Co-Kinetic Journal Issue 84 - April 2020 by Co-Kinetic

1999

2020

ISSUE 84 APRIL 2020 ISSN 2397-138X

Weâ&#x20AC;&#x2122;ve gone GREEN!

what’s inside PRACTICAL

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THE 10 MOST DISCUSSED PIECES OF RESEARCH IN PHYSICAL THERAPY (JAN - MAR 2020)

HOW TO HELP YOUR PHYSICAL THEREAPY BUSINESS SURVIVE CORONAVIRUS

TO FLEX OR NOT TO FLEX? IS THERE A RELATIONSHIP BETWEEN LUMBAR SPINE FLEXION DURING LIFTING AND LOW BACK PAIN? A SYSTEMATIC REVIEW WITH META-ANALYSIS Journal of Orthopaedic & Sports Physical Therapy

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THE 10 MOST PIECES OF RESEAR DISCUSSED CH IN MANUA (JAN - MAR 2020) L THERAPY

THE ELEPHANT IN THE ROOM: TOO MUCH MEDICINE IN MUSCULOSKELETAL PRACTICE Journal of Orthopaedic & Sports Physical Therapy

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2 1

YOUNG ATHLETES WHO RETURN TO SPORT BEFORE 9 MONTHS AFTER ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION HAVE A RATE OF NEW INJURY 7 TIMES THAT OF THOSE WHO DELAY RETURN Journal of Orthopaedic & Sports Physical Therapy

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AN UPDATE OF SYSTEMATIC REVIEWS EXAMINING THE EFFECTIVENESS OF CONSERVATIVE PHYSICAL THERAPY INTERVENTIONS FOR SUBACROMIAL SHOULDER PAIN

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359 3

& Neonatal Nursing

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Biology of Blood & Marrow Transplantation

INFOGRAPHIC. EXERCISE FOR INTERMITTENT CLAUDICATION British Journal of Sports Medicine

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Journal of Science and Medicine in Sport

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The PDF version of this infographic includes hyperlinks to the individual pieces of research. Click here to access https://spxj.nl/33f5qxm

Journal of Manual WE WAITING FOR? & Manipulative Therapy

EFFECTIVENESS OF DEEP TISSUE MASSAGE THERAPY, AND SUPERVISED STRENGTHENING AND STRETCHING EXERCISES FOR SUBACUTE OR PERSISTENT DISABLING NECK PAIN. THE STOCKHOLM NECK (STONE) RANDOMIZED CONTROLLED TRIAL

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Musculoskeleta l Science and Practice

DOES MANUAL THERAPY AFFECT FUNCTIONAL AND BIOMECHANICAL OF A SIT-TO-STAND OUTCOMES POPULATION WITH TASK IN A LOW BACK PAIN? A PRELIMINARY ANALYSIS

Chiropractic

EFFECTS OF MANUAL THERAPIES ON STABILITY IN PEOPLE MUSCULOSKELETAL WITH PAIN: A SYSTEMATIC REVIEW Chiropractic

ISOMETRIC EXERCISE AND PAIN IN PATELLAR TENDINOPATHY: A RANDOMIZED CROSSOVER TRIAL

& Manual Therapies

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Produced by:

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THE EVOLUTION OF EDUCATION: WHAT MANUAL THERAPY ARE

THE BENEFITS OF FIFTEEN-WEEK WINDOW FOR RECURRENT MUSCLE STRAINS IN THERAPY WITH MASSAGE FOOTBALL: A PROSPECTIVE COHORT OF 3600 MUSCLE STRAINS OVER IMPACT ON ANXIETY, BMT PATIENTS: DEPRESSION AND 23 YEARS IN PROFESSIONAL AUSTRALIAN RULES FOOTBALL PAIN SYMPTOMS British Journal of Sports Medicine

Journal of Manual & Manipulative Therapy

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OF 2 EFFECTS MASSAGE THERAPY 3 ON INDIRECT HYPER0 BILIRUBINEMIA IN NEWBORNS

INTERNATIONAL OLYMPIC COMMITTEE CONSENSUS STATEMENT: METHODS WHO RECEIVE FOR RECORDING AND REPORTING OF EPIDEMIOLOGICAL DATA ON INJURY PHOTOTHERAPY JOGN Nursing: AND ILLNESS IN SPORT 2020 (INCLUDING STROBE EXTENSION FOR SPORT Journal of INJURY AND ILLNESS SURVEILLANCE (STROBE-SIIS)) Obstetric, Gynecologic British Journal of Sports Medicine

y Therapies in Medicine

DIAGNOSIS, PREVENTION AND TREATMENT OF COMMON LOWER EXTREMITY MUSCLE INJURIES IN SPORT - GRADING THE EVIDENCE: A STATEMENT PAPER COMMISSIONED BY THE DANISH SOCIETY OF SPORTS PHYSICAL THERAPY (DSSF) British Journal of Sports Medicine

Complementar y Therapies in Medicine

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EVALUATION IS TREATMENT FOR LOW BACK PAIN

MASSAGE THERAPY FOR SYMPTOM REDUCTION AND IMPROVED QUALITY OF LIFE IN CHILDREN WITH CANCER IN PALLIATIVE CARE: A Complementar PILOT STUDY

CONSEQUENCES OF PHYSICAL INACTIVITY IN OLDER ADULTS: A SYSTEMATIC REVIEW OF REVIEWS AND META-ANALYSES Scandinavian Journal of Medicine & Science in Sports

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2 17

Journal of Orthopaedic & Sports Physical Therapy

THE EFFECTIVENESS OF TRADITIONAL THAI MASSAGE VERSUS COMPRESS AMONG MASSAGE WITH HERBAL ELDERLY PATIENTS WITH LOW BACK PAIN: A RANDOMISED CONTROLLED TRIAL

THE EFFECT OF A SINGLE SPINAL MANIPULATION ON CARDIOVASCULAR AUTONOMIC ACTIVITY RELATIONSHIP TO AND THE PRESSURE A RANDOMIZED, CROSS-OVER,PAIN THRESHOLD: SHAMCONTROLLED TRIAL

Chiropractic

& Manual Therapies

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& Manual Therapies

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MANUAL THERAPY & PHYSICAL THERAPY INFOGRAPHICS

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TIME-SAVING RESOURCES FOR PHYSICAL AND MANUAL THERAPISTS

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PHYSICAL THERAPY

Produced by: Introduction TIME-SAVING

RESOURCES

FOR PHYSICAL

AND MANUAL THERAPISTS

FASCIA | SURGERY | 20-04-COKINETIC FORMATS WEB MOBILE PRINT All references marked with an asterisk are open access and links are provided in the reference list.

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Wound healing is a complex process, involving not just skin and muscle but also blood vessel, nerves and fascia. The effect of wound healing on fascia and the biotensegrity of the body is discussed in more detail in other chapters of the book, _Scars, Adhesions and the Biotensegral Body_, and is very briefly summarised here as it is important to bear these ideas in mind when learning about ScarWork. In almost everyone except the very young, scars form as the result of the body repairing itself following a wound. Wound healing happens in four phases: bleeding, inflammation, cell proliferation and remodelling, and the resulting scar tissue is not quite the same as the original tissue as it arises from repair rather than regeneration. If the wound is a small surface wound, the scar will be small and eventually fade to be (virtually) imperceptible, but which can nevertheless have consequences on the surrounding tissue. However, the deeper the wound, such as from surgery or severe accident, the more underlying tissue there is to heal. As we now know, fascia is one of these underlying tissues that is of huge importance – allowing body-wide tensional force transmission and free movement. If, in the healing of a wound, the fascia becomes stuck together in an adhesion, proper force transmission through and free movement of the fascia becomes restricted, an effect that can be translated through the body causing malalignment and/or movement restriction at distal as well as local sites. Sharon Wheeler is a Structural Integration practitioner who originally trained with Dr Ida P. Rolf, the founder of Rolfing. Sharon started developing ScarWork more than 45 years ago and it is her own, original work when she found that gentle manual manipulation of scar tissue gave amazing results in reducing the effect of restrictions. So far there has been little research, yet ScarWork is being taught and practised worldwide due to its tangible results. Here, Sharon discusses her own approach to scars. Co-Kinetic Journal 2020;84(April):34-41

CANCER EXERCISE AND MASSAGE

The Beginning

ScarWork emerged from my Structural Integration practice in 1973. It shares some general philosophy and basic orientation with Structural Integration, however, the hands-on working techniques for ScarWork are completely different. ScarWork seems to affect only the scar tissue and not much else. Working with scar tissue is like speaking a different language in the world of fascia. I was in the process of giving Joan (not her real name) a standard Structural Integration 10 session series. She had been in a car accident 15 years earlier. The car’s steering mechanism failed. With no control, she veered across the oncoming lanes, just missing a head-on collision with a semi-truck, and tumbled down the embankment on the far side. She was not wearing a seatbelt and was thrown halfway out of her window. As the car rolled, both of her legs were broken. Her left leg did all right, but her right leg needed surgery. Her surgeons operated five times through the fascia lata. They even shaved off part of the head of the fibula before they gave up and told her that she had better keep what she had because if they kept going, she may well end up worse. Her right knee was unable to bend to 90°. It was difficult and painful for her to walk or sit for any length of time. She managed her long-term problems with muscle relaxants and pain medication ‘every day by noon’. Joan was also a nurse and she helped me understand what had happened to her medically. Her scar was about 16cm long. Thickened, vertical edges formed a square hollow with a gap so deep and wide I could hide my finger in it; 3cm either side of the incision were stiff, shiny, irregular ripples with random blotches of red and white colouration. Large areas were still numb. Dr Rolf had advised me to ignore the scar and establish the function, but this strategy was not working for Joan. One of the major functional goals of the third session of Structural Integration is to free the knee so that it can move straight forward and back. I was not having any success. In truth, I was having a fair amount

SCARWORK:

A DIFFERENT APPROACH TO WORKING WITH SCARS

of trouble in establishing any kind of knee movement at all. This impressive scar with its adhesions seemed to be the problem. I wondered if something good might happen if I could soften up the scar a little. I had no idea what to do so I allowed my hands to work by feel. I took what I knew about changing tissue from the perspective of Structural Integration and applied it to the scar on a micro-level. Joan was quite comfortable with what I was doing, so we started a conversation about the movies showing at the town’s cinema. We discovered that we shared an appreciation for the wit and talent of Marilyn Monroe. For about 20 minutes I worked on the bottom half of the scar. When I stopped to see if I was making any progress, I was surprised to see that the square gap was gone, the edges were together, and the ripples on the sides of the scar were smooth and supple. Joan reported good sensory nerve function. The colour of the scar matched the rest of her. The surface of the skin had normal polyhedral lines

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SCARWORK A DIFFERING APPROACH TO WORKING WITH SCARS

By Sharon Wheeler BSc, MCSP

Almost all adults will have a scar of some sort somewhere on their body. Reading this article will give you an insight into how to decide if your patient’s scar is contributing to their symptoms and how to work with the tissue to allow the return of proper alignment, free movement and more normal looking skin. As the author says, “If I can get the scar unstuck the tissue ‘goes home’.” This article has been extracted from chapter 9 of the book Scars, Adhesions and the Biotensegral Body by Jan Trewartha and Sharon Wheeler. Read this article online <URL> with a matte finish and what looked like fine fuzzy hair. I asked Joan to sit up and take a look at her scar. She looked it over, touching and feeling it, then said, ‘I didn’t know you could do that.’ I replied, ‘Me neither.’ When I started to work again, I realised that I did not remember a single thing that I had done. So I restarted our conversation about Marilyn and the movies, and did my best to let my fingers fly, hoping I would find my way back to what I had been doing previously. Somehow this strategy succeeded. As I worked, I took a little peek now and again. I was able to match up the top half with the bottom half and know what I had done. It felt like normal tissue. Neither of us could find any irregularities left in the texture of the scar. With the scar out of the way, I found the fibula and got it unstuck. This allowed Joan’s

SCARWORK DOES NOT AFFECT NORMAL TISSUE

Co-Kinetic.com

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TENDINOPATHY REHABILITATION: CHOOSING THE CORRECT LOADING STRATEGY

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JOURNAL WATCH

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PONDERING POSTURE

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ISSUE 83 JANUARY 2020 ISSN 2397-138X

We’ve gone GREEN!

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

CLICK ON RESEARCH TITLES TO GO TO ABSTRACT DESCRIPTIVE EPIDEMIOLOGY OF INJURIES IN PROFESSIONAL ULTIMATE FRISBEE ATHLETES. Hess MC, Swedler DI, Collins CS et al. Journal of Athletic Training 2020;55(2):195–204 OPEN This is a descriptive epidemiology study of 16 male teams in the American Ultimate Disc League during the 2017 season. A total of 299 injuries were reported during 8963 athlete-exposures with an injury incidence rate of 33.36 injuries per 1000 athlete-exposures. Most injuries affected the lower extremity (72%). The most common injuries were thigh-muscle strains (12.7%) and ankleligament sprains (11.4%). Running was the most frequent injury mechanism (32%). Twenty-nine percent of injuries involved collisions; however, the concussion rate was low. Injuries were more likely to occur during competition and in the second half of games. An artificial turf playing surface did not affect overall injury rates. These injury rates are comparable with similar collegiate and professional level sports.

Co-Kinetic comment The authors believe that this is the first epidemiologic study of professional ultimate frisbee injuries. A quick bit of internet research suggests that semi-pro is a better description as players are not earning a full-time wage. Still it’s a start, Rugby Union wasn’t pro till 1995 so good luck to them.

The purpose of this study is to identify the extent and characteristics of exercise use in specialised and nonspecialised burn centres worldwide via a web-based survey. Fifty-eight percent of the surveyed clinicians worked in cities of 1 million inhabitants or more, and 92.3% worked in hospital-based burn centres. Exercise was used by 64.1% of the participants at the intensive care unit (ICU) level, 75% in burn wards before complete wound healing, and 80.1% in rehabilitation units after wound healing. The type of exercise offered, parameters assessed, and characteristics of exercise programmes varied notably among burn centres and clinicians consulted. Of the 145 participants using exercise, passive movements (n=116, 80%) and active/assisted

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DIAGNOSING PCL INJURIES: HISTORY, PHYSICAL EXAMINATION, IMAGING STUDIES, ARTHROSCOPIC EVALUATION. Verhulst FV, MacDonald P. Sports Medicine and Arthroscopy Review 2020;28(1):2–7 The purpose of this article is to give an overview of the clinical, diagnostic and arthroscopic evaluation of a knee posterior cruciate ligament (PCL) injury. There are some specific injury mechanisms that can cause a PCL injury including the dashboard direct anterior blow and hyperflexion mechanisms. During the diagnostic process it is important to distinguish between an isolated or multi-ligament injury and whether the problem is acute or chronic. Physical examination can be difficult in an acutely injured knee because of pain and swelling and, thus, PCL injuries are often missed. However, there are specific functional tests that can indicate a PCL tear. Standard X-rays and stress views are very useful imaging modalities, but magnetic resonance imaging remains the gold standard imaging study for detecting ligament injuries. Every knee scope should

be preceded by an examination under anaesthesia. Specific arthroscopic findings are indicative of a PCL tear such as the ‘floppy anterior cruciate ligament (ACL) sign’ and the posteromedial drive through sign. History, physical examination and imaging should all be combined to make an accurate diagnosis and initiate appropriate treatment.

Co-Kinetic comment Another great ‘all you need to know’ article. The take-home message is that PCL injury is often missed so go looking for it. The tests are simple enough and you will find lots of videos on the internet for the sag test, posterior drawer and the quadriceps active test. If you are wondering what the ‘floppy ACL sign’ is, it is the seeming elongation of the ACL due to insufficiency of the PCL. It is also known as a ‘pseudo ACL tear’.

THE USE OF EXERCISE IN BURNS REHABILITATION: A WORLDWIDE SURVEY OF PRACTICE. Flores O, Tyack Z, Stockton K et al. Burns 2019;pii:S0305-4179(18)30679-X exercises (n=122, 84.1%), were the most frequently used interventions in the ICU. Interventions in ICU listed as ‘other’ included equipment-assisted movement, Tai Chi, yoga exercises, arm ergometer, and a bed bicycle. Passive movements (n=126, 86.9%) and active/assisted exercises (n=129, 89%) were also the most frequent type of exercise used by clinicians at the burn ward/unit. Other exercise interventions were also reported, such as endurance exercises (using arm and stationary bikes), yoga, treadmill exercise, aerobic exercise and resistive exercise using elastic bands. After wound healing, stretching was the most frequently used modality (89.0%), with play and functional activities used by 80.7% of the clinicians. In addition, balance, proprioception, hydrotherapy,

rowing and coordination exercises were reported by participants. Some barriers to using exercise were reported including medical instability, lack of facilities, lack of staff, unsupportive staff and the belief that the use of common spaces and equipment would increase the infection rates before wound healing. Following hospital discharge, the barriers to continuing exercise also included distance from centre, concerns regarding time and cost of travel from home to the centre, and patient reluctance to attend exercise sessions once discharged from hospitalisation.

Co-Kinetic comment If you are involved in a burns unit, or are likely to be, this is a must-read paper. Apart from the medical instability of the patient, the other reported barriers are just logistics.

Co-Kinetic Journal 2020;84(April):4-7

RESEARCH INTO PRACTICE

Journal Watch Physical Therapy

A literature search was completed with the start date of 1 January 2001. This date was chosen because the first International Conference on Concussion in Sport was held in November 2001. Search terms used included a combination of population terms (coach, official, referee, umpire) and concussion terms (such as traumatic brain injury, mild brain injury, head injury and others). The search identified 20,880 papers, of which eventually 27 were included in the analysis. There were 26 cross-sectional studies and 1 randomised controlled trial; 20 assessed sport-related concussion knowledge among coaches, 1 considered only officials and 6 studies assessed both groups. Concussion knowledge among coaches and match officials was deemed moderate in most studies, although significant knowledge gaps were identified. Most were aware of identification, initial management

A systematic literature search for records reporting footballor rugby-related injuries was conducted by a certified librarian and reviewer in March 2019. All studies reporting football-related or rugbyrelated genitourinary injuries were included. Twenty-two records (11 research studies, 11 case reports) were identified. In the paediatric population, the reported football-related kidney injuries were 0.1–0.7% of all footballrelated injuries, 0.07–0.5% of all sportsrelated injuries, and 1.5–37.5% of all sports-related genitourinary injuries. Injury per exposure rates were minimal. Paediatric football-related testicular injuries were reported to be 0.11% of all football injuries, 0–0.07% of all sports-related injuries, and 0–37.5% of

Co-Kinetic.com

A SYSTEMATIC REVIEW AND QUALITATIVE ANALYSIS OF CONCUSSION KNOWLEDGE AMONGST SPORTS COACHES AND MATCH OFFICIALS. Yeo PC, Yeo EQY, Probert J et al. Journal of Sports Science and Medicine 2020;19:65–77

and return-to-play criteria and could identify common signs and symptoms of concussion. They understood the importance of immediate removal from play and returned players to play only under the guidance of medical advice. However, important gaps in knowledge were still present and telling in recognition, management and prevention of concussion. For example, although coaches and officials recognised common physical and cognitive signs and symptoms, most failed to recognise emotional signs and symptoms as well as sleep disturbances. Although the majority of coaches and officials understood that loss of consciousness is not a necessary feature for the diagnosis of concussion, a significant proportion of coaches failed to recognise and appropriately

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manage concussion without loss of consciousness. With regard to concussion prevention, there was a misconception that headgears had a protective role when in fact there is some evidence that they increase brain injury, especially if they are ill-fitting.

Co-Kinetic comment Apparently, concussion was first documented by Hippocrates approximately 2400 years ago so you would think we would know a bit about it by now. The number of initial hits in the search would suggest someone is writing about it a lot. To be fair, this study shows that coaches and officials do know a bit although they could get to know more. One thing mentioned that does not help, was a coach’s ‘win at all cost’ mentality and officials failing to enforce the rules. If you are a team therapist maybe you should push a copy of this paper under the doors of the coach’s office and the ref’s room.

A SYSTEMATIC REVIEW OF GENITOURINARY INJURIES ARISING FROM RUGBY AND FOOTBALL. Kim JK, Koyle MA, Lee MJ et al. Journal of Pediatric Urology 2020;pii:S1477-5131(19)30443-7 all sports-related genitourinary injuries. In adults, there was no proportion of genitourinary injuries that could be determined, and football-related kidney injury incidence was minimal. No adult literature investigated testicular injuries. Eleven case reports were additionally identified. Review of the case reports suggests that patients with previously existing urologic abnormalities such as ureteropelvic junction obstruction may predispose an individual to kidney injuries. The conclusion is that there is little to suggest that those engaged in football or rugby have a significant risk of genitourinary injury; therefore, future guidelines should reflect this.

Co-Kinetic comment Well done to the authors for doing this because it is one less thing for therapists in sport to worry about. No reports of adult testicular injuries is strange. Were there really no injuries or is that no one is reporting them? Maybe a new study there for someone.

EFFECTS OF NORDIC HAMSTRING EXERCISE ON HAMSTRING INJURIES IN HIGH SCHOOL SOCCER PLAYERS: A RANDOMIZED CONTROLLED TRIAL. Hasebe Y, Akasaka K, Otsudo T et al. International Journal of Sports Medicine 2020:doi:10.1055/a-1034-7854 Subjects consisted of 259 male soccer players from seven high schools randomly clustered into two groups, a Nordic hamstring exercise (NHE) group and a control group. Training and match time were logged, as were details of hamstring injury; subsequent time lost to hamstring injury was recorded over a period of 27 weeks. The NHE compliance rate, injury rate per 10,000 playing hours and time-lost-to-sport-injury rate were calculated. The relative risk and hamstring injury severity were also calculated. The intervention group performed the NHE, with exercise compliance and hamstring injury recorded over a 27-week period. The NHE was undertaken after normal training and before cool-down. At week 1 they performed 5 sets of 2 reps. This gradually increased until by week 27 they were doing between 8 and 10 sets of 3 reps twice a week. The hamstring injury rate was 1.04/10,000h in the control group and 0.88/10,000h in the intervention group. The relative risk for hamstring injury was 1.14. The time-lost-to-injury rate was 1116.3/10,000h in the control group and 113.7/10,000h in the intervention group; with relative risk 9.81. This is equal to 50 days lost in the control group and 6 days in the intervention group.

Co-Kinetic comment Fewer injuries in the NHE group but, more importantly, the return-toplay time is much better.

MANY HIGH-QUALITY RANDOMIZED CONTROLLED TRIALS IN SPORTS PHYSICAL THERAPY ARE MAKING FALSE-POSITIVE CLAIMS OF TREATMENT EFFECT: A SYSTEMATIC SURVEY. Bleakley C, Reijgers J, Smoliga JM. Journal of Orthopaedic & Sports Physical Therapy 2020;50(2):104–109 A search was made of the Physiotherapy Evidence Database (PEDro) for parallel-design, 2-arm randomised controlled trials (RCTs) reporting positive treatment effects, based on null-hypothesis significance testing, and scoring greater than 6/10 on the Physiotherapy Evidence Database scale. No restrictions were made on pathology, intervention, or outcome variables. Out of 212 RCTs, 62 reported positive effects in at least 1 outcome variable. False-positive risk (FPR) was estimated with an online calculator, based on number of participants, P value, and effect size. For each study, FPR was estimated using a range of prior probability assumptions: 0.2 (sceptical hypothesis), 0.5, and 0.8 (optimistic hypothesis). Of 189 statistically significant findings reported across 44 trials, the median FPR was 9%. Sixty-three percent of statistically significant results (119/189) had an FPR greater than 5%, and 18% (35/189) had an FPR greater than 50%. Changing the prior probability from sceptical to optimistic reduced the median FPR from 29% to 2%.

Co-Kinetic comment Apparently 11/8ths of the world’s population don’t understand fractions. For those of you in that group what this study means in English is that a lot of biomedical literature suffers from a surfeit of false-positive results. Researchers are falsely concluding that there was a treatment effect in their studies when there wasn’t. A bit of a nail in the evidence-based medicine coffin.

DIAGNOSIS AND TREATMENT OF SCIATICA. Jensen R, Kongsted A, Kjaer P et al. BMJ 2019;367:l6273 According to this paper, what you need to know about sciatica is that it is a clinical diagnosis based on symptoms of radiating pain in one leg with or without associated neurological deficits on examination. It adds that most patients improve over time with conservative treatment including exercise, manual therapy and pain management. You should urgently refer patients with signs of urinary retention or decreased anal sphincter tone, which suggest cauda equina syndrome. Surgery may speed up recovery if symptoms do not improve after 6–8 weeks of conservative treatment but after 1 year the effects of conservative care and surgery are similar. The types of exercise are not recorded but manual therapy is described as ‘spinal mobilisations’. Guidelines

from the National Institute for Health and Care Excellence (NICE) advise against traction and electrotherapies. Acupuncture is not recommended. Non-steroidal anti-inflammatory drugs are no more effective than placebo in improving pain and disability, though there is low quality evidence of overall improvement in patients. The jury is out on corticosteroids and, to add to the patient’s misery, evidence for the use of paracetamol, benzodiazepines, opioids and antidepressants for patients with sciatica is limited and their use is not recommended.

Co-Kinetic comment According to a systematic review by Trompeter et al. (Prevalence of back pain in sports: a systematic review of the literature. Sports Medicine 2017;47(6):1183–1207

https://spxj.nl/2TzHbp9) the incidence of back pain in sports may be as high as 94% so there is a lot of it about. The only thing that seems to work is manual therapy and exercise, which is great for the physical therapy industry. This paper by Jensen et al. states, ‘The term “sciatica” is not clearly defined and it is often used inconsistently by clinicians and patients’. So stop using it then. Sciatica is a lazy diagnosis. It is pain along the sciatic nerve caused by either irritation of the nerve root or muscle spasm in the back or buttocks. The former can be via lumbar spine stenosis, degenerative disk disease or spondylolisthesis. The latter usually has something to do with the piriformis muscle because the sciatic nerve passes through or under it. There are clinical tests for all of these so why not actually find out the real problem and treat it?

Co-Kinetic Journal 2020;84(April):4-7

RESEARCH INTO PRACTICE

EFFECT OF A 16-MONTH EXERCISE TRAINING PROGRAM ON FUNCTIONAL CAPACITIES IN A CENTENARIAN MALE MASTER ATHLETE: A CASE STUDY. Federici A, Ferri-Marini C, Brandoni G et al. Journal of Human Sport and Exercise 2020;15(4):doi:10.14198/jhse.2020.154.20 A 99.5-year-old male, with a history of world records in master athletic competitions (ie. triple jump, weight throw, throws pentathlon, 60-meter sprint, long jump, and shot put), participated in the study. Before enrolment he was involved in an unstructured, self-prescribed and self-administered exercise training programme. Before and after a 16-month training intervention the participant underwent a test battery for flexibility (YMCA sit and reach), balance (single-leg stance), upper limb strength (hand grip and pinch strength), as well as lower limb power (counter movement jump) and muscular endurance (horizontal leg press with 85kg load). The weekly training programme was composed of: (1) three sessions per week of resistance exercise, aiming to train muscular strength and endurance, followed by balance exercises and specific drills, such as approach and take-off drills for the jump competitions, where the subject, respectively,

accelerates to a maximum controllable speed and generates vertical velocity and minimises the loss of horizontal velocity; (2) at least one training session per week was dedicated to specific exercises for the competitions in which the participant was competing, aiming to train the sport-related techniques, skills and performances; and (3) two sessions per week of aerobic exercise (eg. brisk walk and jog), aiming to train cardiorespiratory endurance. After training, sit and reach (−3cm) and counter movement jump (−0.5cm) scores decreased, whereas single-leg stance (+1.3s), left-hand grip (+2.0kg), right-hand pinch (+0.5kg), and horizontal leg press (+2 repetitions) scores increased. Right-hand grip strength and left-hand pinch strength did not change after training. When preand post-training scores were compared to gender-matched normative values, flexibility resulted well below average, maybe because of a relatively broad age category (>65 years). When more specific age categories were available,

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the participant’s balance was slightly below average (age category 80–99 years) and upper limb strength above average (age category >85 years). No normative values were found for lower limb power and muscular endurance.

Co-Kinetic comment A centenarian athlete? There is hope for all of us.

FIELD MANAGEMENT OF FACIAL INJURIES IN SPORTS. Hwang K. Journal of Craniofacial Surgery 2019;doi:10. 1097/SCS.0000000000006132 This paper starts with statistics that show that there are a lot of facial injuries to deal with. They account for 3–29% of sports injuries, and sports injuries account for 11.3–42.1% of facial fractures. Fractures of the nasal bone were the most common in all sports (40–60.5%); mandibular fractures were common in martial arts (33.3%) and soccer (11.1%), orbital bone fractures were common in basketball (20.0%), ice sports (18.2%) and baseball (15.8%); and fractures of the zygoma occurred frequently in martial arts (13.3%) and soccer (10.0%). Facial lacerations may injure nerves (facial and trigeminal), salivary ducts (parotid or submandibular), and the lacrimal apparatus. Facial fractures are inspected by palpating the bony prominences bilaterally. For simple lacerations, if the Co-Kinetic.com

player does not have to return to the court, the wound should be cleansed as needed and surgical adhesives can be applied in the field. However, if return to play is an issue, sutures are recommended rather than surgical adhesives. For nasal injuries involving a gross deformity, immediate closed reduction may not be necessary unless airway competency is compromised. Severe cases of nasal fracture treated immediately by closed reduction should be evaluated by a trained plastic surgeon.

Co-Kinetic comment This is one of the ‘everything you need to know’ papers we like. The authors point out that in sports, facial injuries are prone to be missed and therefore anyone working pitch side should be aware of the high numbers of facial injuries, have the knowledge needed to manage these injuries and should prepare emergency management kits. 7

CLICK ON RESEARCH TITLES TO GO TO ABSTRACT This is a case presentation of a convenience sample of 6 patients (4 male, 2 female; 20.2±1.3 years of age), who were classified with acute grade 1 lateral ankle sprains (LAS). The inclusion criteria were that participants were 18–40 years of age, underwent 150min/week of physical activity, had an evaluation and classification in ≤3 days and a diagnosis of a grade 1 LAS. Subjects were excluded if they had an acute fracture to lower extremity, a syndesmotic or medial ankle sprain, lower extremity surgery over the past 12 months or gross laxity in the lateral ankle ligaments. Each completed a battery of tests including what the authors called a weight-bearing lunge test (knee-to-wall

USE OF THE MULLIGAN CONCEPT IN THE TREATMENT OF LATERAL ANKLE SPRAINS IN THE ACTIVE POPULATION: AN EXPLORATORY PROSPECTIVE CASE SERIES. Bianco L, Fermin S, Oates R et al. The Journal of the Canadian Chiropractic Association 2019;63(3):154–161 test in the UK) and a Y-balance test which is a shortened version of the star excursion balance test. Each patient was treated with either the fibular mobilisation with movement (FMWM) or modified fibular mobilisation with movement (MFMWM). Four of them received 2 treatments and the other two 3. The duration of treatment is not recorded. During the treatment period none of the patients took part in sporting activity. Three of the patients were treated with

THE EFFECTIVENESS ASSESSMENT OF MASSAGE THERAPY USING ENTROPY-BASED EEG FEATURES AMONG LUMBAR DISC HERNIATION PATIENTS COMPARING WITH HEALTHY CONTROLS. Li H, Du W, Fan K et al. IEEE Access 2020;8:7758–7775 OPEN This study investigated the immediate effects of Chinese massage on four eletroencephalogram (EEG) rhythms, using the eight entropy-based features of 26 patients with a lumbar disc herniation (LDH) and 24 healthy controls. EEG signals were acquired for 3min before and immediately after massage. Subjects were asked to close their eyes, lie prostrate on the massage bed quietly wearing the EEG headset and refrain from talking, falling asleep, or moving during EEG measurement. The Chinese massage treatments were performed by professional massage therapists. The treatment was for about 15min per subject, and is not described other than to say that acupoints on the subject’s back and hips were massaged for deep kneading penetration to relieve sore and aching muscle pain. Results showed that after the intervention there were more positive changes in the EEG of the massage group than the control. The authors conclude that this is a promising index of the massage effectiveness.

Co-Kinetic comment We have been a bit vague on the details of the EEG rhythms and features. They are very detailed in the paper. Given that two of them are called ‘fuzzy entropy’ and ‘inherent fuzzy entropy’ you may understand why. If you are up to speed on all things EEG then feel free to dig deeper into the paper. The point of this study was to find an objective way of measuring the effectiveness of massage, and this method appears to do so. If you are interested in other ways of measuring massage effectiveness, or how massage can help a range of conditions then the reference list of this paper is for you. They cite previous studies on Parkinson’s and dementia and on different parts of the body, including the neck, posterior shoulder, lower back and foot, and tools including the 10-point visual analogue scale, the short form McGill pain questionnaire, state anxiety inventory, hospital anxiety and depression scale, and the Oswestry disability index. In respect of the tools they say, ‘although these tools have clinical meaning, they are subjective and rough’.

ice, compression and elevation for about 5min, one time on the first day following the mechanism of injury, for pain relief. The clinical outcomes for the patients treated with both FMWM and MFMWM improved and patients returned to activity levels at about three days after three treatments.

OPEN

Co-Kinetic comment This is a frustrating paper. On the one hand it is proving that Mulligan Concept has some validity but on the other it is lacking in detail. SPINAL DISPLACEMENT DURING THORACIC SPINAL MANIPULATIVE THERAPY. Chiradejnant A, Jungrungsakul S. Journal of Musculoskeletal Research 2020;1972001 The objective of this research was to prove that the application of force to a spinal segment impacted adjacent areas of the spine. Forty-one healthy males were asked to lie prone and hold their breath at the end of normal expiration while a therapist applied a grade III central posterior anterior (PA) mobilisation to the T6 spinous process for 30s. The PA spinal displacements of C3, C5, C7, T2, T4 and T6 were investigated using a motion capture system. The PA displacement of the T6 and the PA displacement of the marked spines (T4, T1, C7, C5 and C3) correlated well. A trend towards a decrease in spinal displacement was noted when the distance from T6 spine increased.

Co-Kinetic comment Seems obvious really. One link in a chain affects others.

Co-Kinetic Journal 2020;84(April):8-11

RESEARCH INTO PRACTICE

Journal Watch Manual Therapy

EFFECT OF TWO MASSAGE PROTOCOLS ON CLINICAL PARAMETERS OF SWIMMING ATHLETES: A RANDOMIZED CONTROLLED CLINICAL TRIAL. Carvalho FA, Batista NP, Machado AF et al. International Journal of Sports Physical Therapy 2019;14(6):S24-S24

This was a crossover clinical trial in which 21 young swimming athletes of competitive level undertook 12min of deep massage (DM), superficial massage (SM) and passive recovery (PR) after exercise. The athletes performed approximately 40min of general exercises including squats, pushups, sit-ups, vertical jumps, burpees, mountain climbers and resisted upper arm exercises. The DM was applied in three different intensities for 3min on the anterior thighs, 3min on the

upper arms and 6min on the back. The SM was applied superficially with only one intensity at the same sites and duration. For the PR the athletes maintained their normal routine out of the water. Before the beginning of the study the athletes were asked about their perceptions during a normal training session to consider the specificity of the modality. Then they rated these perceptions (wellbeing, heaviness, tiredness, discomfort and pain) by a 5-point Likert scale (nothing,

little, moderate, very much, extremely) before and after the interventions. The results showed that all clinical variables improved over time for both massage groups. For pain there was a significant small group effect that SM and DM interventions differed from PR but not from each other.

Co-Kinetic comment Both worked. Another positive study for massage.

THE IMMEDIATE EFFECTS OF PASSIVE JOINT MOBILISATION ON LOCAL MUSCLE FUNCTION. A SYSTEMATIC REVIEW OF THE LITERATURE. Pfluegler G, Kasper J, Luedtke K. Musculoskeletal Science and Practice 2020;45:102106 In this paper the term ‘muscle function’ is used to describe muscle strength (maximal voluntary activation capacity), muscle coordination (muscle activation patterns) and/or muscle endurance (number of repetitions). The literature search concentrated on immediate effects. A total of 17 studies were included, of which 10 studies reported data on asymptomatic individuals and 7 studies reported data on symptomatic individuals with various conditions. There is a moderate level of evidence that joint mobilisation immediately

decreases the activation of superficial muscles during low load conditions in symptomatic individuals. For asymptomatic individuals, there is a low level of evidence that passive joint mobilisation improves maximum muscle strength when compared to sham mobilisation, opposed to a very low level of evidence suggesting no effect in symptomatic individuals. The five studies reporting data on both changes in muscle function as well as changes in pain, suggest that other, non-pain-related mechanisms

may play an important role regarding the reported improvement in muscle function.

OPEN

Co-Kinetic comment This paper proves that the mobs have some effect on muscles but as it says, ‘The specific mechanisms of action involved remain unclear and require future basic science research’. This is after an initial literature search that found 2352 papers that were whittled down to the final 17 and only 7 of them were on symptomatic patients. A massive effort on the authors’ part. Is further research worth the effort? Anyone who has performed passive joint mobilisation on symptomatic patients with the aim of reducing pain and/or increasing ROM knows it works. Shouldn’t this be enough?

EFFECTS OF MULLIGAN AND CYRIAX APPROACH IN PATIENTS WITH SUBACUTE LATERAL EPICONDYLITIS. Abbas S, Riaz R, Khan AA et al. The Rehabilitation Journal 2019;3(2):107–115

OPEN

This study investigated the effects of deep transverse friction massage and Mill’s manipulation (Cyriax group), compared with mobilisation with movement and taping (Mulligan group). Thirty patients were equally and randomly allocated to each test group. They all completed a patient-related tennis elbow evaluation questionnaire at the 0, 1st, 2nd, 3rd, and 4th week. Both groups showed significant improvement in pain, function ability and hand grip strength throughout the treatment duration. The Cyriax group showed significant improvement after the 2nd week while Mulligan’s approach showed more improvement than Cyriax in functional ability from the 2nd to 3rd week. Hand grip strength in both groups did not show any significant difference.

Co-Kinetic comment Do them both and see if it doubles the effect. Co-Kinetic.com

EFFECTS OF PRE-EXERCISE MASSAGE ON MUSCLE SORENESS. Deininger A, Sandmann H, Romo V et al. International Journal of Exercise Science (Conference Proceeding) 2020;2(12):Article 8 Twenty participants (age, 30.3±6.3 years; height, 167.6±11.4cm; weight, 82.5±15.5kg) were provided with 5min of massage on the right anterior leg and 5min of massage on the right posterior leg. After completion of the massage, participants performed 2 sets of squats to a chair, first with an 8lb weight (3.6kg, males) or a 5lb weight (2.2kg, females) to a metronome that was set to 60 beats per minute. All participants were then instructed to fill out a pain scale questionnaire over a 24h and 48h period. There was no interaction between legs among time points. There was, however, a main effect on the massaged leg when time was combined, with a lower soreness rating in the massaged leg compared to the nonmassaged leg.

Co-Kinetic comment This is a conference report so we do not have full details of the massage protocol, but it ticks the box that says preexercise massage is good.

In this crossover study, nine healthy male athletes completed a highintensity intermittent sprint protocol, followed by massage therapy or control condition. Inflammatory markers were assessed pre-exercise; post-exercise; and at 1, 2, and 24h post-exercise. Muscle performance was measured by squat and drop jump, and muscle soreness on a Likert scale. Significant time effects were observed for monocyte chemoattractant protein 1 (MCP-1), interleukin-8 (IL-8), interleukin-6 (IL-6), interleukin-10 (IL-10), tumour necrosis factor alpha (TNFα), drop jump performance, squat jump performance, and soreness. The massage protocol was 30min in duration and included traditional effleurage of the lower body muscles and the lower back muscles for 6min, neurolymphatic activation for 18min, followed by a further 6min of effleurage of the lower body muscles. Treatments were administered by one of three certified sport massage therapists trained in the neurolymphatic activation technique. The control group participants sat quietly in the laboratory for the 30min period equivalent to the massage protocol. 10

EXERCISE-BASED REHABILITATION AND MANUAL THERAPY COMPARED WITH EXERCISE-BASED REHABILITATION ALONE IN THE TREATMENT OF CHRONIC ANKLE INSTABILITY: A CRITICALLY APPRAISED TOPIC. Walsh BM, Bain K, Gribble PA et al. Journal of Sport Rehabilitation 2020;doi:https://doi.org/10.1123/jsr.2019-0337 The CINAHL, MEDLINE and SPORTDiscus databases were searched for peer-reviewed articles that examined the difference in outcomes for patients with chronic ankle instability (CAI) between manual therapy with exercise and exercise-based rehabilitation alone. Three peer-reviewed RCTs were identified. (1) Two groups (a balance training group and a balance training plus combination of calf-stretching, ankle joint traction, anterior/posterior ankle joint mobilisations and plantar massage group) received treatment 3 times a week for approx. 20min over 4 weeks. There were no statistically significant differences between groups in the posttest values. (2) Two groups (a proprioceptive and strengthening exercise group and

a proprioceptive and exercise group with additional manual therapy) received treatment twice a week for 4 weeks. There were significant improvements in VAS scores and Cumberland ankle instability tool (CAIT) scores in the group receiving manual therapy at post testing. (3) Three groups (a calf muscle stretching group; a neuromuscular training group that received sham joint mobilisation; and a neuromuscular training group that received intermittent traction plus a variety of mobilisations) received treatment twice a week for 4 weeks. There were significant improvements in CAIT scores between the manual therapy group and the stretching group at post-testing.

Co-Kinetic comment As Meat Loaf said, ‘Two out of three ain’t bad’.

MASSAGE THERAPY MODULATES INFLAMMATORY MEDIATORS FOLLOWING SPRINT EXERCISE IN HEALTHY MALE ATHLETES. White GE, West SL, Caterini JE et al. Journal of Functional Morphology and Kinesiology 2020;5(1):9

No significant effects for condition were observed. However, compared with control, inflammatory marker concentrations (IL-8, TNFa, and MCP-1) returned to baseline levels earlier following the massage therapy condition. IL-6 returned to baseline levels earlier following the control versus massage therapy condition. No differences were observed for performance or soreness variables. MCP-1 area under the curve (AUC) was negatively associated with squat and drop jump performance, whereas IL-10 AUC was positively associated with drop jump performance.

Co-Kinetic comment The overall conclusion is that massage therapy promotes resolution of systemic inflammatory signs, which is a tangible benefit of postexercise recovery massage, but we knew this from previous research. Most of that involved traditional Swedish massage techniques, principally effleurage and petrissage. This one added the neurolymphatic activation technique but it did have an effleurage element. It would be great if someone could do it all again with more subjects and compare effleurage alone, neurolymphatic alone and a combination. If you want more information on how to set it up this is an open access paper so start there.

OPEN

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RESEARCH INTO PRACTICE

This starts with a brief summary of earlier work that reported that in some muscles, less than 20% of the muscle fibres span the full length of the muscle from origin to insertion and that the majority end in the muscle belly being connected only by their endomysium. This architecture strongly suggests a forcetransmitting or force-absorbing role of the intramuscular connective tissue, which was itself shown in work on force transmission in rat tendons. In other words, the fascia surrounding muscle is a force-transmitting structure. This paper set out to find evidence that muscle strain injuries may not therefore

This is an open access ebook that you can obtain at https://spxj.nl/32MSw9A. The author says that the book, “exists to facilitate interprofessional education and collaboration between massage therapists and health care teams”. As the practice of massage therapy moves into mainstream medical care for a number of physical ailments, students and practicing massage therapists have an urgent need for a clinical resource that will be continuously updated as new research becomes available. The primary goal of this resource is to turn recent policy changes into actionable gains for the advancement of our profession globally, by: Twenty students were randomly allocated into two groups of 10 each. To produce delayed onset muscle soreness, a 45 reps of eccentric elbow curl in 3 sets was performed. Venous blood samples were obtained before and after supplementation, immediately, 24h and 48h after exercise for analysis of creatine kinase (CK) and lactate dehydrogenase (LDH). Pain was assessed by visual analogue scale (VAS). One group received an extract of grape seed in 400mg capsules to a total of 1200mg/day, 7 days before exercise for up to 48h. The control group received the same amount of lactose as placebo in the same pattern. There was a significant increase in CK activity after exercise compared with before exercise in both groups‚ Co-Kinetic.com

IS IT ALL ABOUT THE FASCIA? A SYSTEMATIC REVIEW AND METAANALYSIS OF THE PREVALENCE OF EXTRAMUSCULAR CONNECTIVE TISSUE LESIONS IN MUSCLE STRAIN INJURY. Wilke J, Hespanhol L, Behrens M. Orthopaedic Journal of Sports Medicine 2019;7(12):2325967119888500 be restricted to the muscle itself. Imaging studies using MRI or ultrasound describing frequency, location and extent of soft tissue lesions in lower limb muscle strain injuries were identified. A total of 16 studies (fair to good methodological quality) were identified. The prevalence of strain injury on imaging studies was 32.1% for myofascial lesions, 68.4% for myotendinous lesions, and 12.7% for isolated

muscular lesions. Evidence regarding associations between fascial damage and return-to-play duration was mixed.

OPEN

Co-Kinetic comment This suggests that the term ‘muscle strain injury’ does not adequately reflect the actual injury because only around 12% of the reviewed injuries were pure muscle. The others involved collagenous connective tissue. The authors suggest use of the term, ‘myocollagenous strain injury’. Can’t see it catching on.

EVIDENCE-BASED MASSAGE THERAPY: A GUIDE FOR CLINICAL PRACTICE. Lebert R. eCampusOntario

OPEN

1. Identifying and describing key postulates and applications of an evidence-based framework. 2. Providing an overview of current research findings and their practical implications for massage therapists. 3. Fostering a culture of evidence-based practice by incorporating new scientific findings and methods into clinical practice.”

Co-Kinetic comment This is an excellent piece of work and a must-read for anyone involved with soft tissue treatment. It has chapters on the science behind massage therapy, examinations and treatments for a host of conditions. It is fully referenced and has links to instructional videos.

THE EFFECT OF GRAPE SEED EXTRACT SUPPLEMENTATION ON DELAYED ONSET MUSCLE SORENESS (DOMS) IN YOUNG HEALTHY FEMALE STUDENTS. Raees-Sadati J, Nakhostin-Roohi B, Siahkouhian M. International Journal of Sport, Exercise and Health Research 2019;3(1):10–13 but no significant differences between the two groups at any time in CK or LDH. However, the VAS scores were significantly lower in the grape seed group 24h and 48h after exercise.

Co-Kinetic comment According to research quoted in this paper, grape seed extract is one of the supplements that has been introduced in traditional medicine as an anti-inflammatory agent and is a main source of oligomeric proanthocyanidin. This antioxidant appears to help protect cells against damage from free radicals.

Granny Smiths and Red Delicious are full of it as well so maybe ‘an apple a day keeps the doctor away’ is true. There is also a lot of it in red wine – any excuse! Please, please be careful of any supplement if you are a sports person who is likely to be drug tested – you never know what else is in them. 11

THE 10 MOST DISCUSSED PIECES OF RESEARCH IN PHYSICAL THERAPY (JAN - MAR 2020)

TO FLEX OR NOT TO FLEX? IS THERE A RELATIONSHIP BETWEEN LUMBAR SPINE FLEXION DURING LIFTING AND LOW BACK PAIN? A SYSTEMATIC REVIEW WITH META-ANALYSIS Journal of Orthopaedic & Sports Physical Therapy

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THE ELEPHANT IN THE ROOM: TOO MUCH MEDICINE IN MUSCULOSKELETAL PRACTICE Journal of Orthopaedic & Sports Physical Therapy

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AN UPDATE OF SYSTEMATIC REVIEWS EXAMINING THE EFFECTIVENESS OF CONSERVATIVE PHYSICAL THERAPY INTERVENTIONS FOR SUBACROMIAL SHOULDER PAIN Journal of Orthopaedic & Sports Physical Therapy

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CONSEQUENCES OF PHYSICAL INACTIVITY IN OLDER ADULTS: A SYSTEMATIC REVIEW OF REVIEWS AND META-ANALYSES Scandinavian Journal of Medicine & Science in Sports

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INTERNATIONAL OLYMPIC COMMITTEE CONSENSUS STATEMENT: METHODS FOR RECORDING AND REPORTING OF EPIDEMIOLOGICAL DATA ON INJURY AND ILLNESS IN SPORT 2020 (INCLUDING STROBE EXTENSION FOR SPORT INJURY AND ILLNESS SURVEILLANCE (STROBE-SIIS)) British Journal of Sports Medicine

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FIFTEEN-WEEK WINDOW FOR RECURRENT MUSCLE STRAINS IN FOOTBALL: A PROSPECTIVE COHORT OF 3600 MUSCLE STRAINS OVER 23 YEARS IN PROFESSIONAL AUSTRALIAN RULES FOOTBALL British Journal of Sports Medicine

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INFOGRAPHIC. EXERCISE FOR INTERMITTENT CLAUDICATION British Journal of Sports Medicine

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ISOMETRIC EXERCISE AND PAIN IN PATELLAR TENDINOPATHY: A RANDOMIZED CROSSOVER TRIAL Journal of Science and Medicine in Sport

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THE 10 MOST DISCUSSED PIECES OF RESEARCH IN MANUAL THERAPY (JAN - MAR 2020) 2 1

THE EFFECTIVENESS OF TRADITIONAL THAI MASSAGE VERSUS MASSAGE WITH HERBAL COMPRESS AMONG ELDERLY PATIENTS WITH LOW BACK PAIN: A RANDOMISED CONTROLLED TRIAL

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EVALUATION IS TREATMENT FOR LOW BACK PAIN Journal of Manual & Manipulative Therapy

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MASSAGE THERAPY FOR SYMPTOM REDUCTION AND IMPROVED QUALITY OF LIFE IN CHILDREN WITH CANCER IN PALLIATIVE CARE: A PILOT STUDY

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EFFECTS OF MASSAGE THERAPY ON INDIRECT HYPERBILIRUBINEMIA IN NEWBORNS WHO RECEIVE PHOTOTHERAPY

JOGN Nursing: Journal of Obstetric, Gynecologic & Neonatal Nursing

THE BENEFITS OF MASSAGE THERAPY WITH BMT PATIENTS: IMPACT ON ANXIETY, DEPRESSION AND PAIN SYMPTOMS Biology of Blood &

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DOES MANUAL THERAPY AFFECT FUNCTIONAL AND BIOMECHANICAL OUTCOMES OF A SIT-TO-STAND TASK IN A POPULATION WITH LOW BACK PAIN? A PRELIMINARY ANALYSIS

Marrow Transplantation

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EFFECTS OF MANUAL THERAPIES ON STABILITY IN PEOPLE WITH MUSCULOSKELETAL PAIN: A SYSTEMATIC REVIEW

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THE EFFECT OF A SINGLE SPINAL MANIPULATION ON CARDIOVASCULAR AUTONOMIC ACTIVITY AND THE RELATIONSHIP TO PRESSURE PAIN THRESHOLD: A RANDOMIZED, CROSS-OVER, SHAMCONTROLLED TRIAL Chiropractic & Manual Therapies

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TENDINOPATHY REHABILITATION: TENDINOPATHY | RUNNING | 20-04-COKINETIC FORMATS WEB MOBILE PRINT All references marked with an asterisk are open access and links are provided in the reference list By Kathryn Thomas BSc MPhil

endon overuse injuries, namely tendinopathies, pose a significant clinical problem, particularly in musculoskeletal and sports-related medicine, accounting for up to 30% of general practice musculoskeletal consultations. The pathogenesis of tendinopathy is multifactorial and complex and, even though several theories have been suggested, the exact causative factors remain unknown. The incomplete understanding of the mechanisms underpinning tendon pathophysiology continues to hamper the development of targeted therapies, which have been successful in other areas of musculoskeletal medicine. The most common exacerbating factor is thought to be overuse (particularly during sporting activities) causing repetitive microtrauma and consequent degeneration due to failure of the healing process. Manifestations range from mild pain and swelling to complete loss of function, and diagnosis is usually based on a thorough history and physical examination; however, imaging modalities such as ultrasound and MRI can be useful, especially for identifying tears. Tendinopathy appears to result from an imbalance between the protective/regenerative changes and the pathological responses that result from tendon overuse. The net result is tendon degeneration, weakness,

The causes of tendinopathy are complex and not fully understood but the results – ranging from mild pain and swelling to complete loss of function – and the frustratingly slow recovery can be devastating, particularly for an athlete. The current consensus is that the best treatment is a careful programme of strengthening and load management. This article clearly describes how to tailor a rehab programme to your patient’s precise needs, and, importantly, what not to do. Read this article online https://spxj.nl/2We8459 tearing and pain. As the basic science of tendinopathy has evolved, so have the treatment options for these conditions. First-line treatment comprising several modalities ranging from relative rest and progressive loading to invasive pharmacological interventions continue to be the mainstay of treatment. Apart from loading, which is widely recognised to be effective for the treatment of tendinopathies, the benefits of the remaining available therapies are equivocal, and treatment options are usually tried sequentially starting from the least noxious (1*). There has been a lot of progress over the last two decades with tendinopathy treatment. Most physical therapists have (hopefully) moved on from the days of ultrasound, interferential and tendon massage, to strengthening, load management and helping patients prepare their body for the demands of running, sport and everyday life. There are a lot of exercise options – eccentrics, isometrics, isotonics, functional, plus hopping, jumping and plyometric programmes, which all seem to have benefits. Once you decide on the type of exercise, you have to figure out the weight, sets and repetitions to use, and

how quickly your patients can get back into running or sport. Back in 2015, a new paper by Rio et al. (2*) reported a large reduction in tendon pain with the use of isometric exercises. The study participants’ pain dropped from an average of 7 out of 10 (during a single-leg decline squat) down to an average of 0; yes – zero! Research results like this aren’t common so the news spread quickly and isometrics were soon widely adopted for reducing pain in tendinopathy. It definitely has its merits but like any study one needs to delve deeper beneath the headlines; for example, the sample size was only six men with no control group. It’s not to say isometrics don’t help; however, several research groups have examined the effects of isometrics

THE MOST COMMON EXACERBATING FACTOR IN TENDINOPATHY IS THOUGHT TO BE OVERUSE 14

Co-Kinetic Journal 2020;84(April):14-23

PHYSICAL THERAPY

since this key paper and their findings have been far more mixed (which will be highlighted later in this article). Well, what about the eccentric loading exercises that become highly popularised after a Scandinavian author (3) showed hugely successful results in 1998? Though effective, the results of eccentric exercises observed from other study groups have been less convincing than originally reported, with only around 60% of good outcomes reported after a regime of eccentric training both in athletic and sedentary patients. The best evidence to date does demonstrate that eccentric exercise is likely to be a useful management modality for tendinopathy, but this evidence is currently insufficient to suggest it is superior to other forms of therapeutic exercise (4,5). These mixed findings needn’t mean you have to consign isometric or eccentric exercises to the scrapheap when dealing with tendinopathy. They are effective possibly at different times during the rehabilitation process and to different levels of efficacy in different individuals. So, that raises the question of what to use when? It can be frustrating not having a handful of clinical trials with conclusive results pointing to one exercise type. Consensus, however, does exist for an exercise-based loading regime when managing tendinopathy injuries (4,6*). This article will discuss the options of what exercises to use when and how to progress them, with the ultimate goal of getting your patient back to full sport or activity.

What NOT to Do!

This may be a good starting point to narrow down the options. The pathogenesis of tendinopathy and the primary biological change in the tendon that precipitates pathology have historically generated several patho-aetiological models. The continuum model of tendon pathology, proposed in 2009, synthesised clinical and laboratory-based research to guide treatment choices for the clinical presentations of tendinopathy. Although the continuum has been cited extensively in the literature, its Co-Kinetic.com

clinical utility has yet to be fully elucidated. The continuum model (7*) proposed a model for staging tendinopathy based on the changes and distribution of disorganisation within the tendon. However, classifying tendinopathy based on structure in what is primarily a pain condition has been challenged. The interplay between structure, pain and function is not yet fully understood, which has partly contributed to the complex clinical picture of tendinopathy (8*). It may be beneficial to revisit this model (7*,8*) to better understand tendon morphology, pathology, tenocyte and collagen response, inflammation, degeneration and more. The continuum model suggests that management may be optimised by tailoring interventions to the stage of pathology and targeting the primary driver (cell activation) and inter-related alterations in matrix integrity (8*). Although exercise and load are fundamental to management, a plethora of intratendinous and peritendinous interventions exist to ‘treat’ tendinopathy – this increases the complexity of the clinical decisionmaking process (8*). Tendinopathy is a heterogeneous clinical presentation because of the variable change in matrix structure, pain and dysfunction. Phenotyping of patients based on structure, pain, dysfunction and load capacity may allow you to direct appropriate treatments at the critical limiting factors (6*,8*). To revise the continuum and phenotyping for tendinopathy patients you can access the free articles via: https://spxj.nl/38KwUfe and https://spxj.nl/38KwXaU. Research has investigated many treatment options, but consistent, positive, clinical outcomes remain elusive. Treatment should be active (eg. exercise-based), and a consistent and ongoing investment in rehabilitation is required. It is important to maximise this investment by understanding (and conveying to patients) the treatments that do not help. Jill Cook (9) suggests, therefore, a good starting

THERE HAS BEEN A LOT OF PROGRESS OVER THE LAST TWO DECADES WITH TENDINOPATHY TREATMENT

point may be one of considering what not to do with a tendinopathy patient.

1. Don’t Rest Completely

Treatment should initially reduce painful, high tendon load (point 2 below) and introduce beneficial loads [eg. isometrics (2*)]. Once pain is low and stable (consistent on a loading/provocative test each day), load can be increased slowly to improve the capacity of the tendon (9). Rest decreases the load tolerance of tendons, and complete rest decreases tendon stiffness within 2 weeks. It also decreases strength and power in the muscle attached to the tendon and the function of the kinetic chain, and likely changes the motor cortex, leaving the person less able to tolerate load at multiple levels.

2. Don’t Prescribe Incorrect Exercise

Understanding the concept of ‘load’ is essential for correct exercise prescription. High tendon load occurs when it is used like a spring, such as in jumping, changing direction and sprinting (10). Tendon springs must be loaded quickly to be effective. So slow exercises, even with weights, are not high tendon load and can be used early in rehabilitation. Bear in mind, 15

TENDINOPATHY BEGINS WITH A MISMATCH BETWEEN THE TENDON’S LOAD CAPACITY AND LOAD PLACED ON THE TENDON

however, that exercising at a longer muscle–tendon length can compress the tendon at its insertion (11), which adds substantial load and should be avoided (even if done slowly) early in rehabilitation (9).

3. Don’t Rely On Passive Treatments

Passive treatments are not helpful in the long term as they promote the patient as a passive recipient of care and do not increase the load tolerance of the tendon. Treatments like electrotherapy and ice temporarily ameliorate pain only for it to return when the tendon is loaded (9).

4. Avoid Injection Therapies

Clinicians who support injection therapies incorrectly suggest they will return a pathological tendon to normal. Injections of substances into a tendon have been shown to be no more effective than placebo in good clinical trials (9). There is little need to intervene in the pathology as there is evidence that the tendon adapts to the pathology and has plenty of tendon tissue capable of tolerating high load. Injections may change pain in the short term as they may affect the nerves, but should only be considered if the tendon has not responded to a good exercise-based programme (9).

5. Don’t Ignore Tendon Pain

Pain usually increases 24 hours after excess tendon load. An increase in pain of 2 or more (out of 10) on a daily loading test should initiate a reduction in the aspects of training that are

TABLE 1: EXAMPLES OF OVERLOADS ON THE ACHILLES TENDON Reproduced with permission from Cook JL, Purdam CR. The challenge of managing tendinopathy in competing athletes. British Journal of Sports Medicine 2014;48:506–509 (12) Type of overload

Example

Single high-intensity session

Repeated uphill running

Increased frequency of training

High-load training more than five times a week

Different drills

Rapid introduction of plyometric training

High loads when fatigued

Sprints at the end of training

Change in footwear

Shoes that provide less support, or stiff soles, shoes mandate a forefoot strike or have a lower heel wedge

Change in surface

Running in soft sand, running on uneven surfaces

Training with muscle stiffness

Training session following heavy-weight session

overloading the tendon (point 2 above). The overload is likely to be due to excessive spring-like movements such as jumping, running and changing direction (9). Daily recording of pain (documented by the patient or therapist on treatment days) will provide feedback to their tolerance and response to loading which will guide progression either forward or backwards when necessary.

6. Don’t Stretch The Tendon

Aside from the load on a tendon in sport, there are compressive loads on the bone–tendon junction when it is at its longest length. Stretching only serves to add compressive loads that are detrimental to the tendon (9).

7. Don’t Use Friction Massage

A painful tendon is overloaded and irritated (reactive tendon pathology). Massaging or frictioning the tendon can increase pain and will not help the underlying pathology. An effect on local nerves may reduce pain in the short term only for it to return with high tendon loads (9).

8. Don’t Use Tendon Images for Diagnosis, Prognosis or as an Outcome Measure

Abnormal tendon images (ultrasound and MRI) in isolation do not support a diagnosis of tendon pain as asymptomatic pathology is prevalent. There are also no aspects of imaging, such as vascularity and ‘tears’, that allow a clinician to determine outcome. Pathology on imaging is usually very stable and does not change with treatment and reduction in pain, so images are not a good outcome measure (9).

9. Don’t Be Worried About Rupture

Pain is protective as it causes unloading of a tendon. In fact most people who rupture a tendon have never had pain and do not present clinically, despite the tendon having substantial pathology. Fear of rupture or ‘permanent’ damage may inhibit the patient’s ability or willingness to load the injured area (6*).

10. Don’t Rush Rehabilitation

A tendon needs time to build its strength and capacity. So does the Co-Kinetic Journal 2020;84(April):14-23

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muscle, the kinetic chain and the brain. Although this can be a substantial time (3 months or more, sometimes up to 12 months), the long-term outcomes are good if the correct rehabilitation is completed (9). Setting unrealistic timeframes can be a major pitfall. Understandably there may be great pressure from an athlete, coach or parent (6*). Malliaris and Cook et al. (6*), comment that in their experience, poor baseline neuromuscular function, muscle atrophy, pain irritability, as well as multiple previous intratendinous interventions (eg. platelet-rich plasma or other injections) appear to be associated with longer rehabilitation times (6*). This point should possibly not be last, as in number 10, but rather the first point – to suggest having these timeline discussions with patients and their stakeholders (be it parents or coaches) right at the onset of treatment. The idea is not to waste valuable time and resources. A progressive programme that starts with a muscle strength programme and then progresses through to more spring-like exercises and including endurance aspects will load the tendon correctly and give the best long-term results.

What to DO!

Tendinopathy begins with a mismatch between the tendon’s load capacity and load placed on the tendon, most commonly through a sudden and/or substantial change in the load. This can include a return to sport from an (often unrelated) injury or after the off season, where the load capacity of the tendon is reduced owing to a loss of a regular high-load stimulus, or a sudden change in training intensity; or simply the couch potato who wants to now run 5km. As tendons respond very slowly to load, a tendinopathic response is triggered if the magnitude or temporal distribution exceeds the tendon’s threshold (12). In a runner presenting with Achilles tendinopathy, examples of the types of overloading can be seen in Table 1. A rehabilitation protocol for a runner suffering from Achilles or patellar tendinopathy may consist of simple and pragmatic exercises designed to incorporate progressive Co-Kinetic.com

TABLE 2: PROVOCATIVE CLINICAL TESTS USEFUL TO MONITOR TENDON PAIN Reproduced with permission from Cook JL, Purdam CR. The challenge of managing tendinopathy in competing athletes. British Journal of Sports Medicine 2014;48:506–509 (12) Tendon

Low-load clinical test

High-load clinical test

Achilles

Single-leg heel raise

Hop

Patellar tendon

Decline squat

High single-leg jump, landing from a height

Hamstring tendon

Single-leg bent knee bridge

Single-leg dead lift

Gluteal tendon

Single-leg stance

Hop

load to the tendon: isometric work, strength (including eccentric and concentric), functional strength, speed and jumping exercises to adapt the tendon to the ability to store and release energy (Link 1) (13*). First, load modification is used with the goal of reducing pain. This involves initially reducing high-load energy-storage activities that may be aggravating the pain. Intensity seems to be the most important feature; therefore this is the first factor you should modify by removing intensity peaks (ie. sprinting, sets, Fartlek, fast changes of direction, explosive jumping) (13*). Frequency is a very flexible value that we can use to adapt the load (more or less resting hours between workouts depending on the pain level of the next day). Volume seems to be the less aggressive feature, if there is enough time of rest among workouts; therefore, at early stages you can keep the volume of training and change intensity and frequency (13*). Volume and frequency (number of days per week they are performed) of the highest-intensity activities, such as maximal jumping, cutting, and pivoting may need to be reduced in consultation with both the athlete and coach. Both load modification and eventual progressive loading are based on careful pain monitoring. Some pain is acceptable during and after exercise, but symptoms should resolve reasonably quickly after exercise and should not progressively worsen over the course of the loading programme, as monitored by the 24-hour response (6*). Pain response should be closely monitored on a daily basis throughout rehabilitation. Patients will need to be responsible for recording their pain and reporting back to the therapist

so as to adjust exercises accordingly. Pain response can be measured using provocation tests (Table 2). The test is administered daily, at the same time of day, throughout the entire rehabilitation process. As tendon pain is intimately linked with load, the response to the test as called ‘load tolerance’. If the pain score on the load test (eg. 1 repetition of the single-leg decline squat test at the same depth) has returned to baseline within 24 hours of the activity or rehabilitation session, the load has been tolerated. If the pain is worse, load tolerance has been exceeded. Some studies have suggested that a pain level of up to 3–5 on a 0-to-10 numeric rating scale (0 is no pain and 10 is the worst pain imaginable) during exercise is acceptable (6*). However, a pain rating of 3/10 or less is defined as acceptable and ‘minimal’ pain. This should be a guide and can be adjusted according to the individual. It is reiterated that greater emphasis should be placed on the 24-hour pain response to a predefined load test, rather than to pain during or immediately before an activity (6*).

THE KEY TO TENDINOPATHY REHAB IS TO PROGRESS THE LOAD BASED ON TOLERANCE

Managing tendinopathy in season is a challenge for all sports medicine practitioners. Early intervention in athletes with tendinopathy is a key element. As with managing stress fractures, early identification, modification of training and return to sport using realistic timelines are fundamental to a good outcome. Identification of at-risk athletes, individualising training, monitoring changes in pain and immediate adjustment of loads are essential. Maintaining well-distributed functional loads relevant to the sport during the off season in an effort to reduce deconditioning of the muscleâ&#x20AC;&#x201C;tendon unit and kinetic chain appears to be a key consideration. Further, for athletes who have had significant downtime as a result of surgery or illness, avoiding a rapid return to high tendon load is also essential (12).

Rehabilitation

Stage 1: Isometric Loading

Video 1: Isometrics Exercise for GTPS | Gluteal Tendinopathy (Courtesy of YouTube user Physiotutors) https://youtu.be/YNkxh046sa4 18

Isometric exercise can be used as an initial treatment and/or in-season pain management for tendinopathies. Isometric exercises are indicated to reduce and manage tendon pain and initiate loading of the muscleâ&#x20AC;&#x201C;tendon unit when pain limits the ability to perform isotonic exercises. Performing the isometric exercises in mid-range is often more comfortable initially. Resistance should be increased as quickly as tolerated and the exercise should be performed on a single leg where possible (6*). The exercise dosage depends on individual factors; however, 5 repetitions of a 45-second hold, 2 to 3 times per day, with 2 minutes of rest between holds to allow recovery is a good place to start. A 70% maximal voluntary contraction load, which has been associated with reduced pain, can be estimated clinically (6*). The key is to progress the load based on tolerance and, as discussed earlier, regular reassessment of pain response with load tests. A good prognostic sign for isometrics is an immediate reduction in pain with loading tests (eg. a single-leg decline squat test) after isometric exercise. It is important that there be no muscle fasciculation during the isometric exercises, as this

may indicate that the load is too high. In stage 1, isometric exercises should be used in isolation. This stage may last a few weeks (sometimes longer) when managing individuals with a high level of pain irritability. Other exercises, involving surrounding muscles and joints of the kinetic chain, to address strength or flexibility deficits throughout the lower extremity can be initiated during this initial phase (6*). Does isometric contraction provide the strongest initial pain relief for tendinopathy? Four recent studies have addressed this question (14*). The studies showed mixed results with some patients reporting no change in pain, some an increase in pain, others no difference in pain when performing isometric or isotonic exercises. Interestingly, the original study from Rio et al. (2*), could not be replicated in a pre-registered replication study using the same methods and outcomes in 20 individuals suffering from patellar tendinopathy (14*). A recent study by Clifford et al. (15*) found that both isometric and isotonic exercises were effective in reducing pain by 55% and 58%, respectively, in patients with greater trochanteric pain syndrome (GTPS) (15*). An example of isometric exercises for GTPS can be found in Video 1. When used as in-season management, there have been suggestions of immediate pain relief following both isometrics and isotonics in athletes with patellar tendinopathy with no superiority of isometrics over isotonics (14*). Recent large-scale studies with sample sizes in excess of 600 suggest that maintained preand in-season strengthening and conditioning without any specific bias towards concentric, isometric or eccentric modes reduce the inseason prevalence of shoulder and groin problems (approx. 30â&#x20AC;&#x201C;40%). Furthermore, there is evidence that using a pain-monitoring model and adequate adaptation periods during rehabilitation will enable continued sporting without adverse effect on recovery (14*). Key points for stage 1 (13*): 1. Pain inhibits the athlete using Co-Kinetic Journal 2020;84(April):14-23

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the elastic (energy storage and release) capacity of the tendon, thereby compromising function and performance. 2. Excessive training volume or too intense training involving the elastic function of tendons may induce tendon overload and are important factors in the onset of athletic tendinopathy. 3. Repeated training combined with too short resting periods can result in a net degradation of the matrix and lead to overuse injury. 4. Managing tendinopathy in season centres around load management: this includes strategies that control pain, both reducing aggravating loads and introducing pain-relieving loads. 5. No medication or injectable treatment to date has been shown to alter tissue properties – only tendon load can stimulate remodelling. 6. Loads that reduce pain should be introduced as early as possible. Loading to decrease pain will maintain a load stimulus on the tendon that is critical to maintain cell function and matrix integrity. 7. In highly reactive and painful tendons, bilateral exercises, shorter holding time and fewer repetitions per day may be indicated.

Stage 2: Isotonic Loading

Loaded isotonic exercise is initiated when it can be performed with minimal pain (3/10 or less on a numeric painrating scale). A positive response to regular reassessment of pain with load tests continues to be important. Isotonic load is important to restore muscle bulk and strength through functional ranges of movement. A common pitfall is including only double-leg, multi-joint exercises (eg. double-leg squats) that may not address quadriceps strength asymmetry if the athlete spares (protects) the affected side. Exercises that can be progressed easily to singleleg loading, including leg press, split squat, and seated knee extension (leg extension machine) may be beneficial (6*). Eccentric musculotendinous loading has become the dominant conservative intervention strategy for Co-Kinetic.com

Achilles and patellar tendinopathy over the last two decades. Eccentric loading involves isolated, slow lengthening muscle contractions. Systematic reviews have evaluated the evidence for eccentric muscle loading in tendinopathy, concluding that outcomes are promising but high-quality evidence is lacking (13*). Video 2 demonstrates a routine proposed by Alfredson et al. (3) for Achilles tendinopathy. Eccentric loading may not be effective for all patients (athletes and non-athletes) affected by tendinopathy (13*). It is possible that in athletes, eccentric work alone is an inadequate load on the muscle and tendon. A rehabilitation programme aiming to increase tendon load tolerance must obviously include strength exercises, but should also add speed and energy storage and release. Despite the widespread clinical use of eccentric exercise for the treatment of tendinopathy, there are limited high-quality data that demonstrate positive clinical outcomes of this approach (4,6*,13*,16). Kongsgaard et al. (17*) performed a randomised clinical trial comparing heavy slow resistance (HSR) exercise and the decline squat programme. The HSR programme consisted of concentric/ eccentric squats, hack squats, and leg presses, using both lower extremities. For each exercise, 3 to 4 sets were performed, progressing from an initial load based on 15 repetition maximum (15RM) to 6RM. Pain and functional outcomes on the VISA-P were similar at 6 months, but patient satisfaction of those using the HSR programme was significantly greater (70%) than patient satisfaction of those using the decline squat programme (22%). The

Video 2: Alfredson Achilles Tendinopathy Rehab Protocol (Courtesy of YouTube user Physiotutors) https://youtu.be/fHHbn_Odk4E

Video 3: GTPS Exercise Protocol | Gluteal Tendinopathy (Courtesy of YouTube user Physiotutors) https://youtu.be/477OFkR0syE authors of a recent systematic review (16) determined that there was limited evidence supporting the decline squat programme and moderate evidence supporting the HSR programme (16). As isometric exercises appear to be more effective during the competitive seasons for short-term pain relief, HSR or eccentric exercises are more suitable for long-term pain reduction and improvement in function (18). Stage 1 exercises should be continued on the ‘off’ days to manage pain within the limits of muscle fatigue and soreness associated with the isotonic loading. Stage 2 exercises should be continued

TABLE 3: EXAMPLES OF FORCE AND LOADING RATE ON THE PATELLAR TENDON Sourced from Malliaris P et al. Patellar Tendinopathy: clinical diagnosis, load management, and advice for challenging case presentations. Journal of Orthopaedic & Sports Physical Therapy 2015;45(11):887–898 (6) Exercise/activity

Force

Loading rate

Bilateral leg press (not an energystorage loading exercise)

5.2× body weight

2× body weight per second

Landing phase of vertical jump

5.17× body weight

38× body weight per second

Horizontal landing – stop, land/jump sequence

6.6× body weight

93× body weight per second

LOAD MODIFICATION AND PROGRESSIVE LOADING ARE BASED ON CAREFUL PAIN MONITORING throughout rehabilitation and return to sport. Video 3 demonstrates some rehabilitation exercises for GTPS.

Stage 3: Energy-Storage Loading

The power needed for jumping, landing, cutting and pivoting when participating in sports requires tendons to repetitively store and release energy. Energy storage and release (similar to a spring) from the long tendons of the lower limb are key features for high performance while reducing the energy cost of human movements. Repetition of this springlike activity over a single exercise session, or with insufficient rest to enable remodelling between sessions, can induce pathology and a change in the tendon’s mechanical properties, which is a risk factor for developing symptoms. Reintroduction of energy-storage loads on the myotendinous unit is critical to increase load tolerance of the tendon and improve power as a progression to return to sport. Initiating this stage is based on the following strength and pain criteria: (1) good strength (eg. ability to perform 4 sets of 8 repetitions of single-leg press with around 150% body weight for most jumping athletes); and (2) good load tolerance with initial energy-storage exercises, defined as minimal pain

(3/10 or less on a numeric pain-rating scale) while performing the exercises, and return to baseline pain (if there was an initial increase) during load tests, such as the single-leg decline squat, within 24 hours (6*). As with the other stages, individualisation and clinical reasoning are necessary. In addition, progression should be developed within the context of the loads the individual patient is required to attenuate for their sport and performance level. Table 3 provides an understanding of the major change through activities in the rate of loading of the tendon, which should be progressed gradually through relevant energy-storage activities for the individual athlete. Exercise choice will depend on the demands of the individual sport. Thus, the selection and parameters of energy-storage programmes may vary greatly among individuals who participate in different sports, as well as among positions in the same sport. Planning for this stage requires close consultation with the athlete and coach to appropriately determine the training frequency, volume, and intensity of the energy-storage exercise, and the type of exercise. Energy-storage exercise options may include jumping and landing, acceleration, deceleration, and cutting/change-of-direction activities, depending on the demands of the sport (6*). The progression can take several weeks to months for some athletes (eg. for volleyball players to build up to the 300 landings typically performed in a single training session). For athletes who do not require significant volumes of jumping and landing in their sport (sprinters, rugby players), a similar progression targeting acceleration, deceleration, and/or cutting/change-of-direction manoeuvres may be emphasised (6*). Accurate quantification of load is important at this stage. In jumping sports, the number and intensity of jumps and all other energy-storage activities should be considered to ensure that loads are progressively applied to meet the ultimate demands of the sport. For example, a high jumper may progress through doubleto single-limb small vertical jumps and hops, to horizontal bounding (eg. 4–6

times, 8–12 contacts), 2-legged hurdle jumps up to 1m high (eg. 3 times, 8 contacts), scissor jumps over the bar from 5-step run-up (8–10 contacts), then flop jump from 5-step run-up (8– 10 contacts), and finally to a full run-up flop jump (8–10 contacts). In essence, the volume (ie. number of contacts or jumps) is progressed before the intensity (jump height and speed) for each exercise to approach the optimal training intensity and energy-storage exercise demands of the sport (6*). The introduction of energy-storage exercises is often the most provocative stage, so loading is performed every third day initially, based on a 72-hour collagen response to high tendon loading (6*). Progressions are guided by pain experienced in the provocative test 24 hours after exercise, as described earlier. Stage 1 isometric loads can be used in combination to manage stable pain following energystorage exercise; however, increased pain in the load response test the day after a stage 3 training session indicates that load tolerance has been exceeded (irritable pain) and loading should be adjusted accordingly (eg. regress to the previous level of training, or further, to restore load tolerance on load tests again). In some instances, pain may increase for days after an energy-storage progression that was not gradual enough (6*).

Stage 4: Return to Sport

Progression to sport-specific training can be commenced when the individual has completed energystorage progressions that replicate the demands of his or her sport in regard to the volume and intensity of relevant energy-storage functions. In the early phases, training should match the volume and intensity of final progression of stage 3 exercises, gradually replacing stage 3 activities with a volume and intensity similar to those of training drills to replicate the participation and fitness demands of the sport. Return to sport is recommenced when full training is tolerated without symptom provocation (24-hour response on provocation test) and any existing power deficits have been resolved (6*). Co-Kinetic Journal 2020;84(April):14-23

PHYSICAL THERAPY

Maintenance Exercise

It has been suggested that a maintenance programme, once athletes have returned to sport, continues with stage 2 strengthening exercises. They should be performed at least twice per week, preferably using loaded and single-leg exercises (for example split squats, seated knee extension, leg press in patellar tendinopathy). Stage 1 isometric exercises can be continued and performed intermittently (eg. before or after training) for their immediate effect on pain. Athletes should also continue addressing other relevant flexibility and strength deficits identified throughout the lower extremity, such as gluteal or calf-strengthening exercises (6*).

ankle dorsiflexion in a landing has the potential to increase the load on the patellar tendon (12). Other considerations for patellar tendinopathy may include gluteal strengthening and recruitment, calf strengthening and landing re-education, encouraging energy absorption to be distributed across all three major joints or segments. Much of this can be commenced very early in the management cycle, providing symptomatic gains as the presenting tendinopathy is effectively unloaded (12). Links 2 and 3 show examples of progressions for exercises and rehabilitation for patellar tendinopathy in Malliaris et al. (6*).

Kinetic Chain Considerations

Conclusion

Management focusing on the presenting tendinopathy is simplistic, as the distribution of absorption of energy across the kinetic chain is an important consideration and each tendinopathy requires a holistic approach to rehabilitation. For example, a restriction of

KEY POINTS

Tendinopathy can frequently be difficult to manage often resulting in frustration and disappointment with continued pain and prolonged recovery time. The cornerstone of tendinopathy management and rehabilitation remains a highly specific and thorough approach to progressive

lT endons are highly responsive to increased mechanical loading and adapt through changes of their mechanical, material and morphological properties. lE ach component of the rehabilitation programme, in particular loading, must be handled in relation to the nature, speed and magnitude of the forces applied to the muscle–tendon–bone unit in order to achieve the goals of the particular management phase without causing exacerbation of the pathological state or pain. lR ehabilitation can progress through 4 stages: isometric early stage; isotonic or strengthening stage including both concentric and eccentric as well as functional exercises; energy-storage stage involving plyometric type activities; final stage of return to sport. lP rovocative testing and daily documentation of pain scores is crucial in determining load tolerance and progression. l I ndividuals display a very varied response to isometric exercises used for pain management. lA lthough a number of exercise-based interventions have significant positive effects on pain and function in tendinopathy, the current evidence does not support the recommendation of one type of exercise programme over another. There seems to be not one exercise type, be it eccentric or isometric, that is superior to or inferior to other exercises. lP rogressive load may be more important than the exercise type. lK inesiophobia may influence both short- and long-term response to load. lP atients and therapists should not have unrealistic time frames: recovery from tendinopathy can take in excess of 12 weeks. lT he ultimate goal is that the athlete should be able to use the elastic capacity of the tendon and have regained function of the kinetic chain suitable for performance. Co-Kinetic.com

loading of the tendon as well as the associated kinetic chain. Rehabilitation should progress through stages of off-loading and pain reduction followed by gradual strengthening and introduction of plyometric and sports specific exercises. No one exercise type has been found to be superior or inferior to the other. The focus should be on load response and increasing load tolerance. Each individual will present differently and the exercise prescription will need to be altered according to their pain, function and tendon reactiveness. The ultimate goal is that the athlete should be able to use the elastic capacity of their tendon and regain function of the kinetic chain suitable to the sport and level of performance. 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/2wlzdIi

RELATED CONTENT

lD iagnosing Achilles tendinopathy: a ‘how to’ guide [Article] http://spxj.nl/1Gy4m8a lT endinopathy loading programmes: an overview of current concepts [Article] http://spxj.nl/1D12deC l Running Injury Patient Information Resources [Printable leaflet] https://spxj.nl/2P0NX5I l Patient Information Leaflet: Achilles Tendinopathy Injuries in Runners [Printable leaflet] https://spxj.nl/2KxZXaR l Don’t Run into Trouble: A Content Marketing Campaign for Therapists http://spxj.nl/2F6OCvm

DISCUSSIONS

l For the most common tendons (Achilles, patellar, hamstring and gluteal), which provocative tests do you use and find most accurate in testing tendon pain? l What do you believe is an acceptable pain score in order to progress the exercise load: less than 3/10 or can a patient work into some degree of pain with ratings of 3–5/10? l What exercise do you prefer to use for each tendinopathy (Achilles, patellar…) where you can progress it over the different rehabilitation stages?

Want to share on Twitter? Here are some suggestions

Tweet this: Isometric exercises are a useful initial treatment to reduce and manage tendon pain. https://spxj.nl/2We8459 Tweet this: Single-leg loading exercises may be beneficial for quadriceps asymmetry in tendinopathy rehab. https://spxj.nl/2We8459 Tweet this: Load progression based on tolerance is key in tendinopathy rehab. https://spxj.nl/2We8459 Tweet this: Strengthening surrounding areas of the kinetic chain is an important part of tendinopathy rehab. https://spxj.nl/2We8459 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

LINKS

LINK 1: Figure 1: Programme to incorporate progressive load to the tendon. Mascaro A et al. Load management in tendinopathy: clinical progression for Achilles and patellar tendinopathy. Apunts Sports Medicine 2018;53(197):19–27 (13) https://spxj.nl/2HPXybL LINK 2: Figure 2. Progression of patellar tendinopathy rehabilitation. Malliaris P et al. Patellar tendinopathy: clinical diagnosis, load management, and advice for challenging case presentations. Journal of Orthopaedic & Sports Physical Therapy 2015;45(11):887–898 (6) https://spxj.nl/3bX4Jwy LINK 3: Table 1: Rehabilitation stages and progression criteria. Malliaris P et al. Patellar tendinopathy: clinical diagnosis, load management, and advice for challenging case presentations. Journal of Orthopaedic & Sports Physical Therapy 2015;45(11):887–898 (6) https://spxj.nl/3bX4Jwy 22

Owing to the important performance benefits of strength training (ST), it should be considered an essential addition to a well-planned training programme for middle and long distance runners of all levels. There is a belief among some health professionals, running coaches and runners, that to maximise the benefits to running performance, ST should be high repetition, low resistance to mimic the endurance demands of running. This is incorrect. Improvements in muscular endurance are achieved specifically by running and should not be the goal of a ST programme. Completing endurance type exercises (eg. 3 sets of 20 reps or more with light resistance) has been reported to be less effective than heavy resistance and explosive resistance training in achieving benefits to running performance (1). As such, ST should include heavy resistance, explosive resistance and plyometric training for endurance runners (1,2,3,4).

Key Benefits

1. Improved Running Economy (RE) (4)

ST interventions lasting 6–20 weeks, added to the training programme of a distance runner with >6 months running experience, have been reported to enhance RE by 2–8% (1). RE improvements will theoretically enhance endurance running performance by allowing the runner to run at a lower oxygen or energy cost during training and racing (1). These benefits have been reported in runners from a recreational level through to highly trained elite athletes (1). Although the impact of ST on RE is well established, the mechanisms that explain this phenomenon are still not clearly understood. Plausible mechanisms underpinning the mechanism of RE improvements with ST are: a. Agonist-antagonist co activation (3) l ST improves motor unit recruitment and co-ordination, therefore the relative proportion of active muscle is reduced. l Decreased activation of antagonist muscles during swing and propulsion phase during running can attenuate unnecessary exergy expenditure. b. Trunk kinematics (3) l Free weight training improves trunk kinematics. l Improved trunk kinematics might reduce energy expenditure with lateral oscillation and trunk rotation. c. Relative load (3) l Resistance training increases maximal strength. l In stronger muscles, submaximal contractions performed while running might recruit smaller and more efficient motor units. d. Achilles tendon stiffness (3) l Maximal strength and power training increases Achilles tendon stiffness. l Stiffer tendons allow for lesser shortening length and velocity of active muscles during the stretch-shortening cycle, which could result in lesser energy expenditure. e. Vertical oscillation (3) l Rate of force development increases following power training.

Co-Kinetic Journal 2020;84(April):14-23

PHYSICAL THERAPY

High Load, Low Reps and Explosive Exercises are the Go-To for Strength Training in Runners l Greater rate of force development shortens the interval required to produce the force required to sustain body mass during ground contact, potentially reducing vertical oscillation.

2. Faster Time Trial Performance (4)

Faster time trial performances over middle (1500–3000m) and long distance (5–10km) events, with improvements ranging from 2 to 5%, have also been reported in groups of runners who undertake ST (1). For a recreational runner with a personal best 10km time of 50min, this equates to an improvement of between 1 and 2.5 minutes.

3. Faster Maximal Sprint Speed (4)

Faster maximal sprint speed following ST may be another benefit for distance runners (1). Consistency is key. If ST is removed from a training programme, loss of performance benefits occur within 6 weeks (4). Therefore, staying consistent with appropriately periodised ST leading into goal events may be needed to maximise performance. Although there is evidence that consistent ST, when combined with other exercise interventions, may assist in reducing the risk of overuse injuries in other sporting populations, the effect on injury risk in runners remains unclear (5). Further high-quality research is required to establish if the important physiological adaptations that occur in response to ST result in increased tissue capacity and reduced injury risk in running populations.

Practical Considerations

Heavy resistance exercises commonly used include barbell squats, deadlifts, steps-ups, lunges and calf raise variations. Completing exercises with moderate resistance, for example,

Co-Kinetic.com

60–80% of 1 repetition maximum for 3–6 sets of 5–15 repetitions has been reported to benefit performance. For distance runners, training to repetition failure is not recommended (1). The addition of two to three supervised strength sessions per week, initially focusing on a periodised heavy resistance training programme is recommended (1). For runners without ST experience gradual progress to reduce the risk of injury and overtraining would be required (1). A well-planned programme should not negatively impact other running sessions. At least 3 hours’ recovery after highintensity running before completing ST, and at least 24 hours’ recovery after ST before a high-intensity running session is scheduled (1). ST can be the vaccine against injuries. Physically training harder and smarter (choosing appropriate exercises) can develop physical qualities in a runner that can protect them against injury (6)! References

1. Blagrove RC, Howatson G, Hayes P. Effects of strength training on the physiological determinants of middle- and long-distance running performance: a systematic review. Sports Medicine 2018;48:1117–1149 2. Denadai BS, de Aguiar RA, de Lima LCR et al. Explosive training and heavy weight training are effective for improving running economy in endurance athletes: a systematic review and meta-analysis. Sports Medicine 2017;47:545–554 3. Lima LCR, Blagrove R. Infographic. Strength training–induced adaptations associated with improved running economy: potential mechanisms and training recommendations. British Journal of Sports Medicine 2020;54:302–303 4. Alexander JLN, Barton CJ, Willy RW. Infographic. Running myth: strength training should be high repetition low load to improve running performance. British Journal of Sports Medicine 2019;pii:bjsports-2019-101168 5. Lauersen JB, Bertelsen DM, Andersen LB. The effectiveness of exercise interventions to prevent sports injuries: a systematic review and meta-analysis of randomised controlled trials. British Journal of Sports Medicine 2014;48:871–877 6. Gabbett T. Infographic: The training–injury prevention paradox: should athletes be training smarter and harder? British Journal of Sports Medicine 2018;52:203.

PONDERING POSTURE

osture is a frequent topic of discussion for patients, clinicians, the media and society. A common belief is that spinal pain is caused by sitting, standing or bending ‘incorrectly’. Despite the absence of strong evidence to support these common beliefs, a large posture industry has flourished, with many interventions and products claiming to ‘correct’ posture and prevent pain. A recent publication highlighted the fact that many healthcare professionals provide advice in line with this non (or little)-evidence-based perspective. Questions have been raised over the beliefs regarding posture and spinal health and why they are so widely held. How can clinicians positively influence or justify these postural beliefs in the absence of controlled clinical trials proving that pain and posture are interconnected? This is a tricky debate, as there are areas where research shows posture correction as being beneficial. However, this is possibly in isolated joints or situations, rather than looking at entire body posture. Perhaps there are too many factors that interlink with whole-body posture (be it standing or sitting) that make designing and implementing randomised controlled trials difficult; hence, the lack of evidence supporting posture correction. The future of 24

By Kathryn Thomas BSc MPhil

Having good posture is an ideal that is instilled in us from early on – has anyone not been told to sit or stand up straight at some point in their life? There is, however, virtually no evidence to support these beliefs. This article discusses what the research actually tells us about posture, allowing you to determine when posture might or might not be influencing your patient’s pain, if modifying it might help or if one/some of the other many and complex factors might be having a greater effect. Read this article online https://spxj.nl/2TPYDXX LOW BACK PAIN | PSYCHOLOGY | 20-04-COKINETIC FORMATS

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All references marked with an asterisk are open access and links are provided in the reference list posture research may require more thought but, for now, how can you use it in your practice and where should the emphasis be?

Beliefs About Posture

It is typically believed, by healthcare professionals and the community, that avoiding spinal flexion is the safest way to sit and bend (1). Patients and pain-free members of the community

are commonly advised to sit upright and undertake bending and lifting tasks in a ‘natural’ lordotic posture. Manual handling guidelines in the United States and the United Kingdom advocate a straight back or slightly bent back during lifting tasks (2,3). A slightly lordotic posture is commonly identified as the ideal standing posture (4). The assumption is that maintaining these postures

DESPITE WIDESPREAD BELIEFS ABOUT CORRECT POSTURE, THERE IS NO STRONG EVIDENCE THAT AVOIDING INCORRECT POSTURE PREVENTS LOW BACK PAIN Co-Kinetic Journal 2020;84(April):24-29

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might protect spinal structures, where posture beliefs reflect the ‘fact’ that sitting, standing and bending are often provocative of pain, especially low back pain (LBP). Awkward postures, or sustained postures and heavy lifting are believed to precipitate episodes of acute LBP and there are some links between lifting and injury reports (1). Despite widespread beliefs about correct posture, there is no strong evidence that avoiding incorrect posture prevents LBP, or that any single spinal curvature is strongly associated with pain (5*). The poorly understood aetiology of LBP is reflected by the multitude and diversity of suspected risk factors (5*). Given that LBP commonly afflicts working adults, resulting in lost productivity with farreaching economic consequences, occupational risk factors continue to be of interest. If occupational factors causing LBP were identified, primary prevention could attempt to limit or modify exposure (5*). Occupational risk factors commonly thought to be associated with LBP include heavy physical work, a static work posture, repetitive bending, twisting, lifting and whole-body vibration (5*). Other occupational risk factors include psychological issues such as satisfaction with relationships between colleagues or supervisors, job monotony/repetitiveness, work satisfaction, psychological demands, social support at work, and work demands. Several organisations have attempted to characterise occupational risk factors that may lead to musculoskeletal injuries such as LBP, including the World Health Organization (5*). Clinical studies might look at one occupational risk factor in isolation (eg. handling heavy loads) in order to establish its role in the development of pain; however, workers are often exposed to multiple risk factors. Therefore, delineating the contribution of one specific risk factor, be it posture, lifting, sustained positions, stress, etc, to the development of LBP is complex. Equally challenging is the interpretation of findings from single studies examining only one aspect of a causal relationship between a potential risk factor and outcome (5*). Co-Kinetic.com

Individual clinical factors of a patient and the best available scientific evidence about the effects of occupational physical activities on workers are the key elements in any such assessment. Sadly, it can be difficult to reconcile these two considerations, especially as the evidence evolves and begins to challenge commonly held beliefs. For example, it is often assumed that occupational physical activities such as bending, lifting, sitting or twisting can predispose workers to developing disabling LBP. However, it has been found that only weak or conflicting evidence exists to support any such potential causal relationship (5*). Protecting the spine is also advocated by the fitness industry. Common advice is that the ‘core’ muscles of the trunk must be consciously activated to maintain a ‘correct’ posture and protect the spine. Advice about ‘perfect form’ given in relation to weight-training is often applied away from the lifting platform. Although additional muscular effort is required for correct posture when sitting and lifting, there is no evidence to suggest that correct posture prevents or reduces pain and disability. People with LBP bend their spine less and show more trunk muscle activity when forward bending and lifting. The notion that people with LBP must be careful and ‘protect’ their spine is further challenged by the association of higher levels of fear and lower selfefficacy with a guarded way of moving (6). The non-evidence-based perspective that pain can be prevented by avoiding incorrect posture, such as slouching, is reinforced by fearinducing messages in the mainstream media. People might become concerned about their spinal health when they are exposed to articles about potentially damaging postures and advertisements for posturecorrection aids. Unhelpful posture ideals are also reinforced by longstanding stereotypes that suggest posture reflects a person’s sex, dignity, respectability, attractiveness and morality (7). Where does that leave you? There is insufficient or poor-quality

scientific literature to strongly prove a cause–effect relationship with pain and posture. However, some clinical findings (which we will highlight later in this article) do not preclude the possibility that individuals may attribute their pain to posture or occupational activities and evidently may benefit from posture correction.

Where Do You Stand?

So, where does that leave you and what should you be doing about posture related issues? Clinically, ‘corrective’ postural interventions and advice are commonly used by physical therapists in managing spinal pain, based on the presumption that postural variations from the ideal posture are causative of pain (4). Although evidence suggests that a large percentage of individuals are susceptible to spinal-symptom development during standing there is limited evidence that any specific spinal posture is causative of LB, even though various postural interventions have shown some potential to reduce the incidence of LBP, reduce low back discomfort, and reduce disability and pain (4). Although the specifics of ‘optimal posture’ (OP) remain broadly debated, community perceptions seem to be consistent despite a lack of solid evidence. Before concluding if and how spinal posture should be modified in people with spinal pain, it is important to understand perceptions regarding OP and the importance attached to OP by physiotherapists.

THERE ARE, HOWEVER, CLINICAL STUDIES THAT SHOW THE BENEFIT OF POSTURE CORRECTION WITHIN CERTAIN JOINTS AND POPULATION GROUPS 25

Figure 1: Seven seated postures used as options in the study by Korakakis V, O’Sullivan K, O’Sullivan PB et al. Physiotherapist perceptions of optimal sitting and standing posture. Musculoskeletal Science & Practice 2019;39:24–31 (4).

A recent study (4) found that: l 93.5% of physiotherapists believe that postural education is important in clinical practice. l Upright lordotic sitting postures were selected as optimal by 70.5% of the physiotherapists. – Sitting postures (SP) involving an increased lordotic lumbar curvature were selected by 70.5% of the physiotherapists based on visual observation, including the most lordotic posture (SP 2) in contrast to less lordotic curvatures (SP 5, 6 and 7) that were selected by 28.9% (Fig. 1). l 98.2% of selected standing postures did not incorporate forward head posture. – Upright standing posture (postures 4 and 5) that did not incorporate thoracic flexion or forward head posture were selected as most optimal (Fig. 2). l Posture selection was related to biomechanical beliefs and stereotypes. l These beliefs are likely to influence physiotherapists’ clinical practice.

Figure 2: Five standing postures used as options in the study by Korakakis V, O’Sullivan K, O’Sullivan PB et al. Physiotherapist perceptions of optimal sitting and standing posture. Musculoskeletal Science & Practice 2019;39:24–31 (4).

Interestingly, although there was variation in exactly how upright the various OPs selected were, OP almost never involved lumbar flexion or forward head posture. While we know that healthy individuals often habitually adopt flexed SPs (8), the belief that upright lordotic sitting is best appears to be common among both clinicians and members of the community (4). Therefore, it is important for clinicians to understand that patients may hold strong posture beliefs that influence their behaviours, whether these are evidence-based or not (9*). In contrast, there may be no one OP, but rather any position – lordotic or kyphotic – maintained for a period of time without interruption may lead to discomfort and pain (4). Given the seeming lack of evidence of a cause–effect relationship with posture and pain, do you dump posture correction all together? Apparently not yet; physiotherapists still hold strong opinions on its importance. There is clinical evidence showing the benefit of posture correction – be it in an isolated area (a shoulder girdle for example), or demographic (young versus old) – for pain reduction or improved function. It cannot be neglected. Although there may be many more studies (well conducted or otherwise), here are a few examples highlighting the fact that we may not be able to completely neglect the importance of posture when managing a patient. One study aimed to verify whether body posture in adolescence can be enhanced through the improvement of neuromuscular performance, attained by means of targeted strength, stretch,

and body perception training, and whether any such improvement might also transition into adulthood (10*). To do this, Ludwig and colleagues followed children from ages 14 to 20 years old performing a 2-hour/ week postural awareness and exercise programme (compared to controls). Results showed that anthropometric parameters, additional athletic activities and sedentary behaviour did not influence posture parameters significantly. However, those participating in the additional athletic training of 2 hours per week, including elements for improved body perception, seemed to have the potential to improve body posture in symptom-free male adolescents and young adults (10*). This may be an important consideration when treating adolescents or children, as the literature states poor posture or posture weakness prevalence is 22–65% for 10–18-year-old children and adolescents (10*). Murta et al. studied the influence between pelvic posture, the trunk and shoulder. Active reduction of anterior pelvic tilt decreased trunk extension; which in turn increased lower trapezius activity. This may have significant effects on shoulder girdle stability and movement, correcting or preventing shoulder pain syndromes, and should be considered when assessing a patient and planning an exercise protocol (11). Therefore, modifications of posture in one body segment may influence the posture of adjacent and nonadjacent segments and muscular activity (11). Similarly in another recent study, thoracic extension increased scapular posterior tilting and external rotation. Thoracic extension reduced glenohumeral horizontal extension and increased maximum shoulder external rotation. The study showed how thoracic extension can contribute to the reduction of mechanical demand in the glenohumeral joint during throwing, potentially reducing shoulder injuries (12). A recent review on neck pain showed that increased thoracic kyphosis was positively correlated with the presence of forward head posture but not uniformly associated with neck pain intensity and disability Co-Kinetic Journal 2020;84(April):24-29

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(13*). Thoracic mobility was reduced in the neck pain population, and the role of thoracic kyphosis as a risk factor for pain development could not be confirmed. Thus, an association exists between thoracic kyphosis and postural alteration in the cervical spine. The review favours the inclusion of thoracic spine assessment and treatment in mechanical neck pain patients (13*). Head and shoulder postural malalignments are thought to influence the muscular balances surrounding the shoulder. Forward head posture (FHP) is associated with shortening of the upper trapezius, the splenuis and semispinalis capitis and cervicis, the cervical erector spinae and the levator scapulae musculature. An 8-week exercise intervention programme aimed at strengthening weak musculature and stretching tight, overdeveloped musculature, commonly found in FHP and rounded shoulder posture, was studied. Statistically significant improvements were seen with reductions in cervical angle and forward shoulder translation. Shoulder function, as measured by the American Shoulder and Elbow Surgeons scores, although not statistically different following the intervention, demonstrated a trend towards a decreased level of perceived shoulder pain and dysfunction. This trend suggests that there may be a relationship between the correction of FHP, rounded shoulder posture and shoulder pain (14). FHP is a common postural deviation associated with older age, cervical muscle weakness, poor balance, anteriorly displaced centre of mass, increased postural sway and fall risk, impaired cervical proprioception, and possibly vestibular dysfunction. Studies have found increased fall risk in older adults with FHP but have not identified a casual reason for this relationship (15). Research has shown that performing an exercise programme for 1 hour, twice weekly for 8 weeks (which consisted of specific exercises to enhance breathing, thoracic mobility and stability, and improve awareness of thoracic alignment) was beneficial in improving spinal posture (16). Posture Co-Kinetic.com

was measured as the angle of thoracic kyphosis,kyphosis index calculated both in relaxed and best posture using flexi-curve, the ratio of the kyphosis index calculated best posture/relaxed posture, craniovertebral angle, and tragus-to-wall distance. The use of the therapeutic strategies utilised in this study to enhance thoracic posture, balance, and well-being of older women with thoracic hyperkyphosis is recommended (16). From these few examples, it is possible that the challenges in the research come in proving the global benefit in altering sitting or standing postures and the changes to a person’s pain or overall health – something hard to control for variables or quantify.

COMFORTABLE POSTURES VARY BETWEEN INDIVIDUALS, SO IT IS USEFUL TO EXPLORE DIFFERENT POSTURES

Clinical Recommendations

There is no evidence to support posture or movement screening for primary prevention of pain in the workplace (1). People come in different shapes and sizes, with natural variation in spinal curvatures. Preferential lifting style and posture adaptability are influenced by spinal curvatures (19*). The mandatory manual handling training and ergonomic assessments in offices that pain-free people are often subjected to may perpetuate a misconception that common daily tasks and working environments are dangerous (1). There may be a place to screen professional or competitive athletes for example, as posture can give indications of muscle imbalances which could predispose them to injury. Likewise, understanding the loads on joints in different postures, in different sporting disciplines, may reduce the risk of developing repetitive strain injuries (20,21,22*).

1. Assessing the Posture of People in Pain

Observing the posture of a person presenting with musculoskeletal pain has a role. It may help patients to feel they are being taken seriously and allow the clinician to identify rare cases of clinically relevant deformity, such as a significant, deteriorating scoliosis. Importantly, the clinician may observe overly protective postures, levels of muscle tension, apprehension, vigilance, distress, mood, and body image that can provide insights into behavioural responses and how people make sense of their pain experience. We strongly encourage the therapist to build a relationship with the patient to explore why they adopt certain postures. Although there is evidence that people with LBP may find certain postures provocative (17), it cannot be concluded that the postures are the cause of pain. The chicken or the egg scenario has its role to play in posture. Did poor posture lead to back pain and now certain postures provoke the pain further; or did the patient develop a certain posture subsequent to the pain developing and again finds certain positions or movements now painful? By the time the patient presents to you it is often too hard to tell. A similar scenario occurs in neck pain patients with or without FHP. Studies have shown that FHP does not explain pain and disability in chronic

neck pain patients and that FHP is not associated with cervical flexor or extensor muscle performance. However, the muscle size–endurance relationship is affected in chronic neck pain patients, and deep cervical muscles are selectively affected in the presence of pain, which in turn may alter a patient’s neck posture (18*).

2. Assessing the Posture of People Without Pain

3. Help People to Sit, Stand and Move More Easily

Helping people to adopt more relaxed postures, while reassuring them that these postures are safe, can provide symptom relief (1). Comfortable postures vary between individuals, so it is useful to explore different postures. The clinician might consider how to expose people to postures and ways of moving that they have avoided, and how to encourage change in habits that may be provocative. Alterations in 27

posture or movements that feel good in the acute stage may not be needed long term (1). There is an infographic (Fig. 3) that accompanies the paper by Slater et al. (1), which is available at the Pain-Ed website (https://spxj.nl/2Vcr03E). Some people who find upright postures provocative may be required to adopt such a posture for their sport/role (eg. ballet dancers, military personnel). It is possible for people to be upright and be more relaxed. If clinicians help people to experience an upright, relaxed posture, it may be beneficial – even symptom modifying! Although the posture may be required for the sport/role, it may not be required for spinal health and, as such, may not need to be transferred to other aspects of life. Figure 3: Surprising Facts About Posture… ‘Sit Up Straight’: Time to Re-evaluate – Infographic [Slater et al. Journal of Orthopaedic & Sports Physical Therapy 2019;49(8):562– 564 (1)

4. How to Talk to Patients

Maybe a lot of this posture confusion has stemmed from the language we use. The iatrogenic (definition: relating to illness caused by medical examination or treatment) nature of LBP is a reminder of the clinician’s responsibility to be mindful of the language you use. Advice given by clinicians can lead to fear and

encourage hypervigilance (1). Examples may include: l ‘ Sit up straight’ In the absence of any good evidence that one posture exists to prevent pain, asking patients to work hard to achieve correct posture may set them up for a sense of failure and create more anxiety when their pain persists (1). l ‘ Sitting is bad for you’ Encouraging people to move and change position can be helpful. Sedentary lifestyles are a risk factor for LBP, among many other health conditions. Nevertheless, it is important for clinicians not to perpetuate worry that sitting down for more than 30 minutes in one position is dangerous or should always be avoided (1). l ‘ It’s caused by your swayback posture’ There is some resistance within healthcare to shift away from the biomedical model of pain. Consequently, pain is often ascribed to relatively ‘normal’ variations and asymmetries, despite the lack of strong evidence. Clinicians are urged to be cautious in their explanations to avoid further worry about posture ‘flaws’ (1).

Future Recommendations

There are challenges in reframing the idea of ‘correct’ posture. Science does not support the common posture and ‘core’ beliefs often held by clinicians, manual handling trainers, and society. Forty years ago, it was common practice to recommend bed rest for people with LBP. Persistent evidence-based education means that bed rest is no longer an appropriate recommendation (1). The spine is a robust, adaptable structure to be trusted. Discussions about spinal health and pain with colleagues, patients and pain-free members of the community should also include other evidence-based factors (such as the benefits about physical activity, stress, and sleep) and not focus solely on how you sit or stand. There is definitely merit in addressing postural issues; however, the time, focus and degree of importance you place on correcting it 28

should depend on the individual, their sporting and work demands as well as their psychosocial health. It may be more that the ‘posture narrative’ needs to be altered and not the patient. References

1. Slater D, Korakakis V, O’Sullivan P et al. “Sit up straight”: time to re-evaluate. Journal of Orthopaedic & Sports Physical Therapy 2019;49(8):562–564 2. Nolan D, O’Sullivan K, Stephenson J et al. How do manual handling advisors and physiotherapists construct their back beliefs, and do safe lifting posture beliefs influence them? Musculoskeletal Science & Practice 2019;39:101–106 3. O’Sullivan K, O’Keeffe M, O’Sullivan L et al. Perceptions of sitting posture among members of the community, both with and without non-specific chronic low back pain. Manual Therapy 2013;18:551–556 4. Korakakis V, O’Sullivan K, O’Sullivan PB et al. Physiotherapist perceptions of optimal sitting and standing posture. Musculoskeletal Science & Practice 2019;39:24–31 5. Kwon BK, Roffey DM, Bishop PB et al. Systematic review: occupational physical activity and low back pain. Occupational Medicine 2011;61:541–548 Open access https://spxj.nl/3bMwkk7 6. Geisser ME, Haig AJ, Wallbom AS et al. Pain-related fear, lumbar flexion, and dynamic EMG among persons with chronic musculoskeletal low back pain. Clinical Journal of Pain 2004;20:61–69 7. Gilman SL. Stand up straight! A history of posture. Reaktion Books 2018. ISBN 9781780239248. Buy from Amazon (Kindle £19.94 Print £20.99) https://amzn.to/2TKZcCc 8. Korakakis V, Giakas G, Sideris V et al. Repeated end range spinal movement while seated abolishes the proprioceptive deficit induced by prolonged flexed sitting posture. A study assessing the statistical and clinical significance of spinal position sense. Musculoskeletal Science & Practice 2017;31:9–20 9. O’Sullivan PB, Caneiro JP, O’Keeffe M et al. Cognitive functional therapy: an integrated behavioral approach for the targeted management of disabling low back pain. Physical Therapy 2018;98:408– 423 Open access https://spxj.nl/3bPh6Lh 10. Ludwig O, Kelm J, Hammes A et al. Targeted athletic training improves the neuromuscular performance in terms of body posture from adolescence to adulthood - long-term study over 6 years. Frontiers in Physiology 2018;9:1620 Open access https://spxj.nl/3bJTuHM 11. Murta BAJ, Santos TRT, Araujo PA et al. Influence of reducing anterior pelvic tilt on shoulder posture and the electromyographic activity of scapular upward rotators.

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Brazilian Journal of Physical Therapy 2019;pii:S1413-3555(18)30393-9 12. Suzuki Y, Muraki T, Sekiguchi Y et al. Influence of thoracic posture on scapulothoracic and glenohumeral motions during eccentric shoulder external rotation. Gait & Posture 2019;67:207–212 13. Joshi S, Balthillaya G, Neelapala YVR. Thoracic posture and mobility in mechanical neck pain population: a review of the literature. Asian Spine Journal 2019;13(5):849–860 Open access https://spxj.nl/324lNwd 14. Lynch SS, Thigpen CA, Mihalik JP et al. The effects of an exercise intervention on forward head and rounded shoulder postures in elite swimmers. British Journal of Sports Medicine 2010;44:376–381 15. Migliarese S, White E. Review of forward-head posture and vestibular deficits in older adults. Current Geriatrics Reports 2019;8(3):194–201 16. Jang HJ, Hughes LC, Oh DW et al. Effects of corrective exercise for thoracic hyperkyphosis on posture, balance, and well-being in older women. A double-blind, group-matched design. Journal of Geriatric Physical Therapy 2019;42(3):E17–E27 17. Dankaerts W, O’Sullivan P, Burnett A. Discriminating healthy controls and two clinical subgroups of nonspecific chronic low back pain patients using trunk muscle

activation and lumbosacral kinematics of postures and movements: a statistical classification model. Spine 2009;34:1610– 1618 18. Ghamkhar L, Kahlaee AH. Is forward head posture relevant to cervical muscles performance and neck pain? A case–control study. Brazilian Journal of Physical Therapy 2019;23(4):346–354 Open access https://spxj.nl/37CaNao 19. Pavlova AV, Meakin JR, Cooper K et al. Variation in lifting kinematics related to individual intrinsic lumbar curvature: an investigation in healthy adults. BMJ Open Sport & Exercise Medicine 2018;4:e000374 Open access https://spxj.nl/2SCVpX5) 20. Clark RA. Hamstring injuries: risk assessment and injury prevention. Annals of the Academy of Medicine, Singapore 2008;37:341–346 21. Thigpen CA, Padua DA, Michener LA et al. Head and shoulder posture affect scapular mechanics and muscle activity in overhead tasks. Journal of Electromyography and Kinesiology 2010;20(4):701–709 22. Sonvico L, Spencer SM, Fawcett L et al. Investigation of optimal lumbar spine posture during a simulated landing task in elite gymnasts. International Journal of Sports Physical Therapy 2019;14(1):65–73 Open access https://spxj.nl/2HzvzwT.

KEY POINTS

lT here may not be one correct posture for everyone. lT here is no strong definitive evidence showing a causal relationship between posture and back pain. lP hysiotherapists still believe in the importance of postural education in clinical practice. lA n upright, with slightly lordotic lumbar spine, in sitting or standing is the most optimal posture viewed by physiotherapists. lT he spine is stronger and more robust than you may believe and should be trusted – rather than focusing on overprotection and fear of hurting your spine. lT here are clinical studies showing the benefit of posture correction within certain population groups and joints. lC linicians may observe overly protective postures, levels of muscle tension, apprehension, vigilance, distress, mood, and body image that can provide insights into behavioural responses and how people make sense of their pain experience. lW atch your posture language; advice given by clinicians can lead to fear and encourage hypervigilance. lO ne posture doesn’t fit all. lT here is definitely merit in addressing postural issues; however, the time, focus and degree of importance you place on correcting it should depend on the individual, their sport and work demands as well as their psychosocial health.

RELATED CONTENT

lH ow to Unpick Postural Locks [Article] https://spxj.nl/2YyEdDx l Classification Systems: A Review of Low Back Pain Care [Article] http://spxj.nl/2BSZKKn

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DISCUSSIONS

l Do you feel generic posture campaigns directed at the public are beneficial or potentially harmful? l What are your goals when assessing and managing postural issues, do you have an optimal posture? l Will you continue to place value, emphasis and focus on posture now, knowing the scientific evidence behind its clinical relevance is weak?

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Tweet this: Science does not support the common posture and ‘core’ beliefs often held by clinicians and society. https://spxj.nl/2TPYDXX Tweet this: There is no strong evidence that avoiding incorrect posture prevents low back pain. https://spxj.nl/2TPYDXX Tweet this: Many individuals with pain may benefit from posture correction. https://spxj.nl/2TPYDXX Tweet this: Observing the posture of a person presenting with musculoskeletal pain has a role in assessment. https://spxj.nl/2TPYDXX Tweet this: Helping people to adopt more relaxed postures can provide symptom relief. https://spxj.nl/2TPYDXX 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 29

istorically, massage has MASSAGE mistakenly been viewed as a THERAPY | contraindication for individuals 20-04-COKINETIC who are currently undergoing treatment FORMATS WEB MOBILE PRINT for, or who have a history of, cancer. Cancer is a broad term used to All references describe a set of diseases characterised marked with an by cell mutation and uncontrolled asterisk are open division of cells in the body that often access and links are provided in the spread to surrounding tissue, forming tumours. Traditionally, it was believed reference list that massage could exacerbate a plethora of illnesses and that massage therapists would even potentially expose themselves to contracting illnesses while spreading it around the body via soft tissue therapy. With advancements in science and a more comprehensive understanding of how the body works, we now know these myths to be just that, myths. However, with some of these misconceptions so ingrained within our society it will take both patience on our part and unequivocal proof in order to dispel these falsehoods. Cancer is not a new disease; archaeological studies have even found it prevalent in the autopsies of dinosaurs. Nevertheless, it has become so pervasive in our society today that, according to the statistics, 1 in 2 people will develop cancer at some point in their lives; some preventable through healthy living, others not. With varying survival rates ranging from 5% (in sufferers of lung cancer) to 78% (in breast cancer) (1*), there are myriad factors that can affect an individual’s chance of developing cancer and surviving it. In this article, we will look at the implications of exercise in the development of cancer and how oncological massage has been attributed to greatly improved recovery post-treatment, along with a better quality of life.

Societal Misconceptions Surrounding Athletes

Athletes have long been considered the epitome of health by society; however, recent research has suggested that such perceptions are, in fact, false. Athletes face fairly high health risks both competing and training. A compromised immune system coupled with the great strain that professional sport places on the body have been linked to a greater probability of athletes developing recurrent infections during periods of intense training and competition. In order to examine why athletes may be at a greater risk of developing cancer and how massage can benefit individuals throughout recovery, we must first, briefly define two notable factors that influence damaged cell growth: inflammation and stress. One definition explains inflammation as a localised physical condition in which part of the body becomes reddened, swollen, hot and painful, as a direct reaction to injury or infection. However, there are also other forms of inflammation that arise from lifestyle choices such as diet, smoking and drugs. Stress, often recognised as a factor that could contribute to increased cancer risk, is defined by physiological disturbance or damage caused to an organism by adverse circumstances, such as the previously mentioned lifestyle choices. Stress is often cited as a significant contributing factor to the development of inflammation. Stress, and the production of serum cortisol, provide prime conditions for mutated cell division and damaged growth. Sheldon Cohen, a professor at Carnegie Mellon University, says, “stressed people’s immune cells

ENDURANCE SPORTS HAVE BEEN PROVEN TO HAVE THE GREATEST NEGATIVE IMPACT ON AN ATHLETE’S IMMUNE SYSTEM 30

become less sensitive to cortisol. They are unable to regulate the inflammatory response when they’re exposed to a virus” (2*). It has also been seen that stress can result in a reduced immune response following vaccination. Hence, higher stress levels may mean that vaccination against cancer-causing viruses is less effective, leaving patients more vulnerable to cancers caused by those viruses (3*). The phrase ‘athlete and cancer’ feels like an oxymoron. What we see when we look at a strong, fit athlete would be the general interpretation of health. But, unfortunately, being fit is not the same as being healthy. Most people can immediately think of a number of famous athletes who developed cancer during their careers. There are a number of plausible theories about why athletes may develop cancer, including the demands put on them through incredibly intense and strenuous training regimes. In order for any professional athlete to compete to the best of their ability, they must constantly push their bodies to the max. This, in turn produces an inflammatory state within the connective tissue. Our connective tissue is considered to be the home of the immune system and long-term inflammation has been linked to cancer, providing conditions which allow the disease to thrive. Intense training schedules that can last 6–8 months put a gruelling strain on the body and athletes often put off waiting for a full recovery in order to continue their necessary training.

Endurance Sports and Cancer Endurance sports have been proven to have the greatest negative impact on an athlete’s immune system. Oxidative stress is a process the body goes through during long periods of exercise, producing an imbalance of highly reactive free radical molecules and antioxidants. These extended periods of training

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CANCER, EXERCISE AND MASSAGE

Endurance athletes, while being incredibly fit, are not necessarily very healthy. The demands placed on their bodies by intense and prolonged training regimes can leave them with high levels of inflammation – something that is linked to immunosuppression and potentially an increased risk of cancer. This article describes how massage can be used to reduce inflammation levels in athletes, helping perhaps to reduce their risk of cancer, as well as in patients with cancer to improve their well-being through the course of their disease and its treatment. Read this article online https://spxj.nl/2wWMwz3 By Susan Findlay BSc RGN, Dip SMRT, MSMA, MCNHC, MLCSP, Director NLSSM bring with them increased free radical production and thus oxidative stress; placing a great strain on the immune system and causing an inflammatory response, and even in some cases immunosuppression – partial or complete suppression of the immune system (4). This allows higher levels of free radicals to react with other cells in the body causing mutation and division of cells, a symptom characteristic of cancer (5). The progressive build-up in training intensity, coupled with a lack of rest, leave athletes’ immune systems extremely depleted and vulnerable.

Inflammation, Cancer and Massage

Serious inflammation has been linked to a range of chronic diseases including diabetes, heart disease and cancer. Among professional athletes, the main sports noted as significantly contributing to an increased risk of cancer are endurance swimming, cycling and running. Chronic phases of inflammation are hypothesised to increase the risk of cancers developing by facilitating the degradation of healthy cell growth, in turn creating prime conditions for damaged cellular growth to continue and heighten the Co-Kinetic.com

risk of tumour development (6*). The repetitive muscle movements in cycling, running and swimming cause inflammation to the soft tissue around the joints, making recovery an essential component of the training schedule. In their 2004 study on the effect of selected recovery conditions on performance of repeated bouts of intermittent cycling separated by 24 hours, Lane and Wenger reported that massage was the most effective recovery method, in combination with active rest, as it allowed an athlete’s body to recover for the next training session (7). As well as causing a lot of inflammation to the soft tissue around the joints, the sports that put the greatest strain on the immune system are also endurance cycling, swimming and running (5). In relation to the impact of inflammation on the body, Helene Langevin, a prominent researcher in the use of complementary medicine, completed a study with her

colleagues, looking at the effects of how stretching impacts inflammation resolution in connective tissue (8*). In her work she explains that cancer is not just a collection of tumour cells growing out of control, but rather that primarily these cells need a base in which the cancer can spread. She describes the base like railway tracks of dense connective tissue that allow the cancer to grow undisturbed and then use these tissue tracks to travel along. Therapists often refer to these areas as ‘tension’ or ‘adhesions’, but in reality they are areas where there is poor movement and persistent inflammation. Langevin also discusses the enthusiasm of massage therapists to make a change in the ‘length’ of the tissue, in order to make it more pliable, flexible and attempt to return it to a more normal length. A common consequence of this approach, however, is that the treatment used is often administered with too much

ONCOLOGY MASSAGE THERAPY CAN HELP TO ALLEVIATE POTENTIAL SIDE EFFECTS FROM CANCER TREATMENT 31

MASSAGE CAN DECREASE INFLAMMATION AFTER LONG PERIODS OF PHYSICAL ACTIVITY AND ALSO DECREASE RECOVERY TIME BETWEEN WORKOUTS aggression – resulting in the fibroblasts reacting in such a way that more inflammation is actually caused, rather than moving the tissue into a state of healing (8*). In a study conducted by McMaster University, Toronto, Canada, researchers found that massage after prolonged periods of physical activity stimulated production of mitochondria and reduced inflammation. In addition to this, the university also found that massage between workouts and athletic events decreased recovery time; highlighting the importance of massage in aiding recovery (9*).

Massage Within Medical Discourse and the Development of Oncology Massage Therapy

Massage is a medicinal practice that has been observed for nearly 5,000 years and was first noted in Ancient China, at around 2,700 BCE. It would take around 4,550 years for the word massage, to make its way into modern medical discourse in the US. However, today, the practice is as widespread as it has ever been. Defined as the manipulation of soft tissue of the body, massage has been linked to reduced inflammation, a reduction in cortisol levels and improved circulation among its users. Yet, over the last 20 years one specialisation within the massage therapy discipline has seen its prevalence in post-treatment cancer programmes increase significantly. Oncology massage therapy (OMT) uses conventional massage techniques and applies a tailored approach to individuals suffering from cancer. Unlike regular massage therapy, OMT places a heavy stress on the client’s needs and is a complimentary therapy that works in tandem with conventional medicine; helping to alleviate potential side effects that may develop from cancer treatment, it provides clients with a greater sense of 32

mental wellbeing which improves their quality of life. The practice ensures that therapists are able to modify massage techniques on an ad hoc basis, and are engaging with the client at all times in order to meet their physical needs. Recent studies have yielded positive results; one US study of 39 patients suffering from cancer of the blood found an overall decrease in the production of serum cortisol – a stress hormone. The study randomised patients that were to receive either aromatherapy, massage or told to rest. They found that massage significantly decreased stress hormone levels in patients suffering from cancer of the blood, highlighting the importance of massage in recovery after cancer treatment (10). Widely cited as most effective in relieving symptoms of cancer, OMT in recent years has been used primarily to tackle what is commonly known as the Big Five: pain, fatigue, nausea, depression and anxiety. In one of the largest studies to date, the Memorial Sloan-Kettering Cancer Centre in New York interviewed 1,300 patients receiving either a 20- or 60-minute massage therapy session following treatment. While conducting the study, staff at the centre noted an improvement in all of the ‘Big Five’ among the patients. Results showed a 47% improvement in pain levels, 42% improvement in fatigue, 59% improvement of anxiety levels, and 48% in depression levels (11*). Findings of the study found that prolonged massage time provided longer lasting relief for patients while showing significant improvement among all five of the ‘Big Five’ – highlighting the importance of conventional medicine working alongside complimentary therapies. OMT’s holistic approach towards clients equips therapists with the skills to adapt massage techniques in real time, including speed, duration

and depth of massage. By taking a holistic approach to massage, OMT training ensures that therapists are able to adapt moment by moment to what they observe while working with clients. In doing so, students learn to pull information together and organise it, resulting in better decision-making and communication skills to offer a more effective session. In terms of working with athletes, this approach emphasises recovery from treatment, as well as recovery from training. Studies have shown that clients undergoing treatment have reduced levels of side effects from cancer treatment, such as chemotherapy and radiotherapy. Therapists are also able to create a comfortable environment, for both themselves and the client, that promotes communication and a clear dialogue that enriches the therapists’ ability to tailor the massage. ‘Less is more’ and ‘inch forward’ are values that are instilled from the onset of training and underpin OMT. This tailored approach is what allows oncology massage therapists to work effectively in conjunction with conventional medicine and produce some of the aforementioned results in this article.

Summary

Contrary to societal perception, athletes, although physically fit, actually suffer from a suppressed immune system, which in some instances mirrors that of degenerative diseases such as HIV and cancer. As touched upon earlier, this suppression of the immune system during heavy training and competition, places them at a great risk of contracting recurrent infections and could lead to the development of more serious conditions. As we can see from the evidence provided above, athletes in a number of disciplines run an enormous risk of contracting illness, owing to their heavy training schedules suppressing the immune system and making them more vulnerable to infection. We can even go as far as to say that prolonged endurance exercise (such as that undertaken by elite athletes) can increase inflammation in the body, and that inflammation can contribute to the Co-Kinetic Journal 2020;84(April):30-33

MANUAL THERAPY

development of cancer; hence there is the potential for endurance athletes to be at a higher risk of cancer than the general population. As outlined in this article, the importance of massage is evident, not only to aid recovery from the extreme stress an athlete’s training schedule imposes, but also to prevent inflammation that can lead to cancer, and improve physical and mental wellbeing. References

1. Data and statistics. Cancer Research UK [Website] Open access https://spxj.nl/3a4ilEp 2. Sifferlin A. Why stress makes it harder to kick the common cold. Time 2012 Open access https://spxj.nl/2vhwXBK 3. Kress R. Stress, inflammation, immunity. RN.com (AMN Healthcare Education Services) 2018 [Website] Open access https://spxj.nl/2PrJlpI

4. Elkington LJ, Gleeson M, Pyne DB et al. Inflammation and immune function: can antioxidants help the endurance athlete. In: Lamprecht M (ed.) Antioxidants in Sport Nutrition. CRC Press 2014. ISBN 978-1466567573. (Print £85 Kindle £41.99) Buy from Amazon https://amzn.to/2TN8CNv 5. McTiernan A. Mechanisms linking physical activity with cancer. Nature Reviews. Cancer 2008;8(3):205–211 6. Brown JC, Winters-Stone K, Lee A et al. Cancer, physical activity, and exercise. Comprehensive Physiology 2012;2(4):2775–2809 Open access https://spxj.nl/3a7oRuh 7. Lane KN, Wenger HA. Effect of selected recovery conditions on performance of repeated bouts of intermittent cycling separated by 24 hours. Journal of Strength and Conditioning Research 2004;18:855–860 8. Berrueta L, Muskaj I, Olenich S et al. Stretching impacts inflammation resolution in connective tissue. Journal of Cellular Physiology 2016;231(7):1621–1627 Open

KEY POINTS

lT he statistics are that one in two people will develop cancer during their lives. l A healthy diet and lifestyle can reduce your cancer risk. lA thletes, particularly in endurance sports, can be fit but not necessarily healthy. lH eavy training and competing loads, coupled with insufficient recovery time, can result in a compromised immune system. lP rolonged periods of training can increase oxidative stress, increasing the inflammatory response, which has been linked to chronic diseases such as diabetes, heart disease and might contribute to an increased cancer risk. lR esearchers found that massage after prolonged periods of physical activity stimulated production of mitochondria and reduced inflammation. lR esearch has shown that levels of the ‘Big Five’ side effects of cancer and its treatment can be reduced with massage therapy. lO ncology massage therapists are trained to work carefully with their clients to tailor their practice to the client’s needs in real time. THE AUTHOR Susan Findlay BSc RGN, Dip SMRT, MSMA, MCNHC, MLCSP, Director NLSSM, is director of the North London School of Sports Massage, where she is a sport and remedial massage therapist and lecturer. Susan’s experiences as a ballet dancer, gymnast, personal trainer, and nurse have allowed her to develop both an applied and a clinical understanding of human movement, physical activity, anatomy, and physiology. Susan is the co-founder of the Institute of Sport and Remedial Massage. She also serves as chair of communications on the General Council of Massage Therapies and as an educational advisor to the Sport Massage Association. In her free time, Findlay enjoys motorbiking, cycling, and yoga. Email: info@susanfindlay.co.uk Twitter: https://twitter.com/susanfindlaystt LinkedIn: https://www.linkedin.com/in/susanatnlssm/ Facebook: https://www.facebook.com/SusanFindlayUK Website: https://www.susanfindlay.co.uk/ Co-Kinetic.com

access https://spxj.nl/3a8I1jc 9. Crane J. Massage is promising for muscle recovery: McMaster researchers find 10 minutes reduces inflammation. McMaster University 2012 [Website] Open access https://spxj.nl/2TbG2E8. Full paper: Crane JD, Ogborn DI, Cupido C et al. Massage therapy attenuates inflammatory signaling after exercise-induced muscle damage. Science Translational Medicine 2012;4(119):119ra13 10. Stringer J, Swindell R, Dennis M et al. Massage in Patients undergoing intensive chemotherapy reduces serum cortisol and prolactin. Psycho-Oncology 2008;10:1024–1031 11. Cassileth BR, Vickers AJ. Massage therapy for symptom control: outcome study at a major cancer centre. Journal of Pain and Symptom Management 2004;28(3):244–249 Open access https://spxj.nl/382QCT8.

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l I s Massage an Effective Sports Recovery Strategy? [Article] http://spxj.nl/2s7halA lM assage for Tendon Pain [Article] https://spxj.nl/2xHIquV l Patient Information Leaflet: The Benefits of Massage [Printable leaflet] http://spxj.nl/2mXhrpL l Other articles written by the same author https://spxj.nl/2VxW12d

DISCUSSIONS

l Athletes are ‘fit’ but are they ‘healthy’? Discuss what these terms mean to you. l Think about how you would assess an athlete to see if their training regime might be putting their health at risk. l If you were performing oncology massage therapy would there be any additional considerations or contraindications that you would bear in mind?

Introduction

FASCIA | SURGERY | 20-04-COKINETIC FORMATS WEB MOBILE PRINT 34

Wound healing is a complex process, involving not just skin and muscle but also blood vessel, nerves and fascia. The effect of wound healing on fascia and the biotensegrity of the body is discussed in more detail in other chapters of the book, Scars, Adhesions and the Biotensegral Body, and is very briefly summarised here as it is important to bear these ideas in mind when learning about ScarWork. In almost everyone except the very young, scars form as the result of the body repairing itself following a wound. Wound healing happens in four phases: bleeding, inflammation, cell proliferation and remodelling, and the resulting scar tissue is not quite the same as the original tissue as it arises from repair rather than regeneration. If the wound is a small surface wound, the scar will be small and eventually fade to be (virtually) imperceptible, but which can nevertheless have consequences on the surrounding tissue. However, the deeper the wound, such as from surgery or severe accident, the more underlying tissue there is to heal. As we now know, fascia is one of these underlying tissues that is of huge importance â&#x20AC;&#x201C; allowing body-wide tensional force transmission and free movement. If, in the healing of a wound, the fascia becomes stuck together in an adhesion, proper force transmission through and free movement of the fascia becomes restricted, an effect that can be translated through the body causing malalignment and/or movement restriction at distal as well as local sites. Sharon Wheeler is a Structural Integration practitioner who originally trained with Dr Ida P. Rolf, the founder of Rolfing. Sharon started developing ScarWork more than 45 years ago and it is her own, original work after she found that gentle manual manipulation of scar tissue gave amazing results in reducing the effect of restrictions. So far there has been little research, yet ScarWork is being taught and practised worldwide due to its tangible results. Here, Sharon discusses her own approach to scars.

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The Beginning

SCARWORK:

A DIFFERENT APPROACH TO WORKING WITH SCARS By Sharon Wheeler

Almost all adults will have a scar of some sort somewhere on their body. Reading this article will give you an insight into how to decide if your patient’s scar is contributing to their symptoms and how to work with the tissue to allow the return of proper alignment, free movement and more normal looking skin. As the author says, “If I can get the scar unstuck the tissue ‘goes home’.” This article has been extracted from chapter 9 of the book Scars, Adhesions and the Biotensegral Body by Jan Trewartha and Sharon Wheeler. Read this article online https://spxj.nl/3aR1Ko8 of trouble in establishing any kind of knee movement at all. This impressive scar with its adhesions seemed to be the problem. I wondered if something good might happen if I could soften up the scar a little. I had no idea what to do so I allowed my hands to work by feel. I took what I knew about changing tissue from the perspective of Structural Integration and applied it to the scar on a micro-level. Joan was quite comfortable with what I was doing, so we started a conversation about the movies showing at the town’s cinema. We discovered that we shared an appreciation for the wit and talent of Marilyn Monroe. For about 20 minutes I worked on the bottom half of the scar. When I stopped to see if I was making any progress, I was surprised to see that the square gap was gone, the edges were together, and the ripples on the sides of the scar were smooth and supple. Joan reported good sensory nerve function. The colour of the scar matched the rest of her. The surface of the skin had normal polyhedral lines

with a matte finish and what looked like fine fuzzy hair. I asked Joan to sit up and take a look at her scar. She looked it over, touching and feeling it, then said, ‘I didn’t know you could do that.’ I replied, ‘Me neither.’ When I started to work again, I realised that I did not remember a single thing that I had done. So I restarted our conversation about Marilyn and the movies, and did my best to let my fingers fly, hoping I would find my way back to what I had been doing previously. Somehow this strategy succeeded. As I worked, I took a little peek now and again. I was able to match up the top half with the bottom half and know what I had done. It felt like normal tissue. Neither of us could find any irregularities left in the texture of the scar. With the scar out of the way, I found the fibula and got it unstuck. This allowed Joan’s

SCARWORK DOES NOT AFFECT NORMAL TISSUE 35

Before Skin to scar: 1.79 cm

Before Skin to scar: 1.79cm

(a)

After Skin to scar: 2.74 cm

After Skin to scar: 2.74cm

(b)

Skin to scar distance hascm increased byto0.95cm after ScarWork treatment A 0.95 increase skin scar after ScarWork (a) Ultrasound of the scar on 6 January 2012 before ScarWork treatment on 21 January 2012, showing the distance of the skin to the scar as 1.79cm. (b) Ultrasound of the tissue on 26 February 2012 after ScarWork, showing the distance of the skin to scar as 2.74cm – an increase of 0.95 cm. Figure 1: Subject 1: ultrasound images of the abdominal scar before and after ScarWork Before

Fascial‘bleb’ “bleb” atatclosure Before Fascial closure

(a)

After

Fascial “bleb” After Fascial ‘bleb’is integrated is integrated

(b)

Restoration of normal fascial layers of tension to abdomen Restoration of normal fascial layers of tension to abdomen (a) Ultrasound of the scar on 6 January 2012 before ScarWork treatment on 21 January 2012, showing the distance of the skin to the scar as 1.79cm. (b) Ultrasound of the tissue on 26 February 2012 after ScarWork, showing the distance of the skin to scar as 2.74cm – an increase of 0.95 cm. Figure 2: Subject 1: longitudinal view ultrasound images before and after ScarWork Before

scar:<1cm < 1 cm Before SkinSkin to to scar:

(a)

After

scar:2.25cm 2.25 cm After SkinSkin to toscar:

(b)

Skin to scar distance has increased by 1.25cm after ScarWork A difference of 1.25 cm increase skin to scar after ScarWork Restoration of normal fascial layers tension to abdomen Restoration of normal fascialoflayers of tension to abdomen (a) Ultrasound of the scar on 1 July 2012 before ScarWork treatment on 16 July 2012, showing the distance of the skin to the scar as <1cm. (b) Ultrasound of the tissue on 3 August 2012 after ScarWork, showing the distance of the skin to scar as 2.25cm – an increase of 1.25 cm – and the re-establishment of normal abdominal tensional fascial layers. Figure 3: Subject 2: lateral ultrasound images of the scar before and after ScarWork. Restoration of normal fascial layers of tension to abdomen

knee to bend most of the way and she could walk and sit without pain. Joan was able to stop taking all of her medications. Her scar has stayed good to this day. I hope Joan is pleased to be remembered as the beginning of ScarWork. I incorrectly assumed that I had figured out what everyone else already knew. I saw a sign advertising massage on scar tissue in Carmel, and I remember wishing that I had taken that class. I gave myself a small, congratulatory pat on the back for finding out how to work on scars all by myself and carried on without saying much about it to anyone. My clients allowed me to explore their scars and I became fascinated. This was very different work from the depth and power of Structural Integration, which I dearly love. The profound results of this light, easy, happy and painless work are a mystery to me. Eventually, the word got out that I did ‘things that worked for scars’. Some of my colleagues asked for advice so I published an article called ‘On Scar Tissue’ (1). I was hoping to exchange information with my colleagues. I did not get any new information back, but I did receive requests to run classes. I reframed my publication as a ScarWork manual and designed a workshop format to reflect the spirit of the work. Teaching pushed me to develop ways to communicate the content. I had to unpack the elements of each of the different techniques for my students and identify and clarify some basic principles. I started teaching with 12 techniques; today there are over 30. Periodically, I edit the ScarWork manual to reflect ongoing growth and development. Each class I teach is a flood tide of new experiences and information. I get to work on all of the students and all of the class models who volunteer from the local community for free work on their scars. Classes are a total immersion in the subject of scars, and this leads to innovation. For me, classes are like Christmas!

Preliminary Research

Communicating with medical people requires science and science requires numbers. Medical imaging can provide Co-Kinetic Journal 2020;84(April):34-41

MANUAL THERAPY

some acceptable measurements to generate the numbers necessary for science. I am fortunate to have encountered some excellent researchers. It looks like we will shortly have the opportunity to start a scientific inquiry. I have some preliminary research to share, consisting of a set of three ultrasound images, which were presented at the Fascia Research Congress in Washington DC in 2015 (2). Kristi Blessitt, MD, a gynaecological surgeon, took the images and interpreted them. My colleague, Richard Ennis, BS, did the scientific writing, and I did the ScarWork. A Mindray DC-6 Doppler Ultrasound machine (2.5-6.0 MHz) was used for all of the imaging. Images were taken before and after a single, 1-hour long session of ScarWork.

Subject Number 1

The first subject was a 66-year-old woman with a single 43-year-old midline abdominal scar. She had been in a car accident and the front of her body had impacted on the steering wheel. She was losing blood pressure and her doctors performed emergency exploratory surgery, repairing several sites of internal bleeding. She still experienced pain and could feel a strong pull from her scar, especially when she stretched her hands above her head. After ScarWork, her abdomen was smooth and soft. She was pain free with no pulling (Fig. 1). The longitudinal view (Fig. 2) shows the restoration of all the normal abdominal tensional lines of force including Camperâ&#x20AC;&#x2122;s and Scarpaâ&#x20AC;&#x2122;s fascia.

Subject Number 2

The second subject was a 58-year-old woman with three surgeries: a 22-yearold ileo-anal anastomosis, a second ileo-anal anastomosis of 20 years, and a 15-year-old caesarean section (C-section) (Fig. 3).

Control

Dr Blessitt wanted to see what ScarWork would do to normal tissue. After ScarWork, the skin to scar distance only increased by 0.1cm. This number was not sufficiently large to be considered statistically significant, which suggests that ScarWork does not affect normal tissue (Fig. 5).

ScarWork Orientation

ScarWork is a tactile art form. The goal is smooth tissue. The work is performed primarily through the sense of touch, although vision does play a part. I only use my hands to do the work. I do my best to follow the tensional vectors by feel as my hands seem to sense and know the most about tactile matters. I work with the intention of putting the scar back together, reversing the damage, mending the tissue, and reassembling any misaligned, surgically created layers. I counter every tensional vector in the fascia head-on, directly, with just enough pressure to free a tiny bit of scar tissue. These small, nearly undetectable changes Before

BeforeTubal Tubal pregnancy pregnancy scar at scar arrowat arrow

THE RETURN OF IMPAIRED FUNCTIONS APPEARS AS A BYPRODUCT OF SMOOTHING THE WHOLE SCAR accumulate quickly into noticeable results. I have observed most impaired functions re-establish themselves with ScarWork. These improvements are fortuitous, unintended, and a source of great delight. They are so common that I use them as indicators of how well a session is going. I have noticed that these functions return during the time of the session and then continue to improve markedly over time. Sensory nerve function and sometimes motor nerve function returns. Internal organs function better. Lymphatic and blood circulation improve. Tissue strength and flexibility improve. The individual techniques do not reliably produce one particular functional result. The return of impaired functions appears as a byAfter

AfterTubal Tubal pregnancy scar released pregnancy scar released

Figure 4: Subject 3: ultrasound images of the tubal pregnancy scar before and after ScarWork Before

Skin fascia 1.8 cm Before Skin totofascia: 1.8cm

After

fascia 1.9 cm After SkinSkin totofascia: 1.9cm

Subject Number 3

The third subject had three abdominal surgeries: a 30-year-old left sided tubal pregnancy that had ruptured, a 27-year-old C-section, and a 12-yearold hysterectomy (Fig. 4).

Co-Kinetic.com

Figure 5: Subject 3: ultrasound images control and after ScarWork Normal tissue is notof shown to betissue affectedbefore by ScarWork

FOR ABOUT 20 MINUTES I WORKED ON THE BOTTOM HALF OF THE SCAR. WHEN I STOPPED …THE RIPPLES ON THE SIDES OF THE SCAR WERE SMOOTH AND SUPPLE product of smoothing the whole scar. When the scar tissue feels like normal tissue it starts to function like normal tissue. Therefore, possibly the form of the tissue has something to do with its function. I have respect and a high regard for scars. They consist of precisely the right stuff needed for remediation. They are a treasure trove composed of good tissue that is stuck together all ‘cattywampus’, to use one of Dr Rolf’s favourite words. Every single scar is unique. Cross typing and matching scars and techniques looking for shortcuts does not work as well as hoped. An appendix or C-section scar does not always receive the same techniques or the same sequence of techniques. Natural scars from an accident or injury are all one of a kind. There are so many variables in a fall down the stairs or a car accident that it is easy to understand each natural scar being different from any other. Surgical scars are also one of a kind. The way a surgical procedure is performed depends on who the surgeon studied with, at which hospital, and during which years. Another source of variation in scars is the healing. An infection may alter the surgeon’s good work and produce many more adhesions. 38

Stitches may tear out, metal plates and pins are put in and taken out, and a surgical procedure may require several revisions. Scars can get complicated. ScarWork can be used with people of any age. Because it is painless, even babies usually tolerate it with a smile. Some of my colleagues have used ScarWork with animals and have reported success. It does not appear to matter how old a scar is. Mature scars of many years are easy to work on with excellent resolution. ScarWork seems to work for most scars. To date, keloids are the one exception. The scar is not merely a mark on the skin, it is connected from the surface of the skin down into the farthest reaches the surgeon explored, including the fluid pools. While the surgeons are in there to remove an appendix, they may decide to take a look at the gallbladder. The scar develops fascial adhesions to all of these places. The entire scar is an irregular, three-dimensional form with odd asymmetric appendages. Keyhole or laparoscopic procedures are popular for many kinds of surgeries. Patients like them because of the small surface scars. However, if you include all of the tunnels the surgeon makes from the surface incisions to the area of interest,

then the amount of scarring is more extensive than a single incision directly over the area. The tunnels are not easy to find. The leakage of fluid from the severed tissues blurs the outline of the tunnel, making it feel amorphous. If you tug on the little surface scars, you will feel the tunnels. Use your other hand to feel for the connection and locate their direction. Scars feel different from the surrounding, undamaged, normal tissue. The texture is uneven. The textural quality may consist of lumps, holes and strings with stiff, dense areas. These elements have tensional vectors. I work to counter head-on each tensional vector with just enough pressure to win. The scar resolves in the reverse of the direction that created it. Using precision in countering these tensional vectors increases the speed and quantity of change. I experiment with pressure, using different angles, shear, rotation and velocity until I find something that changes the scar, and then I use repetition. When the change rate slows down, I look for a more productive way through the tissue. I take on what is the most obvious in the moment. I go to the worst, most dense places first as those are the easiest to find, and they will yield the most good. I cannot plan strategies and protocols in advance. Co-Kinetic Journal 2020;84(April):34-41

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ScarWork is a continuous tactile exploration into the unknown, similar to exploratory surgery in medicine. If I can get the scar tissue unstuck it ‘goes home’. In my experience, and as demonstrated by the ultrasound scans shown above, it does not end up randomly adhering to some other place where it does not belong, forming new adhesions and causing more trouble. If I cause pain by pressing too much or trying to go too fast, the tissue has a way of keeping me out. It feels like the threatened tissue locks arms with its neighbours and won’t let me in to help until I mind my manners. I try to work without causing any pain. I need feedback to avoid causing pain because there is no way to know if there is pain unless people tell you. If there is pain, I try adjusting my touch to be lighter or I change techniques. In hypersensitive situations, I move far away from the painful area to a place where the tissue is not painful and then work my way back towards the painful area. If the hypersensitivity resolves, I can work on the scar. If a scar is pain free and comfortable, I can allow my touch to become more casual and flowing. When the work feels really wonderful, I can allow for a bit of enthusiasm – which looks a lot like working with bread dough. I ask people to test their range of motion, feel the texture of their scar, and give me a report periodically. This informs me, allows them to track their progress, and gives them an opportunity to talk about their experience. Knowing their stories helps me make sense of the tensional vectors.

operation. l We advise not working on inserted mesh. Mesh used in breast reconstruction does not have the problems of abdominal/pelvic mesh and is safe for work. l For a client with a recent history of cancer, we recommend requesting a letter from their oncologist to confirm the client is safe for work. l We advise not working on pregnant women. l The scar should not be open, infected, inflamed, weeping fluids, or very painful. Tenderness is acceptable. l Do not work if there is redness or swelling around the scar due to radiation therapy. l Do not use abrasion on keloid or hypertrophic scars. l Do your best to work without causing your client pain.

Techniques

Starting to Work on Scars

All of the work is based on countering tensional vectors. Techniques are ways of working that I have identified as having a pattern. If that pattern works for many people, it becomes a technique. Some of the techniques are more general and all-purpose; others are specific for a particular tissue arrangement. The names given to the techniques reflect the playful quality of this work. Techniques are obviously best learned in a classroom where teachers help students calibrate the right kind and depth of touch. The full version of this chapter in the author’s book does, however, provide access to videos that support the following techniques for working with scars. The descriptions that follow are to give you an idea of what is involved with ScarWork.

Always work within the guidelines of your therapy profession, as defined by the professional body you are registered to in your country. The guidelines below are in addition to your standard considerations for treatment. l Before you work with a client, make sure they are signed off by their surgeon and are safe for work. This is normally 6–8 weeks post-

Feather Light Sweeping Use Feather Light Sweeping to start work on most scars. It provides an opportunity for an overall exploration of the extended area and it starts to soften the texture of the scar. When in doubt, go lighter. If you used a long flight feather, it would approximate the proper amount of pressure for sweeping. I use a single finger because it keeps

Cautions and Contraindications

Co-Kinetic.com

SCARWORK IS A TACTILE ART FORM. THE GOAL IS SMOOTH TISSUE my enthusiasm in check. More fingers can be used depending on the size of the scar and the angles you need to generate. This does much more than you would expect, so do not skip it to get to the other techniques. My sweeping finger is moving before making contact with the surface and moving as it breaks contact with the surface. There is a slight drag to the motion, much like petting a small mouse. Sweep towards the scar from all around and through the areas where there may have been swelling and bruising. Bracing or stabilising the tissue with my other hand yields more change at a faster rate. Bracing uses a light, resting, relaxed contact without stretching or pulling. The sweeping is performed from the bracing hand towards the scar. Go up to the scar but do not cross the midline of the scar. You do not want to pull the scar apart; you want to put it together. This technique may seem simple but do not underestimate it; giving plenty of time for sweeping will improve the resilience of the skin; it appears to work on the free nerve endings under the skin, and will generally improve the look and texture of the area. The Cat The Cat is particularly well suited for abdominal scars and adhesions. It is also useful in many other areas. Both relaxed hands sink into the tissue, resting the weight of your arms from your shoulders. Your whole hand stays in contact while gently pushing with a fluid rolling wave. This motion resembles the Hawaiian hula dance hand gesture for ‘ocean’. Alternate your hands and keep moving your contact around as you work. It does look a lot like kneading bread dough, and very much like a cat. It is easy, relaxed and casual. Work from both sides of the body for balance. It should feel wonderful for the client. 39

When you are not sure what to do, try The Cat. Scraping Use one hand for scraping and one for a brace. Partially curl your fingers and slowly and gently scrape through the tissue from the brace to towards the scar. Pick up your fingers and do this again in the same direction. Go up to the edge of the incision but not over the edge or down the centre of an incision. When surgeons make a minimal incision, they must stretch or retract the tissues wide open to create enough room to work in. It feels like some of the tissues get stuck in the retracted position. This leaves wrinkles under the surface. Scraping smooths and flattens wrinkles. I use the example of making a bed: if you miss pulling a blanket layer flat in the middle of the process, it leaves a wrinkle under the top layer. You can scrape that blanket layer smooth through the top layers rather than undoing everything to make the blankets lie flat and smooth. Matching Layers We refer to layers as artefacts created by surgery or damage. Matching Layers is a complex technique that has several elements to be considered. Adapt your hands to the constraints of the location, size and shape of the scar. Use both hands. For longer scars, make contact with the whole hand, using a flat contact. Your hands are a mirror image of each other with your index fingers parallel and one finger on each side of the scar. Push both hands down slightly to capture the two large sheets of tissue that form the two sides of the scar. Start working away from the edges of the scar and push your hands together to push up two rolls of tissue, one on either side of the scar. There is an optimum distance away from each scar and finding it requires a little experimentation. Push the rolls forward and back to the comfortable excursion limit of the skin to address any displacement in the plane that is horizontal to the body surface. Move along the entire scar as you work. Push 40

THE SCAR IS NOT MERELY A MARK ON THE SKIN, IT IS CONNECTED FROM THE SURFACE OF THE SKIN DOWN INTO THE FARTHEST REACHES THE SURGEON EXPLORED, INCLUDING THE FLUID POOLS the rolls up and down to address any displacement in the vertical plane. Along with the forward and back and up and down motions, tilt each of your hands into different angles or planes. Experiment with some wiggling as you push the two sides towards each other. This motion is similar to pushing two hairbrushes together to interdigitate the bristles. Down the Rabbit Hole This technique is used when a scope has been inserted into the body (during laparoscopy or arthroscopy), and also for drain sites or cannula insertions. The scope or drain being inserted and removed creates local trauma and tracking adhesions. With drains, there is simply a straight in and out sensation, but where a surgeon has been investigating, you will feel yourself being pulled into the different areas where that scope has already gone. This technique is based on intention as much as anything else, so keep your focus on your fingertip. Put your fingertip on the scar. In navel laparoscopy scars this is sometimes impossible, so just put your finger in the navel. Do not apply pressure. Just stay there, very lightly, and follow the tissue; you will usually

feel it moving under your finger. If there is anything to clear, you will feel the tissues drawing you in until it might feel as if your finger is fully inside the body. The client may also feel this as the intention and touch appears to transmit into the deeper fascia. When the movement eventually stops, you will feel as though you are being pushed out; that is the time to finish. Note: a laparoscopy may generate several scars, so go back and check them during later sessions until you no longer receive any response from them and they feel complete.

Final Words

This article is a glimpse of how very gentle touch can bring amazing results regarding scar tissue. Please see the book Scars, Adhesions and the Biotensegral Body for a deeper discussion and understanding of fascia, biotensegrity and how these are affected by scars and adhesions as well as more detail on how to assess and treat your client. References

1. Wheeler S. On scar tissue. Structural Integration 2008;36:26–30 2. Wheeler S, Blessitt K, Ennis R. Integrating scar tissue into the fascial web. Journal of Bodywork and Movement Therapies 2015;19(4):669–670.

KEY POINTS

l During wound healing, the fascia can become stuck together and the adhesion restricts proper force transmission through and free movement of the fascia. l Restriction of the fascia can cause malalignment and prevent free movement at distal as well as local sites in the body. l ScarWork is a very gentle manual therapy technique that aims to reverse the damage in the tissue. l ScarWork therapy should be pain free – good communication with and feedback from the patient is essential for this. l Understanding the history of the injury helps to make sense of the tensional vectors in the healed tissue. l No two scars are the same. l Manual therapy can help the physical restrictions and the emotional consequences of scars. l There are a number of cautions and contraindications for working with scars – be aware of them.

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Scars, Adhesions and the Biotensegral Body

Jan Trewartha and Sharon Wheeler (eds) Handspring Publishing 2020; ISBN 9781-912085-46-0 Buy it from Handspring https://www.handspringpublishing. com/product/scars-adhesions-and-thebiotensegral-body/ This highly illustrated book explains the effects of scars and adhesions on the body through the lens of biotensegrity, a concept that recognises the role of physical forces on their formation, structure and treatment. It includes contributions from specialists in the fields of fascial anatomy, biotensegrity, movement, surgery and other manual therapies. It takes a comprehensive approach to providing a better understanding of these complex issues and will be valuable to every hands-on practitioner. The text is supported with online videos demonstrating five ScarWork therapeutic techniques.

CONTENTS

Chapter 1: Introduction Joanne Avison Chapter 2: What lies beneath? Jan Trewartha with contribution from Niall Galloway Chapter 3: The adaptive body Jan Trewartha with contributions from Niall Galloway and Tracey Kiernan Chapter 4: Modeling the effect of scars and adhesions on the body Graham Scarr Chapter 5: The unreasonable effectiveness of light touch Leonid Blyum Chapter 6: A clinical anatomist’s experience of scars and adhesions in the cadaver John Sharkey Chapter 7: Scar tissue in movement Joanne Avison Chapter 8: Emotional aspects of scars Jan Trewartha with contribution from Katerina Steventon Chapter 9: A different approach to working with scars Sharon Wheeler with contribution from Wojciech Cackowski Chapter 10: Assessing and treating your client Jan Trewartha Chapter 11: Case studies Jan Trewartha

Co-Kinetic.com

RELATED CONTENT

lA ssessment of Fascial Dysfunction [Article] https://spxj.nl/35L1gNV l Connectivity: Fascia-Related Therapies [Article] http://spxj.nl/2h9ii4i l Biotensegrity’s Tipping Point - Has it Finally Arrived? New Concepts in Movement Science and Manual Therapies [Article] http://spxj.nl/2ExwjDN l Tensegrity and Biotensegrity: Will it Change Our Understanding of Human Anatomy? [Article] http://spxj.nl/2ExdOz9 THE AUTHOR Sharon Wheeler had an unconventional early schooling which gave her a taste for the unusual. She found a welcome home at Esalen Institute and taught Esalen’s Massage program in the sixties. Sharon was fortunate enough to study with Dr Ida Rolf, PhD, who trained her in Structural Integration in the summer of 1970. Further training in Rolf Movement and Advanced Structural Integration in the seventies consolidated her skills in this work. Her love of working with people and attempting the apparently impossible, combined with a particular skill in sensing disruptions to the body’s three-dimensional flow have combined to generate Sharon’s two ‘discoveries’: ScarWork and BoneWork. She teaches these new modalities in workshops around the world. She maintains a private practice in Structural Integration at home in Port Orchard, Washington, USA. Sharon’s society affiliations include: Guild for Structural Integration, Rolf Institute for Structural Integration, International Association for Structural Integration, Fascia Research Society, and NCBTMB workshop provider. Website: http://www.wheelerfascialwork.com/ Facebook: www.facebook.com/Sharon-Wheeler-Europeanworkshops-101645970267154/

DISCUSSIONS

l Think about what you know/remember about scar formation. How does it happen and how is scar tissue different from normal tissue? l Have you ever treated a patient with scarring and wondered if the scar was causing or contributing to their symptoms? How did the tissue around the scar feel? l Think about or discuss how you would decide if a scar or adhesions were causing a patient’s symptoms. How would you treat them?

Want to share on Twitter? Here are some suggestions

Tweet this: The intention of ScarWork is to reassemble any misaligned, surgically created layers of tissue https://spxj.nl/3aR1Ko8 Tweet this: The small, nearly undetectable changes from ScarWork accumulate quickly into noticeable results https://spxj.nl/3aR1Ko8 Tweet this: Scars feel different from the surrounding, undamaged, normal tissue hhttps://spxj.nl/3aR1Ko8 41

HOW TO HELP YOUR PHYSICAL THERAPY BUSINESS SURVIVE CORONAVIRUS And Build New (and Ongoing) Streams of Revenue

t the time of writing, the UK stock market has just gone into free-fall, plummeting nearly 8% in a single day based on concerns about Covid-19, and the World Health Organisation has finally declared it a pandemic. All of which led me to post a poll on my Business Success for Physical Therapists Facebook group asking how people felt about the impact of Covid-19 on their businesses. Here are the results: reported they were “mildly concerned”

BY TOR DAVIES, CO-KINETIC FOUNDER AND FORMER PHYSIOTHERAPIST

While we’re all sick of hearing about coronavirus, the reality is that this is likely to lead to a dramatic number of cancellations and possibly clinic closure. This article is a highly practical guide containing a range of strategies you can employ to mitigate the effect of this drop in appointments on your business and your cashflow. In fact, you may also find some revenue-generation ideas which will help you to strengthen and grow your business going forward. Read this article online https://spxj.nl/2WbKaXS

7.5% of people rated themselves “very concerned” (sensible people) BUT of people were “not concerned at all” (not sensible people!) While I appreciate there’s been a lot of scaremongering and hysteria, and while I’d love to say there’s no need for concern, we also have to be realistic and I can’t actually think of a single business out there (unless it specialises in hand sanitisers or bizarrely as it transpires, loo roll, pasta or rice) that is likely to come out completely unscathed, while this virus wreaks

THERE ARE A WHOLE HOST OF THINGS WE CAN DO TO HELP OUR BUSINESSES AND USE OUR TIME WELL 42

havoc on the world. Inevitably, it will signal the death knell for some small businesses, particularly those that are vulnerable, don’t have a robust marketing foundations and/or don’t have a financial buffer to fall back on. At this point, my main hope is that we manage to avoid a global recession. What we have to realistically expect, is that most of us will face a dramatic change to our businesses as we know them as people attempt to protect themselves from exposure and employ a range of social-isolation measures. But despite these challenges, it doesn’t mean we have to sit there passively, waiting for the axe to drop, there are in fact a whole host of things we can do to help our businesses and use our time well. In this article, I’m going to outline some practical ideas and strategies that you can employ to try and mitigate the impact these inevitable appointment cancellations will have on your business and your cashflow. The added benefit

is that the changes you make now, will also help you build a stronger business for the future.

The Importance of Adapting for Survival

Anyone who reads my content regularly will know that I often use the phrase “adapt or die”, usually in reference to a business’s ability to do just that when it faces a challenge or threat. Put bluntly, businesses that can’t adapt to new threats, be they temporary ones like life-threatening viruses, or permanent ones like a competitor moving in down the road from you, will inevitably, eventually die. Businesses that can and do adapt, or pivot into a new position in response to the threat, even if that pivot is temporary, will thrive and become much stronger, not just now, but also in the future. The lengths you need to go to achieve this ‘pivot’, will depend on Co-Kinetic Journal 2020;84(April):42-50

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how severely the loss of what might be a significant proportion of your appointments over the coming weeks and months, will be to you, and the people who depend on you. Part of the problem is that we don’t know how long this situation will go on for, but hopefully it will peak and begin to recline in a few weeks (maybe it already is, by the time you’re reading this). If you can sustain this loss without it compromising you or your family, then you’re in an enviable position. That said, it’s still a perfect opportunity to grow and strengthen your business going forward. If you can’t afford to lose these appointments without it significantly impacting your way of life in the future, read through this list of strategies and start thinking about the ones you can implement most quickly and most effectively. The important thing is not to get spooked. You will come out from this stronger, both as a person and a business owner, but the sooner you take action, the better the outcome is likely to be. Every cloud has a silver lining (which often isn’t obvious at the time it’s happening) but it’s up to us make that work to our advantage. That’s the quality of a true survivor.

What State Is Your Email List In Right Now?

That might seem an odd question to ask at this stage of the article, but quite simply, a lot of the strategies that will help you pivot or adapt your business, even in the short term, especially if you need to replace lost revenue, will rely on the responsiveness of your email list and the relationship you have with that list. The warmer, more trusting, and more nurtured that list is, the higher the number of people you will be able to galvanise to take the actions you need them to take. In other words, the perfect position you could be in right now, is to have a warm, active, well-nurtured email list of a couple of thousand people. Co-Kinetic.com

However, I know from experience, that very, very, very few of you are in that position and that’s exactly why last night (at the time of writing this article) I sent an email out to my own email list, urging you to start the email nurture process ASAP, before your need to galvanise that list into action, becomes more pressing. If you have absolutely no idea what I’m talking about, read the article entitled, “The Powerful Influences of Nurture Emails” (see the Further Resources box at the end of the article). Very simply, nurturing your email list means sending frequent but short, helpful, value-add emails which build trust and establish a sense of reciprocity (the desire to give back or return the favour) between yourself and the reader. One of the easiest ways of providing value through your email, is to offer simple things like downloadable patient information resources within the emails.

People Respond to People

Most of us will never have experienced a threat to our business of this kind before, but it’s a good lesson to learn. The success of our survival will depend on our relationships. That means the relationships we have with our existing clients, our past clients, our email list and even within our local community and with other local businesses with whom we can build partnerships. The strength of trust that we have with those people will give us opportunities to rally the troops, which is exactly why I constantly emphasise the importance of building relationships with your email list. While most of the other relationships I’ve mentioned above, are built 1-to-1, and take time to build, the relationship you have

IT’S A PERFECT OPPORTUNITY TO GROW AND STRENGTHEN YOUR BUSINESS GOING FORWARD with your email list can be built ‘at scale’, with a relatively short investment in time. You only have to invest once in writing an email, regardless of whether you have 100 people on your email list, or 10,000 people. Of course you can’t build the same depth of relationship that you can 1-to-1, but this is all about getting the best bang for your buck. Taking time to have 1-to-1 meetings with 10,000 people would be impossible, but you can build trust through a consistent, value-added email newsletter, with 10,000 people. This is exactly why implementing a regular nurture email schedule, falls firmly into one of my 20% of activities that will give you 80% of your marketing results. It requires very little effort, but can generate significant reward, as you’ll see shortly. Let me give you some ideas of the strategies you can employ in the coming few weeks/months and it will become clearer why I’ve said this.

So What Can We Do With Our New Availability?

It turns out, quite a lot! Here are some options, which can not only help you right now, but also after dust of Covid-19 has settled: 1 Do jobs that you never usually have time to do (you know the ones!) 2 Further yourself educationally (suggested resources below) a. Marketing and business b. Clinical education c. Learn to use web platforms or software you need for your business 3 Build your marketing presence a. I nvest in building relationships by finding ways to add value to: i. your email list ii. your customers (past and present) iii. your local community iv. your social networks and online groups v. other complementary local business providers b. Focus on growing your email list (ie. lead collecting) c. Create content you don’t usually have time to create d. Use the time to ask for customer testimonials on Facebook and Google e. Update your website and refresh your Google Business listing 4 Generate new revenue 1. Can you take some of your services online (in a modified form)? 2. Sell passes or packages of services which can be redeemed later 3. Do you currently sell physical products? If so, can you offer these to wider groups? 4. Offer an online live version of your appointments 5. Give online presentations or build a mini-course – pre-recorded or live and sell access to it 6. Collaborate with other people who are active on social media or have a responsive email list and combine skillsets 7. Get another job utilising your wider business or knowledge skillset eg. being a virtual assistant, doing online tutoring 8. Explore whether there are any state aid, benefits, grants or other financial support that’s available to you 9. Set up affiliate accounts and earn commission on sales i. F or example you could review physiotherapy products or books on Amazon and include affiliate links ii. O r you could write blog posts on related topics like groups of books on a given topic with affiliate links iii. I f you have an email list of other physical or manual therapists, you could join my new affiliate programme and recommend my free webinars and resources (more details below) iv. Just google ‘top affiliate programs’ and see if any fit for your expertise 10. F or a bunch of other ideas, try Googling “passive income streams” and see which ones might work for you (see Further Resources below) 11. P roduce content for people who will pay for it, for example: i. I will pay for content like patient leaflets, cheatsheets, posters etc – click here to submit ideas https://spxj.nl/2xNYiwl ii. M agazines may pay for articles (and even if they won’t pay, it could still help you market yourself, or build your email list)

Now let’s discuss some of those ideas in a bit more detail. I should say that these are just ideas to get the creative juices flowing. Not all of them will work for you, but if you have the desire and drive to survive, there’s plenty of fertile ground to get started with.

Further Your Education

I think the ‘why’ you should do this, is probably fairly selfexplanatory so I’ll stick to highlighting some useful resources you could use. And because I’m always looking to try to help you squeeze the most out of your time, if you can, you should prioritise courses which will either give you something extra you can sell during this down time, or that can impact your business going forward – then it’s two birds for the price of one.

Clinical Education

Video l The Physio Channel (YouTube) – loads of excellent free videos https:// spxj.nl/3aIA3xE l Physio-pedia have a range of paid and free courses https://members.physio-pedia. com/learn/ l Clinical Edge has a free 7 day trial and some excellent paid courses at www.clinicaledge.co l Stuart Hinds is an inspirational massage therapist, he has paid courses at https://stuart-hinds. com/ and you can also find a ton of brilliant free videos on the Premax YouTube channel http://spxj.nl/2gObKXb and on our Co-Kinetic site (https://www. co-kinetic.com/profile/3688). Podcasts l If podcasts are more your thing you can find some suggestions of physiotherapybased ones here https://player.fm/podcasts/Physio

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l And massage therapy ones at this link https://player.fm/podcasts/ Massage - N.B not all are focused on the practitioner, some are specifically aimed at patients.

l The Cash-Based Practice l The Massage Business Blueprint l Massage Therapist’s Business & Marketing Podcast

Clinical Resources Online l It would be a bit remiss of me to not mention my Co-Kinetic Clinical Education subscription which includes a quarterly print journal, and more than 2,000 articles, infographics, videos and podcasts online, covering practical aspects of managing various aspects of musculoskeletal health: – View recent Physical Therapy content at this link https://www.co-kinetic.com/ category/pt – View recent Massage Therapy content at this link https://www.co-kinetic.com/ category/mt – Recent Co-Kinetic Journal articles at this link https://www.co-kinetic.com/ category/print-journals

Want to just get better using Excel, or learn how to build websites, or do a business course? If this is more your bag then Lynda.com (also known as LinkedIn Learning) has courses on just about anything and everything. You also get a 30 day free trial which lets you explore all the courses.

Business Development and Marketing

Training l If you haven’t already, then watch my free webinar “Discover the 20% of Marketing Activities That Will Give You 80% of Your Marketing Results” http://co-kinetic.com/8020 l Vicki Marsh has some excellent resources including a Facebook Ad course, a Massage Therapists’ Business & Marketing Podcast and a business development programme https://www. massagetherapistbusinessschool. com/ l My good friend, physiotherapist Andy Hosgood is running a 2-day Client Experience workshops – more info here https://elevateyourclinic. com/events/ l Paul Wright, also a physio, has some great courses and resources at this link https://www. healthbusinessprofits.com/index. php Podcasts l The PT Entrepreneur Podcast l Breakthrough PT Marketing Co-Kinetic.com

Software and Technology

Strengthen Your Marketing Presence

This is your ideal opportunity, while you have some downtime, to strengthen your marketing foundations. As you’ll appreciate fully when we delve into the ‘revenue generation’ strategies next, having a good marketing foundation, and specifically a trusted and nurtured relationship with your email list, makes generating revenue when you need it, significantly easier and more effective. Building an email list and nurturing that email list regularly with valueadded content has always been for me, THE number one priority marketing activity. I know it doesn’t sound all that ground-breaking, but as you’re about to discover, the impact it can have on your business can be a game-changer. It can protect you at times of challenge (like now), by helping you to build additional revenue streams, and it can help you generate new clients, from a standing start, when you need to take on for example, a new therapist, move to a new clinic or hire some admin support. And as we’ve said, the beauty of using email is that it’s scalable. You only have to write one email. There’s no more effort whether you have a list of 200, 2,000 or 20,000. So your first priority is to create, sign up to, or utilise any existing patient resources you have access to, to help you add value to your existing list, and then get into the habit of sending out a new email every 2-3 weeks under ‘normal’ circumstances. In this particular situation I would recommend you accelerate this process and send an email every 3-4 days. The important thing is to

THIS IS YOUR IDEAL OPPORTUNITY, WHILE YOU HAVE SOME DOWNTIME, TO STRENGTHEN YOUR MARKETING FOUNDATIONS. ensure the email is short but provides value, for example a link to a useful patient resource. Your email list should be made up of existing and past customers and you must constantly focus on growing this list. For ideas on how to do this, read the article “25 Ways to Grow Your Email List” in the Further Resources section. If you’re worried about GDPR, I have a resource which explains more about that too (again the link is also under Further Resources). Take this time to write patient resources you’ve been meaning to write for ages (I may also be interested in commissioning these, and paying you for them – see Revenue Generation for more details). Or utilise ready-made patient leaflets, like the ones included in all our Co-Kinetic subscriptions (you can explore the leaflets at this link https:// www.co-kinetic.com/category/ patient-resources-by-topic). We’re not the only ones that produce patient resources, other companies like Rehab My Patient (rehabmypatient.com) also have a large repository of leaflets. And if you don’t have a subscription to

one of the exercise prescription websites this is probably the time to think about it, as it will allow you to support your customers from a distance by sending them progressive exercise programmes. In addition to RehabMyPatient, there’s also Physiotec (physiotec.ca), ExercisePrescriber.com and a whole host of other platforms – and if you’re looking for some input into which platform may work for you best, just post a question for feedback in my Business Success for Physical Therapists Facebook Group (https://www.facebook.com/groups/ businesssuccessforpts) or any other physical therapy groups that you’re a member of. So, here’s a summary of your marketing priorities: end out a regular nurture email (ie. containing value1 S added resources) se some of the strategies in my “25 Ways to Grow 2 U Your Email List” to start building your email list 3 I f you have either of our marketing subscriptions, get those social media posts out onto your social networks and liven up your social network pages (while at the same time building your email list) – alternatively use the downtime to create some of your own resources blog posts (or use our pre-written ones) that you 4 Write can publish both now but in the weeks ahead when your appointments start to re-fill, so you don’t have to do it then rite your most important patient resources that 5 W you’ve never had a chance to write (and if you want to earn money for these resources, put them forward for publication by me. Submit your suggestions at this link https://spxj.nl/2xNYiwl pdate your website and refresh your 6 U Google Business Listing end out an email or letter, asking people to write 7 S testimonials for you ideally on your Google Business listing or your Facebook page.

Ways to Generate New Revenue

Now to the part that everyone is probably waiting for. The harsh reality is that most people will cancel their appointments (if they haven’t already). And for most people, if you’re not delivering, you’re not earning (this is a good chance to change that). Now remember, we’re not asking you to do this over and above seeing clients. These strategies are specifically recommended to productively fill in the free time you may have as a result of clients cancelling/not booking. As soon as those clients start to rebook, you can decide if any of your new strategies are worth continuing, or you can drop them and focus on what you were doing before (although be mindful that this situation may re-occur in the future). 1 Review Your

Cancellation Policy

The first thing you should review is your cancellation policy. If you feel comfortable doing it, you could postpone the booking, so keep it, but let them move the time. The goal is to retain as much as you can, even if you have to put it off for a few weeks. Have a think about what you can do with your cancellation policy that’s fair to your customer, but also protects you where possible (and be honest with people about why you’re making that call – people will understand the situation, we’re all in it together). 2 Sell Passes, Packages &

Memberships to Support Cashflow

The next thing that will result from these cancellations, will be a drop in cashflow. So your first priority will be how to try and sustain this cashflow with the least amount of effort. This is where you can utilise passes, memberships and/or packages. This could be a bundled group of appointments offered at a reduced

price, but purchased upfront. A pass or voucher could be a discounted appointment for example, that they buy now, but redeem later (I’d advise setting a ‘use by’ deadline, one that’s reasonable given the current circumstances, but not so far ahead that they will become a burden to you in the future. You could put together a package of anything. In the simplest form it could be 6 x 30 minute massage appointments or 5 physio sessions at a 10, 15, 20% discount – it’s your call. If you have an email list (it won’t be the first time I say it!), test these offers to smaller groups (if your email list is big enough) and see which ones get more interest. You need to make sure you give people a way to pay for their purchases, whether that’s to phone you with credit card details or book through an online booking system, or a simple Shopify store front, or even just a simple PayPal button. You can also use Calendly to schedule appointments and take payments. I use Stripe as an online payment processor and can thoroughly recommend it, and it integrates with most other ecommerce (shopping carts). I don’t use Shopify because we built our own ecommerce solution, but if I could, I would! My very shrewd fellow business and marketing therapist Vicki Marsh, actually sells annual memberships to her massage and injury clinic for a few thousand pounds. This only works with your most dedicated and committed clients, so have a think about who might be interested, and what you could bundle together. The more cash you’re asking them to part with, the better the deal needs to be. It could be an appointment a week for a period of time, or a bundle of passes to be used around an event that person might be taking part in. You’re the only one who knows your clients, and knows what they want, so let your imagination run riot and

YOU’RE THE ONLY ONE WHO KNOWS YOUR CLIENTS, AND KNOWS WHAT THEY WANT, SO LET YOUR IMAGINATION RUN RIOT 46

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test, test, test, the smaller offerings using your email list. If for example you have 3 variations on a package offer and you have 600 people on your email list, send one offer to 200 people, the second offer to another 200, and the last offer to the last 200 and see what gets the best take up. Or if you don’t want to make the offer upfront, why not email your list, give some suggestions of what you’re thinking about and then ask them for their feedback, or send them to a Survey Monkey survey or Typeform questionnaire. Don’t make the options so flexible that they don’t know where to start, give them clear structures and options to choose from. Again the bigger, more engaged and more trusting your email list, the better the uptake will be. The smaller and less nurtured the list, the harder it will be to get a response and therefore a definitive answer to your test. The benefit of doing this, is that you’ll know who’s interested in what (so make sure to ask for their email address so you can identify who likes what). And ALWAYS ask them to forward the survey to anyone they think would be interested (you should also add this as a PS in any nurture email you send out – sometimes you just have to ask, to get the desired action). Again, you can be completely honest about why you’re doing this. Even if you’ve always been afraid or wary of discounts, this is a one-off situation that shows you’re being proactive about your business. 3 Sell Physical Products There are two ways of doing this, if you already sell physical products, widen your audience and promote these products further afield to sports teams, clubs, fitness centres that don’t sell their own, and promote them through

Co-Kinetic.com

online groups and through your email list (there we are again!). If you’ve already paid for the stock, this means immediate cashflow to the bottom line. If you don’t currently sell physical products, I wouldn’t recommend investing the time in figuring out how to do it now – it’s labour intensive and not always very profitable, at least at the start. Instead I’d suggest contacting the main physio supplier companies in your country and asking them if they have a ‘clinic kickback’ scheme. In the UK this would be https://www.physiosupplies.co.uk/, https://eurekaphysiocare.co.uk/, and https://www.physique.co.uk/. In Australia https://astiraustralia.com. au and in New Zealand https://www. amtech.co.nz/ both also have clinic kickback schemes. Alternatively ask your normal medical supplies company if they do something similar where you can earn a percentage of commission on any sales you generate from patients. You can also do this through Amazon (although the commissions are likely to be smaller). The benefit of affiliate programmes is that you’re just there to deliver traffic, you don’t have to get involved in sending products, or receiving returns which trust me, can be a pain, we’ve been there and done it! We discuss this more in section 9 on the next page. 4 Offer Online Versions of

Appointments or Guided Classes

That might sound difficult to start with, but think about it, you can carry out musculoskeletal assessments, give exercise advice, or advice on relaxation, reducing stress, meditation, teaching someone self-guided massage, mobility, strength-testing and you can definitely give exercise progression advice online. You could offer packages for people training for events like marathons which could incorporate a bunch of

different elements like a flexibility and/ or injury prevention assessment, and some pre- and post-event treatments. You could also include a pack of patient resources (we have loads), and you could teach people how to self-massage areas that are vulnerable to injury. You could offer guided meditation or relaxation classes, pregnancy massage, couples massage, strength classes for back pain, or hip mobility. You could even teach people about essential oils. Let your mind go wild for a moment. There’s a good chance as a health care professional, you’ll be a great educator, it doesn’t even have to be profession-specific, think about what you’re good at, or what you love doing. If you’re an expert at something, whatever it is, there’s your opportunity. Also think about how you can support your clients. Everyone will be going through a stressful time, and sometimes that 40 minutes with you, is their only time out. Give them options and ways that they can still benefit from your input. The sorts of tools you might use could be Zoom, which is an online video conferencing tool, and there’s a free plan which includes unlimited 1-to-1 meetings. Other tools include Skype which is free, Facetime, Freeconference.com, Whereby.com and ClickMeeting.com, all of which have free plans. Things you’ll need to think about are cameras and who needs to be seen and at what distance, whether you want to charge for your event and if so how you sell access and also how many people you can accommodate in a class. I’d start smaller, maybe 1-to-1 first and make it clear to your clients that to start with it’ll be a bit ‘trial and error’. Also think about your pricing compared with what you’d charge if you were face to face as that will need to be lower unless of course you can deliver a superior service online. 5 Online Presentations

or Webinars

This is a variation on the above theme, but worth mentioning separately and possibly easier to implement. Have you got presentations you’ve given in 47

JUST 5-10 SIGN-UPS WILL REPLACE THE INCOME FROM A MISSED APPOINTMENT. THE MORE VALUE YOU OFFER, THE MORE YOU CAN AFFORD TO CHARGE the past that you could resurrect? If not, for the period of the coronavirus outbreak only, we are making 4 of our off-the-shelf pre-written PowerPoint presentations available to existing subscribers as part of their current subscription. Full-site subscribers have access to 22 existing presentations. And if you are not currently a subscriber, you can purchase for a small fee, single presentations. We have pre-written presentations on topics like Posture, Workplace Health, Chronic Pain, Women’s Health, Physical Activity Promotion for Health, and Headaches along with about 15 sports injury related presentations on Running, Cycling, Swimming, Rugby, Concussion, Tennis, Golf, Soccer/ Football, Skiing etc. Also, by the time you read this article, I will have adapted our Co-Kinetic platform to enable you to charge and take sign-ups to your webinar through Co-Kinetic, eradicating the hassle of building sign up pages, collecting the new sign ups,

adding payment buttons, collecting payments and delivering your new customer to your presentation or resources. All you need to do is record yourself doing the presentation, upload the final version to YouTube or Vimeo and then enter the video link at the Co-Kinetic end. We’ll take care of the rest. As we’re looking to this strategy to generate revenue for you, it would be sensible to charge for your webinar, but I wouldn’t go mad, I’d stick with something nominal, like £5-10 and make sure you give them something of real value to take-away (like the accompanying set of patient information leaflets we produce on each topic). Just 5-10 sign-ups will replace the income from a missed appointment. The more value you offer, the more you can afford to charge. You could even offer some sort of one-time-only upsell, like a physical appointment, on the final webinar page, or email it to people later. The beauty of this strategy is that you can record it once, and it can literally sell while you sleep. It also doesn’t matter where those people are based, they could be anywhere. In other words it’s another revenue stream that can run on its own, even when we get out from under our current coronavirus challenges. And once again, this is where your email list comes in, as this is who you

want to sell to first. The more trusting and active your email list, the more purchases you’ll get. Once you’ve promoted it a few times to your list, you can look at running Facebook ads to promote your events, using online forums, business partners/collaborators and local networks (although to be fair, the world is literally your oyster when it comes to online events and webinars). Also make sure to publish the webinar on your social networks – just do one post on each social network and then after people have attended your webinar, ask them to like and comment on that specific post (give them a link straight to the exact post, not your whole Facebook page). You can then use this same post (as long as it conforms to Facebook’s Advertising policies) as your actual ad which means you’ve already built up some social proofing on the post, before it runs as an ad. I will be doing a video on this topic which hopefully will also be live by the time you read this article (yup I’m trying to move even faster than usual for you this month!). In order to record your webinar, you can use PowerPoint. I’ve included a link in the Further Resources box with more info on recording using PowerPoint. Other tools you can use are Camtasia or Quicktime Pro. Ask colleagues or friends if they use these sorts of tools and whether they have feedback, or can help you get set up. And if you’ve got ‘youth members’

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within your reach, capitalise on their IT literacy and commandeer them to help you out! If you’re pretty happy with the presentation but just want to cut a few ‘ums and ahs’ out here there, or the odd mistake or verbal slip up, and it’s technically beyond you, don’t fret, you can always ask someone at the freelance site, Fiverr (or alternatively Upwork) to help you out. Just send them the recording with a bullet list of changes you want made or cut, and the exact minutes and seconds that the moment you want changing occurs at, and they will be able to help you out very speedily and at a low cost. If you don’t want to use the Co-Kinetic system (which is totally fine) you can use the webinar platforms I’ve mentioned in the previous section, just make sure they have the ability to take payments. 6 Collaborations If this all sounds rather overwhelming to start with, why don’t you find someone locally that you can team up or collaborate with, who can help with the technical aspect. Ideally they would be people who are active on social media, who have a healthy email list and who have the skills you lack. Perhaps you could do classes together or you could team up to discuss common injuries or weight-loss strategies. Whatever the topic, make sure it has real value to the viewer – WOW them with value if you can, because it’s going to be the value of the session, that governs the price you can charge. Find resources you can throw in as part of the event to boost its value,

Co-Kinetic.com

things like ebooks or leaflets work well, whatever you can find. And if your collaborator doesn’t want to charge for the event, that’s fine because you’ll get more bums on seats if you don’t charge, just use it as a training exercise to learn better what needs to be done and make sure you agree to share the email addresses of the people signing up. 7 Get Another Job If thinking about doing any of the above items is stressing you out, or not appealing to you, then let’s look outside your profession. You run a business, so you have more skills than you probably appreciate. So get a temporary job. If you want to do things online, think about becoming a virtual assistant (VA). Just Google ‘hire a VA’ or ‘apply to be a VA’. Most VA companies will have a link at the bottom where you can apply for jobs. If you have a past career in marketing, design, copywriting, or video editing for example, you could sign up and do some work on the freelance services site Fiverr or Upwork. Alternatively, if you live somewhere which has a national health system, can you go back and temp? If schools are shut and kids are kept home, most businesses will be seriously shortstaffed. You may even get temporary job-sites being set up to find shortterm staffing. 8 Do You Qualify for Any Loans, Grants, Benefits?

This is worth looking into. It may just provide you with enough cashflow to see this current threat out. Interest

rates are low, so you may be able to get a business loan from your bank, or lenders like Funding Circle. Alternatively do you qualify for any tax benefits or grants that you may not be claiming? At the very least it’s worth a conversation with a specialist in this area. Make sure you know whether you have any insurance that might cover you for lost earnings and whether you can claim sick pay allowances should you get ill. Ask your governing body if they have any information that can help you out, but don’t hold your breath, particularly if your governing body is big. The bigger they are, the slower they move, in general! 9 Set Up Affiliate links Similar to number 3, sign up with companies you like or use, who have an affiliate programme (like Co-Kinetic). That way you can earn commission from anyone who you direct to the sites in question, who purchases products, or in our case subscriptions. If you have an email list of physical or manual therapists (remember I don’t want patients), you can earn between 10–20% on 6–12 months off every subscription that is purchased by someone you’ve recommended. That means if someone signs up to my Social Media subscription at £29 a month, you could earn £87 from that one person alone. The percentage you earn is based on whether you have a subscription with us and if so which subscription you hold. There are plans for both subscribers and non-subscribers, so don’t worry everyone qualifies. And you don’t need to ‘sell’ anything. All you need to do is recommend people to my free webinars and resources with your unique affiliate link, and when someone who came in via your link, subscribes, you accrue income which is paid to you monthly. If you are They won’t even know the interested in signing link is an affiliate one, but up to our affiliate programme start a you can tell them if you chat with me on prefer the transparency. the chat tool on our You can do the website. same with companies like Amazon. How easy is it to insert a few affiliate links to products, or books, or anything 49

TAKING PROACTIVE ACTION NOW, WILL HELP YOU FEEL LESS HELPLESS AND MORE IN CONTROL OF YOUR FUTURE you feel like recommending through your blog posts, emails, or on your social networks? Also make sure to join everything up, in other words, if you’re running a webinar or classes, make sure to include links to any products they might want to buy, and make sure to include the sign up link to these classes or webinars in any relevant blog posts, that way even if you’re plugging your blog post, you will still be generating webinar sign-ups. Link everything together. It seems a lot to get your head around at first, but it’s all about reinforcing all your efforts, everywhere. There are loads of ideas for generating income like this, which is often referred to as ‘passive income’. Just Google ‘passive income ideas’ or

Further Resources

the ‘best passive income sources’ and see what appeals to you. 10 Paid-for Content Last but not least, produce content that can generate you revenue. Have you been meaning to write that long-awaited book. If so, now is the time to approach the publishers and see if you can get it commissioned. I wouldn’t recommend writing anything until you have a commission however, it will take you a lot of time, and you may well end up almost completely re-writing it or changing it altogether if you find a publisher who wants it. If you have ideas for patient resources use the links in this article to suggest them to me. I commission patient leaflets, cheat sheets, posters and all sorts of content that’s pitched at the patient. Alternatively, ask your local newspaper or magazines if you can contribute an article. They probably won’t pay, but it’ll be a nice piece of advertising for you. If you have our full site subscription, I suggest you use our blog posts and newsletters for exactly this purpose.

l Coronavirus and the Massage Therapist – excellent blog post by Rachel Fairweather at Jing Advanced Massage Training https://spxj.nl/2Qb0aWd l The Powerful Influences of Nurture Emails http://spxj.nl/2BU2UO3 l 25 Ways to Grow Your Email List https://spxj.nl/2KdQgCs l Business Success for Physical Therapists Facebook group https://spxj.nl/2PvQcNV l The 19 Best Ways to Generate Passive Income in 2019 https://spxj.nl/2W7xSjm l GDPR Facts or Fiction? Don’t let scaremongering paralyse you, here are the facts https://spxj.nl/2TK2Hc1 l How to Record a Presentation in PowerPoint https://spxj.nl/3cU0tyw l Co-Kinetic Affiliate Programme – spread the word about the Co-Kinetic resources to other physical or manual therapists and earn between 10–20% on all subscriptions that result from your introductions – get in contact with me on the chat tool of the Co-Kinetic website. Co-Kinetic.com

Last Words

So, I know that’s been a whopper of an article, but hopefully you’ve found some ideas in here that give you some encouragement and inspiration. This is uncharted territory for everyone, but taking proactive action now, will help you feel less helpless and more in control of your future. You know as well as I do, that when your mindset is good and confident, rebookings go up and when we’re lacking in confidence, our rebookings slow down. Let all this information sit and percolate and filter through what would work best for you. Some things will suit you better, others won’t even get off first base, but that’s OK. This isn’t a list to work through, it’s a list of strategies which you can pick and choose from, if and when you need them. Situations like these force us to realise the vulnerabilities in our business models, so take this opportunity to shore up those weaknesses and plug the gaps. This is how we can learn to thrive against unpredictable challenges.

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

Co-Kinetic Journal 2020;84(April):42-50

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TOR DAVIES

Physio-turned Co-Kinetic founder http://co-kinetic.com While Tor trained as a physical therapist, she has been an entrepreneur for more than two decades now. Her focus is providing resources to help practitioners and therapists develop their businesses and to work more efficiently, a topic that she speaks on regularly at global conferences. The marketing practices and principles that Tor advocates, will help you turn a business that is only just surviving into one that thrives in just a matter of weeks