Co-Kinetic Journal Issue 82 - October 2019

ISSUE 82 OCTOBER 2019 ISSN 2397-138X

1999 – 2019

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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

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DISCLAIMER While every effort has been made to ensure that all information and data in this magazine is correct and compatible with national standards generally accepted at the time of publication, this magazine and any articles published in it are intended as general guidance and information for use by healthcare professionals only, and should not be relied upon as a basis for planning individual medical care or as a substitute for specialist medical advice in each individual case. To the extent permissible by law, the publisher, editors and contributors to this magazine accept no liability to any person for any loss, injury or damage howsoever incurred (including by negligence) as a consequence, whether directly or indirectly, of the use by any person of any of the contents of the magazine.

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CLICK ON RESEARCH TITLES TO GO TO ABSTRACT Skeletal muscles make up roughly 40–45% of the total human body mass and are essential to sustaining life. Their proper function permits mobility, joint stability and postural maintenance, as well as breathing, metabolic control, thermoregulation and energy storage.

Muscle injury is common in sport; for example, in soccer players they typically occur in the lower limbs affecting the hamstring (37%), adductor (23%), quadriceps (19%), and calf (13%) muscles and range from minor strains and bruises to partial or complete muscle tears. Strains can potentially be complicated to treat if a tear occurs at the myotendinous junction, as is often the case in injuries of the rotator cuff or lower limb muscles. Although minor muscle trauma heals without severe consequences, no reliable clinical strategy exists to prevent excessive fibrosis or fatty degeneration, both

CELL THERAPY TO IMPROVE REGENERATION OF SKELETAL MUSCLE INJURIES. Qazi TH, Duda GN Ort MJ et al. Journal of Cachexia, Sarcopenia and Muscle 2019;10(3):501–516 of which occur after severe traumatic injury and contribute to muscle degeneration and dysfunction. This essay looks at current conservative and surgical management but its main thrust is about cell manipulation relating to remodelling scar tissue, promoting myofibre regeneration, and reversing fatty deposits that plague the muscle after severe injury. Existing limitations of cell therapy approaches include issues related to autologous harvesting, expansion and sorting protocols, optimal dosage, and viability after transplantation. Several clinical trials have been performed to treat skeletal muscle injuries using myogenic progenitor cells or multipotent stromal cells, with promising outcomes on feasibility for muscle regeneration depending, to an extent, on the

muscle injury model used. Recent improvements in the understanding of cell behaviour and the mechanistic basis for their modes of action have led to a new paradigm in cell therapies where physical, chemical and signalling cues presented through biomaterials can instruct cells and enhance their regenerative capacity. Altogether, these studies and experiences provide a positive outlook on future opportunities towards innovative cell-based solutions for treating traumatic muscle injuries.

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Co-Kinetic comment This is a heads-up for the future rather than something that will help physical therapy now. The authors are very optimistic about the capacity for influencing muscle growth, not just with the sporting population but with traumatic injury from any cause as well as degenerative conditions such as muscular dystrophy. Watch this space.

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INTERSECTION SYNDROME: AN ACUTE SURGICAL DISEASE IN ELITE ROWERS. Hoy G, Trease L, Braybon W. BMJ Open Sport & Exercise Medicine 2019;5(1):e000535 Intersection syndrome is a relatively common condition in elite rowers which affects the lateral side of the forearm when inflammation occurs at the intersection of the muscle bellies of the abductor pollicis longus and extensor pollicis brevis where they cross over the extensor carpi radialis longus and the extensor carpi radialis brevis. The mechanism of injury is usually repetitive resisted extension, as with rowing, weight lifting or pulling activities. It is often misdiagnosed as De Quervain’s tenosynovitis.

There is some controversy over what it actually is and it has been described in the literature as tendinitis crepitans, traumatic stenosing tenosynovitis, tenovaginitis and compartment syndrome. Clinically, it presents as tenderness on palpation of the intersection point, 3–8cm proximal to Lister’s tubercle, focal swelling and crepitus to both palpation and auscultation.

This is a review of a case series in a national rowing squad and the effect on time loss produced by the condition. Approximately 5% of the squad suffered intersection syndrome during a 3-year period.

The condition affected between 20 and 40% of sufferers’ training time in the observed 3-year time period. The authors consider it to be a true tendinitis of the second wrist compartment caused by fascial compression from hypertrophied first compartment muscles. They advocated early surgery and almost immediate return to training in order to minimise muscle wasting caused by the condition and technique modification. Doing this they were able to get five of six rowers to achieve career goals in a matter of weeks after surgical intervention.

Co-Kinetic comment Have you noticed that almost everything described as ‘a syndrome’ does not have a definitive diagnosis? That doesn’t really matter as long as they get fixed does it? Surgery here, however, is a wristy [groan] business.

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Co-Kinetic Journal 2019;82(October):4-7

RESEARCH INTO PRACTICE

Journal Watch Physical Therapy

ADDUCTOR SQUEEZE TEST AND GROIN INJURIES IN ELITE FOOTBALL PLAYERS: A PROSPECTIVE STUDY. Moreno-Pérez V, Travassos B, Calado A et al. Physical Therapy in Sport 2019;37:54–59

During preseason training, 71 players in the Portuguese First Division had their maximal hip adductor strength measured via a isometric adductor squeeze test. Hip adductor strength, normalised by body mass, was compared between players who suffered a groin injury (n=18) versus uninjured players (n=53). Most of the reported groin injuries occurred during competitive matches (5.5 per 1000 match hours). Maximal isometric hip adductor strength was lower in the groin-injured group compared with their uninjured colleagues. Maximal isometric adductor strength lower than 465.33N increased the probability of suffering a groin injury by 72%. Force relative to body mass lower than 6.971N/kg increased the probability of suffering a groin injury by 83%.

Co-Kinetic comment Stronger lasts longer. It seems obvious but it is nice to have the proof.

WHEN IS IT SAFE TO RETURN TO SPORT AFTER ACL RECONSTRUCTION? REVIEWING THE CRITERIA. Kaplan Y, Witvrouw E. Sports Health 2019;11(4):301–305

The information here came from a database search using the words ‘return to play’ and ‘return to sport’ in combination with ‘guidelines’, ‘criteria’, and ‘anterior cruciate ligament reconstruction’. After research quality was taken into account, 83 papers were examined. Five principal criteria were found, including psychological factors, performance/functional tests, strength tests, time, and modifiable and nonmodifiable risk factors, although there is, at present, very little evidence for the validity of the physical tests. The paper stresses the importance of minimising re-rupture via the psychological factors including fear of new injury, repeated injury, and lack of trust in the knee. Athletes who were more

psychologically ready to return to play were more likely to return to their preinjury level and do so faster. People under 20 are 6.3 times more at risk of reinjury than those over 20; additionally, 35% of the younger group sustain a second injury.

Co-Kinetic comment There are a lot of ACL reconstructions going on. In the USA alone there are 250,000 annually, which is a lot of rehab work for therapists. This paper is a ‘must read’ if you are one of them.

The sections on psychological factors and risk are particularly relevant in preventing reinjury.

THE EPIDEMIOLOGY OF OVERUSE INJURIES IN ICE HOCKEY: AN ANALYSIS FROM 29 SEASONS IN THE SWEDISH ELITE LEAGUE. Jonsson J, Jonsson M, Tegner Y. Orthopedics and Sports Medicine 2019;2(4):doi:10.32474/ OSMOAJ.2019.02.000143 An overuse injury is considered to be the result of iterated microtrauma or monotonous movements that cannot be related to any particular event. The absence of a specific trauma often delays the diagnosis. These types of injuries are often ignored because of the limited amount of pain and functional loss. The athlete often continues the exercise without sufficient time for the affected area to heal, resulting in increased dysfunction and severe pain.

In technical sports, as well as in team sports, overuse injuries are commonly due to the considerable amount of training hours and monotonous repetitive movements. Typically, athletes in cycling, running, swimming, crosscountry skiing and skating suffer from them.

All injuries and all attendances at training and games were registered in all the players in a Swedish ice hockey Co-Kinetic.com

team in the Swedish Hockey League.

The records from the season 1984/85 to the season 2012/13 were included in the study. There were 6496 training sessions, on average 224 per season, and 1784 games.

In total, 1942 injuries were reported among 267 players. The definition of an overuse injury in this study was ‘a gradual onset injury caused by repeated micro trauma without a single identifiable event responsible for that injury’ and which resulted in absence from ice hockey. Applying this definition, there were 141 first-time overuse injuries and, including relapsing injuries, there were a total of 315 overuse injuries (16.2% of all injuries) in 99 players. They occurred in 13 body areas; by far the greatest number were the hip/groin (76.9%), followed by the back and knee.

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Co-Kinetic comment This is a great piece of record keeping. The stats are broken down into months when the injuries occurred, with the majority coming early in the season. Hence, the obvious lesson is a need to look at preseason preparation. According to the Total Sportek website, ice hockey is the ninth most popular sport globally, as determined by 13 factors including global base and audience, TV ratings, player salaries, gender mix and number of countries playing in the top competitions. It is played in 76 countries and UK readers will be glad to know that the Great Britain men’s team are now in the top world pool along with the big boys such as Canada and Sweden, so expect more and more injured players to come your way. For the record, the top three world sports were football, basketball and cricket.

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ASSESSING “PCL PLUS POPLITEUS” INJURIES. O’Neil S, Nord A, Dupree JI et al. Journal of Orthopaedics 2019;16(3):245–248 Posterior cruciate ligament (PCL) injuries account for about 38% of all acute knee injuries.

Roughly 56% of those occur in the setting of polytrauma and 30% occur because of a sports-related injury. In athletes, the injury most commonly occurs secondary to a direct blow to the tibial tubercle causing the tibia to translate

posteriorly, or as the result of a fall on the knee while the foot is in plantar flexion.

PCL injuries do not primarily occur in isolation, and it has been reported that other ligamentous structures may be involved in up to 95% of PCL injuries.

The most commonly associated ligamentous and soft tissue injuries include the anterior cruciate ligament (ACL), the posterolateral corner (PLC), and the medial cruciate ligament (MCL).

The posterior draw test is the standard assessment although some studies have doubted its efficacy. A PCL tear can be graded 1–3 dependent on the amount of tibial translation on the femur.

This study looked at 38 patients with grade 3 PCL laxity but no ACL problem.

Of these, 34 (89.5%) had a concurrent popliteus muscle injury. The four patients without the popliteus injury did have a

medial meniscus tear. Other injuries were MCL injuries (10.5% [n=4]), medial meniscal injuries (21% [n=8]), and lateral meniscal injuries (10.5% [n=4]). At the latest follow-up, 16 months on average, posterior drawer test results for all patients found 28.9% (n=11) classified as stable, 31.6% (n=12) with grade 1, 36.8% (n=14) with grade 2, and 2.6% (n=1) with grade 3 laxity. The authors speculate that the missed popliteus injury is a major contributing factor to the failed reconstructions.

Co-Kinetic comment There is no specific test for a popliteal injury and they tend to get missed on MRI partly because they get taken for a lateral meniscus injury. Maybe the answer is to assume it’s damaged and treat accordingly.

HIP INJURIES IN KICKING ATHLETES. Chahla J, Sherman B, Philippon MJ et al.

Operative Techniques in Sports Medicine 2019;27(3):138–144 Kicking sports (soccer and rugby) are among the most popular sports in the world. In the USA, soccer accounts for the fourth highest number of sports injuries with an incidence of 228,000 injuries per year. Of these, hip and groin injuries are common and range from 11 to 16% of all injuries in elite male soccer players.

The Doha Consensus Agreement (2015) on terminology and definitions in groin pain in athletes defined three areas of potential pathology: (1) defined clinical entities for groin pain (adductor, iliopsoas, inguinal, and pubic-related groin pain); (2) hip-related groin pain [femoroacetabular impingement (FAI), chondral, or labral tears]; and (3) other causes (such as anterior inferior iliac spine, ischial pathology).This review paper looks at different causes of hip and groin pain in each of these categories. The highlights of which are as follows.

For adductor- and psoas-related groin pain, MRI is the most reliable 6

and useful imaging study to confirm the diagnosis (86% sensitivity and 89% of specificity). Conservative treatment is typically successful with anti-inflammatory medication, core strengthening with physical therapy, and activity modification with an average return to sport in 2 weeks. Proximal avulsion fracture or complete tears with significant retraction may need surgical treatment.

For pubic-related groin pain, diagnosis is made clinically; however, radiographs, if performed, may show characteristic symphysis widening, sclerosis and lysis. The vast majority of instances are treated successfully with conservative treatment consisting of anti-inflammatory medications, injections, heat, activity modification and gentle stretching after symptoms have resolved.

The classification of groin pain encompasses a group of conditions with a wide range of eponyms and nomenclature including athletic pubalgia, sports hernia, sportsman’s hernia/groin, core muscle injury and inguinal disruption, among others. Inguinal-related groin pain is characterised by dysfunction of the

adductors, core musculature and abdominal muscles. It is strongly associated with FAI. Initial treatment is usually conservative management with anti-inflammatory medication, core strengthening/physical therapy and activity modification, but surgery is often required.

FAI has been identified as an important cause of hip pain in athletes, which often results in reduced range of motion and impaired performance.

Athletes with physical exam finding suspicious for FAI should receive radiographic evaluation. Conservative treatment can be tried but, again, surgery is an option.

Other causes of groin pain include anterior inferior iliac spine impingement and ischiofemoral impingement.

Co-Kinetic comment This is a superb piece of work. The same issue of the publication has similar articles for hip pain in contact sports, overhead athletes, endurance athletes and ice hockey goalkeepers and the bonus is that they are open access.

Everyone dealing with sporting hips should read them.

Co-Kinetic Journal 2019;82(October):4-7

RESEARCH INTO PRACTICE

Hamstring injuries most commonly occur in sports that require high-speed running or kicking, including soccer, football, dancing and sprinting – because of the repetitive kicking or sprinting associated with them – and they can have a substantial impact on overall function and ability to train. It has been reported that among track and field athletes, 26% of all injuries and 12–15% of all Australian football and soccer injuries can be attributed to hamstring injuries. The key fact from this paper is that the most predictive factor for hamstring injury is a previous hamstring injury. MRI is the most useful study for determining the extent of the hamstring injury and whether surgical intervention is warranted.

Conservative treatment is indicated for acute hamstring strains, partial tears and single-tendon avulsions. Surgical repair of complete proximal hamstring

Hip pain is the second most common cause of lower limb musculoskeletal pain, and is commonly seen in active individuals including 16% of football injuries. Hip and groin pain may have intra-articular and/or extraarticular causes. Acute muscular or musculotendinous injuries occur most frequently in the gluteal, hip flexor and groin regions. Pathologies of the gluteus medius and minimus, hamstrings, iliopsoas and adductor tendons and adjacent bursal or fascial structures may also be implicated in the development of hip pain in these regions. Extra-articular impingements have been described: ischiofemoral impingement of the quadratus femoris muscle, anterior inferior iliac spine or subspine impingement of the direct head of rectus femoris and iliocapsularis, and impingement of the iliopsoas tendon against the acetabular rim, adjacent labrum and iliopectineal bursa. It is also possible for the greater trochanter to impinge painfully into the superior or posterior soft tissues.

Femoroacetabular impingement (FAI) syndrome and the associated pathologies are common intra-articular causes of hip and groin pain in active individuals. It is considered a movement Co-Kinetic.com

HAMSTRING INJURIES: RISK FACTORS, TREATMENT, AND REHABILITATION. Heer ST, Callander JW, Kraeutler MJ et al. The Journal of Bone and Joint Surgery 2019;101(9):843–853 ruptures, both acute and chronic, results in improved outcomes compared with non-operative management. Repair of acute proximal hamstring tendon tears results in better functional outcomes than repair of chronic tears. Stretching and strengthening the hamstring tendons with eccentric exercise is useful for physical therapy after injury and may reduce the risk of reinjury.

Several studies have demonstrated that completing Nordic hamstring exercises immediately after sports training or physical activity has this preventative effect on hamstring injuries among soccer players.

Co-Kinetic comment This is a comprehensive review of all things hamstring.

Nothing really new but if you are interested in the subject there is an extensive references list.

CURRENT TRENDS IN SPORT AND EXERCISE HIP CONDITIONS: INTRA-ARTICULAR AND EXTRA-ARTICULAR HIP PAIN, WITH DETAILED FOCUS ON FEMOROACETABULAR IMPINGEMENT (FAI) SYNDROME. Kemp J, Grimaldi A, Heerey J et al. Best Practice and Research: Clinical Rheumatology 2019;33(1):66–87 disorder, where particular hip morphology results in abutment of the femoral head against the acetabulum resulting in pain. It is currently unclear if pain relates to abnormal morphology, or associated changes to intra-articular soft tissues. There are three types of FAI: cam morphology, which refers to extra bone formation on the femoral head–neck junction; pincer morphology, which refers to a deep or retroverted acetabulum (and subsequent over coverage of the anterior/superior femoral head); or thirdly a mixture of both. Clicking, locking, catching, giving way and pain on twisting may suggest the presence of labral or chondral pathology. Pain at rest and at night may indicate the presence of synovitis. FAI may be aggravated by prolonged periods of hip flexion. It has been suggested that kicking sports are a more common cause of hip pain, whereas sports, such as long distance running, gymnastics and dance may cause stress fractures. Notably, almost no tests have adequate specificity or positive likelihood ratios to accurately

confirm a diagnosis. Imbalance in muscle strength, range of motion and function can be measured clinically. For treatment, surgery is becoming less popular so physiotherapy with emphasis on hip and trunk muscle strength in all planes and correcting activity impairments.

Co-Kinetic comment This is the sort of paper we love. All you need to know about a condition and how to fix it. This one even has pictures of exercises. A highly recommended read.

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CLICK ON RESEARCH TITLES TO GO TO ABSTRACT A 50-year-old woman presented with a 7-day history of right lower extremity pain. She had a repeated history of pain in the back and right gluteal area, which had improved after L5 transforaminal epidural steroid injection. Physical examination revealed focal tenderness at the right gluteal muscle, where the sciatic nerve passes.

The patient had no previous history of trauma, except self-massage of the right gluteal muscle using a massage ball. There was no weakness of the right lower extremity; sensory impairment and dysesthesia were checked in the medial area of the calf muscle and the right sole area. At 8 days after pain development, an electrophysiological study was performed.

In the nerve conduction study, there was no abnormality of the motor and sensory nerves on both lower extremities.

However, needle electromyography

ISOLATED INJURY TO THE TIBIAL DIVISION OF SCIATIC NERVE AFTER SELF-MASSAGE OF THE GLUTEAL MUSCLE WITH MASSAGE BALL. A CASE REPORT. Cho JY, Moon H, Park S et al.

Medicine 2019;98(19):E15488 OPEN revealed active denervation with reduced interference pattern in the tibial-innervated muscles, but not in the peroneal-innervated muscles.

No abnormalities were observed in the quadriceps, adductor longus, iliopsoas or paraspinal muscles. The electrophysiological findings were consistent with right tibial neuropathy, proximal to the branch supplies of the hamstring muscles.

To rule out spaceoccupying lesions and to define the site of tibial nerve injury, an MRI of the lumbar spine and pelvis was conducted, which showed that there was no difference in the protruded L4/5

intervertebral disc as shown on previous MRI. However, the axial T2-weighted MRI of the pelvis showed high signal intensity and swelling of the right sciatic nerves, from the superior gemellus level to the quadratus femoris level. After considering both radiologic and electrophysiologic findings, the conclusion was that patient‘s right lower extremity pain was due to right sciatic neuropathy (mainly tibial component) at the gluteal area.

Co-Kinetic comment We bring you this one as a warning. Massage either by a training therapist or given as a self-applied home treatment programme is one of the safest treatments around but there are exceptions, especially when given with other treatments.

In this case, the poor women has had a pain dulling epidural and then managed to compress her own nerve to the point of damage. Ouch!

EFFECT OF OSTEOPATHIC TREATMENT ON A SCAR ASSESSED BY THERMAL INFRARED CAMERA, PILOT STUDY. Riqueta D, Houel N, Bodnar J-L. Complementary Therapies in Medicine 2019;45:130–135 Twelve subjects participated in this study. Four had scars from wounds and eight from operations. The majority of the scars were localised to the abdomen (seven scars) and to the thigh (three scars). Where the other two were is not reported. The mean age of the scars was 12 years (±10.9 years).

The scars were cooled with ice for 2min and then treated with percutaneous traction, which is basically a fascial stretch around the scar – first described

by Fourie in Leon Chaitow’s book Fascial Dysfunction: Manual Therapy Approaches [Handspring Publishing 2014. ISBN 978-1909141100 (https:// spxj.nl/2lTztco)]. The treatment lasted

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for 15min. The scar and the area around it was photographed using a thermal imaging camera.

The theory behind this approach is that the scar appears as a hypothermic area compared to the surrounding peri-scar tissue.

The peri-scar area was defined as an area of 2cm around the scar.

After the treatment, ice was again applied for 2min. A significant difference was found between the scar (4.88°C±1.17°C) and the periscar area (6.07°C±1.77°C) before treatment. No significant difference after treatment was found between the scar (4.79°C±1.93°C) and the peri-

scar area (5.47°C±2.07°C).

Co-Kinetic comment

Even the authors admit that the temperature change does not have an obvious clinical significance but something is going on – it’s just not clear what. A much more practical paper on fascial stretching and scars is ‘Treatment of the scar after arthroscopic surgery on a knee’ by Alvira-Lechuz J et al. [Journal of Bodywork and Movement Therapies 2017;21(2):328–333 (https://spxj.nl/2lTxAfP)], which demonstrates its effectiveness on joint range of motion.

Willie Fourie is mentioned above. Sadly, in May 2019 he was killed in a cycling accident near his home in Johannesburg, South Africa. He was a pioneering research physiotherapist who made many trips to the UK to educate colleagues in fascial techniques originally for general orthopaedic use but latterly specialising in post-

Co-Kinetic Journal 2019;82(October):8-11

RESEARCH INTO PRACTICE

Journal Watch Manual Therapy

FASCIA IS ABLE TO ACTIVELY CONTRACT AND MAY THEREBY INFLUENCE MUSCULOSKELETAL DYNAMICS A HISTOCHEMICAL AND MECHANOGRAPHIC INVESTIGATION. Scheilp R, Gabbiani G, Wilke J et al.

Frontiers in Physiology 2019;10:336

Samples of human fasciae were taken as surplus tissue from 3 autopsy studies or as surplus tissue from diagnostic muscle biopsies of 28 individuals (n=31, 25 males, 6 females, mean age 43±37 years; range 17–91 years).

Sections were taken from the following sites: middle of plantar fascia, lumbar fascia (posterior lamina of posterior layer, 3–4cm laterally of the spinous process of L3) and the fascia lata at the lateral thigh at midpoint between the greater trochanter and the fibular head. Sections from biopsy donors were taken from the described fascia lata location only. In addition, for immunohistochemical comparison between rodent and human fasciae, 20 pieces of rat lumbar fasciae Sex plays a role in mediating different susceptibilities and outcomes of disease and injury, including sporting ones.

Anatomical differences, hormones (especially during menstruation), and genetics all play a role in this.

This essay looks at several common conditions. The authors have highlighted the differences other than those above.

For the anterior cruciate ligament (ACL), there is abundant data that demonstrate that female athletes are particularly susceptible to ACL injury.

Females carry a 4–6-fold increased risk for ACL injury compared with males. Differences in landing patterns between the sexes have been described as predictive for ACL injury.

Females tend to demonstrate valgus collapse and increased abduction movements of the knee. Differences in the bone anatomy of the knee have been described. These include differences in femoral condyle shape, hip version, and length of the femur compared with pelvic width.

Co-Kinetic.com

were randomly chosen from the rat tissue. These were then subjected to a range of mechanographic and immunohistochemical examinations.

The immunohistochemical findings in the study provide evidence for the existence of contractile cells, ie. myofibroblasts, in different fascial tissues. The related density appears to vary considerably between the examined tissues. The increased density of myofibroblasts in human lumbar fascia – in comparison with all other human or murine tissue sources used in the examinations – suggests a possible association with the prevalence of myofascial pain in the human lumbar region. The mechanographic measurements with

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rats showed a contractile response to several substances.

Co-Kinetic comment This study is not an easy read. It is mainly cellular/ chemical and mechanical science but the bottom line is that fascia is contractile. The contractile forces can impose only minimal direct mechanical effects on the body. Probably not sufficient to have an effect on spinal stability or other important aspects of human biomechanics but there is enough force to influence mechanosensation. Earlier research suggests that any alteration of mechanosensation is potentially able to modify muscle coordination and reflex regulation of functional joint stability and thus disrupt the accuracy of proprioception and coordination. Meaning that the contractile nature of fascia could possibly be a contributor to the likelihood of injuries.

SEX DIFFERENCES IN COMMON SPORTS-RELATED INJURIES. Matzkin E, Garvey K. NASN School Nurse 2019;34(5):266–269 Patellofemoral pain syndrome is disproportionately more common in females relative to males (2.23 times more likely), particularly in those who regularly participate in running and jumping activities. Differences between males and females on measures of Q angle, dynamic lateral patellar tracking, and lower extremity muscle strength are noted. Dynamic patellar maltracking is a risk factor more prevalent in females than in males that affects load transmission on the joint.

At the shoulder, reportedly, males are 2.6 times more likely to present to the emergency department with a shoulder dislocation than females.

Additionally, the male population has shown an increased risk of developing recurrent shoulder instability after an initial traumatic dislocation. Patients whose glenoid is tall and thin have a higher risk of shoulder instability than one whose glenoid is short and wide.

Females tend to have smaller glenoids

and higher inclination angles, meaning the glenoid is more oval for females and more round in males.

Co-Kinetic comment This publication is aimed at school nurses but there are people in many other professions who can benefit from a realisation that sex can make a difference to risk factors and, therefore, be more proactive in finding ways to minimise the risk.

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Eleven males undertook 6×25 eccentric knee extensions to induce muscular damage. Each participant was involved in two identical eccentric protocols with 3 weeks between sessions in a randomised, counter-balanced cross-over design.

The intervention was foam rolling (FR) to specifically target five lower extremity areas (3min per area) of the right leg. The participant consistently placed as much body mass as bearable

FOAM ROLLING AS A RECOVERY TOOL FOLLOWING ECCENTRIC EXERCISE: POTENTIAL MECHANISMS UNDERPINNING CHANGES IN JUMP PERFORMANCE. Drinkwater EJ, Latella C, Wilsmore C et al. Frontiers in Physiology 2019;10:768 onto the foam roller and they were instructed to roll their body weight along the roller as evenly as possible at a rate of one rolling motion per second.

The control group (CON) sat quietly for a 15min rest following exercise and before each testing point.

A battery of tests was performed immediately and at 24, 48 and 72h post-training. The results demonstrated

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that a countermovement jump was greater after FR compared to CON at 72h, with moderate effects observed at 48 and 72h. Pressure pain threshold was greater with FR at 48h only, with moderate to large effects noted at alltime points. No significant differences were reported between groups for maximal voluntary isometric contraction, voluntary activation, peak twitch torque, time to peak twitch, rate of twitch torque development and mid-thigh circumference.

Co-Kinetic comment The foam rolling is doing something, just not everything that was measured.

Massage is called ‘green medicine’ by the World Health Organization because of its remarkable effect, low price and no toxic side effects. It is widely used in sports and there is evidence of its efficacy in a number of conditions including autism, pain syndromes, hypertension, autoimmune conditions, immune conditions (including human immunodeficiency virus), breast cancer and aging problems, but how does it work? This is a literature search to find out. This resulted in papers which fell into four categories.

Biomechanical mechanisms: Crosman et al. found that 9–12min massage for lower extremities can significantly increase the hip flexion and knee extension; Nordschow and Bierman used the finger-to-floor test to evaluate the flexibility of the lumbar region, the results showed that massage can increase lumbar range of motion. Potential mechanisms of action may include reduced adhesion and muscle spasm and the stimulation of proprioceptors of muscles in the tissues being massaged. Thai massage, in

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THE POSSIBLE MECHANISMS OF MASSAGE THERAPY. Zhong H, Wang W, Wan Z et al. Biomedical Research 2019;30:1–6 particular, was highlighted as increasing muscle blood supply.

Physiological mechanisms: Drust et al. reported an increase in intramuscular and skin temperature of the vastus lateralis muscle irrespective of massage duration. JoEllen et al. reported that massage treatment can significantly increase the temperature in five regions: anterior upper chest, posterior neck, upper back, posterior right arm, and middle back. The reasons for it are not very clear; the increase of temperature may be due to massage, heat transferring from the hands of therapist, or both. Massage has shown some experimental evidence for increasing parasympathetic activity through reducing blood pressure and heart rate, increasing heart rate variability, reducing cortisol level.

Neurological mechanisms: one study reported that the Hoffman reflex (H-reflex) amplitude of each massage condition were reduced compare to the control group, the reason perhaps being not due to the mechanical stimulation of cutaneous receptors, but for rather the deeper mechanoreceptors. Numerous studies investigated the effects of massage on pain, and the results of several studies

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have shown that massage can relieve pain. Reasons for this are still speculative but include the pain gate theory and the possibility that the level of toxins and residual substances inside the body reduces, and the flow of nutrients to tissues is enhanced.

Psychological mechanisms: there is ample evidence that massage can reduce anxiety, including that from Field et al. who found that moderate pressure of massage contributed to increased dopamine which led to decreased norepinephrine levels and, therefore, decreased anxiety levels.

In addition relaxation, which massage undoubtedly can induce, reduces stress which is accompanied by diminished activity of the sympathetic nervous system and vagal outflow.

Co-Kinetic comment In the interests of balance we should point out that the authors do cite a couple of contrary papers showing no significant effects of massage. The difficulty of massage, and indeed all manual therapy research, is the dosage of the application of force. Even if a bright engineer came up with a gadget that replicated a therapist’s hands and could tell us how much force is used, you still have to account for the fact that the level that may affect one subject may not have the same effect on another. Still, if there are doubters out there who deny that there is evidence for massage, this paper will change your mind.

Co-Kinetic Journal 2019;82(October):8-11

RESEARCH INTO PRACTICE

THE EFFECTIVENESS OF POSITIONAL RELEASE THERAPY IN MYOFASCIAL TRIGGER POINTS ASSOCIATED WITH RECURRENT LATERAL ANKLE SPRAIN – A CASE STUDY. Viswanath VS, Rajalakshmi SP. World Journal of Pharmaceutical Research 2019;8(7):2290–2298 Positional release therapy (PRT), which also known as strain/ counterstrain, is a soft tissue technique which places the affected part of the body in a position of the greatest perceived comfort through passive motion while palpating tender points. Holding this position for a period of time (authors vary from 5 to 20min), allows a pain-free return to the original position. Essentially it is the opposite of stretching.

This is a case study about a 20-year-old male professional dancer referred 1 month after an ankle sprain. The injury had been recurring over the previous 6 months. The treatment was based on the idea that trigger points in the peroneal muscles were contributing to the recurrence. They were hunted down and taken out using PRT. After treatment the fellow had less pain and a greater range of movement.

Forty-eight male rats were randomly divided into a model group (n=24) and a massage group (n=24). A gastrocnemius muscle atrophy model was established by transecting the right tibial nerve of the rats. On the second day after the operation, the gastrocnemius muscle of the rats in the massage group was given manual intervention and the model (ie. control) group had no intervention. Six rats were sacrificed at the four time points of day 0, 7, 14 and 21. The gastrocnemius of the rats were obtained and weighed to

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Co-Kinetic comment The technique is described in many massage/soft tissue textbooks. The prolific author and osteopath Leon Chaitow has a book about it, now in its 4th edition. It works on some muscles in spasm, which was the case for the patient described here.

Why is this published in a pharmaceutical journal? The same issue contains a study on the use of cow urine as a plant enhancer. It also turns up in another journal aimed at trauma patients. It might have something to do with the fact that it is one of a growing number of titles that charge authors for publishing their work and this one is cheap at $50. Some of the others are $1000. There are over 200 articles in this edition alone so if you want to be a published author put your hand in your pocket. A particular favourite was ‘Suppository: a review’. If you want to know the pros and cons of this delivery method, this article is for you (seriously it is quite good) and it is open access.

THERAPEUTIC EFFECT OF MASSAGE ON DENERVATED SKELETAL MUSCLE ATROPHY IN RATS AND ITS MECHANISM. Wan XF, et al. Chinese Journal of Applied Physiology 2019;35(3):223–227 allow calculation of the wet mass ratio.

Compared with day 0, the wet weight ratio, cross-sectional area and diameter of gastrocnemius muscle showed a progressive decline in both groups. The wet weight ratio, cross-sectional area and diameter of gastrocnemius muscle in the massage group were higher than those in the model group on day 7, 14 and 21.

Co-Kinetic comment Sadly only the abstract of this paper is available in English so we can’t be more precise about a lot of the gene expression information that is summarised as a reduction of skeletal protein degradation. This is the underlying reason why the authors believe that massage can delay muscle atrophy in rats. Many people are understandably queasy about animal experiments but it is difficult to see how an experiment like this could ethically be performed in humans.

EFFECTS OF DEEP FRICTION MASSAGE AND STATIC STRETCHING IN NON-SPECIFIC NECK PAIN. Yasin IG, Gondal MJI, Qamar MM et al. Medical Journal of Dr. D.Y. Patil Vidyapeeth 2019;12(4):331–334 Fifty‑six patients with non-specific neck pain were randomly located to have static stretching (Group A, n=28) and deep friction massage (DFM) (Group B, n=28). Group A received six sessions of static stretching to the upper part of the trapezius, scalene, and sternocleidomastoid for 3 weeks (two sessions per week), Group B received six sessions of DFM to the same area for the same time. Both

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groups received a hot pack for 10min before the treatment.

Statistically significant improvement was observed in both the groups in improving pain, neck disability index, and range of motion.

No difference was found between groups other than DFM showed superior effects in neck disability index.

Co-Kinetic comment Soft tissue therapists will claim this as another positive for their craft but there is nowhere near enough detail in the paper. There is no duration of the treatment or pictures of the stretches, no mention of the skill and experience of the therapists and the massage

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intervention is not described at all. A few ideas for the causes of the neck pain are given, many of which could have been eliminated by a few tests, but still we have the somewhat woolly description of ‘non-specific’. We bring it to your attention as an example of a good idea ruined by poor methodology and reporting. Can someone do it properly please?

Just in case you are wondering, Dr. D.Y. Patil Vidyapeeth, is actually the name of a multi-disciplinary University Medical School in Pune, India, named after an educationalist and politician who has another 14 institutions named after him including one in Belgium.

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THE 10 MOST DISCUSSED PIECES OF RESEARCH IN PHYSICAL THERAPY (JUL - SEPT 2019) Produced by: TIME-SAVING RESOURCES FOR PHYSICAL AND MANUAL THERAPISTS

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SYNDESMOSIS INJURY PART 1: DIAGNOSIS AND EVALUATION ANKLE | FOOT | 19-10-COKINETIC FORMATS WEB MOBILE

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All references marked with an asterisk are open access and links are provided in the reference list

By Kathryn Thomas BSc MPhil

If missed or misdiagnosed, syndesmosis injuries are one of the most common causes of chronic ankle dysfunction and potential degenerative disease. This article guides you through how these injuries occur and how to best diagnose them, including when to refer for further evaluation. After reading this article you will have a good understanding of the injury and the structures involved as well as how to diagnose the grade of injury confidently to set your patient on the best treatment/ rehabilitation path. Read this article online https://spxj.nl/2ZhRByL

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yndesmotic injuries are consistently associated with higher levels of disability, pain and prolonged periods out of sports participation. They have also been described as one of the most difficult sporting injuries to treat, with rehabilitation potentially taking between 2 and 30 times longer than isolated lateral ligament sprains (1*).

The most common cause of chronic ankle dysfunction (6 months after ankle trauma) is related to syndesmotic injuries (2*).

Although not common compared to lateral ankle sprains, problems from syndesmosis involvement can be devastatingly time consuming for patients and often lead to significant morbidity and degenerative ankle disease – particularly if managed improperly. This is especially troublesome when considering that this injury is most prevalent between the

ages of 18 and 34 years (3*). Nonisolated injury to the syndesmosis has been reported to be associated with 8.5% of all ankle injuries, although studies have documented up to 25% of operatively treated ankle fractures have an unstable syndesmosis injury, most commonly occurring in Weber type C injuries (3*).

Certain sports are characterised by a higher proportion of ankle syndesmosis injuries; these include boot-immobilised sports such as skiing and ice hockey, as well as collision sports such as American football, soccer (football), wrestling and rugby. The reported proportion of isolated syndesmotic injuries among overall ankle ligament injuries ranges from 18 to 74%. This variation can be explained by the fact that some sports have extrinsic risk factors associated with syndesmotic injury. Skiers and ice hockey players wear boots causing rigid immobilisation of the ankle leading to high-torque external rotation of the foot and American football is often played on artificial turf instead of natural surfaces. Another plausible explanation is that an isolated syndesmotic injury

ONE OF THE MOST IMPORTANT FACTORS IN DETERMINING THE SEVERITY OF INJURY IS THE ABILITY OF THE INDIVIDUAL TO COMPLETE THE MATCH/EVENT 14

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can be frequently misdiagnosed as an ankle sprain (4*).

Ankle sprains in athletes are one of the most common injuries and syndesmosis or ‘high ankle’ sprains seem to be diagnosed at an increasing rate. Is there an actual increase in the incidence of syndesmosis injuries or an increased recognition in a previously underdiagnosed/unrecognised injury?

Or is it that the athletes are becoming more competitive, more aggressive in their manner of play, thereby increasing their risk of sustaining (or inducing) a syndesmosis injury through tackles, contact with other players and foul play.

While research and clinical practice continually strive to prevent soft tissue and ligamentous injuries, the nature of syndesmosis injuries means they are more or less impossible to prevent in any contact sport.

This article will show you how you can better assess and diagnose an injury and which clinical tests and MRI findings are the most useful in determining the severity of the injury.

This can then be used as a guide when prognosticating and attempting to rehabilitate patients, be it a minor or more severe post-surgical syndesmosis injury.

Syndesmosis Joint Anatomy

The syndesmosis joint is made up of a number of bony and ligamentous structures; viewed from above this creates a ring of stability at the distal end of the lower leg and mortise within which the talus sits.

The majority of the stability of the syndesmosis joint is provided by the tibia and fibula; specifically, the medial and lateral malleoli. Between these bony prominences sit the anterior inferior tibiofibular ligament (AITFL), posterior inferior tibiofibular ligament (PITFL), interosseous ligament (IL) and the interosseous membrane. These structures work in conjunction with the deep and superficial (anterior) deltoid ligament and the lateral ligament complex primarily to prevent diastasis of the fibula from the tibia (1*).

An injury to the syndesmosis joint will involve one or all of the primary syndesmotic structures, whereas more serious injuries can also include the lateral ligaments (5*).

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Mechanism of Injury

This large variation in injury incidence statistics may indicate an underreporting of these injuries, reflecting the difficulty identifying syndesmotic ligament damage. Sporting populations are more likely to suffer from syndesmotic injuries owing to the forces required to damage the ligaments (1*).

One of the most important aspects of the diagnostic procedure is being able to review the mechanism of injury. However, we are unlikely to be fortunate enough to have multiangle replays available unless you are treating a professional athlete and the injury occurred during match-play.

The reality is most of your patients may have injured themselves during practice or other matches/sports but will probably not have video footage of the incident. It is important to clearly understand, or visualise in your mind how the patient was injured as this is key in diagnosis.

The mechanism associated with syndesmosis injury is that of direct impact to the syndesmosis region with a forced lateral/external rotation of the foot (relative to the tibia) with the ankle in dorsiflexion. This can occur in reverse with the tibia medially rotating over a fixed foot; the end range position is the same with the foot ending up dorsiflexed and laterally rotated (Link 1).

This forced rotation coupled with the mortise shape of the joint results in an outward force within the syndesmosis joint and injury to the one or all of the main supporting structures.

In effect the syndesmosis is forced apart by these rotational forces (5*).

Isolated syndesmotic injury occurs when there is disruption of the distal tibiofibular articulation without associated fracture. This appears to be an entirely different population from the traditional syndesmosis disruption that occurs in the presence of a fracture; further, these patients remain some of the most poorly studied. The rate of isolated syndesmotic injury in ankle sprains has been reported to occur in up to 20% of the athletic population. Both stable and unstable syndesmotic injuries are more common in collision sports, during direct contact

INJURY RECOGNITION IS CRUCIAL, ESPECIALLY IN ATHLETES WHERE A MISSED DIAGNOSIS HAS BEEN SHOWN TO BE ASSOCIATED WITH LONG-TERM ANKLE DYSFUNCTION such as tackling and blocking, and have higher incidence on artificial turf relative to natural grass (6).

Injury Classification

The injury can be thought of as a ‘peeling mechanism’, working from the anterior part to the posterior part of the joint. The AITFL is injured first, followed by the IL, PITFL and then the deltoid ligament. If an injury to the PITFL is suspected, then this would suggest a high-grade injury, as the AITFL and IL will also be involved.

Most often grading is based on MRI findings as suggested by Sikka et al. (7): l Grade I: isolated injury to the AITFL l Grade II: injury to the AITFL and IL l Grade III: injury to the AITFL, IL and PITFL l Grade IV: injury to the AITFL, IL, PITFL and deltoid ligament.

The MRI grading system above can give a more relevant grading for the minor to moderate, conservatively managed syndesmosis injuries than the clinical grading system by Porter et al (8), which is described below: l Grade I: involves injury to the anterior deltoid ligament and the distal IL but without tearing of the more proximal syndesmosis or the deep deltoid ligament. The AITFL is often very tender to palpation and may have a higher grade injury; because no diastasis is present, the injury is, by definition, stable. l Grade II: involves disruption of the anterior and deep deltoid ligaments as well as a tear in a significant portion of the syndesmosis, resulting in an unstable ankle that is still normally aligned on non-stress radiographs. This poses particular diagnostic challenges, because the extent of the injury and its occult 15

PLAYERS WITH A SYNDESMOSIS INJURY WILL DESCRIBE A MECHANISM DIFFERENT TO THAT OF A LATERAL ANKLE SPRAIN instability are often more difficult to recognise. l Grade III: involves severe external rotation and abduction, with complete disruption of the medial ligaments and extensive disruption of the syndesmosis, frequently accompanied by fracture of the proximal fibula.

Such injuries are overtly unstable on initial examination and standard radiographs.

Not everyone will have access to MRI or present themselves for physical therapy having had such investigations done. A decision may need to be made regarding sending the patient for further investigations to determine the extent of the injury as this plays a large role in their management and prognosis.

The more recent MRI grading system by Sika et al. (7) seems to be the one used most often in the clinic as well as in clinical studies. Grade I injuries are associated with a degree of discomfort but are not unstable as they do not involve a complete rupture.

They can be managed with strapping and a short period of time out of sport.

It is important to differentiate between a stable and unstable grade II injury as this will determine the management plan. A stable grade II (or grade IIa) injury may be treated conservatively, whereas an unstable grade II (or grade IIb) injury may require surgical intervention. Grade III and IV injuries are normally managed with surgical intervention to restore the normal structural stability of the joint, which is then followed up by rehabilitation.

Clinical experience has shown that one of the most important factors in determining the severity of injury is the ability of the individual to continue playing sport (5*). In grade I injuries the player is often able to complete the match and only mention the issue after 16

the game (in football, for example).

The ability of the player to complete the game immediately after the injury is a good clinical guide that a fairly swift recovery from a low-grade injury is possible. In the case of a grade II or III injury the player may not be able to complete the game, which is, therefore, a fairly good clinical guide that the diagnosis is likely to be at least a grade II injury. Of course, further clinical assessment beyond the ability to continue playing should be carried out and this is discussed in more detail in the sections Subjective and Objective Assessment.

With the more severe injuries, the degree of pain at the time of initial assessment may make it difficult to gain exact information from the clinical testing. Therefore, in keeping with the algorithm suggested by Polzer et al. a delayed clinical assessment should be carried out (at 5 days) to allow the pain to settle (Link 2) (9*). By day 5 one would mainly be looking for pain or instability in the syndesmosis-specific tests.

Clinical Assessment

Injury recognition is crucial, especially in athletes where a missed diagnosis has been shown to be associated with long-term ankle dysfunction, missed time from sport and the need for surgical stabilisation. However, the physical and radiographic examinations can be deceiving and accurate diagnosis can be difficult despite improved diagnostic modalities. In addition, there is controversy regarding criteria for surgical intervention and, when indicated, which implants are optimal. Although the recognition of these injuries has improved, there still exists a paucity in the evidence on optimal conservative and surgical management. The primary reasons for this include: (1) inability to properly distinguish between isolated (no fracture) and non-isolated syndesmotic injuries; (2) current diagnostic tests are not very specific; (3) inability to accurately define stable from unstable injury; and (4) inability to sufficiently differentiate between acute and chronic syndesmotic injuries (3*,6).

Syndesmosis injuries can be missed in the early stages as the degree of pain and swelling may not reflect

the severity of the injury. Players may report that something does not feel right and try to continue their participation in sport but find that they are not be able to. Some studies have shown that mean time from injury to diagnosis was as much as 14–21 days (1*). However, some cases may not be diagnosed for 3 or up to 7 months; having followed standard ankle rehabilitation (or no rehabilitation), the persistence of pain, impingement or instability prevents the patient from full functional recovery, raising the question – was something missed in the beginning? Only then is further diagnostic testing initiated (1*).

Early diagnosis of syndesmosis injuries is crucial as the early management strategies are an integral part of the accelerated rehabilitation process. These early management strategies include putting the injured patient in a boot and altering their weight-bearing status.

Subjective Assessment

Once you have had a detailed explanation of the mechanism of the injury, questions that may be of value include (3*,5*): 1. Were you able to continue with the task you were doing?

2. Did you hear or feel anything at the time of injury?

3. Have you had a similar injury before?

4. Where is the location of pain?

5. Was there any swelling or bruising?

As mentioned earlier, the ability of the player to continue with the task gives an indication of the grade of injury. If the player was able to complete the task, then it is unlikely to be higher than a grade I injury. If they could carry on but it didn’t feel right, then this may suggest a stable grade IIa injury. If the player was unable to continue then suspicion of a grade IIb or higher injury is warranted (3*,5*).

Players with a syndesmosis injury will describe a mechanism different to that of a lateral ankle sprain. They may report the foot being trapped during a tackle with a rotational component.

If available, confirm the mechanism of injury by reviewing video footage.

There may be some confusion around what has happened but patients often

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describe that something does not feel right or they don’t feel confident jumping or running on that foot.

The patient’s pain is often located above the lateral malleolus but they may also report pain on the medial side of the ankle if there is deltoid ligament involvement. A higher grade injury may be suspected if a player is struggling to walk and reports higher levels of pain than would be expected.

The ankle may not appear swollen on observation but the player may report reduced confidence and a feeling of instability.

Differential Diagnosis

As a result of the high forces involved in a syndesmosis injury, bony pathology should be considered as a potential differential diagnosis. There may also be secondary damage to the chondral surfaces, which may present as ongoing discomfort and swelling.

Objective Assessment

If a syndesmosis injury is suspected, then immobilise the ankle in a boot and change the weight-bearing status to non-weight-bearing. To improve the reliability of the objective assessment, wait for the initial pain and inflammation to settle for the first 24–48 hours. For a high-grade injury, a formal assessment may be performed at 5 days post-injury (9*).

Use the information gained from this assessment to determine the need for further imaging.

Along with a normal assessment of ankle function following injury [such as ability to walk, swelling, range of motion (ROM) and strength], a number of specific syndesmosis stress tests can be carried out. Pain on palpation over the AITFL and ‘high ankle pain’ increasing with passive dorsiflexion of the ankle may suggest an injury to the syndesmosis. The tests with the highest specificity and usefulness for prognosis include the external rotation test and squeeze test (7,10).

The dorsiflexion/external rotation test has a sensitivity of 92% and although the squeeze test only has a sensitivity of 33%, it is more specific for an injury to the syndesmosis, and if positive it correlates with a longer time to return to sports (Video 1) (10,11).

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Key Objective Tests The key clinical objective tests for syndesmosis injury are described by Sman et al., and include the following (Fig. 1) (10). l Palpation of ligaments (Video 2) l Dorsiflexion range of movement (Knee-to-wall test) (Video 3) Within any group of individuals or athletes, there is large variance in ankle dorsiflexion ROM measured via the knee-to-wall test. Patients with lower baseline knee-to-wall scores may be at higher risk of injury and may find it harder to cope in the early stages post-injury. A patient with a lower baseline score will start to stress the soft tissue structures during simple tasks such as walking.

In contrast a patient with a high knee-to-wall score may be able to run without pain in the early stages (11). l Dorsiflexion external rotation test (Video 4) With the player sitting on the edge of a raised bed and the knee at 90°, one hand is used to stabilise the leg while the other is used to exert an external rotation force on the foot and ankle. A positive test results in pain and/or separation at the distal tibiofibular joint. l Squeeze test (Video 5) With the player in a long sitting position, progressive pressure is exerted by squeezing the tibia and fibula together from proximal to distal. A positive test results in pain at the distal tibiofibular joint. l Fibular translation test (Video 6) l Anterior draw test (Video 7) l Cotton test (Video 8) l Hop test An inability to perform a single-leg hop has the highest sensitivity (89%) of any of the syndesmosis special tests (10).

Used in isolation, no test is accurate enough for diagnosis of syndesmosis injury. Sman et al. suggest using a combination of sensitive and specific signs to confirm ankle syndesmosis involvement (10).

Video 1: Syndesmosis Injury – Signs & Symptoms (Courtesy of YouTube user Physiotutors) https://youtu.be/JMqDnJNZDNI

Video 2: Syndesmosis Ligament Tenderness Palpation | Syndesmosis Injury (Courtesy of YouTube user Physiotutors) https://youtu.be/xfdD7nSDrcg

Imaging Evaluation

Initial imaging investigation of suspected syndesmotic injury may be performed by X-radiography, 17

USE OF A COMBINATION OF SENSITIVE AND SPECIFIC SIGNS IS NECESSARY TO CONFIRM ANKLE SYNDESMOSIS INVOLVEMENT The tests are considered positive if pain is triggered in the area of the syndesmosis. (A) The external rotation test is performed with the tibia fixed and an external rotation is applied. (B) For the squeeze test, the tibia and fibula are compressed above the midpoint of the calf. (C) For the crossed leg test, the patient places the leg to be tested across the kneecap of the other leg.

The pivot point is at the junction of the middle and distal thirds of the tibia and a gentle force is applied on the medial side of the knee by the patient.

Figure 1: Clinical tests for injury of the syndesmosis. (Fig. 5 from Sman AD, Hiller CE, Rae K et al. Diagnostic accuracy of clinical tests for ankle syndesmosis injury. British Journal of Sports Medicine 2015;49(5):323–329 (10); reproduced with permission.)

the indications for which are bony point tenderness suggestive of a fracture, usually on the distal fibula, or suspected syndesmotic widening.

X-radiography of the proximal fibula may also be indicated for high-energy syndesmotic injuries, looking for a fibula neck fracture indicative of a Maisonneuve injury (12*).

X-radiography is often not performed in the majority of high ankle sprains in elite sports clinical practice, as MRI is easily and quickly accessible for this patient group (5*).

Non-weight-bearing X-radiography is relatively insensitive to the detection of syndesmotic ligament injury and radiographic evidence of syndesmotic widening may not be present even in the setting of complete (grade III) disruption of the AITFL. Complete disruption of the AITFL, IL and PITFL may be needed before syndesmotic widening is visible on non-weightbearing X-radiographs (5*,13*).

Therefore, it is advised that weight-bearing anteroposterior, mortise and lateral radiographs of the ankle may help in the diagnosis.

Findings such as increased medial clear space between the talus and 18

medial malleolus, reduced tibiofibular overlap and increased space between the incisural tibial surface and the fibula of greater than 6mm, is highly suggestive of injury. The accuracy of such measurements is questionable, however (3*,11,13*).

MRI is the benchmark imaging modality with 100% sensitivity and 93% specificity for AITFL and 100% sensitivity and specificity for PITFL injuries (11). It clearly demonstrates acute injury of the syndesmotic and deltoid ligament complexes indicated by ligamentous oedema, fibre disruption and laxity. The severity of ligament disruption may be appreciated by careful evaluation of the extent of the ligament fibre injury, allowing grading of injury from grade I sprain (oedema) to grade II (partial tearing) and grade III (complete tearing) (5*).

Small cortical avulsion fractures, usually occurring beneath the fibular footprint of the AITFL, are commonly detected by MRI that may be missed with X-radiography. MRI also identifies tearing of the IL and oedema within the interosseous membrane that would be otherwise missed if X-radiography alone

was used (5*).

Acute on chronic injury of the syndesmosis is commonly seen in the setting of high ankle sprains in athletes, evidenced by thick low signal scarring of the syndesmotic ligaments with oedema or tears. This is an important observation as it may influence the potential for the ligaments to primarily heal, and so precludes conservative management (5*).

The use of X-radiography views taken during dynamic, manually applied syndesmotic stress is still

Video 3: The Weight Bearing Lunge Test or Wall Test | Ankle Mobility (Courtesy of YouTube user Physiotutors) https://youtu.be/U7woPNLUT3Q

Video 4: Dorsiflexion External Rotation Stress Test | Syndesmosis Injury (Courtesy of YouTube user Physiotutors) https://youtu.be/s53uzyUv0bc

Video 5: The Syndesmosis Squeeze Test | Syndesmosis Injury (Courtesy of YouTube user Physiotutors) https://youtu.be/ANgWSz0UoDg Co-Kinetic Journal 2019;82(October):14-20

PHYSICAL THERAPY

advocated by many surgeons, as these may confirm the complete nature of syndesmotic ligament disruption that may be equivocal on MRI (5*).

The role of CT in the acute setting of suspected syndesmotic injury is essentially for evaluation of fractures that are confirmed or suspected from an initial X-radiograph or, more commonly, an MRI image. Small cortical avulsion fractures may be obscured at MRI by low signal ligament fibres or intense soft tissue oedema, and CT may be required to confirm or characterise the size of the fracture fragment or determine whether the fracture requires internal fixation (5*).

Arthroscopy plays a major role in the diagnosis of instability where the clinical and radiological diagnosis is inconclusive, and where associated injuries (such as impingement or osteochondral lesions) can be treated at the same time (11). This invasive process has inherent risks to the patient. Studies are underway attempting to find less invasive methods, such as the Syndhoo Device, to dynamically evaluate the distal tibiofibular stability during external rotation of the ankle as an extension to the available clinical tests (2*).

Not all syndesmosis injuries require further imaging. Imaging may show a higher grade injury than the clinical assessment suggests. It is important in these situations to look at the clinical picture primarily but still respect the imaging findings. If everything on clinical assessment suggests it is a low-grade injury but the imaging suggests a complete rupture of AITFL, IL, PITFL and deltoid it is important not to panic and rush into surgery. If there is no instability, then treat it as a stable grade IIa injury (5*,7).

Conclusion

Too often, it seems, high ankle sprains are missed in the early injury stage.

This leads to prolonged pain and loss of function for the athlete; as well as the risk of poor healing of the syndesmosis due to misguided management. Identifying the injury immediately, based on the subjective history and following some key objective tests, will ensure you make the correct diagnosis and direct your Co-Kinetic.com

treatment accordingly, optimising recovery and facilitating a faster return to play. Don’t miss part 2 of this article which will discuss the surgical options and conservative management following high ankle sprain.

References

1. Latham AJ, Goodwin PC, Stirling B et al.

Ankle syndesmosis repair and rehabilitation in professional rugby league players: a case series report. BMJ Open Sport & Exercise Medicine 2017;3(1):e000175 Open access https://spxj.nl/2T9opEs 2. D’Hooghe P, Bouhdida S, Whiteley R et al. Stable versus unstable grade 2 high ankle sprains in athletes: a noninvasive tool to predict the need for surgical fixation. Clinical Research on Foot & Ankle 2018;6(1):252 Open access https://spxj.nl/2ZAto3F 3. Vopat ML, Vopat BG, Lubberts B et al. Current trends in the diagnosis and management of syndesmotic injury. Current Reviews in Musculoskeletal Medicine 2017;10(1):94–103 Open access https://spxj.nl/2T9dWJ5 4. Lubberts B, D’Hooghe P, Bengtsson H et al. Epidemiology and return to play following isolated syndesmotic injuries of the ankle: a prospective cohort study of 3677 male professional footballers in the UEFA Elite Club Injury Study. British Journal of Sports Medicine 2019;53(15):959–964 Open access https://spxj.nl/2Kzi55c 5. Morgan C, Konopinski M, Dunn A. Conservative management of syndesmosis injuries in elite football. Aspetar Sports Medicine Journal 2014;3(3):602–613 Open access https://spxj.nl/2M413j0 6. Williams BT, Ahrberg AB, Goldsmith MT et al. Ankle syndesmosis: a qualitative and quantitative anatomic analysis. The American Journal of Sports Medicine 2015;43(1):88–97 7. Sikka RS, Fetzer GB, Sugarman E et al.

Correlating MRI findings with disability in syndesmotic sprains of NFL players. Foot & Ankle International 2012;33:371–378 8. Porter DA. Ligamentous injuries of the foot and ankle. In: Fitzgerald RH, Kaufer H, Malkani AL (eds) Orthopaedics. Mosby 2002. ISBN 978-0323013185 (£60.68). Buy from Amazon https://amzn.to/2Ku5lwP 9. Polzer H, Kanz KG, Prall WC et al.

Diagnosis and treatment of acute ankle injuries: development of an evidence-based algorithm. Orthopedic Reviews (Pavia) 2012;4(1):e5 Open access https://spxj.nl/2YKolfM 10. Sman AD, Hiller CE, Rae K et al.

Diagnostic accuracy of clinical tests for ankle syndesmosis injury. British Journal of Sports Medicine 2015;49(5):323–329 11. Ballal MS, Pearce CJ, Calder JD. Management of sports injuries of the foot and ankle: an update. The Bone & Joint Journal 2016;98-B:874–883 12. Porter DA, Jaggers RR, Barnes AF et al.

Optimal management of ankle syndesmosis injuries. Open Access Journal of Sports Medicine 2014;5:173–182 Open access https://spxj.nl/2TaLZAF 13. Schnetzke M, Vetter SY, Beisemann N et al. Management of syndesmotic injuries: what is the evidence? World Journal of Orthopedics 2016;7(11):718–725 Open access https://spxj.nl/2M0nG7T.

Video 6: The Fibular Translation Test | Syndesmosis Injuries (Courtesy of YouTube user Physiotutors) https://youtu.be/W3SHqKqkK14

Video 7: Anterior Drawer Test of the Ankle | Chronic Ankle Laxity & Anterior Talofibular Ligament Rupture (Courtesy of YouTube user Physiotutors) https://youtu.be/vAcBEYZKcto

Video 8: The Cotton Test | Syndesmosis Injury (Courtesy of YouTube user Physiotutors) https://youtu.be/ivGqC0te6uA 19

KEY POINTS

lS yndesmosis injuries can be subtle, and are often missed initially when treating an ankle injury. lU nderstanding the mechanism of injury is critical in diagnosing syndesmosis injury. lM ost often there is direct impact to the ankle with a forced rotation on a fixed or planted foot. lS yndesmosis injuries can be graded according to the extent of the tissue damaged, and thereby the presence of ankle instability. lG rade I is isolated injury to the AITFL; Grade II is injury to the AITFL and IL; Grade III is injury to the AITFL, IL and PITFL; Grade IV is injury to the AITFL, IL, PITFL and deltoid ligament. lT he external rotation test and squeeze test, may be the best clinical tests to assess syndesmosis involvement. lA n inability to perform a single-leg hop test has the highest sensitivity (89%) of any syndesmosis special test. lM RI is the most accurate investigation in diagnosing the extent of the syndesmosis injury and prognosis.

DISCUSSIONS

l Do you feel syndesmosis injuries are being missed because of lack of awareness (we simply don’t look to assess it when faced with an ankle sprain) or is it due to lack of specificity in clinical tests and availability to imaging? l Can you think of a case in the past, where possibly a stubborn ankle sprain with delayed healing may now, in retrospect, have had some syndesmotic involvement? l What dynamic tests, like a hop test, would you use to help diagnose a syndesmosis injury?

LINKS

LINK 1: Figure 1: Typical ‘syndesmosis’ mechanism of injury with a fixed weight-bearing foot forced into external rotation. Morgan C et al. Conservative management of syndesmosis injuries in elite football. Aspetar Sports Medicine Journal 2014;3(3):602–613 (5) https://spxj.nl/2M413j0 LINK 2: Figure 3: Algorithm for diagnosis and treatment of acute ankle injuries. Polzer H et al. Diagnosis and treatment of acute ankle injuries: development of an evidencebased algorithm. Orthopedic Reviews (Pavia) 2012;4(1):e5 (9) https://spxj.nl/2YKolfM 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 Master’s degrees Cum Laude, and with Deans awards. After graduating in 2000 Kathryn worked in sports practices focusing on musculoskeletal injuries and rehabilitation. She was contracted to work with the Dolphins Cricket team (county/provincial team) and The Sharks rugby teams (Super rugby). Kathryn has also worked and supervised physios at the annual Comrades Marathon and Amashova cycle races for many years. She has worked with elite athletes from different sporting disciplines such as hockey, athletics, swimming and tennis. She was a competitive athlete holding national and provincial colours for swimming, biathlon, athletics, and surf lifesaving, and has a passion for sports and exercise physiology. She has presented research at the annual American College of Sports Medicine congress in Baltimore, and at South African Sports Medicine Association in 2000 and 2011. She is Co-Kinetic’s technical editor and has taken on responsibility for writing our new clinical review updates for practitioners.

Email: kittyjoythomas@gmail.com

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Co-Kinetic Journal 2019;82(October):14-20

PATIENT RESOURCE

SYNDESMOSIS INJURY (HIGH ANKLE SPRAIN) A syndesmosis injury, also known as a high ankle sprain, is an injury to the ligaments at the top of your ankle. These high ankle ligaments connect your tibia (shin bone) and fibula (outside leg bone) to your calcaneum (heel bones), and form part of your ankle.

The injury involves the syndesmosis, a ligament that holds the lower part of your tibia and fibula together just above your ankle joint.

High ankle sprains are much less common but are more disabling than your traditional lower ankle sprain (when you roll over the outside of your ankle). They must be diagnosed early and appropriate treatment started, which differs from a traditional ankle sprain, in order to get best results.

WHAT HAPPENS WHEN YOU HAVE A SYNDESMOSIS INJURY?

High ankle or syndesmotic injuries do not heal as well as more common lower ankle sprains. The main reason being a lack of ankle stability when weight-bearing, which can prolong recovery. It is important to determine whether your injury is stable or unstable. If you play sport at a high level, it may require surgical repair.

WHAT CAUSES A SYNDESMOSIS INJURY?

High ankle sprains most commonly occur when your foot is planted on the ground and then an excessive outward twisting of your ankle occurs. This can be caused by you turning on a fixed foot due to studs on your boots, or due to a rigid boot used for skiing, skating or snowboarding. Another mechanism to injure your syndesmosis is if you are standing on your foot and another player makes impact with your lower leg or ankle – as in a sliding tackle in soccer or a tackle in rugby.

WHAT ARE THE SYMPTOMS OF A SYNDESMOSIS INJURY?

● Pain felt above the ankle that increases with outward rotation of the foot ● Pain with walking and often significant bruising and swelling across the higher ankle rather than around the malleolus (ankle bones) ● Inability to perform a one-legged calf raise (going up onto your toes) ● Feeling of instability/‘no confidence’ jumping on the injured leg.

The severity of the symptoms will depend on the grade of ankle sprain. Patients with a high ankle sprain without fracture may be able to stand and walk. Pain over the back of the ankle is of particular concern and may be associated with a fracture or bone bruising.

WHAT’S THE TREATMENT FOR SYNDESMOSIS INJURY?

It is important to have stability between the tibia and fibula because there is a tremendous amount of force that passes through this area when walking and running. Once you rupture or overstretch these high ankle ligaments, the bones of your lower leg move apart with every step causing pain and loss of function. You will often require crutches or a walking boot in the beginning. Most injuries will not require surgery, but all injuries will require good physical therapy rehabilitation.

Physical therapy treatment aims to effectively rehabilitate your ankle and prevent recurrence, or even worse, premature ankle arthritis. These include: ● Injury protection (boot, crutches, strapping), pain relief and control inflammation ● Regain full range of motion ● Strengthen your ankle and calf muscles

● Restore joint proprioception and balance ● Restore normal function ● Walking ● Running ● Jumping and landing ● Speed and agility ● Sport-specific skills ● Resume sport.

Phase 1 of treatment is focused around pain relief and reducing inflammation.

This includes the RICE protocol - rest, ice, compression and elevation. Treatments may also include electrotherapy, strapping and gentle massage after the first 48 hours.

Phase 2 of treatment, the therapist will start mobilising your ankle joint to restore full movement and avoid stiffness. You will be prescribed exercises to move your ankle appropriately and safely without disturbing the stability of the healing ligaments.

Phase 3 is where strengthening of your ankle begins. These may include localised exercises for muscles around the joint and then progress to involve the entire lower limb and functional strengthening with squats and lunges. Balance and proprioception are key to rehabilitation and preventing a subsequent injury.

Your therapist will teach you exercises to improve your ankle and foot balance and adjustments to movement.

Rehabilitation will progress introducing agility, and speed work as well as endurance (when you, and your ankle start to fatigue you increase your risk of injury).

Your physiotherapist will discuss your goals, time frames and training schedules with you to optimise your recovery for complete and safe return to sport.

Depending on the severity of your injury, this may take anywhere from 2-6 weeks, up to 3-6 months if you’ve had surgery.

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

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THE 11 Rs IN CONCUSSION PART 2: Treatment, Rehabilitation and Recovery

HEAD | CONCUSSION | 19-10-COKINETIC FORMATS WEB MOBILE PRINT All references marked with an asterisk are open access and links are provided in the reference list

Introduction

Since the 1970s, clinicians and scientists had begun to distinguish sport-related concussion (SRC) from other causes of concussion and mild traumatic brain injury (mTBI), such as motor vehicle accidents. Although this seems like an arbitrary separation from other forms of TBI, which account for 80% of such injuries, it is largely driven by sporting bodies that see the need to have clear and practical guidelines to determine recovery and safe return to play for athletes with an SRC (1*).

The science and understanding of sports concussion is constantly evolving. The most recently updated consensus statement, the 5th International Conference on Concussion in Berlin 2016, is available for free (1*). From this, the Concussion In Sports Group has identified the 11 Rs of SRC, to help provide a logical flow to clinical concussion management (1*). The sections being:

Having read Part 1 of this article, you will already be able to identify if a player has suffered a sport-related concussion (SRC) and whether they need to be removed from play. Here, Part 2 will allow you to determine the best treatment and rehabilitation for any patient suffering an SRC, as well as how to help them return to sport while being alert to any ongoing effects or potential development of long-term consequences.

Read this article online https://spxj.nl/2MzPxMl

By Kathryn Thomas BSc MPhil 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 [see Fig. 1 in Part 1 of this article (Link 1)].

In Part 1 of this article we discussed the importance of (1) recognising a concussion (and its challenges) as well as providing you with the tools available to help identify and diagnose SRC. With this, (2) removing the player from the field/sport, and allowing

RECENT STUDIES HAVE SHOWN THAT CLOSELY MONITORED ACTIVE REHABILITATION PROGRAMMES INVOLVING CONTROLLED SUB-SYMPTOMTHRESHOLD, SUBMAXIMAL EXERCISE ARE SAFE AND MAY BENEFIT RECOVERY 22

time to (3) re-evaluate the player was discussed. It is strongly recommended that, if you have not already done so, you read Part 1 of this article (Link 1) and go through these first steps in concussion management. Missing a concussion diagnosis or ‘brushing’ it off as a mild ding to the head could have catastrophic consequences for the individual.

Part 2 of this article discusses the remaining Rs: (4) Rest, (5) Rehabilitation, (6) Refer, (7) Recover, (8) Return to Sport, (9) Reconsider, (10) Residual effects and sequelae, and (11) Risk Reduction.

4. Rest

Prescribed rest is one of the most widely used interventions in SRC, and has previously been recommended until such time as the athlete becomes symptom-free. There are some queries presently regarding the evidence of prescribing complete rest.

Following a brief period of rest during the acute phase (24–48 hours) after injury, patients can be encouraged to become gradually and progressively more active while staying below their cognitive and physical symptom-exacerbation thresholds (ie. activity level should not bring on or worsen their symptoms).

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PHYSICAL THERAPY

It is reasonable for athletes to avoid vigorous exertion while they are recovering. The exact amount and duration of rest is not yet well defined in the literature and requires further study (1*).

5. Rehabilitation

‘Rehabilitation’ as such did not exist as a separate section in the previous Consensus Statements. Concussion

literature traditionally has not evaluated early interventions, as most individuals recover in 10–14 days, and rest is the most commonly prescribed treatment. However, a variety of treatments may be required for ongoing or persistent symptoms and impairments following injury. These could include psychological, cervical and vestibular rehabilitation (1*).

In addition, more recent studies

have shown that closely monitored active rehabilitation programmes involving controlled sub-symptomthreshold, submaximal exercise have been shown to be safe and may be of benefit in facilitating recovery. A collaborative approach to treatment, including controlled cognitive stress, pharmacological treatment and school accommodations, may be beneficial (1*).

Table 1: Description of treatments for cervicovestibular rehabilitation in sport-related concussion

Adapted from Schneider KJ, Meeuwisse WH, Nettel-Aguirre A et al. Cervicovestibular rehabilitation in sport-related concussion: a randomised controlled trial. British Journal of Sports Medicine 2014;48:1294–1298 (4).

Type of treatment

Description of treatment

Education on graduated protocol of exertion

Education regarding the graduated return-to-play protocol. Stepwise process where the athlete is asymptomatic before progressing to the next level.

Postural education

Discussion regarding optimal postural position in sitting, standing and lying.

General stretching exercises

Non-provocative exercises to facilitate range of motion and general mobility of the cervical spine and shoulders.

General strengthening exercises

Non-provocative strengthening exercises once progressing through return-to-play protocol beginning with high repetitions and low resistance.

Gaze stabilisation exercises

Exercises to facilitate vestibular adaptation by optimisation of the vestibulo–ocular reflex. Individual looks at a target (eg. letter or number such that identification of blurring of the target is possible) and the head is moved side to side (rotation) or up and down (flexion–extension) while keeping the eyes fixed on a target. This can be performed in a variety of directions and speeds and is context specific.

Habituation exercises

Repetitive motion in a direction that provokes dizziness in order to facilitate desensitisation of symptoms. Motions are repeated up to five times followed by a rest period to allow symptoms to pass. This process is repeated for 1min, three to five times per day.

Standing balance exercises

Varying availability of somatosensory input. Examples include standing with eyes open or closed, wide or narrow base of support, fixed or compliant surface.

Dynamic balance exercises

Varying the availability of balance input while in motion. Examples include walking with head turns, walking and changing gait speed or direction, walking throwing a ball against the wall.

Canalith repositioning manoeuvres

These techniques are used to treat benign paroxysmal positional vertigo. The head is placed in a series of positions that use gravity to move debris through the affected canal and back to the otolith. Liberatory manoeuvres can also be used in the case of a cupulolithiasis.

Smooth pursuit exercises

Eyes following a target in a variety of directions while seated or standing.

Neuromotor training

Exercises focused on training of muscle impairments of the craniocervical flexors and extensors. Low-load exercises to target deep craniocervical flexors as well as cervicoscapular muscles.

Cervicocephalic kinaesthetic awareness exercises

Exercises to improve head and neck orientation in space. To perform these types of exercises, a headband with laser pointer is affixed to the head, eyes are closed and the head is rotated and then relocated back to the perceived neutral cervical spine position. This can also be performed at various predetermined locations in the cervical range of motion or with the eyes open and tracing a pattern.

Manual therapy

Passive, physiotherapist-directed technique to improve mobility of the restricted spinal segment and decrease pain.

Soft tissue techniques

Trigger point release.

Note: Typically, any biomechanical restrictions in the cervical spine are addressed first followed by neuromotor control retraining. Once headaches and neck pain are under control, vestibular rehabilitation exercises are implemented. However, this is an individualised programme so clinical reasoning must be implemented at all stages of treatment including ongoing assessment to re-evaluate the most appropriate course of treatment.

Co-Kinetic.com

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Video 1: Modified Epley Maneuver | Posterior Benign Paroxysmal Positional Vertigo (BPPV) Treatment (Courtesy of YouTube user Physiotutors) https://youtu.be/u23Wuj6zVLM

Cervical and Vestibular Rehabilitation

There is a large body of evidence demonstrating positive treatment effects with vestibular rehabilitation for individuals with vestibular disorders, including sufferers of mTBI. Vestibular rehabilitation may, therefore, be appropriate for individuals with persistent vestibular findings following SRC (2*). Dizziness, neck pain and headaches are commonly reported following SRC and may be persistent.

A combination of cervical and vestibular physiotherapy facilitates recovery in individuals with ongoing symptoms. Research has shown that a higher proportion of individuals treated with multimodal physiotherapy (treatment details are shown in Table 1) are medically cleared to return to sport (within 8 weeks) than that of individuals who receive no intervention (3,4).

Multifaceted physiotherapy treatment regimens that include adaptation, balance, musculoskeletal, aerobic, anaerobic and sport-specific exercises might be useful (2*).

The term sensorimotor describes all the afferent, efferent, and central integration and processing components involved in maintaining stability in the postural control system through intrinsic motor-control properties. From a clinical orthopaedic perspective, the peripheral mechanoreceptors are the most important in functional joint stability; however, in the cervical region they are also important for postural stability, as well as head and eye movement control. Consequently, conventional musculoskeletal intervention 24

approaches may be sufficient only for patients with neck pain and minimal sensorimotor proprioceptive disturbances. Clinical experience and research indicates that significant sensorimotor cervical proprioceptive disturbances might be an important factor in the maintenance, recurrence, or progression of various symptoms in some patients with neck pain, and possibly following concussion.

Treatment methods that progressively address neck position and movement sense, as well as cervicogenic oculomotor disturbances, postural stability, and cervicogenic dizziness could be beneficial (Links 2–4) (5*).

A combination of specific exercises and manual therapy that focus on function is effective for improving pain and function in individuals with cervical spine pain and cervicogenic headaches. Thus, inclusion of exercise and manual therapy in the case of ongoing cervical spine pain and cervicogenic headaches following concussion may be of benefit (2*).

Studies show that controlled exercise performed at an intensity and duration that does not exacerbate symptoms is safe and beneficial following concussion. Athletes participating in submaximal exercise activities typically report fewer symptoms, and recovered to baseline cognitive and balance scores faster (2*,6).

The categories of exercises most frequently provided in vestibular rehabilitation and in the home exercise programme include: l gaze stabilisation exercises [eg. vestibulo–ocular reflex (VOR)×1, in which the individual maintained a fixed gaze position while turning the head from side to side in sitting and standing positions]; l standing balance (eg. standing with feet apart and feet together on foam with eyes open and closed); l walking with balance challenge (eg. walking with head turns, tandem walking, and obstacle avoidance); and l in a few cases, canalith repositioning manoeuvres (Video 1).

Exercises should be done on a daily basis (7*).

A brief description of these

exercises for treating dizziness and imbalance, impairments in the eye– head coordination, standing static balance and ambulation following concussion are as follows (8*). l Eye–head coordination exercises This exercise category contains many exercise types that involve movement of head and/or eyes for the purpose of VOR gain adaptation, symptom habituation, or oculomotor re-education. The exercises include: VOR×1, VOR×2, VOR cancellation, convergence, smooth pursuits, anticipatory gaze shifts, imagined target, and saccades (9). l Sitting balance exercises The patient maintains balance while sitting upright, weight shifting from side to side, or bouncing. l Standing static balance exercises The patient stands with feet in place while upright or weight shifting. The patient can be asked to stand on one leg, stand on a rocker board or stand with one foot on a step. This category also includes the sit-tostand exercise. l Standing dynamic balance exercises The patient stands and moves without walking. The patient might march in place, step forward or backward, step to the side, step up or down, or turn around. l Ambulation exercises The patient walks forward, backward, on stairs, with turns and practices braiding (ie. side stepping in an over and under pattern), skipping, jogging and running.

For each type of exercise, a universal set of 10 modifiers can be used as described in Table 1 in Alsalaheen et al. (Link 5) (8*). Whereas the progression of aerobic and resistance exercises is typically based on increasing the intensity or volume of the same exercise type, vestibular rehabilitation exercises are often based on subtle variations of exercise types that are not able to be classified using the frequency, intensity, time and type principle of the American College of Sports Medicine.

A gradual, closely supervised active rehabilitation programme in the post-

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PHYSICAL THERAPY

acute period (ie. after 1 month postinjury) appears promising for improving the care provided to children who are slow to recover (10). The rehabilitation programme includes gradual, closely monitored light aerobic exercise, general coordination exercises, mental imagery, as well as reassurance, normalisation of recovery, and stress/ anxiety reduction strategies. The introduction of graded light intensity exercise in the post-acute period following concussion is safe, feasible and appears to have a positive impact on adolescents’ functioning (11).

6. Refer

Why or when should you refer? If there are persistent symptoms, referring to a ‘failure of normal clinical recovery’.

That is, symptoms that persist beyond expected time frames (ie. >10–14 days in adults and >4 weeks in children) (1*).

The term ‘persistent symptoms’ does not reflect a single pathophysiological entity, but describes a constellation of nonspecific post-traumatic symptoms that may be linked to coexisting and/or confounding factors, which do not necessarily reflect ongoing physiological injury to the brain.

Treatment should be individualised and target-specific medical, physical and psychosocial factors identified on assessment. There is preliminary evidence supporting the use of (1*): l an individualised symptom-limited aerobic exercise programme in patients with persistent postconcussive symptoms associated with autonomic instability or physical deconditioning; l a targeted physical therapy programme in patients with cervical spine or vestibular dysfunction; and l a collaborative approach including cognitive behavioural therapy to deal with any persistent mood or behavioural issues.

There is little evidence to support the use of pharmacotherapy at this stage. Overall, these may be difficult cases that should be managed in a multidisciplinary collaborative setting, by healthcare providers with experience in SRC (1*).

Co-Kinetic.com

7. Recovery

SRC clinical symptoms typically resolve spontaneously, with 80–90% of concussed older adolescents and adults returning to preinjury levels of clinical function within 2 weeks (12*). In younger athletes, clinical recovery may take longer, with return to preinjury levels of function within 4 weeks (12*).

Clinical recovery is defined functionally as a return to normal activities, including school, work and sport after injury. Operationally, it encompasses a resolution of post-concussionrelated symptoms and a return to clinically normal balance and cognitive functioning (1*).

The strongest and most consistent predictor of slower recovery from SRC is the severity of a person’s initial symptoms in the first day, or initial few days, after injury. Conversely, and importantly, having a low level of symptoms in the first day after injury is a favourable prognostic indicator. The development of subacute problems with migraine headaches or depression are likely risk factors for persistent symptoms lasting more than a month (1*). Children, adolescents and young adults with a preinjury history of mental health problems or migraine headaches appear to be at somewhat greater risk of having symptoms for more than 1 month. Those with attention deficit hyperactivity disorder or learning disabilities might require more careful planning and intervention regarding returning to school, but they do not appear to be at substantially greater risk of persistent symptoms beyond a month. Very little research to date has been carried out on children under the age of 13. There is some evidence that the teenage years, particularly the high-school years, might be the time period with the highest risk for the development of persistent symptoms – with greater risk for girls than boys (1*).

What is the Correct Recovery Time?

These determinations have been limited by lack of a gold standard as well as subjective symptom scores and imperfect clinical and NP testing.

Recent literature suggests that the physiological time of recovery may

PATIENTS WITH SYMPTOMS PERSISTING BEYOND THE EXPECTED TIME FRAMES SHOULD BE REFERRED TO HEALTHCARE PROVIDERS WITH EXPERIENCE IN SRC

outlast the time for clinical recovery (13*). The consequence of this is as yet unknown, but one possibility is that athletes may be exposed to additional risk by returning to play while there is ongoing brain dysfunction. Multiple studies suggest that physiological dysfunction may outlast current clinical measures of recovery, supporting a ‘buffer zone’ of gradually increasing activity before full contact risk. Where advanced care settings are not available, some sports advise compulsory, agespecific stand-down periods, where physical activity is limited to below the symptom threshold (13*). In addition to this a symptom-free waiting period (SFWP) has also shown to be beneficial in reducing the risk of reinjury in individuals. Research has shown a greater use of SFWP, which appears to support improved adherence to clinical management guidelines through increased use of SFWPs after SRC (14,15).

An advanced care setting is an enhanced, well-resourced, clinical environment where individualised management of athletes can occur.

An advanced care setting should be in place when contemplating a faster return to sport, and is the most appropriate environment for managing more complicated cases. This could be 25

THE STRONGEST AND MOST CONSISTENT PREDICTOR OF SLOWER RECOVERY FROM SRC IS THE SEVERITY OF A PERSON’S INITIAL SYMPTOMS IN THE FIRST DAY(S) AFTER INJURY

a well-established sports medicine centre, or in the case of professional teams, who have access to sports medicine doctors, neuro-specialists, computerised and/or formal neuropsychological evaluation, and oculomotor and cervico-vestibular evaluation and rehabilitation (13*).

This advanced care setting is especially important for (13*): l planned accelerated return to sport (<7 days) l delayed recovery (>1 month) l complex cases (eg. athletes with a history of multiple concussions) l athletes with pre-existing comorbidities (eg. psychological/ psychiatric) l decisions regarding athlete retirement for the season or career.

8. Return to Sport

After a brief period of initial rest (24–48 hours), symptom-limited activity can begin while staying below a cognitive

Table 2: Graduated return-to-sport strategy

Reproduced with permission from 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).

Aim

Activity

Goal of each step

1

Symptomlimited activity

Daily activities that do not provoke symptoms

Gradual reintroduction of work/ school activities

2

Light aerobic exercise

Walking or stationary cycling at slow to medium pace. No resistance training

Increase heart rate

3

Sport-specific exercise

Running or skating drills. No headimpact activities

Add movement

4

Non-contact training drills

Harder training drills, eg. passing drills. May start progressive resistance training

Exercise, coordination and increased thinking

5

Full contact practice

Following medical clearance, participate in normal training activities

Restore confidence and assess functional skills by coaching staff

6

Return to sport

Normal game play

Stage

l Note: An initial period of 24–48h of both relative physical rest and cognitive rest is recommended before beginning the return-to-sport progression. l There should be at least 24h (or longer) for each step of the progression. If any symptoms worsen during exercise, the athlete should go back to the previous step. Resistance training should be added only in the later stages (stage 3 or 4 at the earliest). If symptoms are persistent (eg. more than 10–14 days in adults or more than 1 month in children), the athlete should be referred to a healthcare professional who is an expert in the management of concussion.

26

and physical exacerbation threshold (see Table 2). Once concussion-related symptoms have resolved, the athlete should continue to proceed to the next level if he/she meets all the criteria (eg. activity, heart rate, duration of exercise, etc) without a recurrence of concussion-related symptoms.

Generally, each step should take 24 hours, so that athletes would take a minimum of 1 week to proceed through the full rehabilitation protocol once they are asymptomatic at rest.

However, the time frame for return to sport may vary with player age, history, level of sport, etc, and management must be individualised. In athletes with prolonged symptoms each step may take more than 24 hours. If concussionrelated symptoms occur during the stepwise approach the athlete must drop back to the previous level for a further 24 hours’ rotation and then slowly progress again.

9. Reconsider

Special care should be noted for specific populations. Elite and non-elite athletes can be managed using the principles above. However, children and adolescents may need special attention. There are very few studies evaluating SRC in children.

The expected duration of symptoms in children (aged 5–12 years) with SRC is up to 4 weeks. Similar to adults, a brief period of physical and cognitive rest is advised after SRC followed by symptom-limited resumption of activity. Children and adolescents should not return to sport until they have successfully returned to school (Table 3). However, early introduction of symptom-limited physical activity is appropriate (1*,16*): l Students should rest physically and cognitively initially following a concussion with a gradual increase in activities as symptoms allow. l Factors such as symptomatology, age/school level, course load and rest after injury can affect return to school following SRC. l Schools with a concussion policy tend to offer more academic accommodations to students recovering from SRC. l Regular medical follow-up after concussion and provision of a returnCo-Kinetic Journal 2019;82(October):22-29

PHYSICAL THERAPY

to-school letter can help facilitate the provision of academic support. l Many students require a brief absence from school and academic accommodations on return to school following an SRC to avoid significant exacerbation of concussion symptoms.

10. Residual Effects and Sequelae

The literature is inconsistent on neurobehavioral sequelae and the long-term consequences of exposure to recurrent head trauma. One needs to be aware of the potential for long-term problems, such as cognitive impairment, depression, etc, in the management of all athletes.

However, there is much more to learn about the potential cause-and-effect relationships of repetitive head-impact exposure and concussions (1*). The potential for developing chronic traumatic encephalopathy (CTE) must be a consideration, as this condition appears to represent a distinct tauopathy with an unknown incidence in athletic populations. A cause-andeffect relationship has not yet been demonstrated between CTE and SRCs or exposure to contact sports. As such, the reality behind the notion that repeated concussion or sub-concussive impacts cause CTE remains unknown (1*,17*).

11. Risk Reduction

A pre-participation or preseason evaluation, acknowledging the importance of an SRC history (and appreciating the fact that many athletes will not recognise all the SRCs they may have suffered in the past) is invaluable. Such a history may identify athletes who fit into a high-risk category and provide an opportunity for you to educate the athlete as to the significance of concussive injury.

Prevention

Although it is impossible to eliminate all concussion in sport, concussionprevention strategies can reduce the number and severity of concussions in many sports.

The evidence examining the protective effect of helmets in reducing the risk of SRC is limited in Co-Kinetic.com

many sports because of the nature of mandatory helmet regulations.

There is sufficient evidence in terms of reduction of overall head injury in skiing/snowboarding to support strong recommendations and policy to mandate helmet use in these activities.

The evidence for mouthguard use in preventing SRC is mixed, but metaanalysis suggests a non-significant trend towards a protective effect in collision sports (1*).

The strongest and most consistent evidence evaluating policy is related to body checking in youth ice hockey (ie. disallowing body checking under age 13), which demonstrates a consistent protective effect in reducing the risk of SRC (1*).

There is minimal evidence to support individual injury-prevention strategies addressing intrinsic risk factors for SRC in sport. However, limiting contact with youth sports, fair play, tackle training and technique may be beneficial. A recommendation for stricter rule enforcement of red cards for high elbows in heading duels in professional soccer is based on evidence supporting a reduced risk of head contacts and concussion with such enforcement (1*).

Knowledge Translation

The value of knowledge translation as part of SRC education is increasingly becoming recognised. Target

audiences benefit from specific learning strategies. Social media is becoming more prominent as an SRC education tool. Implementation of knowledge translation models is one approach organisations can use to assess knowledge gaps, identify, develop and evaluate education strategies, and use the outcomes to facilitate decision-making (1*).

As the ability to treat or reduce the effects of concussive injury after the event is an evolving science, education of athletes, colleagues and the general public is a mainstay of progress in this field. Athletes, referees, administrators, parents, coaches and healthcare providers must be educated regarding the detection of SRC, its clinical features, assessment techniques and principles of safe return to play.

There are universal challenges in reaching communities in remote areas and those with limited resources.

Incorporating concussion guidelines into coaching material is a practice that has been successfully implemented in Rugby Union. Paramedics and clinicians

CHILDREN AND ADOLESCENTS SHOULD NOT RETURN TO SPORT UNTIL THEY HAVE SUCCESSFULLY RETURNED TO SCHOOL

Table 3: Graduated return-to-school strategy

Reproduced with permission from 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).

Aim

Activity

Goal of each step

1

Daily activities at home that do not give the child symptoms

Typical activities of the child during the day as long as they do not increase symptoms (eg. reading, texting, screen time). Start with 5–15min at a time and gradually build up

Gradual return to typical activities

2

School activities

Homework, reading or other cognitive activities outside of the classroom

Increase tolerance to cognitive work

3

Return to school parttime

Gradual introduction of schoolwork. May need to start with a partial school day or with increased breaks during the day

Increase academic activities

4

Return to school full-time

Gradually progress school activities until a full day can be tolerated

Return to full academic activities and catch up on missed work

Stage

27

SPORTING CODES SHOULD HAVE GUIDELINES AND EDUCATION PROGRAMMES THAT EXTEND TO ATHLETES, PARENTS, COACHES AND SUPPORT STAFF AT ALL LEVELS OF COMPETITION who work in sporting communities should be familiar with the CRT5 and the SCAT5. Other healthcare providers, especially primary care and emergency care physicians, may need additional education and training (13*).

In rural/remote areas, and communities with reduced access to medical support, sporting codes should be more directive in terms of concussion management. This may include mandating specific

LINK 1: Figure 1: Concussion infographic (McCrory P et al. Infographic: Consensus statement on concussion in sport. BJSM2017; 51(21): 1557–1558). In Thomas K. The 11 Rs in Concussion Part 1 Screening. Co-Kinetic Journal 2019;81(July):28– 33 https://spxj.nl/2WDJGu4 LINK 2: Figure 1: An overview of the subsystems in the postural control system https://spxj.nl/2EpFrbb From Kristjansson E, Treleaven J. Sensorimotor function and dizziness in neck pain: implications for assessment and management. Journal of Orthopaedic and Sports Physical Therapy 2009;39(5):364–377 (11) https://spxj.nl/2VICM2i LINK 3: Figure 2: The balance exercises are combined with eye-neck coordination exercises, and task-dependent exercises https://spxj.nl/2JWHt6m From Kristjansson E, Treleaven J. Sensorimotor function and dizziness in neck pain: implications for assessment and management. Journal of Orthopaedic and Sports Physical Therapy 2009;39(5):364–377 (11) https://spxj.nl/2VICM2i LINK 4: Figure 3: Suggested treatment planning showing progressive interaction of treatment interventions https://spxj.nl/2HJABqh From Kristjansson E, Treleaven J. Sensorimotor function and dizziness in neck pain: implications for assessment and management. Journal of Orthopaedic and Sports Physical Therapy 2009;39(5):364–377 (11) https://spxj.nl/2VICM2i LINK 5: See Table 1: The exercise modifiers used for the vestibular rehabilitation exercises from Alsalaheen BA, Whitney SL, Mucha A et al. Exercise prescription patterns in patients treated with vestibular rehabilitation after concussion. Physiotherapy Research International 2013;18:100–108 (14) https://spxj.nl/2McSUcG

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absolute and relative rest times, and graduated return-to-sport time frames.

Similarly, standardised management criteria should be more conservative and directive for younger athletes, as well as in situations where access to appropriately trained healthcare professionals is limited. Additionally, efforts to train medical professionals ranging from nurses, physician assistants and emergency medical technicians become more critical in these environments with a paucity of concussion experts (13*).

Low levels of knowledge and negative attitudes are often encountered from at least some people at management, player and medical levels. It is clear that engagement and education at several levels of sport would be required for successful implementation of effective concussion care (18).

Depending on your working environment or community maybe it’s a challenge for you to undertake and enlighten those around you about SRC. Successful programmes across team collision sports include the following features (13*).

1. Provision of community resources such as websites, online learning modules and access to concussion recognition tools. Examples include the CDC concussion courses and World Rugby’s Player Welfare sites.

2. Training for medical personnel via online modules and courses, posters, booklets and smartphone applications.

3. Training for medical personnel, independent consultants, trainers and spotters through national workshops.

4. Education of match officials and coaches.

5. Education of television commentators.

6. Leadership from well-known players involved in public awareness campaigns.

7. Education of players, teachers

and parents with simple talks, presentations and printed handouts for reference.

A Final Thought

The correct management of SRC is crucial to (i) prevent long-term persistent symptoms; (ii) allow safe return to school and sport; and (iii) reduce the risk of secondary concussion and more severe consequences. Management no longer simply involves rest, but rather physical therapy for symptom relief as well as progressive vestibular rehabilitation, followed by careful monitoring of a gradual return to activity. This is often a ‘two steps forward, one step backward’ process but with patience and understanding this will provide the best outcomes for the patient.

Ongoing awareness, education and training is essential for successful implementation of concussion management protocols. Athletes, coaches, officials, medical and paramedical personnel should receive continuing hands-on and remote training using a range of written materials and ‘online’ modules.

Extending concussion care knowledge to healthcare professionals, such as nurses and emergency medical technicians, should also be a priority.

At some lower levels of competition or sports involving child or adolescent athletes, such as in schools, experienced personnel and/ or resources might be limited. In these situations, a more conservative, but equally thorough, approach to SRC must be adhered to. Sporting codes should have guidelines and education programmes that extend to athletes, parents, coaches and support staff (be it teachers or the school nurse) at all levels of competition. The emphasis should be on recognising the injury, removing from play and referring the player for a medical assessment. That certainly does not mean that amateur sports should not offer comprehensive

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concussion care (18), it may be just that experienced medical professionals may not be available ‘field-side’ in these situations.

Professional and elite sports organisations must continue to share information and collaborate to implement new protocols or rule changes. Communication is paramount for protecting our patients and athletes.

SRC is an important medical issue in contact and collision sports worldwide. As SRC understanding continues to evolve, it is imperative that management guidelines remain dynamic and evolve in line with new information.

The science of concussion is incomplete and, therefore, management and returnto-play decisions lie largely in the realm of clinical judgement on an individualised basis.

References Owing to space limitations in the print version, the references that accompany this article are available at the following link and are also appended to the end of the article in the web and mobile versions. Click here to access the references https://spxj.nl/31ZUGkK

KEY POINTS

lT raditional rest periods of 10–14 days may be modified with a closely monitored active rehabilitation. lF ollowing a brief period of rest during the acute phase after injury (24–48 hours), gradual and progressive activity can commence, while staying below the cognitive and physical symptom-exacerbation thresholds. lM ultifaceted physiotherapy treatment regimens that include cervical spine manual therapy, vestibular rehabilitation (eye–head coordination exercises, gait and dynamic balance), aerobic, anaerobic and sport-specific exercises might be useful. lA patient should be referred for specialist management and tests should their symptoms persist past 14 days in an adult and over 4 weeks in a child/adolescent. lA graduated return to sport, and return to school (before sport in children and adolescents) must be followed once symptom-free. lA part from adhering to sports rules and improving technique there is little sporting equipment or individual conditioning proven to prevent SRC. lK nowledge translation: educating individuals, sporting bodies, coaches, referees, parents, players and medical personnel (providing them with tools to identify SRC) may result in improved care and better outcomes for patient. lT he understanding of concussion is still evolving and therefore the management and return-to-play decisions lie largely in the realm of clinical judgement on an individualised basis.

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DISCUSSIONS

l What exercises and progressions do you use in managing vestibular rehabilitation in a post-concussion patient? l What steps do you follow when progressing a patient through rehabilitation in recording/monitoring their symptoms – such as a personal diary, a daily progress chart, for example? l Do you feel a responsibility, and confidence, being able to discuss and educate members of your community about concussion in sport?

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 master’s 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

RELATED CONTENT

lT he 11 Rs in Concussion Part 1: Screening [Article] https://spxj.nl/2WDJGu4 l Concussion in Sport: Putting the Guidelines into Action [Article] http://spxj.nl/2CpEeNh

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Tweet this: The science and understanding of sports concussion is constantly evolving https://spxj.nl/2MzPxMl Tweet this: The amount of rest needed after sports concussion is not well defined and needs further study https://spxj.nl/2MzPxMl Tweet this: Athletes doing submaximal exercise activities typically report fewer symptoms after concussion https://spxj.nl/2MzPxMl Tweet this: Children and adolescents may need special attention during concussion rehabilitation/recovery https://spxj.nl/2MzPxMl Tweet this: Concussion prevention strategies can reduce the number and severity of concussions in many sports https://spxj.nl/2MzPxMl Tweet this: Standardised concussion management criteria should be more conservative for younger athletes https://spxj.nl/2MzPxMl 29

THE 11 Rs IN CONCUSSION PART 2: 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. Schneider KJ, Leddy JJ, Guskiewicz KM et al. Rest and treatment/ rehabilitation following sport-related concussion: a systematic review. British Journal of Sports Medicine 2017;51:930–934 Open access https://spxj.nl/2M3P0mA 3. Schneider KJ, Meeuwisse WH, Barlow KM et al. Cervicovestibular rehabilitation following sport-related concussion. British Journal of Sports Medicine 2018;52:100–101 4. Schneider KJ, Meeuwisse WH, Nettel-Aguirre A et al.

Cervicovestibular rehabilitation in sport-related concussion: a randomised controlled trial. British Journal of Sports Medicine 2014;48:1294–1298 5. Kristjansson E, Treleaven J. Sensorimotor function and dizziness in neck pain: implications for assessment and management. Journal of Orthopaedic and Sports Physical Therapy 2009;39(5):364–377 Open access https://spxj.nl/2VICM2i 6. Murray DA, Meldrum D, Lennon O. Can vestibular rehabilitation exercises help patients with concussion? A systematic review of efficacy, prescription and progression patterns. British Journal of Sports Medicine 2017;51:442–451 7. Alsalaheen B, Mucha A, Morris LO et al. Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion. Journal of Neurologic Physical Therapy 2010;34(2):87–93 Open access https://spxj.nl/2ErCMhw 8. Alsalaheen BA, Whitney SL, Mucha A et al. Exercise prescription patterns in patients treated with vestibular rehabilitation after concussion. Physiotherapy Research International 2013;18:100– 108 Open access https://spxj.nl/2McSUcG 9. Whitney SL, Herdman SJ. Physical therapy assessment of vestibular hypofunction (Ch21). In: Herdman SJ, Clendaniel R, (eds). Vestibular rehabilitation, 4th edn. F. A. Davis, 2014. ISBN 978-0803639706 (Print £140 Kindle £131.90).

Buy from Amazon https://amzn.to/2MRmqn2 10. Gagnon I, Galli C, Friedman D et al. Active rehabilitation for children who are slow to recover following sport-related concussion.

Brain Injury 2009;23(12):956–964 11. Gagnon I, Grilli L Friedman D et al. A pilot study of active rehabilitation for adolescents who are slow to recover from sportrelated concussion. Scandinavian Journal of Medicine & Science in Sports 2016;26(3):299–306 12. Harmon KG, Clugston JR, Dec K et al. American Medical Society for Sports Medicine position statement on concussion in sport.

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British Journal of Sports Medicine 2019;53:213–225 Open access https://spxj.nl/30L2O8W 13. 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 14. McCrea M, Broglio S, McAllister T et al. Return to play and risk of repeat concussion in collegiate football players: comparative analysis from the NCAA Concussion Study (1999–2001) and CARE Consortium (2014–2017). British Journal of Sports Medicine 2019;doi:10.1136/bjsports-2019-100579 15. Pfaller AY, Nelson LD Apps JN et al. Frequency and outcomes of a symptom-free waiting period after sport-related concussion. The American Journal of Sports Medicine 2016;44(11):2941–2946 16. Purcell LK, Davis GA, Gioia GA. What factors must be considered in ‘return to school’ following concussion and what strategies or accommodations should be followed? A systematic review. British Journal of Sports Medicine 2019;53:250 Open access https://spxj.nl/2WjIRGF 17. Manley G, Gardner AJ, Schneider KJ et al. A systematic review of potential long-term effects of sport-related concussion. British Journal of Sports Medicine 2017;51:969–977 Open access https://spxj.nl/30FWzD1 18. 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;82(October):14-26

YOGA AND BIOMECHANICS: A New View of Stretching Part 2 I

By Jules Mitchell MS, CMT, ERYT500 All references marked with an asterisk are open access and links are provided in the reference list

n Part 1, we found that although stretching is an example of an activity for improving flexibility, there are several different types of stretching and which is of most benefit depends on the desired outcome. In this article, Part 2, we discuss muscle structure, what tissue adaptations occur when muscles are loaded in tension, and how eccentric contractions can be used to increase muscle length.

Muscle Length

As muscles are being stretched, they naturally resist deformation. Some muscles seem to resist deformation stubbornly well, while others tend to yield quite easily. We are apt to call those unyielding muscles tight.

Colloquially, the definition for tight implies something pulled taut. If tight muscles are wound up like guitar strings, then an additional tension would not result in any further deformation. Alas, muscles are not wound up like guitar strings, and the term tight is derived more from imagery than mechanical behaviour.

We might conclude the resistance to deformation occurs because of a structurally shortened muscle, one that has developed a diminished length of tissue between the two attachment points (ie. origin and insertion). If this were true, then the opposing muscles would have inadvertently been fixed in a lengthened position, and one would expect them to have developed an excessive length of tissue between attachment points. I often hear this YOGA | STRETCHING | 19-10-COKINETIC FORMATS WEB MOBILE PRINT

THERE IS A FALSE ASSUMPTION THAT STRONG MUSCLES ADAPTIVELY SHORTEN, AND WEAK MUSCLES ADAPTIVELY LENGTHEN 30

Last time, Part 1 of this article, published in the July issue, looked at the interplay between flexibility, stretching and yoga and what type of stretches to do depending on the desired outcome. Part 2 here further discusses some commonly used terms, such as tight/ loose, strong/weak and short/long, and elaborates on the biomechanics of what happens to muscles when they are loaded under tension, as well as muscle length and eccentric contraction. 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/2ZcRCEZ

regarding the hip flexors. Clients, students, even yoga teachers have all told me they have ‘tight’ hip flexors and ‘weak’ glutes, considering this to be the reason why they stand in Mountain Pose with an anteriorly tilted pelvis. Less often, but still frequently, I hear the opposite. They explain to me their hamstrings are ‘short’ and their hip flexors are ‘overstretched’. I’d like to deconstruct these scenarios in terms of muscle length.

The first problematic issue with the binary short/long line of thinking is that it further assumes that shorter muscles must be strong/tight and longer muscles must be weak/loose.

Muscles, however, don’t get strong by being held in shortened position. They become stronger when exposed to progressive loads. Likewise, muscles don’t become weak from stretching.

They become weak when loads are insufficient. Also, strong muscles are not always tight. Olympic weightlifters have incredible range of motion (ROM) including full overhead shoulder flexion and ankle/ knee/hip flexion needed for a full squat, yet are arguably the strongest athletes in the Olympics. Gymnasts also

demonstrate extreme flexibility, but are not lacking in strength and power, defying the presumed long/weak relationship.

Looking at the inverse relationship, the false assumption is that strong muscles adaptively shorten, and weak muscles adaptively lengthen. I tend to blame bodybuilders for the former impression. The primary training goal of a bodybuilder is aesthetic, to put on muscle mass, and bulk up, not to get stronger. The training methods for building muscle to those extremes are very specific, and while they do get stronger, strength training methods are somewhat different. Therefore, the classic image of a bodybuilder who can’t straighten her arms or reach overhead is often the result of anatomical barriers, not strength. The

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MANUAL THERAPY

latter impression, that weaker muscles adaptively lengthen cannot possibly be true or a sedentary desk job would result in the longest muscles in the office!

The second concern with this assertion is the widespread acceptance that stretching and/or exercise corrects postural deviations. It is an attractive concept to embrace, partly because of its simplicity and partly because of what we have all witnessed, but biology is rarely simple, and assessing a student in Mountain Pose, identifying muscles as either short or long, and assigning stretching or strengthening exercises to correct them is the epitome of simple. Perhaps, several decades ago, when we knew far less, the theory served us well, but today, the evidence forces us to reconsider (1*,2*,3). One of my friends and colleagues who also leads teacher trainings attended a course of mine where we elaborated on this idea.

She shared with us that on day one of her trainings, everyone takes a photo of themselves in Mountain Pose.

Then, months later, at the end of the training, they take a second photo for comparison, and share with the group the change they see in themselves.

As would be expected, everyone is standing ‘taller,’ yet they always attribute it to psychological factors such as confidence, joy, and fulfilment.

It is far easier to assume that the yoga stretched out a short tissue when you are looking at a static photo of a body without the context of human experience. There is no denying we have all

Co-Kinetic.com

witnessed such personal case studies where yoga has improved posture, but we must ask ourselves how much is attributable to actual muscle shortages or surpluses.

I can continue to deconstruct these postulations about muscle length, but I find it difficult to do so without falling into a logical fallacy trap. In part, this is because I don’t really understand the logic behind these assumptions, which have been only explained to me through unsupported conclusions, based in weak reasoning and anecdotal evidence. These conjectures are difficult to refute with evidence when the theories have not, thus far, been validated. Recall with whom the burden of proof lies; she who is making the claim should provide the evidence.

It is difficult to refute a claim that Shoulderstand is the ‘panacea to most common ailments’ (4) when no credible evidence is provided to support the claim. Additionally, many are invested in the long/short line of thinking and have been using language in their teaching to support it. It’s never easy to change beliefs, even when evidence to the contrary is compelling. In the spirit of critical thinking, as you continue to read, I ask you to consider any number of other possible mechanisms that might contribute to the experience of muscle or joint tightness, ‘faulty’ posture, or other states of being we seem to want stretching to ‘correct’.

Muscle Structure

To further explore the topic of muscle length, it will be useful to define a few more terms. It is often argued

Tendon Fascicle

Muscle organ

Muscle fibre

Figure 1: Muscle structure depicting the deep to superficial endomysium, perimysium, and epimysium

Epimysium Endomysium Perimysium

that stretching muscle will make it longer. We have already explained that stretching a muscle will decrease resistance torque and will improve tolerance for the stretch, but what are the components of muscle that might adaptively lengthen when loaded under tension? Let us next begin with the study of muscle structure.

Skeletal muscle is made of muscle cells, also called muscle fibres because of their long threadlike structure, and surrounding connective tissue, called the myofascia. Three layers of connective tissue help define the shape of the muscle body. At the deepest layer, the endomysium envelops each individual fibre.

Bundled together, these fibres form fascicles, encased by the next connective tissue layer, the perimysium. Finally, these fascicles bundled together to form the muscle organ, enclosed by the epimysium.

These fascial layers contour and give shape to the muscle organ (Fig. 1).

A commonly used and convincing analogy is that of an orange.

Underneath the outer peel, the white pithy layer which contains the spherical shape of the orange is likened to the epimysium. The thinner skin that contains each wedge resembles the perimysium which contains the fascicles.

Finally, the individual pockets of juice are contained by an even thinner skin just as the fibres are enveloped by the endomysium (Thought

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Thought Provoker 1: Stretching Resistance If you were to try to stretch an orange wedge, would the resistance you have to overcome come from the juice inside or from the surrounding connective tissue, or both?

If applied to muscle, when you stretch a muscle, is the resistance coming from the bags of connective tissue, or the proteins within, or both?

Table 1: Muscle contraction types Contraction type

Change in length

Concentric

Sarcomeres shorten

Isometric Sarcomeres do not change length Eccentric

Sarcomeres lengthen

Muscle fibre

Myofibril Sarcomere Figure 2: Muscle structure depicting the macro to micro fibre, myofibril, and myofilaments (actin, myosin, titin) (a) Parallel, eg. sartorius; (b) fusiform, eg. biceps brachii; (c) convergent, eg. pectoralis major; (d) unipennate, eg. extensor digitorum longus; (e) bipennate, eg. rectus femoris.

Titin

Actin Myosin

(a) Parallel (b) Fusiform (c) Convergent

(d) Unipennate

(e) Bipennate

Figure 3: Some examples of different types of muscle morphology

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Provoker 1).

The muscle fibre itself is made up of smaller myofibrils, which are made up of myofilaments (Fig. 2). These filaments are made up of proteins organised into sarcomeres. Sarcomeres are known to be the smallest contractile functional unit of a muscle, although some muscle physiologists have recently proposed that it might be the half-sarcomere. Sarcomeres are arranged in series, end to end, to form the long fibrils. Sarcomeres are only a few microns (one millionth of a metre) in length – for perspective, the width of a strand of human hair is about 25 times wider than a sarcomere is long!

The proteins within the contractile sarcomere (actin, myosin, and titin) interact together to generate muscle force. According to the Sliding Filament Theory, actin and myosin link together to form cross-bridges.

Through consecutive linking and unlinking, cross-bridge formations pull the actin toward the centrally located myosin to create a concentric contraction. During an isometric contraction, the cross-bridges still generate a force, but the sarcomere lengths remain the same. Finally, during an eccentric contraction, an opposing force greater than the force generated by muscle pulls the actin away from the centre, lengthening the sarcomeres (Table 1). When the sarcomere is actively stretched (possibly even beyond cross-bridge formation), titin interacts with calcium and maybe even actin to contribute to force production (5*).

In recent years, the role of titin has shed light onto the previously uncertain and unexplainable mechanisms of eccentric contractions. At the risk of veering off topic, the significance for investigating eccentric contractions here is to grasp that muscles do generate force in the absence of crossbridge formations. Although, since the introduction of the Sliding Filament Theory in the 1950s, concentric contractions have been explained thoroughly, lengthening contractions have not been so well understood.

Perhaps it is this uncertainty which led to the speculation that lengthening a muscle is a factor of relaxing a muscle and that fewer cross-bridges would

make for less resistance to the stretch.

The re-evaluation of titin’s role (it was originally considered a passive element, holding the sarcomere together when stretched beyond the actin–myosin overlap) has advanced our understanding of muscle force production from a two filament model (actin and myosin) to a three filament model (5*).

Admittedly, these last few paragraphs provide only a gross oversimplification of muscle physiology. Additionally, the Three Filament Model, at the time of this writing, is just a proposed possible mechanism for eccentric contractions by a select group of researchers – the theory is still new, somewhat controversial, and has yet to make its way into kinesiology textbooks.

As this is not a muscle physiology textbook, I believe it is okay to offer new perspectives, as long as I am transparent about their overall position in the scientific community, and I offer this perspective here in an effort to define terms, which, as I’ve argued, is essential to clear communication.

Simplified, sarcomeres are contractile functional units that produce force via actin–myosin binding at shorter lengths and actin–titin binding at longer lengths (5*).

Muscle Morphology and Force Generation

Now that we understand the structural components of muscle we can study how they are arranged. Muscle morphology explains how muscle fascicles are positioned in relation to the tendon (Fig. 3). Some run parallel to the tendon (at a 0° angle) and some run at a pennation angle. In parallel muscles, 100% of the longitudinally transmitted force transfers to the tendon. In pennate muscles (Fig. 4), if the pennation angle is given, a trigonometric equation can determine the percentage of longitudinal force transferred to the tendon. An example of this force transfer is attempting to move an object horizontally by pushing on it directly from the side versus pushing it at an angle from the top of the object. Both methods can displace the object horizontally, but the amount of force transfer is determined by the

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angle of application.

Practically speaking, pennate muscles accommodate more muscle fibres into their oblique architecture than parallel muscles, thereby increasing their capacity to produce greater overall force. The amount of force not transferred to the tendon is minimal compared to the amount of total force gained by the pennate morphology. Most muscles are morphologically pennate, the significance regarding muscle length being that most muscle fibres are obliquely oriented. An increase in muscle fibre length, therefore, is not always a purely longitudinal growth with respect to attachments points. If the pennation angle also increases, the additional length is even further away from the longitudinal axis relative to the tendon (and attachment points).

Ultimately, the amount of additional muscle tissue length between the two tendon–bone attachments is geometrically determined.

In this regard, muscle length is defined by the length of the muscle fascicles. If we expanded our definition of ‘muscle’ to include the entirety of the muscle organ, which includes the connective tissue layers that merge to become a tendon where the ends of muscle fibres do not reach, we end up with a slightly different interpretation of muscle length. Using the orange analogy, the former definition only accounts for the juice inside the bulbs, whereas the latter accounts for the surrounding materials as well.

Tissue Adaptation

Interestingly, during development, if a limb is immobilised, it will present with a greater proportion of tendon length than mobilised limbs (6). In other words, when muscle fibres are not growing longer, connective tissue replaces it. Again, using the orange analogy, if a bulb were to lose some juice at one end, the space would be filled with extra enveloping material. The envelope itself would not become architecturally smaller, only the proportion of outer material to inner material. Is it possible then that when muscle lengthens, the fibres fill more length of the connective tissue envelope rather than expanding the Co-Kinetic.com

entirety of the envelope?

I’ve been insinuating that muscle proliferates to meet rising demand.

Hypertrophy, the enlargement of muscle fibres, is the muscle growth that occurs when we load muscles (ie. lifting weights). Sarcomerogenesis, the addition of sarcomeres in series, occurs when we load muscles eccentrically.

Sarcomerolysis, the removal of sarcomeres in series, occurs when we load muscles concentrically (7*).

Unsurprisingly, muscle architecture adaptations are load dependent.

Sarcomerogenesis is regulated by chronic stretch. As bones grow longer during development (provided immobilisation is not a condition, as noted above), the growth spurt is met with sarcomerogenesis, meeting the movement demands of the child for optimum function (8). Other examples of chronic stretch include surgical limb lengthening and casting to specific joint angles (9*). Conversely, during deconditioning or immobilisation, sarcomeres are lost, and excess connective tissue accumulates (10*).

In spite of what you may read online, passive stretching alone may not be enough to preserve, or increase, sarcomeres.

Biomechanics tells us load matters.

Muscle contractions, of any type, are needed to regulate sarcomere quantity, presumably because of their energetic expense. Contractile tissue is expensive to operate – it requires an energy source to function. Muscles burn calories. In the evolution of human existence, having enough calories to survive is a modern luxury enjoyed by the privileged. The human body has evolved to conserve energy and would likely not preserve unused tissues with a high energy cost.

A passive stretch is a tensile load indeed, but when muscle contractions are paired with stretching, the load parameters are more effective in regulating sarcomere production and loss (11). A recent meta-analysis concluded that stretch training alone produced ‘trivial’ changes in fascicle length and angle, reinforcing previous statements I’ve made (12). We know stretching does influence muscle architecture, but not as much as it may seem.

Longitudinal force transmitted to tendon is determined by the pennation angle, theta (Θ). Most often, a greater Θ is paired with a shorter fascicle length, resulting in less force transmission to tendon.

Muscle fascicle

Θ = angle of penetration Force vector of muscle fascicle

Force vector parallel to tendon

Force vector 90o to tendon

Tendon

Figure 4: Muscle architecture of a bipennate muscle

Muscle Architecture and Mobility Versus Flexibility

Arguably, muscle architecture plays a greater role in mobility than flexibility since muscles produce the internal force to create movement. If flexibility is measured passively, mobility is measured by how someone performs through a ROM. It has been shown that increased passive ROM does not transfer to twist and reach activities or improvements on an elliptical machine (ie. functional tasks) (13*). What, then, is the benefit of improved flexibility without training in these new ranges?

At surface level, it is easy to accept that ROM is limited by an insufficient length of tissue (ie. short muscles). It is also easy to explain without a detailed conversation about muscle architecture and physiology or differences between flexibility and mobility. When these factors are taken into consideration, however, it challenges the idea that short muscles are the sole cause of limited flexibility.

Whereas a number of studies do show improvements in ROM simultaneous to increases in fascicle

IT MAY BE HELPFUL TO THINK OF CONCENTRIC CONTRACTIONS AS ACCELERATORS AND ECCENTRIC CONTRACTIONS AS DECELERATORS 33

SARCOMEROGENESIS, THE ADDITION OF SARCOMERES IN SERIES, OCCURS WHEN WE LOAD MUSCLES ECCENTRICALLYS length, many do not. Muscle extensibility (think ‘stretchability’ of the tissue) has been shown to increase 13% after a stretch training intervention with no changes in fascicle length or amount of tendon deformation (14*).

In other words, the muscle portion of the entire organ (inclusive of the enveloping connective tissue layers) resisted the stretch less, while the tendon portion did not become more pliable. Unless the definition of muscle length as an architectural adaptation is clarified, increased pliability could easily be falsely interpreted as a sarcomeric muscle lengthening.

Moreover, increased ROM has been shown to be altered by many activities other than stretching. In addition to the effects of anaesthesia and tolerance on ROM discussed in Part 1, core endurance activities (15*), breathing techniques (16*), somatic practices (17*), and foam rolling (18*) have all improved ROM. Improvements have also been observed after interventions involving joints other than the target joint. Foam rolling one limb has increased ROM in the contralateral limb (19*). Static stretching of the upper limb has produced significant changes in lower limb ROM and vice versa (20). None of these activities are associated with muscle lengthening by

Thought Provoker 2: Muscle Relationships In Standing Forward Bend Pose, an instruction we often hear is ‘contract your quadriceps to relax your hamstrings’.

In actuality, on the way into the forward bend from Mountain Pose, as in the beginning of a Sun Salutation, the hamstrings are eccentrically lengthening to control the descent. While the pose is held, the hamstrings are isometrically contracting to counterbalance the load of the trunk and prevent falling forward. What does the reciprocal relationship in the instruction inaccurately imply about how muscles work? Is there a cue you could use instead that would emphasise control of the movement rather than individual muscles?

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any mechanical definitions. If adaptive tissue lengthening is not the driving factor, we are therefore left to consider other mechanisms of action.

Biomechanics, how the human body responds to and adapts to force, is the main topic here. If you recall the different types of stretching discussed, those that involve force production of the target muscles are those that include isometric and eccentric contractions. Although conventionally not discussed in terms of stretching, eccentric contractions including resisted stretches, body-weight exercises, and loaded training are all worthy of reviewing in our expanded view of stretching as a tissue under tension.

Eccentric Contractions

Eccentric contractions are lengthening contractions against a greater opposing load. Muscles cannot willingly lengthen. When a muscle contracts, an electrical signal from the nervous system (an impulse) travels along a neuron to the muscle. At the neuromuscular junction, where the neuron meets the muscle cell membrane, the impulse prompts an electrochemical and then a mechanical sequence of events leading to crossbridge formations. Skeletal muscle can only voluntarily concentrically contract. In order for an isometric contraction to occur, opposing forces must be equal to the force produced by the contracting muscle. In eccentric contractions, opposing forces are greater. The opposing force could come from an external load, like a free weight, or from the internal load produced by surrounding muscles.

When first learning about muscle actions, the process is often described in a binary relationship, contracting, and relaxing. For example, you may have learned that to flex the elbow, the biceps brachii concentrically contract and the triceps brachii relax.

It is quite the contrary, however, because if the triceps were relaxed, the elbow would flex rapidly and clumsily without a decelerating mechanism.

The triceps eccentrically contract and contribute to the ideal combination of forces necessary to achieve the given movement. It may be helpful to think of

concentric contractions as accelerators and eccentric contractions as decelerators. This model of opposing actions is still a reductionist view of elbow flexion. Such a local agonist and antagonist relationship around a single joint ignores the global contractile contributions of other muscles, both proximally and distally, needed to achieve any given movement. Muscles work individually and collectively as motors, brakes, springs, and struts – they work in far more complex patterns than our experimental models have accounted for in controlled laboratory settings (21). Putting aside a detailed exploration of muscle mechanics, for it is somewhat off topic, we will keep our focus on the effects of eccentric training on muscle architecture.

The length–tension relationship of muscle describes the amount of force a muscle can produce at different lengths (Fig. 5). Muscles are generally weaker at very short and extreme long lengths and strongest in mid-range. Additionally, we are somewhat stronger eccentrically than concentrically. Graphically depicted, the length–tension curve represents the ideal length for optimum force production. In response to eccentric training, that curve shifts to the right (22). Eccentric training improves force production capabilities at longer muscle lengths, which may be useful in activities that utilise longer end ranges (ie. require force production at long muscle lengths) such as gymnastics, martial arts, and potentially, yoga (Thought Provoker 2).

Sarcomerogenesis is one of the proposed mechanisms by which the length–tension relationship shifts. It has recently been shown that fascicle length increases after a 10-week eccentric intervention using the highmagnitude body-weight exercise, the Nordic Hamstring Curl (Fig. 6) (23). Body-weight eccentric exercises resembling many common yoga pose transitions, however, have been shown to not provide a great enough load magnitude to shift the curve (24*).

These body-weight exercises, some of which resemble Mountain Pose to Warrior III Pose (Fig. 7), or gliding into and out of Hanuman’s Pose (Forward Splits) (Fig. 8), were effective as overall

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isometric contraction (‘hug muscles to the bone’, for example).

Co-contraction can also be used to develop an internal resistance during transitions in asana. If eccentric contractions are the decelerators, these lengthening contractions can be emphasised by ‘putting on the brakes.’

Imagine you were lowering from Plank Pose all the way to the floor. The path of least resistance would be to go quickly, letting gravity take you down.

But if you were to lower slowly, you would have to create some internal resistance to modulate the pull of gravity. You could further develop this internal resistance if you were to try to push your way back up into Plank Pose while simultaneously trying to pull your way to the floor. Naturally, this approach would ensure slow descent, as well. The point here, however, is not to move slowly, but to explore control through a ROM at a higher demand than that which you might be accustomed to during your yoga practice. Stretching (or lengthening) against external resistance can be used with equipment (eg. resistance band or weight), explored with a partner (eg. resistance stretching), and in body-weight activities, like yoga, using co-contraction.

My intent here is not to establish a right way of teaching asana, but rather to recognise how various approaches have different outcomes. Cueing students to relax their hamstrings under the assumption that a passive stretch is the only way to improve flexibility is incomplete. Eccentric training has been shown not only to increase flexibility, but also to increase fascicle length (28). Furthermore, always cueing to relax the hamstrings reinforces outdated concepts about stretching and fails to highlight beneficial principles of progressive loading, specificity, and adaptation.

DURING AN ECCENTRIC CONTRACTION, AN OPPOSING FORCE GREATER THAN THE FORCE GENERATED

BY MUSCLE PULLS THE ACTIN AWAY FROM THE CENTRE, LENGTHENING THE SARCOMERES Co-Kinetic.com

Pre-training Post-training Tension

strengthening exercises and, in another study, these same exercises did reduce the time to return to sport when compared with conventional exercise (25*). The outcomes of eccentric exercises including sarcomerogenesis appear to be load dependent as well.

That is not to suggest that eccentric exercise is the only way to improve end range force production or alter muscle architecture. Training at long muscle lengths (26*) and isometric training of a muscle in a lengthened position has been shown to increase fascicle length (27*), replicating the effects of eccentric training. In any case, the over-arching theme is that load parameters matter. It appears that contraction type (concentric, isometric, eccentric) is less important than specificity and intensity on causing changes in muscle architecture – a concept that should not be surprising at this point. Of the types of stretching previously discussed, proprioceptive neuromuscular facilitation and resistance stretching utilise contractions. Based on the above evidence, whether the intensity is high enough to promote any substantial muscle remodelling is still doubtful.

Regarding yoga, we know training at long range improves long-range performance, providing load parameters are sufficient. In the absence of any research examining muscle architecture and yoga asana, we are left to draw parallels using the available sport science research.

If eccentric loading associated with common yoga transitions potentially improves strength but falls short of shifting the length–tension curve to the right, isometric training at end range may satisfy that specific adaptation.

It certainly builds a case for holding postures while cueing to co-contract the ostensibly binary/opposing muscle groups to incite a high-magnitude

Angle Figure 5: Length–tension curve before and after eccentric training.

Force production increases at longer muscle lengths (ie. greater joint angles). [Illustration modified after Brughelli and Cronin (22)]

While the ankles are pinned to the floor, from an upright position standing on the knees, the knees begin to extend while the hips and spine remain neutral.

The hamstrings eccentrically lengthen to decelerate and control the descent.

Figure 6: Nordic hamstring curl From an upright position, hip flexes in standing leg while slight bend in the knee is maintained, hip of lifted leg extends maximally while 90° bend in the knee is maintained, and arms stretch out over head.

Figure 7: The Diver (resembling Warrior III Pose) From an upright position, body weight shifts to heel of standing leg while slight bend in the knee is maintained, gliding leg extends (using towel or blanket) maximally before gliding back to starting position, arms used for support (eg. chairs or yoga blocks).

Figure 8: The Glider (resembling Hanuman’s Pose)

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ECCENTRIC TRAINING HAS BEEN SHOWN NOT ONLY TO INCREASE FLEXIBILITY, BUT ALSO TO INCREASE FASCICLE LENGTH

Equipped with this understanding, you are prepared to make educated choices in how you teach that are outcome specific and population dependent. Instead of debating with other teachers what the right way is, we can now debate about which options we think are best given a desired result.

Stretching Redefined

Key Points

l When people discuss their muscles, they often equate short/tight with strong and long/loose with weak, leading to the false assumption that strong muscles become short and weak muscles become long. l Muscles don’t get strong by being held in a shortened position; they become stronger when exposed to progressive loads. l Muscles don’t become weak from stretching; they become weak when loads are insufficient. l Strong muscles are not always tight – gymnasts have both great flexibility and strength. l The Sliding Filament Theory of muscle contraction explains concentric contractions well, but lengthening contractions have not been so well understood. l Simplified, sarcomeres are contractile functional units that produce force via actin–myosin binding at shorter lengths and actin–titin binding at longer lengths. l Eccentric contractions, including resisted stretches, body-weight exercises, and loaded training, are important in our expanded view of stretching as a tissue under tension. l Eccentric contractions are lengthening contractions against a greater opposing load. l Regarding yoga, we know training at long range improves long-range performance, providing load parameters are sufficient. Parallels from sports science research build a case for holding postures while cueing to co-contract the ostensibly binary/ opposing muscle groups to incite a high-magnitude isometric contraction.

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Some time ago, when I was developing the narrative for this book, I took an informal survey of everyone on my mailing list and asked them ‘what is stretching?’ I intentionally made the question open-ended, hoping to get answers that weren’t led by my own words. The responses varied, of course, but three distinct themes came up: ROM, tissue lengthening, and sensation. When we look at conventional stretching as it is described and studied in the research, these themes are absolutely central to the conversations of flexibility, muscle architecture, and tolerance. It seems we can all agree on some basic concepts, but where we get lost is in the details.

In my informal survey, some answers described stretching as a function of muscle relaxation with an insinuation that a stretch is the opposite of a contraction.

Others described stretching as an activity designed to bring ‘strength,’ ‘suppleness,’ and ‘elongation’ to the muscle. I’m hoping you are, at this point, asking what type of stretching would develop strength and how it is measured, while also wondering what exactly ‘suppleness’ might mean.

A clear definition for ‘elongation’ is also needed (is it deformation, tolerance, or sarcomerogenesis?) before determining the accuracy of that perspective. Some responders separated muscle from connective tissue, implying they can be stretched separately and alluding to the notion that different approaches to yoga target different tissues. In our review of conventional stretching thus far, we have discussed very little about connective tissue outside of the fascial layers providing the structure for the muscle organ. In order to establish how stretching might affect tendons and ligaments, we would first need to

define the properties of the tissue, and then the type of stretching, the load parameters, etc. In other words, the details.

I highlight these varied and sometimes contradicting perspectives for you here to explain the importance of coming together to agree on terminology. As the reader, you don’t have to agree with my definitions or interpretations of the literature; however, we must at least agree on the words we use so that we can form our opinions knowing we are talking about the same thing. If you are talking about how muscle tissue behaves during a stretch and I’m talking about how the collagen in connective tissue behaves, we will always be tuned to different channels. This reminds me of the John Godfrey Saxe poem of the six blind men and the elephant. Each blind man’s position near the elephant influenced how they perceived the animal. One man likened the elephant to a tree stump (feeling the leg).

Another argued that the elephant is like rope (being near the tail). While yet another likened the elephant to a spear (feeling the tusk). And so on.

While all the men were partially right, they were all wrong. This poem is also referenced in a research paper about spinal stability (29*), which we return to in a later chapter in the book.

Regarding stretching, the poem also serves to highlight the importance of continuing to define our terms.

In order for us to discuss stretching in terms of connective tissue, it is important that we re-establish the definition of stretching as a load; a tensile load. This will keep us within a framework of biomechanics while including forces that may not fit into any conventional type of stretching.

For example, a concentric muscle contraction applies a tensile load to the tendon (because the force produced by a muscle pulls on the tendon, in turn pulling on the bone to create, or prevent, movement across a joint).

Most would not consider a concentric contraction to be a tendon stretch, but in fact, it is. A passive stretch also applies a tensile load to a tendon, albeit a lesser load due to less muscle force. An isometric contraction at end range, which we have established is

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a type of conventional stretch, might apply a great tensile load to a tendon, depending on degree of muscle contraction. If we want to ascertain how a tendon responds to a stretch, we have to include all types of tensile loading, not just passive stretching. If you recall the conversation I had with my colleague about stretching tendons (See Part 1 of this article), these were some of the concepts we had to go over to move forward in our discussion.

At the conclusion of the book, when in a conversation about stretching, it is my goal for you not to be bound by the limitations of the blind men discussing the elephant.

Incidentally, my favourite response to my stretching survey was from a medical writer who flatly declared ‘I have no idea how to describe stretching’. It takes a vast amount of education to be willing to say, ‘I don’t know’. It also creates a perfect starting point to a discussion on the finer points of loading, stretching, and tissue adaptation (discussed in subsequent chapters in the book). Admittedly,

my ‘what is stretching?’ probe was somewhat of a trick question.

References Owing to space limitations in the print version, the references that accompany this article are available at the following link and are also appended to the end of the article in the web and mobile versions. Click here to access the references https://spxj.nl/31XFfcI

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

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lY oga and Biomechanics: A New View of Stretching Part 1 [Article] https://spxj.nl/2KAQEd8 lB iotensegrity Part 1: An Introduction to Biotensegrity and its Importance to Massage Therapists [Article] https://spxj.nl/2KiKZZ7

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Tweet this: It is a false assumption that strong muscles become short and weak muscles become long https://spxj.nl/2ZcRCEZ Tweet this: Sarcomeres are known to be the smallest contractile functional unit of a muscle https://spxj.nl/2ZcRCEZ Tweet this: Muscle architecture plays a greater role in mobility than flexibility https://spxj.nl/2ZcRCEZ Tweet this: Eccentric contractions are lengthening contractions against a greater opposing load https://spxj.nl/2ZcRCEZ Tweet this: Think of concentric contractions as accelerators and eccentric contractions as decelerators https://spxj.nl/2ZcRCEZ 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.

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YOGA AND BIOMECHANICS: A New View of Stretching Part 2 References

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Breathing techniques affect female but not male hip flexion range of motion. Journal of Strength and Conditioning Research 2015;29(11):3197–3205 Open access https://spxj.nl/2YIrIIK 17. Stephens J, Davidson J, Derosa J et al. Lengthening the hamstring muscles without stretching using ‘awareness through movement’. Physical Therapy 2006;86(12):1641–1650 Open access https://spxj.nl/2Z3Safp 18. Junker DH, Stöggl TL. The foam roll as a tool to improve hamstring flexibility. Journal of Strength and Conditioning Research 2015;29(12):3480–3485 Open access https://spxj.nl/2N3wkCs 19. Kelly S, Beardsley C. Specific and cross-over effects of foam rolling on ankle dorsiflexion range of motion. International Journal of Sports Physical Therapy 2016;11(4):544–551 Open access https://spxj.nl/2OY8iv4

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How animals move: An integrative view.

Science 2000;288(5463):100–106 22. Brughelli M, Cronin J. Altering the length-tension relationship with eccentric exercise: Implications for performance and injury. Sports Medicine 2007;37(9):807– 826 23. Bourne MN, Duhig SJ, Timmins RG et al. Impact of the Nordic hamstring and hip extension exercises on hamstring architecture and morphology: Implications for injury prevention. British Journal of Sports Medicine 2017;51:469–477 24. Orishimo KF, McHugh MP. Effect of an eccentrically biased hamstring strengthening home program on knee flexor strength and the length-tension relationship.

Journal of Strength and Conditioning Research 2015;29(3):772–778 Open access https://spxj.nl/2H8qdcd 25. Askling CM, Tengvar M, Thorstensson A. Acute hamstring injuries in Swedish elite football: A prospective randomised controlled clinical trial comparing two rehabilitation protocols. British Journal of Sports Medicine 2013;47(15):986–991 Open access https://spxj.nl/2P5fBkS 26. Guex K, Degache F, Morisod C et al.

Hamstring architectural and functional adaptations following long vs. short muscle length eccentric training. Frontiers in Physiology 2016;7:340 Open access https://spxj.nl/2KyTGhn 27. Noorkõiv M, Nosaka K, Blazevich A. Neuromuscular adaptations associated with knee joint angle-specific force change.

Medicine and Science in Sports and Exercise 2014;46(8):1525–1537 Open access https://spxj.nl/2Tvvwr7 28. O’Sullivan K, McAuliffe S, Deburca N. The effects of eccentric training on lower limb flexibility: a systematic review.

British Journal of Sports Medicine 2012;46(12):838–845 29. Reeves P, Narendra K, Cholewicki J. Spine stability: the six blind men and the elephant. Clinical Biomechanics 2007;22(3):266–274 Open access https://spxj.nl/33B8jYX.

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By Vicki Marsh, Massage Therapist, Owner of the HeadStart Clinic

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n this article, we will start to reap the rewards for all the hard work we’ve put in so far by getting the clients attending our Open Clinic events to rebook into a paying appointment.

Regardless of whether you’re doing a large scale Open Clinic event like we do, a super-relaxed coffee morning or even using one of the conversion events (talks/lectures) included in the CoKinetic system, this series of articles will give you everything you need in order to run a successful event.

In this article we look at actual conversions. Taking people from a prospect into becoming a paying customer.

Firstly, What are Conversions?

Conversions are the action or behaviour you want your customer to take. This could be as simple as signing up to an email list but in our case it’s booking a paid appointment or buying a pass.

Why is this Different to Rebooking our Normal Clients?

This is a great question!

In reality we are VERY lucky in our line of work. Clients come to us knowing that they have a problem, and have already decided that we can provide the solution.

Generally speaking, unless something goes wrong, then we are able to rebook them for that follow-up appointment (albeit sometimes that isn’t straight away, but generally they do come back!). These are HOT clients – super-ready to buy, or in our case, book.

But with Open Clinic events, or any offer/promotion for that matter, it’s different. The goal of our Open Clinic event is to build on what is commonly referred to as the Know, Like, Trust factor – a key strategy for converting people who are currently effectively bystanders into active customers.

Ideally, you would have started this process by sending regular nurturedriven emails, ie. emails that offer help, advice and value, and don’t ask anything ‘salesy’ of them. The goal at 38

THE BLUEPRINT FOR RUNNING A SUCCESSFUL OPEN CLINIC EVENT:

Part 4 Your Sales and Conversions Strategy This article is the fourth in our series on how to run your own Open Clinic event. Most people attend these events because they want to try something out for free. However, the point of running an Open Clinic is to gain new, paying clients. This article shows you how to do this using a variety of time-limited offers. Read this article online https://spxj.nl/32dyq6T this stage is to warm up your email prospects so they are open to, or even keen, to take whatever next step you’d like them to take. In this case it would be to attend an Open Clinic event.

Admittedly, you could do this without nurturing your email list, but you’ll get a much greater uptake and response if you have put the effort into warming up these prospects first. Not only that, they’re already well down the Know, and possibly even into the Like phase, by the time you meet.

At our Open Clinics, we have different types of clients who turn up.

Some of them will be like our normal clients, ready to book that follow-up appointment, but most won’t.

So why do we even bother?

Because it’s not that simple. We’re used to the ‘Short Sell’; ie. clients who come to us proactively, typically rebooking within a 6-week period for their follow-up.

But with offers and promotions, it can sometimes take up to 2.5 years for that rebooking. Yup, that’s right! I had a client who came for our Open Clinic event and then over 2 years later came back, invested in a very specialist course of sessions with me and hadn’t been for one appointment in between!

So what does this mean?

Offers/Promotions Attract More WARM Clients

It just means we have to approach it differently. Do not get disheartened if your follow-up offer for the event

doesn’t give you a conversion rate at more than around one-third of attendees. That’s absolutely normal.

But if you get your content marketing right and are prepared to give that group of Open Clinic visitors some exclusive follow-up offers, then, over time, in our experience, over 80% of those clients will come back and pay for an appointment.

Not only that, more than half of them will be willing to pay full price, which is an incredible ROI, or return on your original investment.

This is known as the ‘Long Sell’ approach, which I prefer to call the ‘keeping the door open’ strategy.

What Follow-up Offers Should You Do?

If you’re a very skilled practitioner on the ‘soft skills’ involved in booking clients, then you can definitely try to rebook those Open Clinic clients at full price.

Realistically though, it’s a big jump for someone to understand why they might want to start paying >£50 for something that they just wanted to try out in the first place.

Here’s a formula that we find works well for us, which you can easily modify for your practice.

The client attends the Open Clinic appointment and then: l If they are NEW to the clinic they get a 50% off fast-action offer Co-Kinetic Journal 2019;82(October):38-40

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Meaning they have only 24 hours to purchase, otherwise the discount drops to 15%. We find most people purchase a 60-minute follow-up for around £30. For those who like the tech side of things, we use Deadline Funnels (a deadline tool which gives them access to discounted appointments within that 24-hour period), Google Calendar and Zapier to set this up so there’s no manual emailing required and everyone has their own unique deadline based on 24 hours after the end of their Open Clinic appointment time.

Then at THAT appointment we rebook the patient at full price. But in most cases either they didn’t require extensive treatment or are just looking for maintenance and a trusted practitioner so we typically rebook for a 30-minute appointment at full price – which is also around £30.

So from the client’s point of view, the price stays the same, but they make the transition to paying full price for appointments. l If they are a REGULAR client of the clinic we make a membership offer We have a monthly membership programme (and I highly recommend you consider this as it creates guaranteed recurring revenue) and if they sign up and become a member then they get some extra free passes on their account to use compared to normal.

Co-Kinetic.com

How to Create Your Own Offer The key here is to create a tiered structure: don’t just throw them in at the deep end and ask them to pay full price for a full on appointment with you at the Open Clinic event – you’ve got to build Trust.

Consider things like: l creating an offer for off-peak followups only; l testing a new service type for example an express 20-minute appointment to help these WARM clients continue to learn more about you and your sessions; l being brave and also creating a much higher price package (if you are already busy then this is a great opportunity to test the water with a tough audience on a high ticket price package); or even l teaming up with another health/ wellness company for a bespoke offer just for these guys.

The important thing is to have a plan, have fun and use this as an opportunity to TEST what works.

What Results Should You be Getting and How to Fix a Failing Offer

Our Open Clinic event consists of about 200 free taster appointments of different types with different practitioners, offered over the course of 1 week (more details in the previous articles in this series). At the end of

that session we make our offer for converting to a paying appointment.

In the short term around 33% of people should buy your follow-up offer. I normally recommend waiting until you have presented the offer to AT LEAST 10 people (and ideally by the same therapist too), before you make a decision whether an offer is working for you or not.

Fewer people than that, or if you have different therapists making the offer, makes it hard to pin down why your clients haven’t said yes. But when it’s a pattern of people saying no, that’s when you need to pivot quickly and create a new offer.

Again, this is normal to have to adjust. Don’t get put off by seeing other clinics who seem to have everything sorted and converting perfectly. Even if they do, I guarantee they didn’t have the process perfect the first time round.

So, if you do want to adjust your offer what can you do?

Firstly, it is perfectly OK to go back to your original Open Clinic attendees with a new offer. I wouldn’t advise doing this regularly because we don’t want to train your clients to wait it out in case they’re offered a better deal, but as long as you are honest about why you’re going back to them, then I absolutely recommend that you make that offer.

You can just start your email by saying something like, “Since last week lots of you have been saying you wanted to take up the XXX offer but wanted something shorter/with more 39

availability/smaller package [insert the reason], etc. So, I/we went back to the drawing board and have got this for you.”

Then go on to highlight how this new offer helps with any of the objections that you heard when people said no the first time around.

Normally, the most common reasons why people say no comes down to price, availability or time commitment. So when adjusting your offer, look at ways to either reduce the price or increase the value: 1. Reduce the price by increasing the restrictions on when or how it can be used l For example, reduce the appointment length, number of therapists/modalities available with the offer or create an even smaller time frame in which the client can redeem the offer.

NOTE: Wherever possible do not take the same offer and simply slash the price. Give them a different choice of offer instead of discounting the one you already have. l If you did create a big package then create a ‘lite’ scaled-down version with fewer appointments or items included.

2. Keep the price the same but increase the value l Add some other items in for free, such as a follow-up assessment, access to online materials, a free place for a workshop, etc. l Add evening and/or weekend availability – we know these are peak times, so opening up a poorly performing off-peak offer can all of a sudden begin to bring in those sales.

You need to perform at least two rounds of running an offer to start to nail down the details and provide an offer that your clients really want.

We’ve just completed our 4th year of 40

the Open Clinic event and although we ran a smaller event because I’m on maternity, we still increased our sales by almost 20%.

If you scrap an offer after the first attempt, then you’re leaving money on the table and your clients are missing out on the opportunity to work with you. Use the tips and strategies in this article and you’ll be able to create a toolkit of offers to use whenever you need them.

Open Clinic events are excellent for topping up a slow diary/cash flow, for raising emergency funds, or helping to launch a new therapist.

Remember, refining your offer so it serves your clients better is not being salesy. It’s being helpful, in exactly the same way you would adjust your clinical techniques or recommendations based on their needs.

When you started out as a practitioner, it took time to hone your clinical skills, and it’s exactly the same here. You can create an amazing offer structure that serves both you and the client, which doesn’t have to be salesy.

If you want more detail on how I built upon the sales strategy this year with about five different offers to five different client groups (it’s not as complicated as it sounds!) then listen to “The Secrets behind the Offers I use for Our Health Week” (step-bystep walkthrough) podcast episode!) (https://spxj.nl/2ZrgF2h).

The Massage Therapist’s Business and Marketing Podcast

For those of you who are not familiar with Vicki Marsh’s Podcast, it’s worth getting familiar with it because it features some extremely clever but practically focused tips and strategies for overcoming many of the marketing hurdles that physical and manual therapists commonly experience.

Recent Episodes

l What is a fair wage for a therapist anyway?! https://spxj.nl/2NFT63g l Overcoming fear around rebooking https://spxj.nl/2ZmtRdC l The Secrets behind the offers I use for our Health Week (step-by-step walkthrough episode!) https://spxj.nl/2ZrgF2h l 3 ways to break the feast:famine diary cycle https://spxj.nl/2KYjXGa l How to make scarcity your friend (and earn you cash!) https://spxj.nl/30AH7Ic l Turn Cancellations into Rebookings https://spxj.nl/328ThrQ

Listen at the Links Below

l Soundcloud https://spxj.nl/2NzlF2z l Spotify https://spxj.nl/2MERNlF l iTunes/Apple https://spxj.nl/341WefE l Google Podcasts https://spxj.nl/2ZxUc7I l Or through Co-Kinetic https://spxj.nl/2Ht1jnB l It’s also available on all the major podcast mobile apps.

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 l The Blueprint for Running a Successful Open Clinic Event: Part 3 Your Paid Marketing Strategy [Article] https://spxj.nl/2XvD9Pm 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.

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BY TOR DAVIES, CO-KINETIC FOUNDER

g n i t e k r a M W h a tN e e d t o D o ?

Do I

This article details four key marketing cornerstones that are fundamental to building a healthy business. It explains why each aspect is important, as well as how you can bring them to life in practical terms. It doesn’t matter if you’re not yet treating patients, in fact you can benefit particularly by following this advice, but equally if you are already treating patients, or even running an established clinic, the cornerstones remain the same, just their order of priority will change (which I’ve also detailed). I’ve tried to answer the marketing questions I’m most frequently asked by people at all stages of business. As with all my articles, it is packed with practical advice and links to outside resources which will help you to implement the advice, particularly if you are easily intimidated by technology. Read this article online https://spxj.nl/2lDKw9h

SALES REFERS TO ALL ACTIVITIES THAT LEAD TO THE SELLING OF GOODS AND SERVICES. MARKETING IS THE PROCESS OF GETTING PEOPLE INTERESTED IN THE GOODS AND SERVICES EING SOLD Co-Kinetic.com

Introduction

Every marketer you speak to, will have their own thoughts about business marketing priorities, but over the last 4 years I have worked with, and continue to work with, more than a 150 physical and manual therapy businesses on various aspects of marketing. From that experience, I’ve boiled down what I believe are the four key cornerstones to building a healthy, thriving (not just surviving) business. In my view, these are the 20% of actions that will give you 80% of your marketing results.

There are of course additional activities that can amplify and supplement these cornerstones, particularly in my view the use of Facebook ads to increase email lead collection, but I wanted to get the basics in place from which we could build more advanced strategies.

Unfortunately many businesses neglect the basics, which means the investments in the more advanced strategies often fail to deliver what’s expected of them. These four cornerstones alone, will allow you to build a stable business, everything else, should then aim to accelerate, amplify or strengthen the processes already in place.

Sales versus Marketing

First let’s get one definition sorted.

When small business owners say marketing, they usually mean sales, or at least, marketing AND sales (even if they don’t think they do).

What’s the difference? Sales refers to all activities that lead to the selling of goods and services. Marketing is the

process of getting people interested in the goods and services being sold.

Realistically in terms of small businesses and one-wo/man bands, they’re hard to delineate, as they are both necessary to build a successful business.

In reality, among the people I speak to at least, the question most people want the answer to more specifically is, “what marketing do I need to do, to ensure that I can generate enough business to meet my goals”.

And so that’s the question I’m setting out to answer in this article.

What does ‘meeting your business goals’ actually mean?

The first question I always ask my new clients is, what are your business goals?

Most of us set up in business because we want to be masters of our own destiny and in control of our lives, and our time. I’m guessing that most of us don’t set up in business as a physical or manual therapist, to make our millions (although there’s no reason why you can’t).

But everyone most likely wants (and needs) to make a solid, stable income that allows you to provide well for the people you love. Whether that means holidays, private education, good healthcare, a nice home, a decent car and money for some of the luxuries in life, it’s always worth having a clear definition and vision of what ‘success’ actually looks like to you.

When we start out, we do the 41

WHEN YOU GO OUT ON YOUR OWN, YOU HAVE TO BUILD STABILITY, RELIABILITY AND CONTINGENCY. AND A KEY PART OF THAT COMES FROM YOUR APPROACH AND COMMITMENT TO MARKETING simple numbers, “if I work 7 hours a day, 5 days a week, I’ll make X and that will do me nicely”. But that assumes you can fill all of those available hours, that you won’t need any time off, that nothing unexpected happens and your business and life costs are 100% reliable all the time. Unfortunately, real life just ain’t like that!

When you go out on your own, you have to build stability, reliability AND contingency. And a key part of that comes from your approach and commitment to marketing. Like it or not, until you get pretty big and I mean ‘multi-therapist’ big, you will have to get hands on with your marketing, because you’re unlikely to be able to afford the luxury of buying those marketing skills in, at least not decent ones who won’t rip you off.

So that means you need to know how to market and promote your business, and sell appointments.

Having a good foundation and understanding of what you need to do, to achieve this, will stand you in good

Figure 1: Co-Kinetic search on Google

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stead at any stage of your business development.

The other essential thing when you’re starting a business is to focus on the 20% of activities that will give you 80% of your marketing results. All too often we waste time on activities that are less productive than others. My goal is to keep you focused on what will give you the biggest bang for your buck in terms of both your own time, as well as financial, investment.

The Four Marketing Corner Stones

You may be relieved to know, that there are just four key marketing corner stones. The importance of the order of these depends on what stage you’re at in your business, and I touch on that later in the article.

1. A Google My Business Listing 2. An Online Presence (Facebook/ website) 3. Reviews and Testimonials 4. An Engaged Audience That Belongs to You (email list)

These 4 priorities are not optional, they are all obligatory, and the minimum you need to create a solid marketing foundation. Think of them as four supporting pillars of a house. The structure only works if all four of them are in place. That means you can’t do two or three of them, and leave one out. Each one is a mission-critical marketing objective, and they work together and rely on each other.

So let’s look at each of those four cornerstones and explain why they’re important.

Cornerstone 1: Google My Business Listing

What is it? This is a no-brainer. It’s essentially Google’s online business directory listing. It takes no more than 15-30 minutes to set up a listing and when people search for your company name (or something close to it), if you have a business listing, two things happen – first it appears right at the top of the Google Search results page on the right hand side of the page and if the search is specific enough, you’ll also feature at the top of the search results on the left hand side are (this is often referred to as the one-box).

See Figure 1 for my search results for Co-Kinetic.

Why does it matter? According to the statistics website Statista (1) in April 2019 Google had 88.47% of all desktop searches, the closest competitor was Bing with just 4.81%.

Google prioritises businesses that prioritise Google, so you’d be mad not to do everything you can to get into Google’s good books, especially when it’s as easy as setting up a Google My Business Listing.

It also means that Google knows who you are and what your business does, so when someone searches for “physio clinics in Wimbledon” for example, they have accurate data and know you fall into that category.

However…there are a lot of physio clinics in Wimbledon, so how does Google decide how to rank you?

Figure 2 shows the results for my search on ‘physio clinics near me’. It’s worth noting that the results page will look different depending on what your search is for. If you’re looking for t-shirts

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for example, you’d get a completely different looking page with a bunch of t-shirt product images at the top. In this case, because we’re looking for a local business near me, we get a Local Results box.

The top 4 spots are taken up by paid Google ads and then the second area is taken up by the Local Results box. I’ve included a link to Google’s explanation of how their algorithm works out who should appear in this box (3) as well as another resource which gives more detail on how to get into that box (4), in the Resources panel at the end of the article, but this position is heavily influenced by numbers of positive reviews, which

leads me neatly into the topic of Reviews (and testimonials).

Cornerstone 2: Reviews, Testimonials and Social Proof

What are they? Reviews (and testimonials) are basically reviews of you as a treatment provider, your services, treatments, products (if applicable) or business as a whole.

While there are lots of different review services out there, it’s important to focus on getting reviews on services that integrate prominently with your Google My Business Listing. For example, Google used to feature Facebook reviews (now called Recommendations) in your Google My Business listing, my ones for Co-Kinetic used to appear there but are currently not showing, and there doesn’t seem to be any clear verdict on why this is, but it illustrates an important point. When you focus on building important marketing resources, like customer reviews, you want as much stability as possible. Yes, you can get your own reviews and publish them independently on your website, but then they won’t help your search results.

You can also ask for Facebook Recommendations, but if the No. 1 search result engine ie. Google, stops featuring them (which possibly they have now started to do), the time investment you put into building those recommendations will lose a significant element of their impact.

The same goes for third party business review tools if they don’t integrate prominently with Google My Business Listings. So if you’re considering using a third party review tool, make sure this is one of the top requirements.

Personally I would focus on asking people to add recommendations/ reviews on Facebook and Google (just ask them to choose one or the other) so ideally you get a nice spread of reviews across both platforms. If you want to prioritise just one, my advice would be to go with Google purely on the basis of their influence on search results.

You’ll see in Figure 1, there’s a Write Review button about half way down the panel. To make it easy you could include in the email you send asking your clients to post a review, some tips on how to write a good review, some are included in this article (5) (see link at the end of the article).

Don’t forget the other form of very valid ‘social proof’ which is logos of businesses or organisations that you work with, which you could feature on your website (just make sure to check with them that it’s OK to use them, before you do so).

Why do reviews matter? Because ‘social proof’, as it’s known in the marketing world, is one of the most powerful influencers when it comes to buying products and services. It’s actually one of the few things that marketers from all corners agree on.

Different articles will quote different numbers, but overwhelmingly, all support the fact that social proof has a powerful impact on purchasing decisions and particularly trust (6). Most articles quote that at least 80-90% of people are influenced by social proof in some form or another.

We also know that the Google Local Results box is HEAVILY influenced by reviews, and particularly reviews posted through Google – as this helps

Figure 2: Google search results

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to inform relevancy. Google wants to deliver the most relevant results to their searcher, as quickly as possible, so they will deliver sites that get the most clicks when someone searches for a given phrase. What heavily influences clicks on a link? Reviews. Because as we now know, it has a big impact on how people choose businesses to work with (6).

So the upshot is, get a customer review process in place. Make it a habit at a certain point in a treatment plan to ask for a review, or strike while the iron is hot if you know someone has had a great session, or is particularly enthusiastic and pleased with their progress. All it needs to be is a simple email request. Many of us send our patients advice resources or exercise leaflets after an appointment, so if you feel the appointment went well, take this opportunity to ask them for a review at the same time.

Make it as easy as possible for them to post a review, give them direct links in the email to either Facebook or Google for example and give them a little paragraph of text to help them structure their review (but obviously don’t tell them what to say as the whole point of reviews is that they’re authentic). Use the article in reference 5 to get what you need, without unduly influencing what they say or how they say it.

I’d also recommend that you somehow tag a client based on whether they’ve given you a review or not in the past. You don’t want to keep bugging people with reminders if they’ve already given you review, so you need to be able to quickly identify if they have or not, before you send the email. This is one of the benefits of using an email marketing tool, because you can make that a custom tag. It also means you can filter for these people in future, and perhaps offer them some kind of thank you benefit, like first dibs on discounted appointments or education sessions that you run, for example.

Cornerstone 3: Create an Online Presence

What does that mean? When you’re starting out, I’d personally recommend 44

a Facebook Business page over a website (but I know there will be lots of people who disagree with me on that!), so how do I justify that statement?

Here’s 8 reasons why I think a Facebook Business page trumps a website: 1 A Facebook Business page is easier, quicker and cheaper to set up than a website and requires much less technical input 2 Y ou can include most, if not all, of the information you should/would include on a website (I’ve given more specific details about what to include below) F 3 acebook has an inbuilt review/recommendation feature – which allows you to start building up your reviews and testimonials from the get-go A 4 Facebook Business page gives you the opportunity to build a personality and get known, build trust and become liked, in a way that a website doesn’t

ew Facebook posts are easy for anyone to create, so 5 N a Facebook page stays fresh and current, unlike many websites

6 Y our page will automatically be mobile-responsive and easy to navigate (move around), because it’s in Facebook’s interests to make the user experience as good as it can be

7 A nd most importantly in my view, it’s easy to start sharing content, and more specifically content which can help you build an email list, which as you will read next, is indisputably one of the most important, and powerful marketing tools at your disposal 8 I f you use Facebook Ads, it gives you a direct route straight through to advertising to the most geographically relevant people (ie. people that live

OVER-COMPLICATING AND OVER-INVESTING IN A WEBSITE IS ONE OF THE MOST COMMON MISTAKES THAT START-UP BUSINESSES MAKE

in your area) with interest areas that you can target to an almost unbelievable level of detail.

For this reason, I think EVERY local business should have a business Facebook page.

If you’re not confident setting one up yourself then you can pay an almost ridiculously small amount to get someone on the freelance website Fiverr (7) to help you. The link at reference number 7 will give you people who specialise in building Facebook pages specifically.

As a quick aside, Fiverr is also a great site for getting logos created on the cheap and some of them are really good, particularly for what they cost.

They can certainly serve to get you started, and you can always upgrade the logo at a later date when you have a bit more money in the bank. When choosing a freelancer, look for people with a high number of 5 star reviews and guess what…read the reviews.

If you also feel that you want a website as well, and that’s fair enough, after all it’s a more traditionally established business tool and you may feel people expect it, but don’t fall into the trap of over-investing both time and money on it.

I know you’re new on the block, full of enthusiasm about your new venture and you want to make a good impression and a website is often your first chance to shine and impress, but here’s a reality check which is not designed to dishearten you, but to help you keep things in perspective.

The average bounce rate of a website is 50%. That means that half the people who visit your site, will hit the first page and immediately click the back button. This is a pretty standard bounce rate on all but the very best sites across the web, so it says nothing about the quality of your site specifically.

The second thing is the average length of a website visit is 2 minutes and 17 seconds. In other words, it doesn’t matter how amazing or engaging your site is, people won’t hang around for long. Why? Because people just don’t have the time. The chances are that people will be on your site for one of three reasons, either looking for information about how to Co-Kinetic Journal 2019;82(October):41-49

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book an appointment, or directions for getting to their appointment, or they’ll be investigating whether they think you’re the right person to solve their problem. There’s one other possible reason, if you have a blog area and you promote blog posts through marketing material and/or it gets picked up as a search result (the latter of which is a pretty remote possibility, however good your SEO dude says he is), they could also be there reading a blog post.

In short, make it easy for them to find what they want a) how to book an appointment, b) how to get to their appointment and c) how well qualified you are.

Your website needs to be clean, clear, professional, functional and mobile-friendly (ie. it changes format when viewed on a mobile device), but avoid the bells and whistles. Overcomplicating and over-investing in a website is one of the most common mistakes that start-up businesses make.

You need just 4 or maybe 5 pages: 1 Home Page (inc. how to book an appointment) 2 About Me Page – your qualifications, what you’re passionate about, what you excel in 3 Services I Provide – this is more clinical about the different services you deliver and maybe include evidence behind those services, what problem can they solve for the reader 4 How to Find Me – directions, public transport details, parking info, embedded map and clickable contact number in case they need to call you on the move 5 Blog (optional) Every page on the website should ideally feature the following 4 things: l Menu bar/navigation l A book an appointment call to action l Reviews/testimonials (reference 8 tells you how to embed Google Reviews on your own website) l Advert for your latest blog post (with an associated lead magnet – more later) Here are 6 things your website MUST deliver:

Co-Kinetic.com

1

2

3

4

5

6 7

Who

YOU are, what you’re qualified to do, and what you’re passionate about (don’t stay anonymous on a website, even if it’s just you and you’re worried about looking too small, it’s the worst thing you can do in a service-based industry) H ow a website viewer/visitor can book an appointment – don’t use a personal mobile number, buy a local telephone number for £1 a month through a service like Invoco Telecom and redirect that number to your mobile (https://www.invoco.net/) – that way you can control the hours of who can get through to you and when, and when you’re ready, you can redirect it to a callanswering service in the future should you want to D etails about how they find your clinic/workplace and information about parking and public transport if appropriate – embed a Google map in the page to make it even easier to get directions to you, especially if the customer is on the move already (see reference 9 for more details) A call-to-action such as sign up to receive a useful downloadable resource (this helps you build your email list – which as you’ll discover is arguably your most important and powerful marketing tools) T estimonials and/or logos of businesses you work for (make sure you get their permission) or even better, embed Google Reviews on your website – reviews offer big SEO advantages and should be one of your first priorities as I’ll discuss in more detail shortly (see reference 8 for details) Links

to your social networks (only include ones you’re active on) B log (optional) – only do this if you’re going to commit to doing two things with your blog, the first is publish relatively regular content ie. once every 4-6 weeks and the second thing is use the blog posts to build your

MAKE SURE YOU ALWAYS HAVE CONTROL OF YOUR WEBSITE ADMIN LOGIN AND THAT THE ACCOUNT IS SET UP UNDER YOUR EMAIL ADDRESS, NOT YOUR DEVELOPER’S email list by offering extra value downloads (ideally on a similar or related topic) in exchange for an email address. Not only does this help you build your email list and improve your ‘findability’ through the search engines, but it will also help you to segment the people on your email list by interest area at a later date.

Keep your website simple, use a commonly-used platform like Wordpress. There are several advantages to Wordpress, if you can’t build your own website, you can easily and cheaply hire someone on a freelance service like Fiverr, to help you. It’s the most widely-used website creation platform which means there are loads of people who can jump in and help even if your website creator leaves you in the lurch (which most do at some point or other).

Make sure you always have the administration login at all times and that the account is set up under YOUR email address, not your developer’s. That means you can easily reset passwords if you need to, or if you fall out with, or your site is being held ‘hostage’ by, your web

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IF YOU HAVE AN AUDIENCE YOU CAN TALK TO WHENEVER YOU WANT TO, YOU HAVE LEVERAGE TO GENERATE NEW BUSINESS developer (this happens more often than it should). NEVER lose control of the admin rights to your site, otherwise you may well end up having to build a whole new website all over again.

The other advantage of Wordpress is that it has thousands of ‘plug-ins’, which are little bits of software, many of which are free, that you can add onto your site in a couple of clicks and will do just about anything you can imagine or dream of. I wouldn’t suggest experimenting just yet, get the basics in place first, but it will give you lots of flexibility in the future.

Do I Even Need a Website?

Arguably not, but you do need some sort of ‘shop front’ or online point of contact. This could be your Facebook page, just as long as it includes the information that’s listed above. Don’t assume that you MUST have a website, you can build a perfectly strong business without one. But if you do

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want a website, think of it as an online brochure – and don’t go overboard with it, as you’ll just end up wasting a bunch of time and money.

Cornerstone 4: An Engaged Audience That Belongs to You

What is an engaged audience?

It’s a group of people, that trust you enough that you can inspire them to take action. This is how bloggers built businesses 10, 15, even 20 years ago.

They’d write blog posts on a specific niche, they’d encourage readers to sign up to an email newsletter to get more of this niche content, and then they’d nurture that email list by regularly giving those people more and more high-value content that they loved. In that process, they built an army of active, engaged readers that jumped on their every word and purchased products and services the minute they were mentioned, because they trusted the source the recommendation was coming from.

Why is an engaged audience important? In order to be able to generate business and sales, you need to have something to leverage, in other words, you need a list of people that you can ask to take action when you need them to. If you don’t have your own audience, that are warm and receptive to you, then it’s much harder to drum up business when you need it because you have to rely on someone else’s audience, or you just have to wait for people to come to you. Either way this significantly reduces the control you have over your business and it gives you absolutely no scope to bump up revenue, even if you desperately need it. Basically, it leaves you and your business exposed to downturns in the market or competition from other therapists.

If you have a list of people you can make offers to (and I don’t just mean discounts), you have the chance to generate business. If you have an audience you can talk to, whenever you want to ie. you own it, you

have leverage. You could offer any kind of event, such as an educational session around a clinical topic that’s likely to affect people living in your area, or an injury prevention session based on a local sports event that’s due to take place, your imagination is your only limit. But if you have an audience who are receptive to hearing from you, who trust that your intentions are good and that the event will help them, the chances of them attending the event are high.

At that event people can ask you questions, you get to demonstrate your knowledge and skills, and ideally you would offer incentives at the event, to book a follow-up appointments, possibly at an incentivised rate if they book that day, or opportunities to sign up to some sort of paid event like a training programme or regular treatment schedule, again it’s really up to what works for you. But if you’re starting from a blank sheet of paper, and you have no existing customers and no contact list of prospective customers, it makes it very much harder to get this ball rolling.

To start with you could utilise other people like friends or colleagues, or businesses that have built their own audiences, like local publications, online groups or local social networks, sports clubs, local businesses – anywhere where there’s a reason for people to collect either online or offline.

The advantage of using other people’s audiences is that they’re already formed, and you don’t have to do any work to get to them. The disadvantage is that you’re not in control, so they may not always be available to you, you may need to pay to target them, or at the very least give up some of your time for free or offer them freebies or incentives to get in

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ENTREPRENEUR THERAPIST

touch with you.

The advantage of building your own audience is that you own it. It’s yours to do what you want with it.

And while it may take a bit more time to build, once you have it, nobody can take it away from you, and you have something you can leverage, whenever you need it. You also have something that a new competitor moving into your area doesn’t have, which gives you a significant competitor advantage. Having an engaged and constantly growing email list is a business super-power.

has volume-based cost or time implications. l And finally you can leverage an email list when you want to, you are in control of the data, you’re not obligated to someone else in order to use it, and it’s yours to do what you want with it.

Email Is Your Gold Standard

If you spam your email readers with: 1 Long, boring clinic newsletters that take you weeks to write and which to be brutally honest are probably of very little interest to anyone except you and if you’re lucky maybe your mother/ father….what do you expect?

2 Or if you send them constant offers/discounts/sales promos…. well you probably know how you feel about other businesses doing that to you, so that should tell you all you need to know about that 3 Or if you only contact them once in a blue moon and ask them to buy something from you…it’s like the friend you never hear from until they want something – we’ve probably all got at least one – but it should come as no surprise that they don’t respond to you?

You could also collect telephone numbers, postal addresses, or you could ask them to connect with you on social media. The trouble with contacting people by phone is that it’s intrusive, salesy, and time-consuming.

Sending letters is OK but there’s a lot more data for the person giving you their details to fill out, and then you have to pay to write, print and post the letters. Connecting on social media isn’t ideal as you then have to rely on the social network to communicate through, and if the social network decides to change things, you could lose contact altogether.

The quickest, least intrusive, most reliable, and controllable contact medium is email.

Here are 6 benefits of email: l Email is a simple and quick piece of data for someone to enter l People are used to, and comfortable with, being asked for their email address l They are in control of when they read your email, so it’s not intrusive and doesn’t interrupt like a phone call does l Email is cheap or even free if you use a free email marketing tool like Mailchimp which offers a free plan l MOST importantly email is scalable meaning it takes you no longer to send 2,000 emails out, as it does 1 email – unlike pretty much any other method of contact which usually Co-Kinetic.com

But I Don’t Want to Spam People…

….and what about click and open rates, nobody will ever read my email.

Well that, rather bluntly, comes down to you!

It’s not rocket science, the result is low open rates, and even lower click rates because life is busy, there’s too much stuff out there and bluntly…people just don’t care about the things that matter to you.

If on the other hand, you send them helpful, value-added resources that benefit them, or their colleagues, or their family and friends, guess what happens…open and click rates start to increase.

And if you send a friendly, valueadded email regularly and consistently (like every 3-4 weeks) and you avoid the temptation to spam people with sales pitches, those open and click rates will continue to rise.

Data from billions of email campaigns sent through three of the

biggest email marketing platforms (Mailchimp, Campaign Monitor, Get Response) give an average open rate of between 18-22% and an average click rate of between 2.4-3.4%, but if all those people concentrated on offering value, those rates would jump dramatically.

My own Co-Kinetic email open rates over the last year, have moved from an average of 19% up to 30%, that’s 11% in 15 months, and while I have been focusing on adding value through my emails, I haven’t been sending them anything like as consistently as I should have been and consistency matters, so I’m fairly confident I can increase that by at least another 5-10%.

If you focus on consistently offering value, It’s perfectly possible to get at least 1 in 3 people to open your emails. If you have a list of 30 people, that means 10 of them will open that email, if it’s a list of 300 people, then 100 will open it, or 3,000 and 1,000 of them will open it. That’s pretty good numbers and certainly a whole lot better than an advert in a magazine or business directory.

And, if you focus consistently on adding value, you also build trust and reciprocity, which brings with it a much greater willingness to buy or at least take action when you ask them to, whatever that action may consist of.

The crazy thing is, it doesn’t take much to achieve this, a quick email saying here’s a new resource I wanted to share with you with a link to a download, is all that’s needed.

Building An Email List Works at All Stages of Business

The other great thing about building an email list, is that anyone can do it, at any stage of their business, you don’t even have to be ready to treat clients yet. So even if you’re in the contemplation/planning stage of a

HAVING AN ENGAGED AND CONSTANTLY GROWING EMAIL LIST IS A BUSINESS SUPER-POWER 47

business, you can still get started, and it means you’ll be ready to hit that ground running, as soon as you’re ready to start seeing clients.

The upshot of all this is, in order to proactively generate business, you need to be able to talk to people. You need an audience who are warm and engaged and ready to take action.

Most businesses will survive on a supply of clients who arrive seemingly ‘out of nowhere’. These are the people that know they need help and proactively seek it out. They might arrive on your doorstep for a variety of reasons, word-of-mouth, personal recommendations or the results of an internet search, but you have little or no control over the volume or timing of when those people appear. You can influence it to some extent, by making sure you have lots of great Google reviews, and have a good customer referral plan in place, but that’s about it.

The trouble is that when the supply of clients starts to run dry for any reason, like a competing therapist who also happens to be a marketing ninja, moves in around the corner, or a recession kicks in, and everyone starts cutting back on spending, or summer holidays arrive and everyone goes

abroad…you are left with nothing to leverage. Just when you need to be able to put a foot on the gas, to get over a bump in the road, there’s no fuel in the tank and the engine dies. Not only can this make it difficult to survive, but you also have absolutely no chance of building a thriving business either.

How Do I Build An Engaged Audience Ready To Take Action?

a third party website, a patient leaflet or newsletter, or an exercise video that can help with a certain injury.

The point is that you can write and send the email in less than 5-10 minutes a month, and that the reader always gets value, so they can quickly open it and see if it’s relevant to them.

Please don’t make them wade through long, boring emails! If they know they can look at it quickly and work out if it’s useful to them or not, and then move on, you’ll get better open rates.

If you use a proper marketing platform, you can also use clicks on

This is the simple bit. You stay in contact regularly, like once every 3-4 weeks. And you send them additional high-value content without asking them to go through any email lead collection forms.

Keep this simple and don’t overcomplicate the emails. A 150-250 word email is all you need, along with a link to a useful resource. This could be an interesting article you’ve found on

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How do I Physically Go About Building an Email List?

The business principle is simple, publish content on topics that a group of people are likely to be interested in.

This content could range from social media posts, blog posts or articles in local magazines or on local websites.

The key element is that in all those pieces of content, you highlight the availability of an even more desirable, higher value piece of content, which they can download by sharing their email address with you.

Then you create a simple email lead collection form, I provide one through Co-Kinetic, or you can also build these forms yourself using tools included with Mailchimp or other landing page/lead collection platforms like LeadPages, ClickFunnels or Instapage.

When someone enters their email

address, you can redirect them to a page or a link where they can download the resource you’ve promised them. It’s that simple. The lead collection platform you’ve chosen will then store those email contact details for you, ready for you to nurture. The more widely you can promote the existence of that high-value resource through your other pieces of content, the more new email leads you will collect.

How Can Co-Kinetic Help Me With This?

Through Co-Kinetic I create all of the content and the technology you need to do what I’ve described above. I give you the content to help you promote the existence of some high-value downloads (that includes pre-written social media, blog posts and articles you can publish under your own name in local media) and I build and take care of the email collection forms for you. When someone gives you their email address, I collect it for you, store it in Co-Kinetic and send the new person off to their high-value resources. The goal is to take care of all the tricky technical aspects for you, as well as create all the content you need to in order to grow your email list.

You can find out more at this link https://www.co-kinetic.com/marketing

the links to segment people based on who is interested in what, which means when you run an event on a given topic, you have a historical record of who is likely to be interested and most likely to respond.

How Can Co-Kinetic Help Me With This?

All our subscriptions include a rapidly-growing section of patient resources that are perfect for this purpose. Each patient resource comes with a Share Link that you can copy and paste into your email. When the person reading the email clicks the link, it will open the leaflet in their web browser window (and if you have the Branding Upgrade, this leaflet will also feature your logo and business contact details).

To see the patient resources that are available click here https://spxj.nl/2k0ID6k For more information about the subscriptions click here https://www.co-kinetic.com/pricing

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What Should I Prioritise And When?

The answer to this question lies in whether you’re already seeing clients (or are ready to start seeing them immediately) versus whether you’re still in preparation mode.

Regardless of your business stage, the sooner you start, the better, I would just prioritise the cornerstones slightly differently.

If you’re already seeing clients or are ready to start seeing clients today:

1

2 3 4

Google A My Business Listing An Online Presence (Facebook/ website) Reviews and Testimonials An Engaged Audience That Belongs to You (email list)

They’re in this order because if you want to be found on Google, your Google business listing is a fundamental starting point and you need it (and/or an online presence) before you can start getting reviews and testimonials. You can use a Facebook page (and your website) very effectively to build your email list.

As you can see, they’re all interlinked and all equally important, but some have to happen before others can.

If you’re not ready to see clients yet

1

2

n Online Presence (a Facebook A page is enough at this stage) An Engaged Audience That Belongs to You (email list)

And when you’re ready to start seeing clients 3 A Google My Business Listing 4 Reviews and Testimonials If this is your business stage, I’d start a Facebook Business page first, you can leave off any details about booking appointments, or finding your clinic because they’re not relevant at this point. But it does allow you to create a living breathing online presence which you can use to start building an email list.

If you have an email list, however Co-Kinetic.com

small, when you start, you have a starting point. If you’ve been good at keeping in contact with people, as you get your business ready for takeoff, then you will have an audience primed to take you up on any offers you want to make like free treatments and discounts if they want to book additional appointments.

At this point your priority is to get ‘bums on seats’ and as many people through your doors to experience your skills, as you can. While you’re giving your time away either free or cheaply, this is an ideal opportunity to ask for reviews in return, be completely open with the people you see, and explain you’re just getting started, their reviews would make a huge difference to you. If you’ve given them an amazing customer experience, you’ll be surprised how many people will respond to that request (just make it as easy as possible for them to do by following my advice above).

The Business Super-Powers

In conclusion, there are two really strong indicators of a successful, thriving business, the kind of business that people want to work for because they know they can rely on it, and the kind of businesses people want to buy into: 1 A loyal, returning, paying customer base who will sing your praises at every opportunity, something the marketing world calls a ‘raving fan’ 2 A warm (regularly contacted), engaged (good open and click rates) email list with business potential that can be leveraged If you have those two super-powers, you have the opportunity to generate as much business as you want, whenever you want.

Most of us have a fairly good idea about how you build raving fans (whether we choose to do it or not, is another matter) – it’s simply about delivering an awesome customer service and going above and beyond what most other therapists would bother with.

Fewer people appreciate the value of, let alone know how to build, a warm, engaged email list, which is

crazy given it’s so simple and timeeffective to do.

Focus on these four marketing cornerstones, regardless of where you are in your business lifecycle, and you will have all the tools you need to build the business you’ve always dreamt of.

References and Resources

1. Search Engine breakdown https://spxj.nl/2kptTht 2. Set up Your Google My Business Listing https://spxj.nl/2kptPyf 3. How do you get into the local search results https://spxj.nl/2ksa2hw 4. What we Learned About Google’s Local Results from Analyzing 119,221 URLs https://spxj.nl/2lu9msq 5. How to Write Powerful Testimonials https://spxj.nl/2ksbe4v 6. Online Reviews Impact Purchasing Decisions for More than 93% of Consumers https://spxj.nl/2jX8WKF 7. Search results for people on Fiverr who will create a Facebook Business Page for you https://spxj.nl/2lPDwGu 8. How to Embed Google Reviews on Your Website https://spxj.nl/2k2crj2 9. How to Embed a Google Map on Your Website https://spxj.nl/2krR2Qh

Further Reading l 25 Ways To Grow Your Email List [Article] https://spxj.nl/2KdQgCs l Practical Ways to Use Content to Promote Yourself and Your Business [Article] https://spxj.nl/2KxOzhX l How to Run Lead Generating Facebook Ads to Help You Build Your Email List and Get More Clients [Video Training] https://spxj.nl/2PtI3YG l More Marketing Advice http://spxj.nl/2z1V3j6

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.

Join us on Facebook: www.facebook.com/CoKinetic/ Connect with Tor: www.facebook.com/cokinetic.tor 49

MANAGING MUSCULOSKELETAL INJURIES

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he word ‘musculoskeletal’ simply means anything to do with the muscles (musculo) and/or bones (skeletal), including tendons and ligaments forming joints and supporting your spine.

So, a musculoskeletal injury could vary from a muscle tear or strain; to a sprained ankle where the ligaments are overstretched or torn; to a meniscus or cartilage tear in the knee or a large contusion (muscle bruise) on your thigh.

WHEN SHOULD YOU COMMENCE TREATMENT?

In most cases, ‘the early bird catches the worm’. Researchers have found that intervention with physical therapy treatment for acute soft tissue injuries within a few days has many benefits.

Prompt treatment benefits include: l Relieving your pain more quickly via joint mobility techniques, soft tissue massage, electrotherapy l Improving your scar tissue quality using techniques to guide the direction it forms l Getting you back to sport or work quicker through faster healing rates l Loosening and/or strengthening of your injured region with individually prescribed exercises and techniques l Improving your performance when you do return to sport, work or simply daily life l Correcting any biomechanical faults that may be affecting your movement, technique or predisposing you to injury.

It’s important to remember that symptoms lasting longer than three months become habitual and are much harder to solve. The sooner you get on top of your symptoms the better your outcome.

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TREATMENT PHASES

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Acute - Protection Phase Early accurate assessment and prompt appropriate treatment is much better than delay. What may appear to be a simple muscle, ligament or soft tissue injury can include a hairline fracture, bone bruising or dislocation. Regardless of what the injury is or where it is on your body the early management is the same – that means the first 24-48 hours.

A soft tissue injury is termed as acute from the initial time of injury and while the pain, bleeding and swelling is at its worst.

Your body’s aim at this point is to protect your injury from further damage. The usual time frame for your acute symptoms to settle is two to four days post-injury, but this can vary depending on how you treat your injury.

In the first three days after injury, use the P.R.I.C.E. method. If you are unsure on any of these stages ask for advice from your physical therapist Protect: Protection is meant to prevent further injury. For example, an injured leg or foot may be protected by limiting or avoiding weight-bearing through the use of crutches, a cane, or hiking poles. Partially immobilising the injured area by using a sling, splint,

P

I

or brace may also be a means of protection.

Rest (to avoid pain and further damage): Rest from painful exercise or movement is essential in the early injury stage. We call this active rest.

The saying ‘No pain, no gain’ does not apply in most cases. The rule of thumb is - don’t do anything that reproduces your pain for the initial two or three days. After that, you need to get it moving or other problems will develop.

Ice (20 minutes every two to three

hours): Ice is preferred for the initial two or three days post-injury. Ice should also help to reduce your pain and swelling in traumatic soft tissue injuries, such as ligament sprains, muscle tears or bruising.

Compression (to support the injury and minimise swelling): Yes. If it is possible to apply a compressive bandage or elastic support to the injury, it will help to control swelling and bleeding in the first few days.

In most cases, the bandage/support will also help to support the injury as the new scar tissue is laid down.

This should help to reduce your pain.

Some injuries will benefit from more support such as a brace or rigid strapping tape.

C

WHAT IF YOU DO NOTHING?

Research shows that injuries left untreated do take longer to heal and can result in lingering pain. They are also more likely to recur and leave you with abnormal scar tissue formation, joint stiffness and muscle weakness.

PRODUCED BY:

TIME-SAVING RESOURCES FOR PHYSICAL AND MANUAL THERAPISTS

PATIENT RESOURCE

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Elevation (above your heart to assist swelling reduction): Elevation of an injury in the first few days is very helpful. Think where your injury is and where your heart is. Gravity will encourage swelling to settle at the lowest point. Try to rest your injury above your heart. Obviously some injuries are impossible or it would be detrimental to elevate, so please use your common sense and be guided by your pain.

Your chances of a full recovery will be helped if you avoid the H.A.R.M. factors in the first 48 to 72 hours.

What are the HARM Factors?

Heat: Increases swelling and bleeding.

Avoid heat packs, a hot bath and saunas.

Alcohol: Increases swelling and bleeding.

Plus, it can delay healing.

Running or exercise: Aggravates the injury which increases pain, swelling and bleeding. Always check with a health professional before resuming sport or exercise.

Massage: Stimulates circulation which is a benefit for healing and relaxation, except in the acute phase where you are wanting to reduce the bleeding and swelling to the injured area. Direct massage to the injured area may aggravate the damaged tissues and is normally best avoided for the first 48 to 72 hours. Indirect massage (away from the injury site) may be helpful.

2

Sub-Acute – Repair Phase A soft tissue injury is termed as subacute when the initial acute phase makes a transition to repairing the injured tissues.

This phase commonly lasts up to six weeks post-injury when your body is busy laying down new soft tissue and reducing the need to protect your injury as the new scar tissue, muscle or ligament fibres are beginning to mature and strengthen.

The purpose of physical therapy in the sub-acute injury phase is to assist nature to quickly reduce the inflammation, hasten the healing process and avoid complications such as joint stiffness, muscle tightness and weakness which may predispose you to re-injury.

Treatments in this phase may include: l Local modalities are used to assist

pain reduction and the natural healing response via an increase in energy (electrical, sound, light, magnetic, temperature) to the area. Some examples include, cryotherapy, heating, electrotherapy, ultrasound, laser, TENS. These modalities have short-term benefits that can assist with the earlier introduction of other longer-lasting techniques such as exercise prescription. l Massage, acupuncture, dry needling l Joint mobilisation - joint stiffness is a complication associated with both joint and adjacent muscle, tendon and ligament injury. Your physical therapist is highly skilled in regaining full joint motion via a range of skillful hands-on techniques. l Protective strapping, bracing, supportive tape l Exercise prescription has been shown by researchers to be the most effective method to hasten recovery, reduce pain and improve your post-injury function.

These can start early in this phase and gradually the load and intensity will be increased overtime and tissues heal and strengthen.

– Specific stretching exercises – Strengthening exercises: localised and global. This means strengthening the specific muscle that may have been injured with isolated exercises to that one muscle group. But slowly more functional exercises will be introduced where the muscle or joint needs to work in a co-ordinated manner with surrounding areas. Core stability (that being your pelvis and abdominal, lower back area) are also key areas to strengthen in any back and lower limb injury. Similarly an injury to the upper limb or neck requires strength of the upper back and entire shoulder girdle, even your core, as no muscle or joint works in isolation.

– Proprioceptive and balance retraining – Biomechanics correction: Biomechanics is how your entire system (body) works together through a movement or action. For example how your foot position may affect your legs and hips whilst running or how your trunk rotation affects your shoulder and arm when throwing a ball. Your body works

as a chain, all joints and bones being connected through soft tissues; so any stiffness or weakness in one area can affect a different area predisposing it to injury.

– F unction or sports-specific rehabilitation.

3

Late Stage - Remodelling Phase Your body does not magically just stop tissue healing at six weeks post-injury.

Healing is a continuum. At six weeks post-soft tissue injury your healing tissue is reasonably mature but as you stretch, strengthen and stress your new scar tissue, it often finds that it is not strong enough to cope with your increasing physical demand.

When your body detects that a repaired structure is still weaker than necessary, it will automatically stimulate additional new tissue to help strengthen and support the healing tissue until it meets the stresses of your normal exercise or physical function.

The period between six weeks and three months post-injury is commonly referred to as the remodelling phase. Not unlike a growing family putting demands on a small one-up one-down house, a home requires remodelling, expansion and alterations. So as you require more from the injured area so your body does some remodelling!

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Chronic Phase - Ongoing Repair and Remodelling Beyond three months is referred to as the chronic phase and refers mainly to pain that lasts more than 3 months. However, your soft tissue is constantly being injured by your daily activities and workouts, only to magically repair and remodel the tissue to meet your specific exercise demands.

Balancing training, rehabilitation and matches, as well as adequate recovery time, is key to ensure your body adapts in a positive way to the stimulus without becoming overly fatigued and injured.

Your treatment will vary depending upon the needs of your injury. Your physical therapist is an expert in the diagnosis and treatment of soft tissue injuries and the best techniques for your specific injury and phase of healing.

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

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