pain in ROM, subjects undergoing total knee arthroscopic surgery as a treatment for osteoarthritis were tested. The operative knee was measured for maximal knee flexion and extension prior to surgery and during surgery after a spinal anaesthesia followed by a femoral and sciatic nerve blocker (which blocks nerve impulses, not feeling). Average passive ROM across 141 subjects was greater by 13.4° in flexion and 3° in extension under anaesthesia (11). Whether stretch tolerance or other painful symptoms are the limiting factor in ROM, we have support for a sensory

theory that warrants further research. At this point, we are treading dangerously close to the field of neuromechanics, which is not the remit of this article. It is my position that influences in ROM are likely a function of both sensory and mechanical mechanisms, but exactly how, when, or why each is a factor, we don’t yet understand. Thus, where my interest lies is in the question of how, when and why tissues adapt their mechanical properties when loaded in tension. In Part 2 of this article we will delve into the topic of muscle length to elucidate this point, followed by a discussion of eccentric stretching and stretching redefined. References

1. American College of Sports Medicine 2017 website https://spxj.nl/2QzTArt 2. Garber CE, Blissmer B, Deschenes MR et al. American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: Guidance for prescribing exercise. Medicine and Science in Sports and Exercise 2011;43(7):1334–1359 Open access https://spxj.nl/2HLRtOr 3. Ipsos Public Affairs. 2016 Yoga in America study. Yoga Journal 2016 Open access https://spxj.nl/2QAajKU 4. Behm D, Blazevich A, Kay AD et al. Acute effects of muscle stretching on physical performance, range of motion, and injury incidence in healthy active individuals: a systematic review. Applied Physiology, Nutrition, and Metabolism 2016;41:1–11 Open access https://spxj.nl/2YVGvLN 5. Magnusson SP, Simonsen EB, Aagaard P et al. Biomechanical responses to repeated stretches in human hamstring muscle in vivo. American Journal of Sports Medicine 1996;24(5):622–628 6. Nakamura M, Ikezoe T, Takeno Y et al. Effects of a 4-week static stretch training program on passive stiffness of human gastrocnemius muscle-tendon unit in vivo. European Journal of Applied Physiology 2012;112(7):2749–2755 7. Nakamura M, Ikezoe T, Takeno Y et al. Time course of changes in passive properties of the gastrocnemius muscletendon unit during 5 min of static stretching. Manual Therapy 2013;18(3):211–215 8. Magnusson SP, Simonsen EB, Aagaard P et al. A mechanism for altered flexibility in human skeletal muscle. Journal of Physiology 1996;497(1):291–298 Open access https://spxj.nl/2XidOIK 9. Weppler CH, Magnusson SP. Increasing muscle extensibility: a matter of increasing length or modifying sensation? Physical Therapy 2010;90(3):438–449

Co-Kinetic Journal 2019;81(July):34-41

MANUAL THERAPY

Open access https://spxj.nl/2Kf2g5s 10. Krabak BJ, Laskowski ER, Smith J et al. Neurophysiologic influences on hamstring flexibility: a pilot study. Clinical Journal of Sport Medicine 2001;11(4):241–246 11. Bennett D, Hanratty B, Thompson N et al. The influence of pain on knee motion in patients with osteoarthritis undergoing total knee arthroplasty. Orthopedics 2009;32(4):252.

Key Points

l Some teachers do not think that yoga is stretching while some do. l In the American College of Sports Medicine (ACSM)’s five components of fitness, yoga is given as an example activity for neuromuscular training rather than flexibility. l The ACSM classifies stretching as an activity for flexibility training. l There are several ways to stretch: ballistic, dynamic, static passive and active, proprioceptive neuromuscular facilitation and resistance stretching. l Static stretching is mostly done passively but can be active. l Different types of stretching affected different performance parameters differently. l Stretching may improve joint range of motion (ROM) by reducing the passive resistance torque within the joint space (mechanical theory). l Stretching may also improve ROM through improving stretch tolerance (sensory theory).

Yoga Biomechanics: Stretching Redefined

By Jules Mitchell Handspring Publishing 2019; ISBN 978-1-909141-61-2 Buy it from Handspring https://www.handspringpublishing.com/product/yogabiomechanics/

Yoga Biomechanics: Stretching Redefined provides a unique evidencebased exploration into the complexities of human movement and what a safe, effective yoga practice entails. The emphasis is taken off flexibility and centred around a narrative of body tissue adaptation. Conventional approaches to modern yoga are examined through a biomechanist’s lens, highlighting emerging perspectives in both the rehabilitation and sport science literature. Artfully woven throughout the book is a sub-text that improves the reader’s research literacy while making an impassioned plea for the role of research in the evolution of how teachers teach, and how practitioners practise. Yoga teachers and yoga practitioners alike will discern yoga asana for its role in one’s musculoskeletal health. Yoga therapists and other allied healthcare providers can apply principles discussed to their respective professions. All readers will understand pose modifications in the context of load management, reducing fears of injury and discovering the robustness and resilience of the human body.

Contents

Chapter 1: Biomechanics Chapter 2: Stretching Chapter 3: Mechanical Behavior Chapter 4: Structure and Composition Chapter 5: Tissue Adaptation Chapter 6: Emerging Perspectives

Co-Kinetic.com

RELATED CONTENT

lB iotensegrity Part 1: An Introduction to Biotensegrity and its Importance to Massage Therapists [Article] https://spxj.nl/2KiKZZ7

Want to share on Twitter? Here are some suggestions

Tweet this: Resistance stretching is a method of stretching using eccentric contractions https://spxj.nl/2KAQEd8 Tweet this: Not all stretching types suggest the stretched muscle must be relaxed https://spxj.nl/2KAQEd8 Tweet this: Static stretching can be active or passive https://spxj.nl/2KAQEd8 Tweet this: Stretching seems to reduce muscle injury in sprinting-type activities but not endurance sports https://spxj.nl/2KAQEd8 Tweet this: Stretching does not appear to have any effect on overuse injuries https://spxj.nl/2KAQEd8 THE AUTHOR Jules Mitchell MS, CMT, ERYT500 is a Las Vegas based yoga educator, yoga teacher, and massage therapist. Her unique approach blends the tradition of yoga with her extensive study of biomechanics to help yoga teachers develop their craft, and empower them through education. It is her passion to share the most useful and applicable findings from exercise science with the yoga community, and to build confidence in students and teachers by giving them a well-grounded understanding of related research. She leads her own advanced teacher training, teaches workshops and immersion courses worldwide, and offers an ongoing selection of online education and mentoring programmes. As an adjunct faculty member at Arizona State University, she serves as a yoga consultant on various research studies measuring the effects of yoga therapy on special populations including pregnant women, women with depressive symptoms associated with perinatal loss, and patients with cancer. Her future research goals include studying the effects of asana on tissue adaptation, and bridging the gap between research in exercise science and the practice of yoga. Email: yoga@julesmitchell.com Twitter: @julesyoga LinkedIn: www.linkedin.com/in/julesmitchell Website: www.julesmitchell.com Instagram: www.instagram.com/julesyoga Facebook: www.facebook.com JulesMitchellYogaBiomechanics

19-07-COKINETIC FORMATS WEB MOBILE PRINT BY VICKI MARSH, MASSAGE THERAPIST, OWNER OF THE HEADSTART CLINICS So far I’ve shared with you how to plan and use free marketing to create an awesome Open Clinic event to help grow your practice. These days it is VERY easy to get carried away with marketing online, particularly on Facebook. But no matter what paid advertising you are doing you should always be working to maximise your free marketing options FIRST – so please make sure you’ve read Part 2 of this series before you dive in with your paid ads. In this article I share with you Step 3 in the Blueprint of Running a Successful Open Clinic Event – your PAID Marketing Strategy.

What is Paid Marketing?

Paid marketing is, simply put, any marketing that you actually have to pay real, hard cash for. A simple example would be getting leaflets printed to promote an event but, more commonly today, it involves Facebook Ads or Google AdWords. In this article, I’m going to focus on Facebook Ads, because this is what we used and I’m going to share a system that worked brilliantly for us.

How Much Should You Spend?

This is a great question to start with! Whenever you use paid advertising, you want to ensure a return on your investment, an ROI. This means whatever money you invest, you get at least the same amount back from the marketing, if not more. So, if we spend £50 on Facebook Ads we want to ensure that we get at least one appointment booking from that campaign (and ideally more because of the future bookings that client will make). The amount you want to spend on Facebook Ads depends on your answers to the following questions. 1. H ow much advertising budget do you have available – £ vs £££? 42

The Blueprint for Running a Successful Open Clinic Event: Part 3 Your Paid Marketing Strategy

This is the third part in a series of articles leading you step-by-step through how to run your own Open Clinic event and discusses a great strategy to use when you are paying for marketing so that you can maximise the return on your investment. Read this article online https://spxj.nl/2XvD9Pm 2. What is your normal rebooking rate from promotional clients? The higher your rebooking rate, the more budget you can afford to invest. 3. How many clients you want to bring in? The more clients you want normally means a bigger budget. 4. Do you have a tried and tested strategy to get back your ad spend? Don’t worry if the answer to this question is no, I’ll share one with you at the end.

Who Should You Advertise To? There are two ways that you can advertise on Facebook depending on your audience, who will fall into two groups: 1. people who HAVE NOT heard of you before and never been to your website – a COLD audience 2. people who HAVE heard of you before – they’ve visited your website, interacted with your page – a WARM audience.

Of the two options, it’s normally much easier (and therefore cheaper) to get sign-ups from your warm audience. However, it’s a smaller group of people than the much bigger cold audience, and you need to have the Facebook pixel installed so you can identify them – so if you haven’t done this yet, make sure you get it done ASAP. For an Open Clinic event we’re actually trying to attract new clients to the clinic, so targeting a cold audience is going to work well for bringing in that new client base.

How to Find Your Ideal Clients To get your ad in front of the right

people, you first need to create an audience in Facebook. This is a group of people with certain characteristics, so in our case as therapists we are normally looking for people in the ages of 25 to 55 years, male and female but very importantly who live and/ or work locally to our clinic. By using these criteria we can narrow down the audience from the millions of people on Facebook and put our Open Clinic ad up in front of only those who we want to sign up. You can then target down even further by choosing interests to target. Select topics that you know your current client base are interested in, this will make it easier to get sign-ups. You can choose from sports, activities, interests, people who follow other pages. The more you narrow down, the more targeted, and therefore the more effective, your ad will be. If you’re going to offer a free postnatal check-up at your Open Clinic, then target women of childbearing age. Offering a Golf MOT? Then target men and women over 35.

Designing Your Funnel

If you’re a Co-Kinetic Marketing subscriber then you’ll already have a pretty good idea of how this works! If not, here’s how to set up your funnel. The basics of what to create are: 1. Facebook Ad (using the conversion objective), promoting your Open Clinic event (Fig. 1) 2. Sign-up page – this is what ours looks like https://spxj.nl/2I8f63F. If you have a Co-Kinetic subscription, they have premade editable template sign-up pages that you can customise by filling out a simple form. If you don’t, then MailChimp is another simple way to get started 3. Thank you page (Fig. 2), to confirm their Co-Kinetic Journal 2019;81(July):42-43

ENTREPRENEUR THERAPIST

registration (and key to the way to guarantee getting your ad spend back). You can use Mailchimp for this. Figure 1: Example of a Facebook Ad for getting sign-ups

Using the Lead Generation

PRO campaign objective will give you TIP

the native Lead Ad format – this auto-fills an email address for the viewer, saving them time and making it really easy to submit, without even having to leave Facebook. This is a great ad type if you’re trying to build your email list. Tor Davies, at Co-Kinetic put together a free video series on how to set up and run Lead Generation ads specifically (I’ve included a link at the end). I really like using this Lead Generation ad type as it normally outperforms other ad types. BUT my tried and tested method for getting back your ad spend won’t work with this ad type!

Tried and Tested: Getting Your Ad Spend Back

Figure 2: Example of a thank you page with the offer

Last year I wanted to really focus on ROI from the Open Clinic event, seeing just how much income we could generate directly and indirectly from the event. In particular it was the first year I had a decent advertising budget available and I wanted to invest more in Facebook Ads, but was nervous about whether I would get my money back. So I combined two strategies that I knew worked and came up with an awesome approach that doubled my money back before we’d even kicked off

the Open Clinic. Very simply, I took an offer I KNEW worked well – £19 for a 60-minute Sports Massage – most of our therapists would rebook 50% of their clients from this offer to full price appointments. Then I combined that with a standard online marketing approach of putting the offer on the thank you page. So the first page they went to was to register for our Open Clinic event and, once they’d registered, they were then redirected to the thank you page which offered this ‘exclusive’ deal to book there and then for the £19 for a 60-minute massage. They could book appointments right up to the day before the Open Clinic event – but not afterwards. I also let them know that this was a one-time only offer. I spent £150 on FB Ads and got £250 back in initial £19 appointments – over time those clients have provided well over £3k worth of appointments. All from a simple button on the thank you page. So if you’re on the fence when it comes to using Facebook Ads to promote your Open Clinic event, make sure you use this strategy. I was very pleased with the ROI and in the next article I’ll talk about what I did to increase sales during the Open Clinic week itself. In the next article in this series we’ll move 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! https://spxj.nl/2wFDbIR

Further Resources

Need help getting started with FB Ads? 1. I ’ve created a FB Ads 101 course specifically for therapists and clinic owners who want to get started with advertising on Facebook but don’t know how to start. This beginners’ course is perfect for you if: l you’ve never run a Facebook Ad before because you’re scared of losing lots of money l the thought of learning all the tech makes you break into a cold sweat! l you’ve already tried boosting posts and had no luck whatsoever l you decided you wanted to learn more about Facebook Ads but hadn’t found a step-by-step course tailored to you and your business.

Learn more https://www.massagetherapist businessschool.com/fbads101. 2. Tor Davies, founder of the Co-Kinetic Marketing System, has also put together a free video series showing you how to use Facebook Ads specifically to build your email list.

Learn more https://spxj.nl/2PtI3YG.

RELATED CONTENT

l The Blueprint for Running a Successful Open Clinic Event: Part 1 Concept and Planning [Article] https://spxj.nl/2rrhPME l The Blueprint for Running a Successful Open Clinic Event: Part 2 Strategies for Marketing Your Event for Free [Article] https://spxj.nl/2QRQsHe

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.com

PRACTICAL WAYS TO USE CONTENT TO PROMOTE YOURSELF AND YOUR BUSINESS Healthcare professionals can be notoriously shy when it comes to promoting themselves or their businesses. Often it’s because we dread coming across as salesy, which is a fair call and a legitimate concern. The trouble is, if we want new customers, we have to tell people we exist. As we’re very comfortable offering advice and help however, employing this same strategy to promote ourselves and our businesses, is a great fit. This article explains the various different ways in which you can use helpful content as part of your marketing strategy, to increase awareness of your business and grow your client numbers, while at the same time avoiding any risk of seeming salesy. Read this article online https://spxj.nl/2KxOzhX. 19-07-COKINETIC FORMATS WEB MOBILE

BY TOR DAVIES, CO-KINETIC FOUNDER

Fig. 1: Content marketing isn’t new

Fig. 2: Example of content marketing animation

If you’re not using ‘content’ as part of your marketing efforts yet, this article will explain why you should be, and more importantly how you can do this. Along with search engine optimisation (SEO), content marketing is the most predominant marketing strategy in the world. Every major business is using it, and it’s not new (1). The first example of a brand using content to educate its customers was in 1895 when John Deere, the agriculture equipment manufacturer, launched its customer magazine The Furrow. Since then, it has just grown more and more popular. Content marketing is the past, present and future of marketing because it builds trust – and all purchasing is based on trust. Content marketing is about education – it’s not about what you ‘sell’. Content marketing is about your audience and what matters to them. I commissioned a whiteboard animation to explain in more detail how content marketing can benefit physical therapists in particular (you can watch it at this link: https://youtu.be/CUg353y9r38) (Fig. 2).

working in healthcare, because here, more than in most other businesses, the importance of trust cannot be overstated. A client needs to feel confident that you are the right person to trust with something that is causing them physical pain. It can be easy for us as therapists, to forget that acknowledging physical pain in the first place, can be difficult for many and surrendering that pain to someone else’s expertise, requires trust.

The Clinical Tipping Point

Anyone who’s heard me present, will have heard me refer to something I like to call the ‘clinical tipping point’. Often

People Buy From People They Trust Fig. 3: Do you send nurture emails?

It is the single most powerful strategy that any company can use to promote its products and services. But never has that been more true for people Co-Kinetic Journal 2019;81(July):44-49

ENTREPRENEUR THERAPIST

people will survive or self-manage their pain or injury until they hit a point when they can’t any longer. Either it stops them from doing things they love (like participating in sport, or playing with their kids) or whatever they’ve been doing to manage the pain until that point isn’t working any longer. This happens over a period of time. Most people don’t wake up in the morning saying, “Oh I must book an appointment with my physio today – I’ve got a slight niggle in my knee.” They wait until it stops them doing the things they love or leading the life they want to lead, and some of us wait even longer! Which is exactly why the long content game works so well in a physical or manual therapy environment. Something as simple as a regular monthly email offering some content of value, which doesn’t ‘product push’, and builds trust, is all you need to nurture that relationship, until that person is ready to call you. It’s so simple, and yet unfortunately 83.5% of you don’t do it (2) (Fig. 3)! Thankfully that percentage has gone down a little from a few months ago (hopefully on account of some of my education efforts), but it’s still a massively wasted opportunity. Particularly as, according to our Marketing Grader survey results, the average amount of time spent on marketing every month is 9.3 hours. Apart from the fact that you could run our whole Co-Kinetic marketing strategy in half that time, and make returns on that investment of over 30 times, I’m quite frustrated (that’s putting it mildly) that only 17% of people bother with that one single monthly, value-add nurture email. If that was the ONLY activity you did every month, I’m willing to guarantee that it would be significantly more effective at generating business for you, than whatever else you’re doing in those 10 hours. I’m now going to run through all the types of content that physical and manual therapists could use, with some ideas on how to use each one. Remember I’m focusing completely on education-based content because that’s the goal of content marketing. That’s not to say, you couldn’t throw Co-Kinetic.com

in the occasional sales-driven piece of content, just keep the ratio heavily in favour of educational content so you don’t lose trust. I’m not going to beat about the bush here, this is an increasingly large part of what I do through Co-Kinetic. My goal is to create as much content as I can for you, in order to save you time and money, while at the same time giving you a more professional result. All our subscriptions include many of the content types covered below and where that is the case, I’ve added a Co-Kinetic note, to explain what we provide. But whether you have a subscription to Co-Kinetic or not, all the principles still apply.

Content Types Online

1 Social Media Posts Ideally as many of the social media post types as possible would be aimed specifically at achieving one or more of the following, as this will either increase your post exposure or give you some tangible, quantifiable marketing benefit (ie. collecting emails): a) email lead generation (which we focus on specifically through the CoKinetic subscriptions) b) e ncourage comments and conversation (keep it positive) c) encourage engagement, ie. likes, shares, loves, hates etc. Types of social media posts include: l links to downloadable resources l infographics l explainer videos/exercise videos/ animations l images/cartoons/gifs/photos/ motivation l links to research l mini-case studies (you can keep them short and sweet) l links to blog posts or articles you’ve published (they don’t have to be new) l share/promote local events l quotes l questions and answers – very good for encouraging conversation l testimonials/reviews/feedback l links to new research l screenshots

CONTENT MARKETING IS THE PAST, PRESENT AND FUTURE OF MARKETING BECAUSE IT BUILDS TRUST – AND ALL PURCHASING IS BASED ON TRUST l quizzes – ideally combined with email lead collection l polls and surveys – great for encouraging engagement. Co-Kinetic note: we create 25–50 social media posts on a new topic each month (the number depends on which subscription you’re on). It includes many of the types covered above and each is focused on collecting email leads on your behalf, with the system taking care of everything, including posting the posts to your social networks. It takes 5 minutes to set up a campaign that will run for one month and which requires absolutely no technical skills. Emails 2 Emails can be: a) focused on educational topics; and/or b) offering downloadable resources (which allows you to use click rate to track engagement and as a measure of improvement). Co-Kinetic note: we write a nurture email for you each month as part of the Full Site subscription, provide you with images to accompany it and we include a link back to the high value resources that we’ve produced on your behalf.

3 Blog Posts Blog posts have a number of advantages. They: a) are particularly powerful for SEO, Google loves good content; b) are also effective when used in

CONTENT MARKETING IS ABOUT EDUCATION – IT’S NOT ABOUT WHAT YOU SELL 45

CONTENT MARKETING IS ABOUT YOUR AUDIENCE AND WHAT MATTERS TO THEM conjunction with a download offer, to turn your website into a 24/7 lead generation tool; c) increase engagement on your website; and d) establish authority and reputation. Co-Kinetic note: we write a new blog post for you each month as part of the Full Site subscription and provide you with images to accompany it. It’s copyright free and there for you to use/ modify/rewrite as you wish.

4 Podcasts Podcasts can be in the following forms. a) Q uestion and Answer – you could use another therapist to ask questions about a topic which you answer. b) Interviews – with other local businesses, sports personalities, people suffering from an injury or condition, or a patient who is particularly enthusiastic about their treatment experience. c) Self-hosted – you present on a topic and record yourself.

5 Videos Again, videos can take a variety of forms as follows. a) E xplainer videos. These are pretty self-explanatory, popular formats at the whiteboard, where the presenter is drawing the animation. Cheap and easy to commission from Fiverr.com. b) A nimations. These describe concepts such as the Pain Scale (that’s been our most popular animation to date), or the Biopsychosocial Model of Pain. c) I nterviews. Similar to the ideas under the Podcasts section above. d) Q +A Session. As in the Podcasts section above. 46

Co-Kinetic note: we produce explainer videos and animations as part of the Full Site subscription.

Offline

People tend to forget the power of printed content and ironically it’s cheaper and easier to produce these days than it’s ever been. Postal/Mailed Content a) Customer newsletters (contentdriven). Instead of sending people boring stuff about your clinic, that they’re probably not interested in, send them information they actually want to read, or share with others. l Ideas might include a newsletter on Tennis Injuries when there’s a big national tennis tournament taking place, or Preventing Running Injuries in the lead up to local or national running events, or Getting Fit for Snow Sports in the winter months. l They’re cheap and easy to print out – they’re a great way to stay in contact with and keep your past customers engaged. l You could send them out as regularly or as infrequently as you decide. l And it’s really easy to find either local providers who will do the whole process for you, or online providers who will even print the content out, clean your address data and get it posted for you (just Google ‘mailing services’ or ‘mailing on demand services’). It’s a lot cheaper than you think.

then send them to print. Then use a ‘mail on demand’ company to post them out to your customer address list. Co-Kinetic note: we write and design one of these newsletters for you every month and we also create postcards to promote new campaigns – both are included in the Full Site subscription.

7 Posters These can be: a) infographics – these are great eyecatchers on your clinic wall b) anatomy posters – useful to use during patient consultations and add a sense of authority to your own treatment room c) more info posters – use these to raise awareness of campaigns you’re running and promote resources you have available d) promoting the benefits of different treatments or modalities. Co-Kinetic note: we have produced a range of posters and infographics you can print out for your clinic walls.

b) Postcards. Similar to newsletters above, these: l are great for making sure customers who you don’t see (or have email addresses for) are aware of the resources you have available l promote a sense of authority and reputation l keep people engaged with your business l can be imported into a free image editing tool, like Canva canva.com, so you can write your own message on the back with a link to your new resources and Co-Kinetic Journal 2019;81(July):44-49

ENTREPRENEUR THERAPIST

Both Online and Offline

Newspaper/ Magazine Articles This is still an extremely effective way to promote your business and as a publisher myself, it’s something I would encourage you to do more of.

Co-Kinetic note: as a Co-Kinetic subscriber to any of our patient information resources, I would actively encourage you to use those resources to promote your own business in this way. Our customer newsletters in particular, are provided completely copyright free meaning you can take all the credit. Attach your biog and let the local magazines publish them under your name. Face-to-Face Presentations/ Webinars/Open Clinic Events I know many practitioners using these strategies incredibly effectively. It’s a great way to get in front of people, build trust, triage who is most in need of your help, and build relationships. Examples of things you could do follow below. a) Run an evening or lunch-time workshop or presentation. b) If you’re into technology, run regular webinars. c) You could do a Live Q+A on Facebook (or YouTube) (but make sure you’ve got people you can count on who are tuned in, or have them there primed with certain questions). d) Offer mini-assessments or taster sessions like mini-bike fits, muscle imbalance tests, gait analysis, taster massage sessions etc. Then offer ‘event specials’ that encourage people to purchase a product or make an appointment booking, or both.

Co-Kinetic note: We write off-the-shelf PowerPoint presentations which you can use within these sessions, and also provide an editable sign up web page through which you can take event registrations. There are also posters and leaflets you can use to promote the event. These are only included under the Full Site subscription. Co-Kinetic.com

Leaflet-Based Resources Last but not least, the simplest but most versatile of all content types, leaflet-based material can be printable and/or downloadable resources. You can: a) post them to clients you have addresses for; b) email them to clients you have email addresses for; c) print them out and distribute them in your clinic waiting area; d) give them to local businesses who offer services or products on related topics – eg. Cycling Injury leaflets to cycling shops; e) give them to sports coaches or fitness professionals – remember if it adds value to their clients, then it makes them look good too; f) drop health-promotion related resources into local businesses who may not have their own occupational/workplace health team; g) p rint leaflets out and pin them to local noticeboards in libraries or supermarkets; and h) offer your local GP practices or health centres leaflets to put in their leaflet dispensers (and if they don’t have a leaflet dispenser, buy one for them, they’re cheap and the associated ‘endorsement’ will be well worth the investment).

Display and Distribution Devices

In order to make this resource as comprehensive as it can be, here are some ideas of the kind of display and distribution devices you could make use of, with some of the offline resources mentioned above: l picture frames on clinic walls; l external notice boards; l leaflet dispensers (table top/clinic reception/wall-based/floor-based); l pavement signs; l pop-up display stands;

Leaflet-based content types include: l exercise handouts l advice leaflets l newsletters l cheat sheets l infographics l case studies l checklists. Co-Kinetic note: I almost don’t know where to start here, because all our subscriptions include these resources, AND they are also rebrandable, allowing you to add your own business details and logo to them. For their simplicity, they are phenomenally effective both for patient satisfaction of existing clients, as well as for promoting your business and brand in a completely value-added and unsalesy way.

Next Steps – Top 5 Priorities Again, in a mission to make this article as user-friendly and practical as it can possibly be, and to give you some focus (because I appreciate I may have blown a mental fuse by giving you so many ideas) – here are my thoughts on what I would consider your quickest and most cost-effective wins, in priority order.

1 Customer Nurture Email What is it?

A monthly email, ideally with a link to an additional resource (so you can increase your email click rates) like a downloadable advice leaflet or exercise handout on a specific topic.

Why is this a priority?

Because most likely you already have a database to start warming up your relationships with, and we’re looking for quick wins. Just because it’s not new and sexy, don’t dismiss it. It can also be done quickly. This should be the one activity you tick off, every single month without fail. You may not see results instantaneously, but I guarantee you will over time, if you’re consistent with it.

Set-up requirements (one-off job for all future emails):

l an email marketing platform subscription such as Active Campaign or Mailchimp (Mailchimp offers a life-time free plan for up to 2,000 unique email address) l a CSV/Excel spreadsheet containing the first name and email address of as many people as possible, ie. past clients, prospective new clients, etc.

Creation notes

l Write a short introduction that puts the leaflet into context, ie. why you’ve made it your topic of the month, and what’s important to know about that condition/injury. l Don’t go overboard or make it over-complicated. It’s about getting

a quick win. l Focus on explaining why the advice resource is important – explain why it matters to the reader. l Make the email any length you’re comfortable with (400–600 words is a good length but if you’re sending a link to a resource, you could get away with less, like 200–300). l Break the email text into lots of small paragraphs, so it’s not one big block of text. l Use a service like Dropbox or Google Documents to host the downloadable leaflet or, if you have the Co-Kinetic Full Site or Done-for-You Social Media subscription, use the Success Page URL for the campaign in question. l Estimated time is 1–2 hours (30–60 minutes to write and create email and 30–60 minutes to produce and set up the downloadable resource). l Using the Co-Kinetic content will enable you to complete this job in 15–30 minutes, saving you up to 45–90 minutes a month.

2 Distribution of LeafletBased Resources

Why is it a priority?

Because it’s cheap to create the resources (especially with a Co-Kinetic subscription where we do it for you). And it benefits everyone – it delivers a great customer experience to your existing clients, and it gives you huge reach for promoting your business more widely locally, while offering value to everyone who comes into contact with the resources. They’re also easy to share with colleagues and friends.

Creation notes

I’ve got to be brutally honest here – just get one of our subscriptions! The Massage Therapy subscription at just £9 a month is the cheapest of all our subscriptions and gives you a neverending supply of all these resources.

You’d be mad not to take advantage of it. You can also access them under all the other subscriptions we offer. You’re not going to find a quicker, cheaper, more professional resource that you can trust, for anything close to that price. Not even in China or India!!

3 Increase Your Number

of Google Reviews/ Facebook Reviews Why is it a priority?

It helps you get found (and if you don’t already, please make sure you have a Google Business listing set up – it’s super-simple, super-quick and free). Reviews are heavily favoured by Google when deciding how to rank pages, they even take into account Facebook Reviews, despite them being a ‘competitor’ business, that’s how highly they rate them. The review ratings also appear in your Google Business listing. The more good reviews, the more likely you’ll appear high in search results.

Creation notes

Set up your listing here (https://www.google.co.uk/ business/) and then get proactive about asking your customers to review you on either Facebook or Google.

4 Spice/Spruce

up your Facebook Page

Why is it a priority?

l People increasingly check businesses out on Facebook before making purchase decisions so it’s important to make sure you have educational content on the page, not just loads of promotional posts. l Wherever possible make sure those posts are designed to achieve the goals I outlined above, ie. email lead generation, conversationstimulating, engagement-focused. l It’s a great way to warm up prospective customers as well as build reputation, authority and trust.

Co-Kinetic Journal 2019;81(July):44-49

ENTREPRENEUR THERAPIST

l clinic TV displays; l display boards; and l banners.

Creation notes

l Make sure your posts, as often as possible, offer the viewer/ reader value. Make it worth their while to read/engage. This way they’re more likely to take action, or engage with the post. l Make sure the page is current, and the content is fresh. l The most important thing is BE CONSISTENT! Facebook likes consistency and over time, that will help increase your post exposure, which in turn will increase engagement, and it becomes a virtuous circle. If you’re going to take the ‘shit or bust’ approach, then it might be better to focus on another activity.

5 Blog Posts (if you have a website)

Why is it a priority?

Mainly for the SEO benefits (although this would ideally be supported by an SEO strategy which usually don’t come cheap). It also helps you turn your website into an email lead generation tool which if you’re doing your monthly nurture emails, is good news.

Creation notes

We provide a new monthly blog post in our Full Site subscription but equally you can write your own, or outsource it to a blog writer (you can find plenty on sites like Upwork.com). The only downside is if possible pick someone who is medically trained so that you know you can trust the content, and so you don’t need to rewrite the whole thing yourself. If you outsource, it MUST save you the time, otherwise you may as well do it yourself (or subscribe to us!).

Co-Kinetic.com

Inju Avoiding

muscle strength as well as of both technique run. Decent stamina and after combination slopes, run last the day, demand a energy to safe on the now sports to keep stay to have enough and flexibility is key if you’re going it’s just bursts of activity. mountains, (aerobic fitness) to for the downhill cash on a trip to the leading up ed fitness is needed do in the weeks your hard-earn anaerobic reduce your n you can spending preparatio t, as well as So, if you’re prepare. Any nce and enjoymen you don’t a waste if slopes. your performa will improve while on the risk of injury your holiday injury. reducing the suffering an for of chance top six strategies Here are our

Weight gain and loss

1. HubSpot’s Ultimate List of Marketing Statistics for 2019 https://spxj.nl/2MrMmap 2. Turning Email Leads into Paying Customers: Using the Powerful Hidden Influences of Nurture Emails [Article] http://spxj.nl/2BU2UO3 3. Try out our unique Marketing Grader Email Course https://spxj.nl/2Msu0F2 4. More Marketing Advice and Tips http://spxj.nl/2z1V3j6 References

io.co.uk

itphys

etic.com

www.co-kin

020 8819

ILIOTIBIAL

muscles and upper trapezius tensing your neck bracing yourself on when riding. Possibly along at scary speeds, uneven terrain, hurtling due to poor technique or stabilising yourself trunk. your pelvis and lower and swaying from muscles, in fatigue of these This too can result spasm and painful development of muscle as stiffness. trigger points as well

THE INJURY

to ride bikes, we Humans weren’t designed our feet on the ground. were created to have changes the weight Cycling completely spine, your muscles and distribution through an back and neck into but also bends the for that is often sustained unnatural position cycling time. Neck pain from lengthy periods of weak poor posture and usually stems from by neck hyperextension muscles. Pain caused is where you are going) (looking up to see issues on the bike, made worse by positional of flexibility. combined with a lack

YOUR REHABIL ITATION

will reduce pain and Manual therapy techniques as the cervical spine, stiffness by mobilising soft tissues. Massage well as the surrounding and deep tissue with trigger point therapy improve muscle spasm and release will relieve THE CAUSE your may be an effective core stabilisers around flexibility. Acupuncture Just as you have called as well. stabiliser muscles modality in treatment lower back, you have to hold include providing around your neck Physical therapy will deep neck flexors stretches to maintain your neck stabilisers When appropriate up. with head you your the importantly strengthening quickly it is left to flexibility but more are weak or fatigue will neck flexors. These goes from the base exercises for the deep trapezius muscle (that exercises and mini shoulder) to the tucking of tip chin the of to lots include of your skull to And your head. It’s best as you lean forward. sit-ups/crunches with support your head can from your local physical muscles fatigue you get specific exercises when these ‘stand-in’ and of your individual is different the back and sides therapist, as every experience pain in or underlying pathology by keeping the neck there may be other neck. Restore balance be routine whiplash) that could relaxed through a previous injury (like muscles loose and stretching exercises. complicating the problem. of strengthening and be also subconsciously Be aware you may

PREVENTION G TIPS BODY CONDITIONINtogether with the

work n The neck muscles girdle) stabilising muscles, scapular (shoulder and lower trapezius including the middle anterior muscle. muscles and the serratus the will also help off-load Strengthening these scapular and anterior upper trapezius, levator could include rowingneck muscles. Exercises the emphasis on pulling type actions with an push together, as well as scapular back and activities using Swiss ups and many other bands. balls and resistance can provide you with n Your physical therapist to manage your neck a rehab programme it. They can also prevent pain and preferably your ergonomics in offer advice regarding work. This is particularly your daily chores and or for hours at a computer important if you sit

1/2 WALL SQUAT

on the bike. If you’re n Change your posture or your handlebars reaching too far forward, the stem to shorten are too low, shorten bars and riding more your reach. Raise your on the strain you’re putting upright will reduce Don’t forget to change your back and neck. and at regular intervals, your hand positions out stretch, straightening sit up on the bike to the to vary the loads on your neck and back different muscle groups.

SETS

Cadiovascular Disease Depression

Dementia

✗

ng I Be Doi ? Should s of 5 – 17 Activity Age What ween the sical Bet sity phy If I’m us-inten o vigoro nefits ealth be better h ic ly will give even should be aerobities activity ity activ

REPS

Video: http://youtu.be/GIEr1Jgt

ng I Be Doi Should 64? Activity ween 18 – What Bet ity each If I’m cal activ ity

that stre r week times pe

150

ic physi cal activ ty aerob ic physi oderate-intensi-intensity aerob tes of m uts igorous rous-intensity ty or 150 of vigoalth benefits -intensi eater he volving major of at lea tes of moderate brings even gr done in

minutes

l 150 minur 75 minutes of v performed in bo

week, o ctivity should be

l 300 minu physical activity ivities should be ek.

ng I Be Doi Should of Age? rs Activity What Over 65 Yea h week, tivity eac ysical ac If I’m erobic ph

aerobic trengthening act ys a we more da

l Muscle-sgroups on 2 or

Living Long er and Strong er

7% Walking

ponse and dose-res

Active

mins/day

(5 days)

mins/day

(7 days)

g your daily out try breakin utes at a time starting f 10 min If you are bouts o shorter goal into Gradually increase cise the exer intensity Pick s you

1min

Join friends to make it more le enjoyab

2min

moderate y intensit

activitie activity tes vigorou tensity a physical derate-in physical aerobic of at least 10 minu find fun and intensity es of mo aerobic intensity up l 150 minut utes of vigorous- rformed in bouts igorous-intensity mix them r 150 of v or 75 min tivity should be pe r week tensity o days pe g l Aerobic aces of moderate-in health benefits alls on 3 or more r muscle groups, for plannin l 300 minutrings even greater nce and prevent f ne involving majo as a basis upon nce bala uld be do activity b llow. tion 2018 relied ities sho that enha ditions a 2019 Organisa not be inetic and con Health l Activities rengthening activ World abilities and should case. ©Co-K for Health, l Muscle-store days a week ally active as your Activity ation only individual s physic on 2 or m inform s on Physical in each s to be a ce and endation l The goal i Recomm l guidan medical advice e: Global list genera ed as specia Referenc is intend substitute for article a as ed in this al care or ation contain ual medic individ The inform

co.uk

motion.

ack-in-

info@b

Back

ion

in Mot

01603

501299

co.uk/

motion.

ack-in-

www.b

PHYSI CAL

ingbody.co.uk

TIP

l Aerobic ast 10 minutes

muscles.

Body

www.themov

10%

Moderates activitie living of daily

Moderate rous and vigo ivity leisure time act

diU

This Month’s Campaign is on

ic review : systemat OW mortality .ly/2S7BX and all-cause http://bit studies. activity of physical lysis of cohort meta-ana

g More s to Bein First Step

e: Domains Referenc

utes dai

l > 60 min e daily physical gorous - intensst 3 l Most of th d incorporate vi e, at lea and bon l But shoulngthen muscle

muscle

hZiY

Living Long er and Strong er

SETS

SUPINE COW STRETCH

Lie on your back on the floor. Cross your right knee over your left knee. Bring both knees towards your chest and hold on to your ankles if you can reach them, if not just hold further up the leg. You should feel a stretch to your buttock/gluteal

withou

14%

22%

Vigorous exercise and sports

derate t

es of mo

l 60 minut– every day

AhOYQ

SAVIN Ginfo@t hemov RESO journa ingbody.co.uk URCE 020 8819 l AND S FOR 4850MANU

nsity ivity Inte Dying How Act r Risk of s You Reduce

Falls

activity

QgrI

intensity not sing” Moderate talk, but think “Can = 7 or 8 intensity ing Vigorous ifficulty talk g” think “ D t pausin

✓

Type 2 Diabetes

% % 40 % 35 % % 30 30 25 30

Joint and Back Pain

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

Lie on your side, with both knees and squeeze your deep abdominalbent. Keeping your feet together, button inwards. muscles by Open your knees, drawing the belly start position. like a clam, hold, This is a good and return to strengthenin the g exercise for your gluteal (buttock) and muscles. Progress outer thigh/hip the exercises by opening your knees, like a clam, and extend your leg behind you, hold, and return to the start position.

nsity ate Inte Activity? y is Moder What orous Intensit Vig le of 0-10 Versus On a sca = 5 or 6

lly active

N WITH

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

SETS

The Moving

BY:

ise d Exerc ealth tandar H Gold S dations for n e m Recom ✗ Pill

planning

y.com mindandbod info@harris and Harris Mind ISTS y.com ndbod L THERAP MANUAminda Body L AND.harris www PHYSICA CES FOR 44882 VING RESOUR 01635

TIME-SA

IN ASSOCIATIO

SETS

L k info@physio117.co.u CES FOR PHYSICA Physio117 TIME-SAV ING RESOUR STS uk sio117.co. L THERAPI AND MANUAwww.phy journal 07754 432256

physica rcise If Exe ng more active. Staying ng from f sufferi k by bei ances o your ch Reduce your ris reduces

BY:

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

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

Was A

PRODUCED

This Month’s Campaign is on

REPS Video: http://youtu.be/vSrxia0

spine. your lumbar spine. muscle, pressure through your lumbar 200lbs of weak gluteus spine. through muscle, and long over puts your lumbar of pressure hip flexors through or hunched shortened 200lbs weak gluteus muscle, long pressure posture. and ofchin) inover puts 200lbsflexors gluteus Sitting slouched or hunched hip puts (poking long weak posture results forward posture. shortened slouched inover chin)and a head hip flexors Poor Sittingsitting or hunched

results shortened(poking for posture. postureand slouched as a basis in forward shoulders Sitting results a head rounded Poor sitting (poking chin) be relied upon forwardand sitting postureand should not ic 2019 Poor only and a head rounded shoulders shoulders and information each individual case. ©Co-Kinet rounded in guidance as general medical advice is intended for specialist in this article a substitute contained care or as The information individual medical

ITB STRETCH

Open your legs slightly wider than shoulder resting against width, stand a wall, and bend with your back You can either your knees to go up or down, the or hold the down 1/2 squat position. your knee to ‘knock’ inwards, position. Do keep it not allow with your middle toe. This exercise aligned strengthen your will help to quadricep muscles, and legs knee joints

BIKE SET UP TIPS

220 220

Changes es Muscular lar Chang Causess Many Changes Many Muscu d Posture Muscular re Cause Poor Seate d Postu Causes Many Poor Seate d Posture Poor Seate

OF POUNDSS OF COMPRESSIVE POUND

CLAM

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

20” 20” 460 20” 460 460

20” 20” 260

220 10” Bent Sitting, 20” Bent lifting 260 over leaning 10” Bent Sitting, 170 lifting Standing 20” and 260 over 1lb Bent lifting forward 10” Bent over leaning Sitting, Standing 20” upright 170 from 1lb 20lbs lifting away Standing 20” lifting and Bent over 1lb lifting over leaning 20lbs forward upright from lifting back 170 Standing away 20” low uprightfrom Standing from and 20lbslifting over 1lb 20” 20lbs away lifting 1lb forward lifting away 20lbs low back 20” uprightfrom Standing from 20” upright lifting from away 20lbs low back away away back 20lbs 10” low from BACKlifting 1lb 20lbs upright lifting away from lifting low back 20” away low back back LOWER 80 low from 20lbs from away back lifting away upright 10” low backON 20”low FORCE Standing from back LOWER BACK 80 away back ESSIVE 10”low low BACK FORCE ON backCOMPR 80upright Standing SlowOF ON LOWER upright COMPRESSIVE FORCE StandingPOUND

LOW LOW LOW

PROGRESSION

6uEM

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

labour involved in manual driving, or if you are as these could all be and lifting/carrying, in pain. Small changes aggravating your neck chores your work and daily how you carry out in neck posture can make a big difference and subsequent pain.

TE MODERA TE MODERATE MODERA

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

REPS

HIP FLEXION WITH EXTERN ROTATION BILATER AL AL

SETS

20” 20” 635 20” 635 635

HIGH HIGH

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

LEG SWING SIDE

Video: http://youtu.be/4KAS7li

Important tant is Particularly larly Impor Correctly Important is Particu Why Lifting Correctly is Particularly Correctly Why Lifting Why Lifting

BAND STRE TCHES

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

SETS

neural causes ces,neck back and disturban pain, Poor posture stress, and chronic sleep neural tion and ces,neck back degenera posture, causes disturban chronic disc migraines Poor neural sleep strain, causes .ces, tion and , stress, posture , muscle disturban degenera Poor disc migraines sleepproblems problems tion and more , stress, manystrain, . , muscle disc degenera migraines problems more problems . muscle strain, problems, many more problems many

RISK OF INJURY RISK OF INJURY INJURY RISK HIGHOF

PRODUCED

This exercise PROGRAMME programme has specific around upper exercises to thigh, buttock strengthen muscles and hip area across your as well as improve pelvis. In balance injury it is important order to achieve proper rehabilitation to ensure the of your technique. Poor exercises are practice may performed with place potential following leaflet good strain on your includes some injury. The exercises to help in your rehabilitation GUIDANCE . FOR Hold all the stretches STRETCHING EXERCIS for 20 seconds ES each and repeat them five times

MANAGEMENT AND REHABILITATION

Wrist Back Wrist 33% Back 63% Wrist 33% Back 63% 33% 63% Neck Neck 53% Shoulder Neck 53% Shoulde 38% r 53% Shoulder 38% neck pain, 38% back and chronic pain,

.uk

HAN DOU T

Matters

Areas of of Common Areas re of The Most Common Postu Areas Most Pooron re The Comm from Pain Most Poor Postu re The Pain from Poor Postu Pain from

vingbody.co.

www.them

ovingbody.co

NG NECK PAIN AND CYCLI

PRODUCED BY:

info@themo

4850

EXER CISE

ADVIC E HANDO UT

The Final Word

Further Resources

Time off work, money worries, relationship concerns

and mood swings

info@summ

ure Why Post

ow many nights have you spent tossing and turning with often brought back pain, trying every on position awkward sleepingby strain from bad posture, comfortab le and getting possible to get positions, lifestyle habits up the next stress feeling more morning like poor nutrition, and other exhausted consumption than when to bed? alcohol you went and weight gain, to name a few. Worse still, just you spend the next day irritable and Here are 6 strategies weary, only feeling along with accompan to repeat the over again ying exercises, cycle all the next night? that you can to help you that one in Well, it’s something use banish those three of us sleepless nights experience for good, and point in our at some allow you to life. refreshed and wake And as if dealing ready for action. up feeling with back pain the day isn’t during hard 1 ADOPT tends to increase enough, this pain often THE RIGHT night, meaning in intensity through SLEEPIN the G POSITIO the resulting only impacts N lack of sleep on your ability not Refer to our following day, to function leaflet “Sleeping the but Pain” with Positions for lead to depressio can also cause anxiety accompan Back and n. ying videos, position that’ and pick a The chronic s most comfortab back pain cycle is relentless, le for you. it takes more Many people of a toll on find that lying back is the our than most on their most comfortab of us appreciate emotional state back pain. le position , and sleeplessn plays a pivotal Place for role in ess and keep your a pillow under your knees What’s interesting that downward spiral. spine neutral. however, is important The pillow back pain that most — it works isn’t caused is to keep that by serious your lower conditions curve in medical back. like cancer or arthritis. How does Instead, it’s this position sleep on your help? When you back, your weight is evenly distributed and spread Being across the area of your widest less active body. There is less strain pressure points on your and you can alignment achieve better of your spine. Loss of If you don’t ﬁtness,muscle find that comfortab try sleeping weakness, le then on your side joint and use a between your stiffness pillow knees to adjust position and your body improve the alignment spine. If you of your roll onto your THE back once fallen asleep you’ve on your side, and this causes pain, tuck CYCLE OF a pillow behind your back prevent you to from rolling Create a CHRONIC backwards. ‘no go’ list Try and avoid sleeping on of things side all the the same can’t do BACK PAIN time as this can imbalance s and increased lead to muscle pain, try and sure to sleep make on both sides equally. How does this position your side alone help? Sleeping won’t make on It’s using the you feel better. Sleep pillow between problems, the trick. The your knees tiredness pillow will that’s keep and fatigue and spine in better alignment your hips, pelvis, Stress, fear anxiety, . If you have anger and a herniated frustration position is disc then the likely to be fetal the most comfortab position to sleep in. Tuck le your knees your chest toward and gently curl your torso your knees toward and remembe r to switch from time sides to time to prevent any The Movin imbalance g Body s.

Negative thinking, fear of the future, depression

Summit Physio 2738 0800 731

Sleep Strate gies For Back Pa in Sufferers

er you’re are fun. Wheth ng it, snow sports 40 mph, or explori doubt about in at ent, a mounta There’s no involve excitem the side of fun sports always hurtling down much more sports are terrain; snow backcountry tion. But snow and exhilara from the adventure fit. limp in early physically having to injured). when you’re worse than even worse, ed or sore (or There is nothing fully prepar e you’re tired if you’re not for and becaus ts ted slopes workou exhaus are major will you be , not only Snow sports of injury, let’s for your holiday at a much higher risk physically cast. also plaster but you’re e, in home in a most of it, as possibl wants to come you as fit chance to face it, nobody this guide is to get of you the best So, the goal e, and give t time possibl holiday. the shortes injury-free e, have an awesom

The UK-based website XL Displays (https://www.xldisplays.co.uk/) had the widest range of ideas I could find, but it provides inspiration wherever you are in the world.

I think that’s pretty conclusive and there’s not much to add. What I would say, though, is please be aware of the time you spend on your marketing. Are you making the most effective use of your time? Assuming you had customers to treat in the time you spend on marketing, how much does that make your time worth? Have this figure in your head every time you spend time on marketing activities. Is it £35, £55, £75 an hour? If you’re spending the average 9.3 hours a month that our survey reveals most practitioners are spending on marketing, calculate what that would be worth, in revenue if you were seeing clients in that time. In most cases, the time you are spending marketing will be costing you anything from £350 to £750 in lost patient-time. If you can find a way of doing your marketing more quickly, and getting better results (ie. actually generating new paying customers), while also spending less time on things you don’t like doing (ie. marketing), and more time on things you do like doing (ie. treating patients), then it should be a no-brainer. Remember, if you can generate the client bookings, then your time is not free.

ES FOR STRATEGI Slopes ry on the

This Month’s Campaign is on

Living Long er and Strong er

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

Co-Kinetic Subscription Prices

Massage Therapy – £9 per month Physical Therapy – £11 per month Done-for-You Social Media – £29 per month Full Site Subscription – £97 per month *All subscriptions include access to the patient information resources described above.

PATIENT RESOURCES

The Biopsychosocial Explanation Biological (Your Body)

Chemical Breakdown Physical Illness

General Health Diet

Genetics Exercise

Nature

Sexual Performance Depression Fear

Family History

Anxiety

Sports Activities Abuse Trauma

Friendship Financial Concerns

Family Dynamic

Grief

Past Experiences

Psychological (Your Mind)

Injury

Nurture

Mental Breakdown

Sleep

Age

Loneliness Experience and Outings

Society Expectations

Socialising and Entertainment

Relationships

Isolation

Employment

Cultural Beliefs

Social (Your Environment)

PRODUCED BY:

TIME-SAVING RESOURCES FOR PHYSICAL AND MANUAL THERAPISTS

The Cycle of

PATIENT RESOURCES

Being less active Time off work, money worries, relationship concerns

Loss of ﬁtness,muscle weakness, joint stiffness

THE CYCLE OF CHRONIC PAIN

Negative thinking, fear of the future, depression and mood swings

Create a ‘no go’ list of things can’t do

Sleep problems, tiredness and fatigue

Weight gain and loss Stress, fear anxiety, anger and frustration

PRODUCED BY:

TIME-SAVING RESOURCES FOR PHYSICAL AND MANUAL THERAPISTS

NEW SUBSCRIPTION LAUNCH

Done-for-You Social Media PRODUC

the to strengthen and exercises balance e has specificimprove muscle best programm It will To get the This exercise your shoulder. and upper back. technique, around blade with good muscles Poor shoulder correctly. of your the exercises stability perform slowly and you must . Do them benefit injury. g and alignment positionin lead to strain and can practice

SETS 1

REPS 10

Arm Push

Renfpc Video: tu.be/aJlfS http://you

Against

to a with two Lean forwards backwards a band tucked and pull your elbows hands keeping and shoulder is a back in. This ing exercise. strengthen REPS 10

Treatm ent & Rehab l Manua l therap y for pain and to Trainin improve g Tips reduct l RICE, ion mobili strapp ty l Monit ing l Stretch or mileag e and progre l Impro tight should intensity, ssion er structu ve l Avoid gradual res l Streng upper back excess mobili then ive use l Stroke of weak shouldshoulder blade ty correc tion: flat paddles and the midlin and er muscle l Postur kickbo hand entry, e, high ard e correc s throug elbow don’t cross tion, lifestyl chang h, body recove es (comp l Use roll ry and fins to uter work e pull l RICE, offload l Use etc.) strapp other stroke shoulder ing l Soft l Impro tissue ve kicking s, cross train NECK joint mobili work, massa power PAIN ge and l Avoid sation l Streng l Gener kicking then l Warm sets al dull hips, buttoc thigh muscle ache across up adequ around l Breast s and ately k muscle / l Stretch stroke l Sharp neck l Poor s. pull sets l Narrow poking techni l Impro hip joint to rest l Heada que all pain er kick l Poor ve ankle knee stroke che postur s flexibility l Stiffne e – chin l Weak l Spine forwar ss should mobili d l Pain er muscle l Weak dry needli sation or on specifi stabilis s ng, massa manipulation c ing muscle movem front of l Streng BACK ents , ge, heat the neck s PAIN then deep l Stroke l Stretch l Dull correc neck muscle tion: body ache across body roll, l Postur tight muscle s l Sharp alignm s lower bilater e correc l Avoid ent in pain at back al breath tion and in ergon l Stiffne excess specifi l Poor ing, good water, chang ive use c level omics ss techni e undula of kick l Referr que all l Weak tion board stroke ed pain core s into buttoc l Weak and leg l Spine gluteu ks mobili l Pain s and hip muscle dry needli sation or with certain s ng, massa manipulation movem l Streng MUSC ents or , ge, heat LE then core l Avoid activities CRAM muscle muscle l Sudde excess P s ive use s and l Stroke n unexp l Stretch of pelvis – buttoc of correc ected sharp tion: body kick board pain ks and better l Make upper back l Debili hips. rhythm l Tight roll, good and hips chang , impro tating for breast hips, and es to undula ve power home l Stiff, l Poor stroke tion, upper to correc work/school/ tight muscle in pull postur and butter t postur and kick e, excess back sitting l fly e Stretch ive , l Fatigu lifting etc l Massa e ge l Muscle l Heat in l Variety or tense a semi contra throug cted, positio h sessio stroke n prolon s n, chang ged period for l Relax e routine legs while s and l Condi kicking tioning l Avoid to avoid doing fatigue a heavy immed leg streng iately prior thenin to a swim g sessio session n

CHEAT SH EET

arm, push With a straight ball on the a Swiss against exercise is a great wall. This stability to improve shoulder. to your both sides. Perform

Arm Bent Double with Band angle, Over Row 45 degree

SETS 3

REPS 10

Video:

Fp0l-izM tu.be/0Qa

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

TIME-

SAVIN

G RESO

considered sport due a ‘low-impac to the fact t’ supports that the explore the injuries your bodyweigha large percentage water that are sink your of most likely t. And exactly swimming that reason to efforts. for it’s rehabilitatio often used in the n of injuries The Shoulder affected by weightbea to joints If you’ve back, hips, ring ie. invested knees and even a moderate ankles. However, amount if you swim of training general for swimming time fitness, or up and down that in the risk black lane of developingcompetition, it’s likely line, high because an overuse that you will have injury is of the repetitive encountere nature of d some the shoulder ‘swimmer’s and forceful form of as stress shoulder.’ swimmers on the back, revolutions as Given that well annually the water. to hold perform thousands you level hundreds of in In fact, 84% of no surprise arm rotations it should be to learn from overuse of regular swimmers that and this type frequency type injuries. suffer all of this of work So, what the shoulder places a lot of mean to does stress on you? swim? You muscles and joint. It will probably should reduceYou shouldn’t change your training come as that swimmer’s your sport? no surprise, or Let’s face who is prepared shoulder common it, is the anyone to have injury in water for swimming. most basically hours, essentiallytheir head in a blanket It is the in a solitary term for participatin things that sport, must a number g can therefore love doing of the shoulder be injured in want to it and and be able injury risk to manage revolution, joint. During one around and still arm the The benefits continue to swim. their of impingeme shoulder is in it’s for general of swimming nt (pinching a position for 25% - whether structures) fitness and of the time. the desire physical a million Multiply to win competitio activity, that by strokes find your hardly surprising per annum ns, or just quiet place and it’s to outweigh for stress that there cumulative the risk relief - far will be some of injury. damage With this structures. to the squashed in mind, a set of we’ve put resources And before together to help or better you assume you manage, that only yet it’s an injury affects freestyle altogether. prevent, swimming swimmers, injuries the research and butterfly shoulder has shown injury is SINK OR that common strokes, SWIM across all at any age So, let’s THE INJURIE or level competitio dive in at of swimming the deep n. It doesn’t S This may end and discriminat be due e! to the fact strokes between that with all 50–90% of the power

Explores Prevent How to Treat and s Swimming Injurie OUR EVENTS AND

LATEST RESOURCES

TER LET EWS N ER TOM CUS

TIME-SA VING

POSTERS LE SOCIAL M AFLETS & EDIA AD S

TIME-SAV

ING RESOURC

£ 29 £ ISABLE CUSTOM GE PA SIGN-UP

RESOUR

CES FOR PHYSICA

L AND MANUA

L THERAPI

STS

URCE

S FOR PHYS ICAL

AND

MAN UAL

THER APIST

Full Site Subscription

BY:

ES FOR PHYSICA

L AND MANUAL

INT ERPO POW NTATION E PRES

THERAPI

STS

PR PA OSP YIN EC T G CL TO IEN T

TH ON LE) RM B PE ARIA V RS OU L & 6 H NA 2 – PTIO (O

es Explor Treat How to event and Pr ries ju ing In UT OUR CES Swimm DETAILS ABO RESOUR T US FOR LATEST CONTAC NTS AND EVE

for planning

STS

l Pain inner side l Swellin of the knee g l Very sensiti ve to touch l Stiffne ss

Signs & Sympt oms l Pain in front and back should of er l Pain down arm or neck up to l Painfu l arc of l Pain movem sleeping ent l Pain on with swimm side ing

PRODUC

Swimmi ng is one of the most We swim popular in the sea, sports in And given pools, lakes, the world. 70% of the streams, opportu rivers and Earth’s surface nities. even ponds. is water, we’re not short of wimming is

DETAILS ABOUT

L THERAPI

The informa tion contain ed in this individu article is intende al medica d as genera l care or as a substitu l guidan te for speciali ce and informa tion st medica ED BY: l advice only and should in each individu not be relied al case. upon as ©Co-K inetic 2019a basis for plannin g

Sink or Sw im?

Treating and Swimming Preventing Injuries

THIS MONTH’S CAMPAIGN

MANUA L AND

Comm on Cause s l Poor stroke techni l Weak que compo nents should in er compl l Poor ex postur e l Stiff upper back l Lack of should er blade stabilit y l Overu se

Comm on Swim ming In juries

PHYSICA CES FOR

RE LA NU TION RT SH UR IP E

ES UT IN TH 0 M ON –2 10 ER M P

PO STC AR D

AUTORESPONDER EMAIL

VING RESOUR TIME-SA

SWIM MER’S SHOU LDER

ST PO OG L B

BY:

muscle and buttoc s around hip ks l Wide kick l Stiff ankles

ETS LEAD MAGN PRODUCED

l Weak

khtzYbKk Video: tu.be/e6m http://you

BREA STSTROKER’S KNEE

SETS 3

Postcard front

nee pain is often associated running and jumping with sports. ie. high side which Swimming impact one of the function twisting to restrict safest sports is perceived movemen because sideways to participate as ts in the the and Breaststro knee. in, lower limb water takes the – repeated, on the medial kers put tremendo joints. However, weight off common the quadricep forceful contractio us pressure (inner knee pain of their among s (thigh) n of the knees during side) compartm people of breaststro muscles, strains the who perform is ents the legs the kick loads and patellar extend often known ke swimming, a lot phase. When tendon pain. This and are during the resulting can be as ‘Breaststro which is why in propulsive snapped together due to an weakness Whether ker’s Knee’. it’s knee is underlying phase of of you are subject specialist a breaststro the kick, strengthen the quadricep to forceful (legs turned or the ing programm s muscle. A external swimmers not, 3 out of every ke out like the gluteus e including the knee a ballerina), rotation report 4 and hip was not The breaststro breaststro as stretching for which muscles designed. ke knee ligament as well ke kick throughou pain. The inner of movemen is hardly help to t the year collateral the knee, called side t and can prevent a natural can 2. Fat the this ligament, swimmers trigger pad irritation. injury. knee Repeated is then put medial . Though pain in at risk due non-speci stress can under stress. all a small, The ‘fat and result alists may strain the to soft-tissue pad’ is kick, specialistslack of conditioni in inflammat be ligament structure front of pain. Although your knee, ng for the on ion, swelling may have risk due which may the pinched not an impact an even and to much repeated between higher greater rotational training sport, the your kneecapbe (patella) breaststro volume. turning strain and ke on the knee Although the feet breaststro bone (femur).the front of your out and eliminating degenerat (from ke knee thigh pushing) Although pain may you can all ion to the it’s highly can cause it’s only take steps be unrealistic cartilage medial sensitive, small, (inner side) in the knee occurrenc towards be excruciatin , and the reducing e. over time. pain can The forceful its get pinched g. The fat pad long-lever the legs tends adduction (squeezing to WHAT locked-ou when your knee HAPPEN of enormous them together) t position is in a The knee S IN YOUR twisting over straighten (over-exte puts force on If the joint is a large nded/ KNEE? ing); in swimmers the knee. formed weight-be is this occurs by the lower stable, the not sufficiently aring during a strong and and upper risk of injury thigh bone joint stroke on forceful repetitive part of the down the leg (femur) increases. along with contractio kick in freestyle butterfly. shin bone Forceful muscles n of the the (tibia) and (in the adductor which helps small kneecap to the tendon inner thigh) (patella) can WHAT bone knee joint. the muscles work DO of the knee. attachment on cause injury across the Symptoms YOU FEEL? the inner Resulting The joint chronic of in a tendonitis side needs to tendonop could include: breaststroker’s activities or from walking, be strong for also contribute athy over knee all l General squatting to medial time, which can and sitting. running, jumping, knee pain. l Inflammatknee pain activities Some of generate Two other these ion forces l Point times your types of specific swimmers knee pain body weight. in excess of pain, hypersens cartilage , although can affect to touch Within the 8 (meniscus common: they’re on itive area knee is much less ) which absorber or directly the inner side of acts 1. Patellofem and l Swelling over the patella the knee of the bones allows smooth as a shock oral pain movemen tendon tendonitis against and patellar l A sharp of the knee bend and t each other . straighten pain when knee often Pain in the front when you is supported the knee. of the under stress, placing just below The joint occur in by thick like bending the knee all swimmers the kneecap, ligaments lower leg can it with the on either is related and foot l Pain turned outwards to flip turns, of any stroke. It squatting wall, and down l Mild the butterfly pushing off the stiffness and flutter after prolonged or in the PRODUCED kicks morning. sitting BY:

REPS

Video: 0Of3lSPKk utu.be/c4 https://yo

arms straight. with your tucked under position, p ktw5dQ0I Video: Press-U your bottom by bending in a press-up tu.be/mAE line, with yourself the floor back http://you Position a straight body in chest towards is a chest, core, This Keep your PushDrop your position. this do a back flat. l the start and your ed your To progress Return to straighten exercise. Desk Externa up and the elbows. strengthening with n with Band pushed Rotatio forearm on a desk,rotate and shoulder is when you have your into the that Resting 90 degrees, the Up PLUS. more down a bent at push even your arm away from back like elbows, outwards with the your upper your arm for the a resistance with floor raising ing exercise this in contact table creating cat stretch. elbow stays is a strengthen you can perform the at band. Your whole time. This you elbow As you improve the REPS 10 ed and muscles. the desk shoulder arm unsupport SETS 3 rotator cuff with your standing shoulder. 8J3cprDY Video: exercise as your tu.be/XRL http://you same height

PRODUCED

l Turn your social networks into a 24/7 emailgenerating tool for your business l Increase engagement on your social media pages l Build authority and reputation l Offer high value downloads to your social network followers l Save yourself time and money l ZERO technology skills needed

exercise Hold an in, keeping elbows your body. Tuck your next to your 90 degrees up. Move bent at palms face a stretch in Place your to create time, This the same arms outwards band. At of the back. muscles, the exercise shoulder blade the midline seconds. your blades towards Hold for 10 contract your shoulderfor your shoulder. drawing exercise is a mobility 10

REPS 10

SETS 3

Knee Pa Swimmin in ers

with Band hands. Dumb Waiterband in your them

exercise upwards. Place an other end side (45 and lift the slightly to the you have out your arm front). When arm back from the degrees move your mobility your limit, will improve reached exercise Perform down. This to your shoulder. and strength both sides.

SETS 3

’S ONTH THIS M IGN CAMPA

Benefits

needs. specific n. to your progressio adjusted added for at any time you may be may be this. If These exercises can other exercises you through so they it therapist will guide As you improve therapist your physical than simply stopping t consult Your physical rather or discomfor programme, ion feel pain rehabilitat adjust the all together.

s 45 Degree your foot, Band Flexion band under Take

COLLECT EMAILS

S TE NU H MI NT O 10 5– ER M P

Done-ForYou Social Media Subscription

TION WITH ED IN ASSOCIA

ening r Strength r’s Shoulde Swimme

HANDOUT EXERCISE

EM GE AIL NE LE RA AD TIO N

IA SOCIAL MED OS POSTS & VIDE

NEW PAYING CLIENTS ALL FOR

PER MONTH

What does the subscription include?

l A new campaign topic every month l 25 new ready-to-post pieces of social media l A simple inbuilt scheduling tool to post your social media for you l High value pieces of content to attract email sign ups l A new email sign up page for each campaign l A lead magnet delivery page where your new email leads can download their high value content

Everything is taken care for you It takes just 5 minutes to set up a campaign that lasts for a whole month All you have to do is set it going in 4 easy steps

For more information visit www.co-kinetic.com/dfy