Co-Kinetic Journal Issue 85 - July 2020 by Co-Kinetic

1999

2020

ISSUE 85 JULY 2020 ISSN 2397-138X

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How to Monetise Your Therapy Skills Online

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l 14 strategies you can employ to generate ongoing online revenue using specifically your therapy skills l The focus is on building scalable revenue streams which don’t depend on you being physically present and which can thrive despite Covid-19 l I show you step-by-step how to monetise your online strategies and explore a couple of different revenue models l And I’ll explain how to build a marketing funnel from scratch, and then fill it specifically with people primed to want your offering l Finally we look at how you can use a blended online and offline approach, which plays to the strengths of each environment, and helps you to deliver a better overall customer experience

PHYSICAL & MANUAL THERAPY AND HEALTH & WELLBEING INFOGRAPHICS

Recovering from Coronavirus T

helping in the home, working, doing sport, playing with children or grandchildren, or having the energy to socialise again. The shortness of breath may take considerable time to improve. Your body is getting over scarring and inflammation in the lungs. Some doctors report recovery taking two to eight weeks, with tiredness lingering. Spending a long time in bed rest WHEN WILL I BE BETTER? or hospital leads to muscle wasting and Medically, a person must be fever-free weakness. Patients will be weak and the without fever-reducing medications for muscles will take time to build up again. three consecutive days. They must show Some people will need physiotherapy to an improvement in their other symptoms, walk again. including reduced coughing and shortness There does seem to be an added of breath. And it must be at least seven element with this disease – viral fatigue is full days since the symptoms began. definitely a huge factor. There have been In addition to those requirements, the reports from China and Italy of whole-body United States CDC (Centres for Disease weakness, shortness of breath after any Control and Prevention) guidelines say level of exertion, persistent coughing and thatyour a person must test negative for thethe following irregular breathing. Plus needing a lot of You will be given instructions: This test can help monitor coronavirus the tests taken Some people have reported their l The purpose of the test issleep. to walk as far response to treatments for heart, lung twice, with least 24ishours apart. as But is that really symptoms coming and going for weeks possible within 6 minutes. and other health problems.at This test Can you say then that younormal have paceafter l Walk at your to aillness. chair orOne day they are in the shops commonly used for peoplerecovery? with pulmonary recovered from Covid-19? We think not, and walk doing some cone, turn around back to re-supply feeling ok, the next problems or chronic lung disease to assess take you this day they battle to get out of bed. youtostarted. lung function. The results ofsurviving this test the mayvirus may where point but recoveringl from it may to stillwalk be aback and forth We do patients may take a Continue for know 6 lead your doctor or therapist to do more much longer complex process. considerable period, potentially months, tests. They may also test your heart and and moreminutes. Recovery time will depend on how ill to recover. Historically other coronaviruses lung function. you became in the first place. people (such as the SARS virus) have resulted Ideally theSome length of each lap should quickly, but forthis mayinneed reports of patients still battling with be 30m. However, to be WHAT TO EXPECT will shrug off the disease others it could leave adjusted lasting problems. The fatigue and decreased levels of and made shorterchronic depending Preparing for your test: moreare invasive the treatment you receive, physical on available space, especially if you ability are (compared to their level of l Wear clothes and shoes that and the longer it is performed, longer activity prior to the illness) being markedly performingthe a test at home or during comfortable. is likely to take. lower even after 2 years, but it is hard to lockdown with limited access to facilities. l It’s OK to eat a light mealrecovery before your generalise. So the length of each lap may be shorter, test. WHY DON’T I FEEL ‘RIGHT’? but you continue to walk for the 6 minutes l Take your usual medications. Many patients reportand waves ofcalculate symptoms then how far you have l Do not exercise during the 2 hours over a period of weeks following recovery theWILL CORONAVIRUS AFFECT travelled by multiplying number of before your test. – from heart palpitations headaches, MY HEALTH LONG-TERM? laps to with the length of 1 lap. Provided shortness of breath and Decreased know for sure as there are no the fatigue. ground is level and flat We anddon’t the same During the test: lung capacity by doctorsis during long-term data, but we can look at other distance/route used for re-testing then l The person conducting the test will is observed follow-up this can impacts on conditions. the All results be compared. measure your blood pressure, pulseconsultations. and ability Acute respiratory distress syndrome oxygen level before you your start to walk.to return to ‘normal’ life, be it

What is the 6 6-Minute Walk Test? T

he 6-minute walk test is a submaximal (meaning less than the full effort you are capable of) exercise test that measures the distance walked during 6 minutes. The 6-minute walk distance provides a measure for integrated global response of multiple cardiopulmonary (heart/lung) and musculoskeletal (muscle/bone) systems involved in exercise. The 6-minute walk test provides information regarding functional lung capacity, response to therapy and prognosis across a broad range of chronic cardiopulmonary conditions. The main strengths of the 6-minute walk test stem from its simplicity. It is easily understood and performed, meaning that most patients are happy to do it, including those who are unfit, elderly or frail. It is also a very low-cost test and the results are easy to understand.

ABOUT THE 6-MINUTE WALK TEST

The 6-minute walk test is a measure of fitness and how your body functions. It helps your healthcare provider evaluate your ability to exercise, how effectively your lungs are working when stressed and how efficiently your body is accessing and using the oxygen required for activity. During this test, you walk at your normal pace for 6 minutes.

ENTREPRENEUR THERAPIST

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A SHORT REFLECTION ON WHAT COVID-19 MAY MEAN FOR THE THERAPIST AND BEYOND

A Short Reflection on What Covid-19 May Mean for the Therapist in 2020 and Beyond

hen I published the last issue of Co-Kinetic, we had just smacked headlong into the wall of Covid-19 and here we are three months later, a little battered and bruised, but hopefully having had the opportunity to take a good long look at our businesses and make some much-needed changes. I know that a lot of you have well-and-truly grabbed the bull by the horns and got stuck in to doing the things you don’t have time to do usually, particularly when it comes to your marketing. I’ve taken on more than 250 new subscribers in less than 9 weeks, joining up to my ‘virus special’ subscription offer which I discounted by 60% at the start of Covid-19. I’d like to take a sentence to acknowledge the courage each of you had, for facing this chaos head-on, and turning it into something positive. I know first-hand how hard it’s hit each and every one you, and I’ve seen two very distinct camps of people, those who have hidden their heads in the sand and are waiting for the storm to pass, and those who decided the only option was to stand up and face the chaos that was being hurled at their businesses, and do what they could to turn that chaos into something productive. It’s those of you who were brave enough to take that action, that continue to inspire and drive me to work harder and help as much as I possibly can. And that in turn has helped me improve the technology I provide as part of my subscription, to help you do more. So a very grateful Co-Kinetic.com

thank you to each one of you, for giving me that opportunity to learn, develop and improve. With that in mind, we come to the article that will follow this one (and the topic of my new webinar). Like it or not, our lives have changed, and the normal we knew up to March this year, is now gone, certainly for the foreseeable future. I don’t think I’m alone in anticipating that the normal we knew then, is now a thing of the past. Our job is now are to move into the next era of physical and manual therapy delivery. The increased uptake of telehealth, due to Covid-19, may have just caused the single biggest change in the way we deliver MSK services, that any of us will ever experience in our lifetime. I think back to my days studying as a physio at Addenbrookes Hospital in Cambridge and how I bemoaned that the days of the “old school” hands-on physio were over, because students graduating since then, did nothing like the hands-on work that I trained to deliver. And now, ironically, I find myself thinking what a mixed blessing it is that things did move on, because those hands-on skills are the ones that have, and will continue to suffer most, as a result of this virus. What I’m in absolutely no doubt about, is that in order to survive, and eventually once again thrive, we have to move as many of our skills online as we feasibly can. We also need to find a way we can scale, ie. build our businesses without always requiring our physical presence in that process.

To do that we need to become excellent at, and focused about, our marketing, because telehealth suddenly opens up the possibility that you can be ‘treated’ by any therapist, literally anywhere in the world. This hit me when I decided it was now feasible to ask one of the physios I have the most respect for, and trust in, to help me rehabilitate a long-term back/hip issue. Before Covid-19 I wouldn’t even have considered the thought of telehealth. Above anything else, I hate seeing myself on camera! And Chris, my chosen victim/physio, is based in Cheshire, which is a LONG way from me in Wimbledon. But suddenly, those geographical barriers

Turn point

l You can use your usual walking aids, such as a cane or walker, if needed. l If you typically use oxygen while walking, PRODUCED BY: you can use it during your test. l Let the testing staff know if you are having chest pain or breathing difficulty. l You can slow down, rest or stop at any time during the test. After every minute, the tester will tell you how much time remains.

Path of Walk

Start point

Distance 30m

Having listened to yesterdays fab webinar I am now inspired to grow my business! I have subscribed today with the basic package free branding and having looked at what’s on offer to market my business I cannot wait to get going! Thank you, thank you, thank you Tor!

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HAMSTRING INJURY PART 1: ANATOMY, FUNCTION AND INJURY

WHAT CAN BE DONE?

Having a team of medical professionals working with you will get you through this. Physical activity will be critical to re-build your strength and fitness. Pulmonary rehabilitation may be key to improving your exercise tolerance which will improve your ability to do daily chores and return to normal life sooner. Pulmonary rehabilitation is proven to work with patients’ chronic lung disease or individuals recovering an acute lung illness or lung surgery. As Covid-19 primarily attacks the lungs, this may be a good starting point that a physical therapist can guide you through. In combination with this seeking counselling, speaking to professionals and social workers may assist in dealing with stress,

WHAT ARE THE RISKS?

This is a low-risk medical evaluation. Medical help is available during the test.

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Great webinar and really informative resources which I am now using within my Subscription to get new leads for my clinic. Highly recommend!!!

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The results of your test are compared with what results are typical for healthy people at your weight, height, sex and age. The test results can help estimate how well you are responding to treatment. Often, your therapist will ask you to repeat the 6-minute walk test after 6 months or a year. Your therapist may change your exercise programme based on your test results.

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(called ARDS) develops in patients whose immune systems go into overdrive, causing damage to the lungs. There is really good data that, even five years down the line, people can have ongoing physical and psychological difficulties. People also need mental health support to improve recovery. Doctors report how they tell patients “You’re having difficulty breathing, we need to put you on a ventilator, we need to put you to sleep. Do you want to say goodbye to your family?”. PTSD (post-traumatic stress disorder) in these most severely ill patients is not unsurprising. There will be significant psychological scars for many, not just the most severe cases. Sometimes even mild cases of the disease may leave patients with longterm mental health problems – issues from concerns over stress and anxiety of surviving the illness, job security, depression, family and financial worries during lockdown.

HOW TO TO MONETISE YOUR THERAPY SKILLS ONLINE

Safety: l The tester will watch you for any difficulty breathing or chest pain. l Oxygen and other supplies will be nearby if you need them. TIME-SAVING RESOURCES FOR PHYSICAL AND MANUAL THERAPISTS

The information contained in this article is intended as general guidance and information only and should not be relied upon as a basis for planning individual medical care or as a substitute for specialist medical advice in each individual case. ©Co-Kinetic 2020

By Tor Davies, Co-Kinetic founder

I’ve listened to 2 of Tor’s webinar’s on marketing and surviving Corvid-19 she is passionate about supporting physios and small practices in making to most of our time and providing added value for our clients. If you are looking at growing your business you wouldn’t be wasting your time listening to one of these.

A Long and Unclear Road to Recovery

he coronavirus is certainly scary, but despite the constant reporting on total cases and a climbing death toll, the reality is that the vast majority of people who come down with Covid-19 survive it. Just as the number of cases grows, so does another number: those who have recovered.

To survive we need to learn to diversify without losing focus on our strengths

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MANUAL THERAPY

MANUAL THERAPY AND THE PELVIS, HIP AND SACRUM Introduction

Manipulative techniques are commonly used to treat lower back, hip, pelvic and buttock pain that originates from the lower body, particularly the pelvis and the sacroiliac joint (SIJ) (1,2*). Various forms of manual medicine manipulation (eg. manual therapy, osteopathic manual treatment, chiropractic adjustments) have been employed to yield substantial relief from pelvic and SIJ pain (3). This was demonstrated by a recent study that reported the efficacy of manipulation in treating a patient with SIJ dysfunction (4*). Another study found that high-velocity, low-amplitude (HVLA) SIJ manipulation, when combined with lumbar manipulation, yields positive results in patient treatment (5). The latter results, in addition to demonstrating the efficacy of manipulation, illustrate the potential of hybrid approaches for manipulative treatment of the pelvis and SIJ. The therapeutic goal of manual therapists in using manipulative techniques for pain relief in patients with pelvic and SIJ dysfunction is to provide a non-invasive, well-tolerated procedure that produces the best results. The ability of a therapist to comprehend the anatomy and physiology of the pelvic region and its associated joints will have a significant effect on patient outcomes (1,6*,7*). Quite often, the knowledge and skills of the therapist have more to do with the actual outcome, for the patient,

COVID-19 PATIENT RESOURCES

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MANUAL THERAPY AND THE PELVIS, HIP AND SACRUM

By Giles Gyer BSc, Dip. Medical Acupuncture, Dip. Sports & Remedial Massage and Jimmy Michael BSc, BTEC Dip. Sports & Remedial Massage, Dip. Medical Acupuncture of any treatment. This article aims to provide therapists and associated professionals with brief descriptions of the joints of the pelvis, hip and sacrum, their ranges of motion and special diagnostic tests for detecting serious pathology. Later sections give an overview of common injuries to these structures and red flags to be aware of. The approach taken aims to aid development of knowledge for the target audience, with information that is both succinct and actionable.

Joints

The pelvis or the pelvic girdle comprises paired coxal bones, the sacrum and the coccyx, and is interposed between the lower spinal column and the lower extremities (8,9). Each coxal bone is made up of three fused bones, namely, the ilium, ischium and pubis, and it is firmly attached to the axial skeleton at its articulation

with the sacrum, at the SIJ (9). The fused bones of the pelvis are immobile, providing a load-bearing scaffold to sustain the weight of the body. This provides stability, enabling the upper body to rest on the mobile limbs. Table 1 summarises the key joints located in the pelvic region.

Range of motion

PELVIS | HIP | 20-07-COKINETIC FORMATS WEB MOBILE PRINT All references marked with an asterisk are open access and links are provided in the reference list

The hip joint allows a wide range of motion. The motion is enabled by the pelvic muscles that wield three degrees of freedom on three reciprocally perpendicular axes. The most common types of motion include flexion, extension, internal and external

ALTHOUGH THE SIJ HAS A LIMITED RANGE OF MOTION, IT IS NOT COMPLETELY IMMOBILE AS PREVIOUSLY BELIEVED

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REHABILITATION FOLLOWING COVID-19 PART 2: PRACTICAL APPLICATIONS

JOURNAL WATCH

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REHABILITATION FOLLOWING COVID-19 PART 1: THEORETICAL CONSIDERATIONS

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

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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.

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OPEN

= OPEN ACCESS

CONTACT — BUT NOT FOUL PLAY — DOMINATES INJURY MECHANISMS IN MEN’S PROFESSIONAL HANDBALL: A VIDEO MATCH ANALYSIS OF 580 INJURIES. Luig P, Krutsch W, Henke T et al. British Journal of Sports Medicine 2020;doi:10.1136/bjsports-2018-100250 [Published online first] This study looked at video match analyses of injury situations provided by German professional clubs over a 6-year period. Only acute injuries sustained during an official team match that led to time loss of at least 8 days (moderate or severe injury) were considered for video match analysis. Contact injury was defined as ‘any injury due to external forces directly at or adjacent to the injured body site, either through contact with another player or an object such as the goal or the ball’. Indirect contact injury was defined as ‘any injury sustained through external forces that did not directly cause the injury but influenced the natural process of movements, thus indirectly leading to the injury’. A total of 580 injuries were analysed, which comprised wing players (n=109), back court players (n=337), goalkeepers (n=45) or pivot players (n=89). Most injuries affected the knees (n=144; 24.8%), ankles (n=116; 20.0%), hands (n=68; 11.7%) and thighs (n=55, 9.5%). Injuries that did not result in match interruption were less likely to be

This is a case report of a 13-year-old boy who presented with a 2-year history of bilateral swollen proximal inter-phalangeal joints of both middle fingers and radiographic signs of severe apophysitis and physical fractures. This was attributed to his competitive climbing which he took part in 3 to 4 times a week for over 2h a day. The patient was advised to completely rest from climbing as the injuries were too severe to treat in any other way. Because of this patient, the authors reviewed the available literature regarding climbing injuries in adolescents and created some general

identified, such as finger and muscletendon injuries. There was also an analysis of what was going on at the time of injury and the position on the court. Set offence involved 259 (48.5%) injuries, set defence 149 (27.9%), fast-breaks 76 (14.2%) and defence transition 47 (8.7%); 4 (0.7%) injuries were classified as other. All 45 identified injuries of goalkeepers occurred within the goal crease. No differences were found regarding body site, league or match duration or in which half of play. Overall, 365 (62.9%) injuries occurred in a team’s offence area and 211 (36.4%) in a team’s defence area; 4 injuries (0.7%) were classified as other. With 151 injuries (26.1%), most injuries occurred in the central zone between the 6-metre and 9-metre lines. The most common movement patterns were landing (n=177; 30.5%) and running (n=142; 24.5%). Less frequent were stopping (n=55; 9.5%), being mid-air (n=51; 8.8%), change-ofdirection (n=49; 8.4%), standing (n=48; 8.3%), jumping (n=26; 4.1%), sprinting (n=17; 2.9%) and accelerating (n=11;

1.9%). Five injuries (0.8%) were classified as other. The most frequent handball-specific movement patterns were throwing (n=173; 29.8%), one-on-one tackles (n=145; 25.5%), goalkeeper saves (n=39; 6.7%), field players’ defensive blocks (n=36; 6.2%), passing (n=35; 6.0%), catching (n=20; 5.0%), faking (n=26; 4.5%), screening (n=13; 2.2%) and fighting for the ball (n=10; 1.7%). Seventy-five injuries (12.9%) were classified as other.

Co-Kinetic comment This is an excellent breakdown of injury mechanisms that should have coaches thinking of things to do to prevent the loss of their players – the most obvious of which is teaching them to land well from jumps and protect themselves if they do get knocked to the ground. As a bonus there is an analysis of whether the contact injuries were a result of foul play. Twenty-eight percent were but 7% of them were to the player fouling. As icing on the cake, the assessors agreed with 92.5% of the referee’s subsequent decisions concerning the foul.

“OSGOOD SCHLATTER OF THE FINGER” – A CASE REPORT OF APOPHYSITIS OF THE PROXIMAL INTER-PHALANGEAL JOINT OF THE FINGER AND REVIEW OPEN OF INJURIES IN ADOLESCENT CLIMBERS. Ting JWC, Jacomel T, Lindau TR et al. Acta Scientific Orthopaedics 2020;3(1):10–14 guidelines on chronic overuse injuries in climbers. In summary these are: l Complete rest from climbing, especially in patients who present with early, reversible pathologies. l Stretching exercises to avoid the fingers adopting a fixed flexion position at rest. The gradual introduction of training programmes with reduced weight-bearing and increased rest periods.

l Analgesia and splinting if required. l In young patients, intensive and prolonged training should be avoided until their fingers have stopped growing to prevent the injury from occurring in the first place.

Co-Kinetic comment This is a must-read if you are involved with climbers but good luck with stopping them climbing!

Co-Kinetic Journal 2020;85(July):4-7

RESEARCH INTO PRACTICE

Journal Watch Physical Therapy

ANALYSIS OF RUNNINGRELATED INJURIES: THE VIENNA STUDY. Benca E, Listabarth S, Flock FKJ et al. Journal of Clinical Medicine 2020;9(2):438 OPEN

Anthropometric, training, footwear, anatomic malalignment and injury data from 196 injured runners attending an orthopaedic centre in Austria (hence the title of ‘The Vienna Study’), were case-controlled and retrospectively assessed to identify risk factors. The majority of patients were female (56%). The three most frequently observed malalignments included varus knee alignment, pelvic obliquity and patellar squinting. The most common injuries were patellofemoral pain syndrome (PFPS), iliotibial band friction syndrome (ITBFS), patellar tendinopathy, spinal overload, and ankle instability. Previous injury history was a contributing factor for knee injuries and ITBFS. Lower training load was reported with a higher

incidence of PFPS, while a higher training load was positively associated with injuries of the lower leg. Runners with a higher BMI were at a significantly higher risk for lower back injuries.

Co-Kinetic comment If you are a stats person or deeply interested in preventing running injuries, then it is worth getting hold of this paper. All the patient examinations were carried out by ‘senior orthopaedics and trauma surgeons, who were also specialised in sports medicine’ and they came up with PFPS as one of the common injuries. PFPS is a lazy diagnosis but sadly much used. Callaghan et al. (2012) described it as ‘knee pain as a result of problems between the kneecap and the femur’. Surely it would be better to identify exactly what the problem is rather than opt for a catch-all phrase?

FORTY-FIVE PER CENT LOWER ACUTE INJURY INCIDENCE BUT NO EFFECT ON OVERUSE INJURY PREVALENCE IN YOUTH FLOORBALL PLAYERS (AGED 12–17 YEARS) WHO USED AN INJURY PREVENTION EXERCISE PROGRAMME: TWO-ARMED PARALLEL-GROUP CLUSTER RANDOMISED CONTROLLED TRIAL. Åkerlund I, Waldén M, Sonesson S et al. British Journal of Sports Medicine 2020;doi:10.1136/bjsports-2019-101295 [Published online first] Eighty-one youth community level floorball teams with female and male players (aged 12–17 years) were cluster-randomised into an Intervention or Control group. Intervention group coaches were instructed to use the Swedish Knee Control programme and a standard running warm-up before every training session, and the running warm-up before every match, during the season. Control teams continued usual training. Teams were followed during the 2017/2018 competitive season (26 weeks). Player exposure to floorball and occurrence of acute and overuse injuries were reported weekly via a web-based player survey using the Oslo Sports Trauma Research Centre Questionnaire. There were 301 players in the intervention group and 170 in the Control group. There were 349 unique injuries in 222 players. The Intervention group had a 35% lower

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incidence of injuries overall than the Control group. Intervention group teams had a 45% lower incidence of acute injuries. There was no difference between the groups in the prevalence of overuse injuries.

Co-Kinetic comment Floorball is a pivoting sport played with a plastic stick and light plastic ball on a 40×20m-sized pitch with five field players and one goalkeeper in each team. (Roller hockey without skates?) Apparently, there are 300,000 players worldwide and, not surprising considering the stick skills required, the ice-hockey-playing nations dominate the international scene. The Swedish Knee programme originated with the Swedish Football Association and their insurance company to reduce the burden of knee injuries in the sport. It focuses on lower limb and core strength, neuromuscular control, balance, and

jumping and landing technique, and according to this study it works. In the discussion about possible adverse effects of the programme itself, particularly patellofemoral pain during patella loading activities, such as lunges and squats, the authors state, “Teaching coaches how to instruct on correct exercise execution, how to provide feedback to players, and how to modify exercises if necessary, could help reduce such adverse outcomes”. Isn’t this what all coaches are supposed to do?

OPEN

EFFECTIVENESS OF UPPER EXTREMITY PROPRIOCEPTIVE TRAINING ON REACTION TIME IN TABLE TENNIS PLAYERS. Bokil C, Bisen R, Kalra K. International Journal of Health Sciences and Research 2020;10(5):34–39 OPEN

The aim of this study was to examine the effectiveness of upper extremity proprioceptive training on reaction time in novice table tennis players. Both males and females in the age group of 7–15 years were included in the study. They were divided into two groups: Control group (n=17) and Experimental group (n=17). The reaction time of all the players was measured using the ruler drop test before and after the intervention. Basically, a ruler, with zero at the top, is held and then released by the tester without signalling when the drop will occur. The subject holds

out their hand at the bottom of the ruler with a gap between their thumb and first finger. When it is caught the number level with the subject’s hand is recorded. Three readings were taken and the mean was recorded as the reaction time of that subject. For 6 weeks, both groups were given an exercise programme that included lower limb strengthening exercises, core strengthening exercises and agility training exercises. The Experimental group were given a progressive proprioception training programme including rhythmic stabilisation, quadruped holds, and balancing with the hands on a wobble board and gym ball (the full routine and

PHYSICAL THERAPY VERSUS GLUCOCORTICOID INJECTION FOR OSTEOARTHRITIS OF THE KNEE. Deyle GD, Allen CS, Allison SC et al. New England Journal of Medicine 2020;382:1420–1429 Patients in the U.S. Military Health System with osteoarthritis in one or both knees were randomly assigned in a 1:1 ratio (N=156; 78 patients per group) to receive a glucocorticoid injection or to undergo physical therapy. The primary outcome was the total score on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). The secondary outcomes were the time needed to complete the Alternate Step test, the time needed to complete the Timed Up and Go test, and the score on the Global Rating of Change scale. The physical therapy protocol is fully described in an earlier paper by the same group [Deyle GD, et al. A multicentre randomised, 1-year comparative effectiveness, parallelgroup trial protocol of a physical therapy approach compared to corticosteroid injections BMJ Open 2016;6(3):e010528] (https://bmjopen. bmj.com/content/6/3/e010528. long)]. It is an open access paper if you want more details but basically it involved manual techniques to improve ROM immediately before the patient performed reinforcing exercises to help the patient perform the movements with little or no pain. Patients underwent up to 8 treatment 6

sessions over the initial 4- to 6-week period; the patient could attend an additional 1 to 3 sessions at the time of the 4-month and 9-month reassessments. They also had home exercise folders with pictures and instructions for each exercise, compliance logs to document exercise performance, and videos of the core set of exercises to enhance compliance and accurate performance of the exercises. Baseline characteristics, including severity of pain and level of disability, were similar in the two groups. The mean (±SD) baseline WOMAC scores were 108.8±47.1 in the glucocorticoid injection group and 107.1±42.4 in the physical therapy group. At 1 year, the mean scores were 55.8±53.8 and 37.0±30.7, respectively (a finding favouring physical therapy). Changes in secondary outcomes were in the same direction as those of the primary outcome. One patient fainted while receiving a glucocorticoid injection.

Co-Kinetic comment A big shout out for physical therapy. It’s a bit disturbing that someone in the military system faints at the site of a needle.

timings is described in the paper). Within-group comparison showed that the reaction time was not significantly different in the Control group, whereas the reaction time significantly decreased in the Experimental group. Between-group comparison of reaction time showed a significant statistical difference between the Control and Experimental groups, indicating that the Experimental group produced a significantly shorter reaction time at the end of 6 weeks.

Co-Kinetic comment Excellent paper. This training should be standard in school PE lessons if it is not already.

TO PLAY OR NOT TO PLAY? SPORTS PARTICIPATION AND SHARED DECISION-MAKING IN ATHLETES WITH INHERITED HEART RHYTHM DISORDERS. Li COY, Roston TM, MacEwing C et al. British Journal of Sports Medicine 2020;doi:10.1136/ bjsports-2019-101236 [Published online first] This starts by saying that the 2005 American College of Cardiology and the European Society of Cardiology consensus statements recommended uniform and mandatory disqualification of athletes with inherited heart rhythm disorders from competitive sports owing to the potential risk of fatal arrhythmias precipitated by adrenergic stress. It then goes on to suggest that this advice is antiquated practice and that there are now many evidence-based markers that, if monitored, can allow affected athletes to exercise. There are recommendations based around shared decision-making between the patient, parents, physician and other stakeholders (ie. family, coach, athletic trainer, school). A short summary of their recommendations is that patients should rest when they feel symptoms that could be cardiac in nature and contact their healthcare provider. Trying to exercise through palpitations, dizziness, chest pain or acute illness is dangerous. Ensuring adequate hydration for all types of exercise is important. Strenuous physical activity, especially in hot environments, should

Co-Kinetic Journal 2020;85(July):4-7

RESEARCH INTO PRACTICE

This starts with some attentiongrabbing facts. More than one-third of cross-country and long-distance runners experience bone stress injuries (BSIs). In track and field athletes it is up to about 21%. About 50% of track and field athletes report one or more histories of BSI, and up to 12% of cross-country and track athletes with a BSI history are reported to have continued BSI for the next 1–2 years. Of all sports-related injuries encountered in sports medicine clinics, BSIs account for up to 20%. In long-distance runners, half of the BSIs occur in the tibia and most of the other BSIs occur in the femur, fibula, calcaneus and metatarsal bones. Although a stress or complete fracture are at the most severe end of a pathology continuum, early identification of symptoms may

be avoided because of the risk of heat stress, dehydration and electrolyte disturbance. Athletes should be trained to recognise dizziness, increased clouding of consciousness and extreme breathlessness during exercise. The level of physical exertion is the most important determinant of symptoms; however, highrisk activities in which syncope can be fatal (such as rock climbing, deep-water scuba diving and open water swimming) must be avoided. Families and team staff should be well prepared with an emergency response plan in place for a cardiac event. Proficiency in cardiopulmonary resuscitation and rapid access to an automated external defibrillator at home, during training and sporting events and throughout the community are life-saving. Involving families and sports teams promotes engagement and shared management of inherited heart rhythm disorders that extends beyond the immediate healthcare team.

Co-Kinetic comment This is about allowing athletes with inherited heart rhythm disorders to enjoy the benefits of exercise and the joy of being part of a team. This is commendable but if adopted it puts a huge burden on those involved in the decision and an even bigger one on the pitch-side care providers.

Co-Kinetic.com

BONE STRESS INJURIES IN RUNNERS: A REVIEW FOR RAISING INTEREST IN STRESS FRACTURES IN KOREA. Song SH, Koo JH. Journal of Korean Medical Science 2020;35(8):e38 prevent the condition getting to that point. These include local bone pain and tenderness. There are several risk factors that can lead to a higher incidence of BSI: l Biological factors: drugs such as antacids, steroid and antidepressants, lack of vitamin D and calcium. l The female athlete triad: the combination of disordered eating, amenorrhoea and low bone density and osteoporosis. l Biomechanical factors: misalignment or anatomic problems such as leg length discrepancy, small calf circumference, pes cavus, pes planus, average vertical loading rates, peak

hip adduction, rear foot eversion during running, ridged running surface and total mileage of more than 32km per week.

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Co-Kinetic comment This paper speaks for itself. Bone stress injury can be prevented. In addition to addressing the above risk factors, the paper cites a previous study which states that engaging in ball sports, such as football and basketball, for a 2-year period during adolescence has been reported to reduce the risk of BSI. See Tenforde AS, Sainani KL, Carter Sayres L et al. Participation in ball sports may represent a prehabilitation strategy to prevent future stress fractures and promote bone health in young athletes. PM & R 2015;7(2):222–225 (https://bit.ly/3gKbhRL).

ALTERED HIP CONTROL DURING A STANDING KNEELIFT TEST IS ASSOCIATED WITH INCREASED RISK OF KNEE INJURIES. Leppänen M, Rossi MT, Parkkari J et al. Scandinavian Journal of Medicine & Science in Sports 2020;30(5):922–931 The purpose of this study was to examine a link between hip and pelvic control as a risk factor to lower extremity injury. Basketball and floorball players (aged 12–21 years) (N=258) participated in a standing knee-lift test using 3D motion analysis. Two trials per leg were recorded from each participant. Peak sagittal plane pelvic tilt and frontal plane pelvic drop/hike were measured. New non-contact lower extremity injuries, and match and training exposure were recorded for 12 months. Seventy acute injuries were registered. Of these, 17 were knee injuries (8 anterior cruciate ligament ruptures) and 35 ankle injuries. Risk factor analyses showed that increased contralateral pelvic hike was significantly associated with knee injury risk when using categorical variable. Furthermore, significant association was found between high lateral pelvic hike angles and ACL injury risk in female players. Poor combined sensitivity and specificity of the test was observed.

Co-Kinetic comment There have been lots of studies aimed at predicting injuries and this one shows real promise in that the screening is easy to do. If you want more information on what a simple one-leg stance can tell you check out this video by Physiotutors (https://bit.ly/2XVnF8W).

CLICK ON RESEARCH TITLES TO GO TO ABSTRACT EFFECT OF PRESSURE RELEASE AND POSITIONAL RELEASE WITH PHONOPHORESIS IN MANAGEMENT OF MYOFASCIAL TRIGGER POINT OF TRAPEZIUS. Patil SC, Patil C. International Journal of Clinical Skills 2020;14(2):306–311 A total of 60 patients (aged 20–33 years) with identified myofascial trigger points (MTrPs) were assessed for pain, cervical range of motion and completed the neck disability index. They were randomly assigned to either a manual pressure release group in which a therapist applied slow pressure to the MTrPs until 70% of the subject’s pain tolerance. The pressure was sustained for 60s and was monitored to maintain constant pressure. If the subject reported that the pain decreased to 30%, the therapist slowly increased the pressure to restore the perceived pain to the original value of 70%. The second group were treated with positional release therapy. The patient was seated with the cervical

spine in a neutral position. The therapist located the MTrP in the upper trapezius muscle by manual palpation. Then, gradually increasing pressure was applied until the sensation of pressure became one of pressure and pain. At that moment, the patient was then passively placed in a position that reduced the tension under the palpating fingers which caused a subjective reduction of pain by around 70%. The position was usually cervical extension, ipsilateral side-flexion, and a slightly contralateral cervical rotation (5–8°). The patient’s upper extremity was positioned in passive abduction. This position was maintained for the 90s. Finally, the patient was slowly passively placed in the neutral

FASCIA AND SOFT TISSUES INNERVATION IN THE HUMAN HIP AND THEIR POSSIBLE ROLE IN POST-SURGICAL PAIN. Fede C, Porzionato A, Petrelli L et al. Journal of Orthopaedic Research 2020;doi:10.1002/jor.24665 To evaluate the distribution of innervation of the hip joint, soft tissue samples (approximately 1×1cm) were taken from 11 patients (three men, eight women, mean age 84.2 years). Seven samples were taken from the right limb, and four from the left. Samples were also taken from two cadavers, both sides, right and left, from the following layers: skin, subdermal tissue, superficial adipose tissue, superficial fascia, deep adipose tissue, deep fascia, gluteus medius muscle, vastus lateralis muscle, vastus lateralis tendon, iliac-femoral ligament, hip capsule and round ligament. The skin was the most highly innervated, the tendon was the least innervated. The muscles (vasto-lateral and gluteus medius) were the second most innervated structure but with only a few nerves, of large diameters. The capsule was also very poorly 8

innervated. Fasciae were invaded by networks of small nerve fibres, revealing a possible role in pain. Superficial fascia and superficial adipose tissue were more innervated than their deeper equivalates.

Co-Kinetic comment This started as an investigation into why some patients had persistent symptoms, most commonly pain, after otherwise successful hip replacement surgery. The authors state, ‘in general, not enough attention is paid to the breaking and removal of certain structures in hip replacement surgery’. That may well be the understatement of the year. If you have watched a hip replacement either live in a theatre or on video, it will not come as a surprise that it hurts because the joint and surrounding structures take a bit of a battering. The headline, however, is the confirmation that both the superficial and deep fascia are ‘penetrated throughout by a network of small nerve fibres’. This confirms the role of fascia in proprioception, owing to the capacity of fascia to perceive variations of tension in a complex tri-dimensionality, integrating signals from longitudinal, transversal and vertical axes.

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position of the cervical spine. Both groups received phonophoresis: pulse mode ultrasound for 7min with 1% hydrocortisone. All treatments were given daily for 14 days. The results showed a statistically extremely significant improvement in pain and cervical flexion in both the groups. Between-group analysis showed statistically significant improvement in the manual pressure release over the positional release.

Co-Kinetic comment “Extremely significant improvement” sounds very good. The trouble is that there was no third group who only received the drug so we can’t know if it was the drug that made the difference.

This is a case study involving an otherwise healthy 46-year-old female yoga practitioner and runner, who presented with pain in the arch of the right foot that had developed 6 months ago after a 3-mile run. She had tried self-management, which included icing and stretching but this was unsuccessful. She was diagnosed with plantar fasciitis. She received two cortisone injections and was immobilised for 6 weeks with her foot in a brace. Following this she was transitioned to a soft brace, night splint, and was advised to increase her functional activities gradually and initiate self-stretching. She was not able to manage her condition independently and she remained functionally limited. She was not able to return to her normal running activities or participate in her normal yoga activities, and

Co-Kinetic Journal 2020;85(July):8-11

RESEARCH INTO PRACTICE

Journal Watch Manual Therapy

TO COMPARE THE EFFECT OF SPECIFIC YOGA AND AEROBIC EXERCISE PROGRAM ON VITAL PARAMETERS IN YOUNG ADULT FEMALES. Desai B, Desai D. International Journal of Current Research and Review 2020;12(02):1–5

Healthy females aged 18–35 years who had not engaged in physical activity for the previous year and who had no experience of either yoga or aerobics were divided into two groups. One followed a specific yoga 45min programme of three asana and three pranayama all performed in sitting (n =50). The other (n =50) did an aerobics programme of moderate intensity exercise also for 45min, consisting of a warm-up, jogging, aerobics dance with music at 50–75% of maximal heart rate followed by a stretching cool down. All the aerobics were done in standing. There were 3 sessions a week for 3 weeks. Data was collected before and after the programme and at 3 weeks after the

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programme. The yoga group showed significant improvement in heart rate, respiratory rate, systolic blood pressure that was better than with aerobics. Diastolic blood pressure and temperature showed statistically equal improvement.

Co-Kinetic comment Perfect exercise routines for home use. Pick one or mix and match and you are going to improve your fitness markers. Spread the word among friends and family and you could write your own study because the authors are kind enough to suggest that the same study can be done with standing asana, or done on male participants or with a longer followup or other age categories. Go on, what are you waiting for?

THE MANAGEMENT OF PLANTAR FASCIITIS WITH A MUSCULOSKELETAL ULTRASOUND IMAGING GUIDED APPROACH FOR INSTRUMENT ASSISTED SOFT TISSUE MOBILIZATION IN A RUNNER: A CASE REPORT. Sillevis R, Shamus E, Mouttet B. International Journal of Sports Physical Therapy 2020;15(2):274–286 for that reason she was referred to physical therapy where in addition to normal physical examination a musculoskeletal ultrasound imaging (MSK US) revealed there was thickening of the plantar fascia 3cm distal from the calcaneal origination. Additionally, this region demonstrated a tendinosis-type presentation with several areas of disruption. Subsequent treatment involved ankle and talocural joint mobility and decreasing the tightness and hypersensitivity of the plantar fascia using mobilisations, MET strengthening of the tibialis posterior and triceps surae and instrumentassisted massage of the affected area. The MSK US imaging allowed the exact location to be targeted. She

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received 8 treatment sessions over 4 weeks. After 3 sessions, additional hip strengthening exercises and gait training to normalise her neuromuscular recruitment pattern were added. After 5 sessions there was no longer pain during the instrument-assisted massage. By the end she had normal ankle dorsiflexion, no pain with palpation of the plantar fascia, negative windlass test, and she reported no pain during gait. A follow-up MSK US revealed normal presentation of the plantar fascia and she returned to activity with a home exercise programme of stretching and strengthening exercises and arch supports. At 1-month follow-up she was pain-free and reported no functional limitations.

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Co-Kinetic comment Before and after MSK US takes a lot of the educated guesswork out of return-to-play decisions. Handheld ultrasound scanners that feed the image to a tablet or mobile are becoming cheaper. Soon they will be as essential and ubiquitous as the ‘magic sponge’ used to be.

Thirty patients with clinically diagnosed lateral epicondylalgia were enrolled in this randomised, sample size planned, placebo-controlled, patient-blinded, monocentric trial. Women and men aged between 18 and 55 years with unilateral, acute and subacute (pain duration did not exceed 6 months) lateral epicondylalgia humeri were included. An ‘elbow expert’ confirmed the diagnosis by inspection, palpation, range of motion, peripheral blood circulation, sensibility, motor activity, and nerve bottleneck. Provocation tests included gripping, resisted contraction wrist extensors with m. carpi radialis brevis, stretching the forearm extensors or pain on the lateral epicondyle during palpation. At least one of these needed to be positive for the patient to be included

Participants were randomly assigned to either a control group (n=19) receiving ultrasound (US) and prescriptive exercise or to an experimental group (n =24) receiving manual therapy (MT) in addition to US and prescriptive exercise over a 6-week treatment period. US was set at 1.2w/cm2 for 8min applied over the joint line of the affected articulation. MT included massage of the affected area for 5–10min. Stretching with a 10s hold on non-weight-bearing joints and 20s for larger weightbearing ones. Low amplitude joint mobilisation (Maitland grade 1 and 2) was implemented if there were capsular restrictions or high pain levels preventing mobility. Grade 3 end range mobilisation was used for cases of restricted joint mobility. The majority of joint mobilisation

THE EFFECT OF MANUAL THERAPY TO THE THORACIC SPINE ON PAIN-FREE GRIP AND SYMPATHETIC ACTIVITY IN PATIENTS WITH LATERAL EPICONDYLALGIA HUMERI. A RANDOMIZED, SAMPLE SIZED PLANNED, PLACEBO-CONTROLLED, PATIENT-BLINDED MONOCENTRIC TRIAL. Zunke P, Auffarth A, Hitzl W et al. OPEN BMC Musculoskeletal Disorders 2020;21:Article 186 in the study. A placebo group (15 patients) received a 2min one-time sham ultrasound therapy. The treatment group (15 patients) received a grade 3 mobilisation at T5, which is defined as a large-amplitude oscillating mobilisation until the end of movement of the ribs performed at 2Hz (120 impulses per minute) for 2min. The direction of the mobilisation was posterioranterior and lateral and craniocaudal. This specific technique was chosen because of the anatomical positioning of the sympathetic trunk dorsal to the costovertebral joints.

Before and after measurements resulted in significantly increased strength of pain-free grip +4.6kg±6.10 and skin conductance +0.76μS±0.73 as well as a decrease in peripheral skin temperature by −0.80°C±0.35 within the treatment group.

Co-Kinetic comment This is a very detailed paper so congratulations to the authors. They come to the conclusion that the thoracic mobs activate the body’s own descending pain inhibitory mechanisms.

MANUAL THERAPY IS EFFECTIVE IN REDUCING VAS PAIN SCORES IN PATIENTS WITH OSTEOARTHRITIS. Stoski M, Evans J. Physical Therapy and Rehabilitation 2019;6:Article 14 was grade 3 into the restricted range unless visual analogue scale pain level was higher than 6. Distraction of the articulations occurred before any joint glide, roll, or rock technique. Participants in both groups were prescribed exercises consisting of active range of motion of the involved joint, joint preserving exercises, and a functional activity appropriate to the joint. The prescribed exercises were performed at a level that was challenging to the subject: a level where they could not complete

more than 2 sets of 15 reps without experiencing fatigue of the primary muscle group. Exercise routines were carried out during each appointment over the 6-week period and were limited to 5–10 exercises that were specifically intended to promote range of motion, stabilisation, and joint preservation, and reduce the functional limitation seen before joint treatment. The MT group experienced a significantly greater reduction in pain level and this was more evident among women, participants with low or normal BMI scores and those with affected weight-bearing joints. No correlation between change in pain level and basal cortisol was found.

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Co-Kinetic comment On the plus side, if you want evidence that MT works quote this paper. On the downside, the authors may have been a tad ambitious in mixing up subjects with issues at different joints. Their results would have had more impact if backed up by precise treatment details. For example, they do a 10s stretch on smaller joints without naming them, or massage for a stated time but don’t give enough detail for the treatment to be repeated. 10

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MASSAGE: AN ALTERNATIVE APPROACH TO PAIN MANAGEMENT. Horner P, Abshari S, Grove C. Nursing 2020;50(4):17–19 This study began with a hospital in the USA looking to lower its opioid prescription numbers, which is important in a county in the grips of an opioid dependency epidemic. They started to offer 15min massage therapy sessions and after some logistical obstacles (such as picking the right time and day for treatment, not interrupting lunch service and the reluctance of some female patients to be treated by a male) they ended up with results from 32 patients who had participated over an 8-week period. Using various pain questionnaires they found that the average pain intensity score recorded by the patients before the service was 5.88 with a standard deviation of 2.61. After the massage, the average pain intensity score was 2.70 with a standard deviation of 2.41, resulting in a 54% reduction in pain scores overall.

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In addition, from qualitative data obtained from nursing staff and patient comments they found that there were significant improvements in pain intensity level, emotional wellbeing, relaxation, and the ability to sleep. Patients with respiratory issues (a topical complaint as this review is being written during the Covid-19 lockdown) reported not only less pain but they also had improved oxygenation and lung function.

Co-Kinetic comment Given that in the UK the Chartered Society of Physiotherapy evolved from the Society of Trained Masseuses which was formed in 1894 by four nurses, and that this paper points out that in 1882, the ‘American Florence Nightingale’, Anna Maxwell, of Massachusetts General Hospital in Boston, began instructing nursing students in the art of massage, it is difficult to see why massage can be classed as an ‘alternative’ approach but let’s not be picky. It is very positive about the use of the ancient and noble art.

MASSAGE DURING MUSCLE UNLOADING INCREASES PROTEIN TURNOVER IN THE MASSAGED AND NON-MASSAGED, CONTRALATERAL LIMB, BUT DOES NOT ATTENUATE MUSCLE ATROPHY. Kargl CK, Sullivan BP, Gavin TP. Acta Physiologica 2020;e13497 Warning this is an animal study The aims of this study were to investigate possible ways to alleviate the rapid loss of muscle mass following periods of muscle disuse during post-fracture, surgery or bed rest. Rats were assigned to one of 4 groups: normal weight-bearing (WB), WB with massage (WBM), hindlimb suspension for 7 days (HS) or hindlimb suspension for 7 days with massage (HSM). The massage was in the form of cyclic compressive loading. The contralateral limb was used as a control. Contrary to the authors’ hypothesis there were no differences in muscle mass or protein regulation in the massaged or contralateral leg under normal weight-bearing conditions. However, the massage therapy did generate a robust myofibrillar protein synthesis response suggesting increased myofibrillar protein turnover could maintain or even improve myofibrillar protein quality and muscle function. Co-Kinetic.com

There were no differences between HS and HSM for myofibrillar protein degradation or cytosolic protein synthesis rates; however, massage attenuated the HS-induced increase in cytosolic protein degradation. Perhaps the most important finding of the study was that a strong crossover effect was found in the non-massaged, contralateral limb during muscle unloading conditions.

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Co-Kinetic comment The authors were expecting a decrease in muscle atrophy and didn’t get it. They did get an increase in protein synthesis, however, and that is the building block of muscle growth. They admit that ‘the precise implications of these changes in muscle protein regulation in response to massage are unclear’. More work to do then, but what this does show is that massage therapists are right when they point out that something good is happening when they apply force to tissue. Hopefully the science will catch up soon.

COMPARISON OF THREE DIFFERENT METHODS OF ACTIVE AND INACTIVE RECOVERY AND ALSO SPORT MASSAGE ON ASPARTATE AMINOTRANSFERASE AND ALDOLASE ENZYME ACTIVATIONS AND SOME HEMATOLOGICAL BLOOD FEATURES IN FEMALE RUNNERS. Rahmani Ghobadi M, Hoseini SA, Hasanpour G. OPEN Physical Education of Students 2019;23(2):82–88 Three groups of female runners aged between 18 and 24 years were allocated to an active recovery group, an inactive sports massage group and an inactive resting group (n=10 for each group) and all gave blood samples after a 10–12h fast. On competition day they gave a further sample post-event and another after the recovery session. The active recovery is described as stretching and fast running for 35 to 40min, inactive as slow walking and sitting. The results showed that ‘there is not a meaningful relation among the three recovery methods for changing aspartate aminotransferase and aldolase enzyme, blood iron and red blood cell levels’. But ‘there is a positive meaning among inactive, soft and massage recovery in changing of white blood cell, haematocrit and haemoglobin’.

Co-Kinetic comment Sadly this reads like it has been put through translation software. Points are ‘super important’ and the best athletes are described as ‘genius athletes’. Its aims are admirable. It points out that, ‘a bad recovery after an exercise session may lead to dysfunction in next exercise session’ so it is looking to find the best recovery strategy by analysing when markers in the blood return to ‘normal’ levels. It talks a lot about those markers but omits detailed information of the recovery methods. It doesn’t even say what event the subjects took part in, which is a pity because it is a great idea but it doesn’t help an athlete or coach decide on the right recovery for them. Somebody take this further please. 11

THE 10 MOST DISCUSSED PIECES OF RESEARCH IN PHYSICAL & MANUAL THERAPY (APR - JUN 2020)

PHYSIOTHERAPY MANAGEMENT FOR COVID-19 IN THE ACUTE HOSPITAL SETTING: CLINICAL PRACTICE RECOMMENDATIONS Journal of Physiotherapy (Australian

Physiotherapy Association)

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PHYSICAL THERAPY VERSUS GLUCOCORTICOID INJECTION FOR OSTEOARTHRITIS OF THE KNEE New England Journal of Medicine

866 24 INTERNATIONAL FRAMEWORK FOR RED FLAGS FOR POTENTIAL SERIOUS SPINAL PATHOLOGIES

Journal of Orthopaedic & Sports Physical Therapy

931 10 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

1011 21 AN UPDATE OF SYSTEMATIC REVIEWS EXAMINING THE EFFECTIVENESS OF CONSERVATIVE PHYSICAL THERAPY INTERVENTIONS FOR SUBACROMIAL SHOULDER PAIN Journal of Orthopaedic & Sports Physical Therapy

6 7 9 The PDF version of this infographic Facebook Mendely includes hyperlinks to the Tweets posts readers individual pieces of research. Click here to access https://bit.ly/2MLJi6b

10 News mentions

Tweets

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785 11

HOURLY 4-S SPRINTS PREVENT IMPAIRMENT OF POSTPRANDIAL FAT METABOLISM FROM INACTIVITY Medicine

and Science in Sports & Exercise

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THE STANFORD HALL CONSENSUS STATEMENT FOR POST-COVID-19 REHABILITATION British Journal of Sports Medicine

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TEMPORAL MUSCLE-SPECIFIC DISUSE ATROPHY DURING ONE WEEK OF LEG IMMOBILIZATION Medicine and Science in Sports & Exercise

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INFLUENCE OF REDUCING ANTERIOR PELVIC TILT ON SHOULDER POSTURE AND THE ELECTROMYOGRAPHIC ACTIVITY OF SCAPULAR UPWARD ROTATORS Brazilian Journal of Physical Therapy

224 1 Produced by: TIME-SAVING RESOURCES FOR PHYSICAL AND MANUAL THERAPISTS

THE 10 MOST DISCUSSED PIECES OF RESEARCH IN HEALTH & WELLBEING The PDF version of this infographic (APR - JUN 2020)

DEPRESSIVE SYMPTOMS AND OBJECTIVELY MEASURED PHYSICAL ACTIVITY AND SEDENTARY BEHAVIOUR THROUGHOUT ADOLESCENCE: A PROSPECTIVE COHORT STUDY

EFFECTS OF YOGA ON DEPRESSIVE SYMPTOMS IN PEOPLE WITH MENTAL DISORDERS: A SYSTEMATIC REVIEW AND META-ANALYSIS

includes hyperlinks to the individual pieces of research. Click here to access https://bit.ly/2UOcbDx

“The Lancet Psychiatry”

British Journal of Sports Medicine

CONSEQUENCES OF PHYSICAL INACTIVITY IN OLDER ADULTS: A SYSTEMATIC REVIEW OF REVIEWS AND META-ANALYSES

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NATURE CONTACT, NATURE CONNECTEDNESS AND ASSOCIATIONS WITH HEALTH, WELLBEING AND PROENVIRONMENTAL BEHAVIOURS

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EFFECT OF SPORTS MASSAGE ON PERFORMANCE AND RECOVERY: A SYSTEMATIC REVIEW AND META-ANALYSIS BMJ Open Sport & Exercise Medicine

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Mental Health & Physical Activity

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Journal of Environmental Psychology

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CORONAVIRUS DISEASE (COVID-19): THE NEED TO MAINTAIN REGULAR PHYSICAL ACTIVITY WHILE TAKING PRECAUTIONS

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REHABILITATION FOLLOWING COVID-19 PART 1: THEORETICAL CONSIDERATIONS Across the world, most of us have been living in lockdown in response to the Covid-19 pandemic, which has killed hundreds of thousands of people – an almost science-fiction-style scenario. Even with this devastating death toll, many more people are experiencing the disease and surviving. As time goes on we are beginning to discover the complications that recovered patients – particularly those who have spent time in ICU – are living with. This article, Part 1, discusses the many manifestations of Covid-19 and Part 2 discusses how to structure a rehabilitation programme for Covid-19 survivors. Read this article online https://bit.ly/2Aj8dLO

Disclaimer: At the time of publication this article is based on published evidence available. To date there are no follow-up studies or trials that focus on the long-term management and recovery post-Covid-19. Apart from a few case reports, the rehabilitation strategies suggested below are based on the understanding of how the Covid-19 virus attacks the body’s systems, and historic evidence from previous coronavirus outbreaks which have been extrapolated to management strategies of similar chronic illnesses. COVID-19 | 20-07-COKINETIC FORMATS WEB MOBILE PRINT All references marked with an asterisk are open access and links are provided in the reference list 14

By Kathryn Thomas BSc MPhil

s I write, we are currently in the grip of the Covid-19 pandemic – a disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). As we gain more experience of this infection, it’s clear that Covid-19 can be more than just a respiratory disease. It’s joined the ranks of other ‘great imitators’ – diseases that can look like almost any condition. It can be a gastrointestinal disease causing only diarrhoea and abdominal pain. It can cause symptoms that may be confused with a cold or the seasonal flu. It can cause pinkeye, a runny nose, loss of taste and smell, muscle aches, fatigue, loss of appetite, nausea and vomiting, whole-body rashes, and areas of swelling and redness in just a few spots. In more severe cases there have been reports of heart arrhythmia, heart failure, kidney damage, confusion, headaches, seizures, Guillain–Barré syndrome, and fainting spells (or altered levels of consciousness), along with new sugarcontrol problems. These symptoms and other ailments can’t be attributed to the ‘corona pneumonia’ alone. Yes, the primary and most common consequence of Covid-19 is respiratory distress and ultimately acute

respiratory distress syndrome (ARDS); however, the virus can attack many other cells within the body causing a multitude of other complications. To date, the focus of most publications and press coverage has been on patient demographics, risk factors, acute management, supportive care, prevention, medication, vaccines and life-saving strategies. But once the peak has been reached and isolation levels are eased there may be time to take a breath and consider: What now for the survivors? We clapped (and very deservedly so) for all the frontline workers and patients who survived and recovered from ICU, but will we still be clapping in 3 to 6 months’ time or even a year from now when we consider their recovery. When the dust has settled let us consider the millions of people with mild to moderate cases of coronavirus or those discharged from hospital – seemingly better – sent home to rest and recover. Concerns have been raised that it may not be so simple. This virus is unlike any seen before; knowing how it attacks the body’s cells and systems sheds some light on the fact that a little ‘R&R’ may not be the simple long-term recovery strategy for most patients. One open question concerns the long-term effects for survivors.

IT’S CLEAR THAT COVID-19 CAN BE MORE THAN JUST A RESPIRATORY DISEASE Co-Kinetic Journal 2020;85(July):14-21

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What does life look like after being on a ventilator or suddenly needing dialysis? Will we see decreases in heart, lung and kidney function that is long lasting and permanent, or will patients eventually recover? At present, there are no follow-up studies or case reports of patients once discharged from hospital. The opinion is that simple resolution of symptoms may not be the end of the story. The toll on the body may result in the development of a type of chronic fatigue syndrome (CFS). Physical therapy may be required long term, not only in the form of pulmonary rehabilitation, but rehabilitation of exercise tolerance, as well as managing complications from deep vein thromboses (DVTs), pulmonary embolism (PE), myalgia, and even stroke.

How the Virus Invades the Body

As mentioned, Covid-19 is not simply a pneumonia with severe alveolar damage but is often associated with rapid virus replication, infiltration of inflammatory cells and elevated responses to inflammatory proteins such as cytokines resulting in damage in internal organs and ARDS. The pathophysiology also shows it causes a severe ‘cytokine storm’ and possibly disseminated intravascular coagulation, disrupting blood clotting and causing thrombotic events. This is a complex disease; the disruption to the body’s functions is extensive, potentially lengthening the time it takes to fully recover. When viral particles land in your eyes, nose or mouth, ‘spike proteins’ on the surface of the virus connect with a specific receptor, known as angiotensinconverting enzyme 2 (ACE2), on the surface of your cells, allowing entry. ACE2 receptors make a great target because they are found in organs throughout your body. Once the virus enters, it turns the cell into a factory, making millions and millions of copies of itself – which can then be breathed or coughed out to infect others. In order to evade early detection, the coronavirus uses multiple tools to prevent the infected cells from calling out for help. The virus snips off distress signal proteins that cells make when Co-Kinetic.com

they are under attack. It also destroys antiviral commands inside the infected cell. This gives the virus much more time to make copies of itself and infect surrounding areas before it is identified as an invader. This is part of the reason why the virus spreads before immune responses, such as fever, begin (1*,2*). Once the virus is deeply embedded in the body, it begins to cause more severe disease. This is where direct attack on other organs that have ACE2 receptors can occur, including heart muscle, kidneys, blood vessels, the liver and, potentially, the central nervous system (CNS) (2*). This may be one reason for the vast array of symptoms that Covid-19 can cause. Early findings, including those from autopsy and biopsy reports, show that viral particles can be found not only in the nasal passages and throat, but also in tears, stool, the kidneys, liver, pancreas and heart (1*).

Pathophysiology that Kills 1. Cytokine Storm

Severe damage to the lungs may be one trigger that activates and overstimulates the immune system through a barrage of signalling chemicals, known as cytokines. The flood of these chemicals can set off what is referred to as a ‘cytokine storm’ (2*,3*). This is a complex interplay of chemicals that can cause blood pressure to drop, attract more immune and inflammatory cells, and lead to even more injury within the lungs, heart, kidneys and brain. Some researchers say that cytokine storms may be the cause of sudden decompensation, leading to critical illness in Covid-19 patients (2*). When Covid-19 infects the respiratory tract it can cause mild or highly acute respiratory syndrome with consequent release of proinflammatory cytokines, including interleukin (IL)-1β and IL-6. The binding of Covid-19 to Toll-like receptor proteins causes the release of pro-IL-1β which is cleaved by caspase-1, followed by inflammasome activation and production of active mature IL-1β, which is a mediator of lung inflammation, fever and fibrosis (2*). Secondary haemophagocytic lymphohistiocytosis (sHLH) is an under-

A LITTLE ‘R&R’ MAY NOT BE THE SIMPLE LONG-TERM RECOVERY STRATEGY FOR MOST PATIENTS recognised, hyperinflammatory syndrome characterised by a sudden, severe and fatal hypercytokinaemia with multiorgan failure. A cytokine profile resembling sHLH is associated with Covid-19 disease severity, characterised by increased IL-2, IL-7, granulocyte colony-stimulating factor, interferon gamma-induced protein 10, monocyte chemoattractant protein 1, macrophage inflammatory protein 1-alpha, and tumour necrosis factor-alpha (TNF-α) (1*,3*).

2. Abnormal Clotting

The pathogenesis of Covid-19 infection is not clearly understood. Inflammatory cytokine storms and viral evasion of cellular immune responses play a central role in disease progression and severity (4*). Disseminated intravascular coagulation and coagulopathy can contribute to death. DVT and PE can occur in patients with Covid-19 pneumonia (4*). Historically, haematological changes have been seen with sudden acute respiratory distress syndrome (SARS), caused by SARS-CoV (also known as SARS-CoV-1) another strain of coronavirus very similar to that which causes Covid-19. These included lymphopenia, thrombocytopenia, and leukopenia. The possible mechanisms of coronavirus on the blood system may include (5): 1. direct infection of blood cells and bone marrow stromal cells via cell determinant (CD)13 or CD66a proteins; and/or 2. induce auto-antibodies and immune complexes to damage these cells. In addition, lung damage in SARS patients may also play a role in inducing thrombocytopenia by (5): 1. increasing the consumption of platelets/ megakaryocytes; and/or 2. reducing the production of platelets in the lungs (as the most common haematological changes in SARS patients were lymphopenia and immunodeficiency). In clinical practice, frontline clinicians found that approximately 20% of Covid-19 15

THE MECHANISM OF ATTACK OF COVID-19 COULD PRODUCE A SIMILAR PICTURE TO THAT OF CHRONIC FATIGUE SYNDROME patients had severe coagulation abnormalities, and almost all the patients with severe and critically ill Covid-19 infection showed major coagulation disorders. A very recent study showed that markedly elevated D-dimer and fibrinogen degradation products were very common in Covid19-related deaths (6*), indicating a disruption in the coagulation cascade. Moreover, acute inflammation caused by severe infection or sepsis may affect coagulation and fibrinolysis in multiple ways, including a decrease of circulating protein C and antithrombin and an increase of plasminogen activator inhibitor-1 levels, which will finally activate the coagulation cascade and inhibit the fibrinolytic response, thus promoting thrombosis. Therefore, more attention should be paid to the occurrence of potential PE following the shedding of DVT (6*).

3. Additional Laboratory Findings

The differences in abnormalities of laboratory findings between the deceased patients and the survivors were substantial (7*,8*), with deceased patients being more likely to have: l developed leukocytosis, and one third of deceased patients had procalcitonin above 0.5ng/mL, indicating that a large proportion of deceased patients might have had secondary bacterial infection strongly associated with death; l persistent and more severe lymphopenia suggesting a cellular immune deficiency state; l impaired liver and kidney function (mild or moderate elevation of alanine aminotransferase, aspartate aminotransferase, total bilirubin, alkaline phosphatase, gammaglutamyl transpeptidase, blood urea nitrogen, and creatinine and frequent hypoalbuminaemia, 16

haematuria, and albuminuria); l electrolyte disturbance (hyperkalaemia and hypernatraemia); and/or l markedly higher concentrations of creatine kinase, lactate dehydrogenase, cardiac troponin I, and N-terminal pro-brain natriuretic peptide were seen in deceased patients than in recovered patients. Essentially, in the later stages of the disease, patients who die may develop pulmonary and extrapulmonary organ damage, including ARDS, type I respiratory failure, sepsis, acute cardiac injury, heart failure, acute kidney injury, hypoxic encephalopathy, shock, acidosis or alkalosis, disseminated intravascular coagulation, and acute liver injury.

Changes in Lung Tissue and Function

The chest X-ray usually shows bilateral infiltrates which may be evident in early disease (1*,9*). However, bilateral multifocal consolidation can be seen in severe patients, partially fused into massive consolidation with small pleural effusions and even presenting with ‘white lung’ (9*). The computed tomography scan (CT) is more sensitive and specific. CT imaging generally shows infiltrates, ground-glass opacity (GGO) and subsegmental consolidation. CT results can also be abnormal in asymptomatic patients/patients with no clinical evidence of lower respiratory tract involvement. In fact, abnormal CT scans have been used to diagnose COVID-19 in suspect cases with negative molecular diagnosis; many of these patients had positive molecular tests on repeat testing (1*,9*). In patients with Covid-19 pneumonia, focal or multifocal pure GGO and GGO with reticular and/ or interlobular septal thickening as typical crazy-paving pattern have been observed (9*). From mild to severe, Covid-19 pneumonia mainly starts as small subpleural, unilateral or bilateral GGO in the lower lobes, which then develops into the crazy-paving pattern and subsequent consolidation. After more than 2 weeks, the lesions are gradually absorbed with residual GGO and subpleural parenchymal bands. In

patients who recovered from Covid-19 pneumonia, four stages of lung involvement have been defined on CT (10*): 1. Early stage (0–4 days after onset of the initial symptom) In this stage, GGO was the main radiological demonstration distributed subpleurally in the lower lobes unilaterally or bilaterally. 2. Progressive stage (5–8 days after the onset of the initial symptom) In this stage, the infection rapidly aggravated and extended to a bilateral multilobe distribution with diffuse GGO, crazy-paving pattern and consolidation. 3. Peak stage (9–13 days after the onset of the initial symptom) In this stage, the involved area of the lungs slowly increased to the peak involvement and dense consolidation became more prevalent. Findings included diffuse GGO, crazy-paving pattern, consolidation, and residual parenchymal bands. 4. Absorption stage (≥14 days after the onset of the initial symptom) In this stage, the infection was controlled and the consolidation was gradually absorbed. No crazy-paving pattern was present anymore. However, in this process, extensive GGO could be observed as the demonstration of the consolidation absorption. The absorption stage can be extended beyond 26 days. All Covid-19 patients have features of diffuse alveolar damage with pronounced pulmonary oedema and hyaline membrane formation. In some areas, there was interstitial thickening, with mild to moderate fibrosis, but a disproportionately sparse infiltrate of inflammatory cells (mainly histiocytes, including multinucleated forms, and lymphocytes). Dilation of the airspaces was seen, as was focal honeycombing fibrosis. Intra-alveolar organisation of exudates was seen, with the formation of granulation tissues in small airways and airspaces in some cases. These lesions were typically located in the subpleural region and the cellular component consisted mainly of histiocytes (11*). Co-Kinetic Journal 2020;85(July):14-21

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What Causes ARDS?

Capillary permeability is a tightly regulated feature of microcirculation in all organ beds and is fundamentally altered in sepsis, resulting in net extravasation of fluid out of the vascular space and into tissues. A dramatic manifestation of this phenomenon is ARDS, a complication that occurs in up to 40% of patients with sepsis and is marked by leakage of fluid out of pulmonary capillaries and into alveolar septa and air spaces. Excess extravascular fluid in the lung impairs gas exchange across the alveolar membrane and decreases lung compliance. ARDS associated with sepsis has been correlated with adverse clinical outcomes, including 40% mortality (12*, 13*). It has been shown that the renin-angiotensin system in the lung is involved in ARDS. The interaction between angiopoietin-2 and its type 1 receptor causes a disruption of the COX-2, cyclo-oxygenase 2; iNOS, inducible nitric oxide synthase; PUFA, polyunsaturated fatty acids; NFκB, nuclear factor κB

l Viral infections l Bacterial infections l Immune disease

Intervention (primary focus) Immunologic polymorphisms (cytokines IFNγ, IL-10, TNF-α, HLA class II, HLA-KIR, etc) Hypogammaglobulinemia, etc

endothelial architecture leading to pulmonary inflammation and capillary leakage, both of which contribute to the initiation and/or the aggravation of ARDS (13*,14*).

Is There a Risk For CFS?

This section refers to the recovering patients rather than the healthcare workers! Given the pathophysiology with which Covid-19 attacks the systems of the body and the consequential cascade of biological reactions, questions have been raised whether CFS/myalgic encephalomyelitis (ME) could become a common after-effect in survivors. CFS is a debilitating disorder with a hitherto unknown aetiology but of suspected multifactorial origin. After decades of neglect and misjudgement as mental disease there is growing evidence for a complex dysregulation of the immune and autonomic nervous system in CFS/ ME (15*). Common ‘triggers’ include

severe viral infections and emotional stress. This illness is expected to be a complex, multisystem neuroimmune disease (15*). Recently, some novel clues for CFS/ME were found, such as higher levels of immunosuppressive cytokines, especially transforming growth factor beta, an altered composition of the gut microbiome, and potential biomarkers from nanoelectronic assays (15*). However, the clear mechanisms of CFS/ ME or its objective diagnostic markers have not yet been found (15*). Recent findings show that the fatigue and somatic symptoms experienced with CFS are a clinical expression of dysregulated inflammatory, immune, oxidative and nitrosative stress (IO&NS) pathways (Fig. 1). Increased levels of proinflammatory cytokines, oxidative damage, increased cyclo-oxygenase 2 (COX-2) production, increased translocation by Gram-negative enterobacteria and so on, can generate

A Bio(psychosocial) Medical Model for ME/CFS Co-factor

Physiological stress (exercise)

Immunological and gastrointestinal abberations l Inflammation (NFκB, COX-2, IL-6, IL-8, etc) l Immune dysfunction (RNAse-L fragmentation, etc) l Immunosuppression (NK cell cytotoxicity, etc) l Leaky gut and intestinal dysbiosis

Biological sequels l Oxidative and nitrosative stress (iNOS)Damage to DNA, proteins, fatty acids, etcDepletion of antioxidantsMitochondrial dysfunction and/or damageInhibition of aerobic metabolism/ATP synthesis l Channelopathy: ion channel dysfunction l Autoimmunity, neoepitopes

Co-factor

Physiological stress

ME/CFS Characteristic symptoms: l Exhaustion (“fatigue”) l Pain l Post-exertional malaise l Muscle weakness l Neurocognitive impairment, etc

Psychological consequences

Figure 1: The inflammatory and oxidative and nitrosative (IO&NS) pathophysiology of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). Figure first published in Maes M, Twisk FN. Chronic fatigue syndrome: Harvey and Wessely’s (bio)psychosocial model versus a bio(psychosocial) model based on inflammatory and oxidative and nitrosative stress pathways. BMC Med 2010;8:35 (16*) and reproduced under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0)

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EXPERIENCE FROM CHINA AND ITALY SUGGESTS THAT AT LEAST A THIRD OF PATIENTS DISCHARGED FROM HOSPITAL REQUIRE ASSISTANCE IN ACTIVITIES OF DAILY LIVING fatigue and somatic symptoms, including fatigue, a flu-like malaise, pain, symptoms of irritable bowel syndrome, and neurocognitive disorders (15*). Considering a proposed (although not fully understood) pathophysiology behind the development of CFS (illustrated in Fig. 1), one might consider the very real possibility that the mechanism of attack of Covid-19 on one’s body could produce a similar picture to that of CFS. The viral infection [immunological and biological changes, with added symptoms of muscle pain, extended bedrest and inactivity (brought on by illness and/ or isolation protocols)], combined with emotional and psychological stress of surviving Covid-19 and the resultant work, family, social, income, and lifestyle changes may all result in the development of the complex biopsychosocial condition of CFS. CFS is characterised by severe fatigue and exhaustion (prolonged over 6 months), muscular and mental fatigue, exercise intolerance, postexertional malaise (PEM) and a myriad of symptoms including impaired cognitive ability, poor sleep quality,

muscle pain, multijoint pain without swelling or redness, or headache (15*). Many patients suffer from symptoms of autonomic dysfunction including orthostatic intolerance and may complain of dizziness, spatial disorientation, sweating, palpitations or fainting. PEM, which is a hallmark of ME/CFS, is seen as an aggravation of all symptoms of ME/CFS. PEM involves an abnormal response (eg. an inappropriate loss of physical and mental stamina, rapid muscular and cognitive fatigability) following physical, cognitive, emotional or orthostatic exertion (15*). Patients with CFS/ME cannot carry out their normal social routines, work or leisure activities, and some of them are even home- or bed-bound. They experience lower health-related quality of life than those experiencing depression or stroke (15*). The medical impact includes the high prevalence in the working-age population and particularly the high risk of suicide, which is approximately 7-fold higher than in healthy controls (15*). CFS may be an important condition to be aware of in the long-term management of recovering Covid-19

TABLE 1: Complications in patients recovering from Covid-19 (17*) Most frequent l Cardiovascular, pulmonary and musculoskeletal deconditioning l Restrictive lung disease l Affective disorders: depression, anxiety, post-traumatic stress disorder l Post-intensive care syndrome, including critical-illness polyneuropathy, critical-illness myopathy and a combination of these l Other neurological consequences of the virus and critical care, such as encephalopathy, cerebrovascular events and cerebral hypoxia l Acute confusional state, at least in the early stages of rehabilitation l Fatigue l Cognitive impairment

Common, but less frequent l Thromboembolic disease: – Myocardial infarction – Stroke – Pulmonary embolism l Musculoskeletal pain and discomfort l Psychosis l Dyskinesia l Posterior reversible encephalopathy syndrome l Cardiomyopathy

patients. Integrating a component of rehabilitation for CFS with pulmonary/ cardiac rehabilitation may be an important consideration.

What will Covid-19 Rehabilitation Entail?

You may be questioning your role in the healthcare system during a time of an infectious disease pandemic. So what is the connection between physical therapy and rehabilitation in the context of infectious disease outbreaks? Given the relatively high likelihood of survival after exposure to infectious disease, physical therapy can mediate the deleterious pulmonary, respiratory and immobility complications that are commonplace. Moreover, rehabilitation can offer a cost-effective upstream strategy that can restore mental and emotional quality of life during and after medical intervention (17*). Our knowledge of the range of impairments and disabilities is still evolving and we do not know the long-term sequelae of the condition, but there is already information that will assist in estimating the scale and type of response (17*,18*). Covid-19 is a multisystemic condition and some of the effects seem to be long lasting. Experience from China and Italy suggests that at least a third of patients discharged from hospital require assistance in activities of daily living and a similar proportion have significant neurological sequelae (17*,18*). There are some publications that highlight the range of impairments that may present following infection with Covid-19, and other coronavirus infections – and this literature is expanding daily. Table 1 sets out some of the more frequent complications that are likely to be encountered in patients recovering from moderate or severe disease (18*). Clinical experience shows the main repercussions of Covid-19 infection are respiratory, CNS and cognitive, deconditioning, critical-illness myopathy and neuropathy, dysphagia, joint stiffness and pain, and psychiatric problems (19*,20*). Of SARS survivors, at 1-year follow-up, 24% had both significant impairment in diffusing Co-Kinetic Journal 2020;85(July):14-21

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capacity of the lung for carbon monoxide and reduced exercise capacity. Rehabilitation of patients with lung fibrosis secondary to ARDS can be challenging (19*). Several authors have published data on the long-term effects of ARDS and post-intensive care syndrome. Consequences of ARDS include: 1. ICU-acquired weakness in 25–100% of cases, resulting in immobility, suboptimal glycaemic control and iatrogenic use of steroids and neuromuscular blocking agents (21*). 2. Cognitive impairment in the majority of survivors at hospital discharge and in around 10% of patients impairments are persistent at long-term follow-up. These include depression (29%), post-traumatic stress disorder (22%) and anxiety (34%) affecting survivors at 1 year (20*,21*). A pre-Covid-19 study showed posttraumatic stress disorder in patients who had been in ICU for greater than 28 days. They described a clear history of severe weakness, functional impairment and prolonged recovery after hospital discharge. More than 90% still had significant weakness more than 5 years following the ICU stay (18*). Clinical experience from Italy shows that after critical Covid-19, some patients may have confusion, memory and executive function deficits, which may be due to a direct viral involvement of the CNS or the effect of hypoxemia. Considering that nearly 50% of ARDS survivors show cognitive sequelae at 2 years after the injury this could play a significant role in overall disability (19*).

How Can Rehabilitation be Executed?

Rehabilitation will require a personcentred approach, but is likely to involve improving physical strength and stamina alongside optimising psychological health, and addressing neurological rehabilitation needs when necessary (18*). Factors affecting rehabilitation for individuals are (18*): l t he range of impairments and Co-Kinetic.com

disabilities experienced; l t he rate of recovery from these impairments; and lp ersonal and environmental circumstances including: – co-morbidities; – pre-morbid functional abilities; –p sychological background of the person, such as their usual coping mechanisms, self-efficacy and abilities to adapt; – t he home environment or place that the individual will be discharged to; – i ndividual social context, such as the social group the person inhabits and their economic circumstances; –o ccupation, whether paid, ‘informal’ or voluntary work; and –o ther activities that the person finds fulfilling. A further complication to rehabilitation is the infectious nature of Covid-19. Although some advice can be given from a distance, much of rehabilitation (especially in the context of severe physical disability) requires hands-on intervention. Some of the interventions are aerosol-generating procedures, which pose a significant health risk to the professionals who treat patients, as well as a risk of spreading infection to others. Regular and repeated testing for Covid-19 will be necessary to support segregation (of those still positive from those being negative) and it is essential that staff have access to the all the necessary

personal protective equipment to be able to treat patients safely (18*). It is strongly advised to implement teleconsultation and telerehabilitation devices, minimising exposure risk and implementing communication technologies to help patients and families reduce barriers imposed by isolation (19*). Telehealth consultations may be the only initial treatment possible following discharge and during continued lockdown periods. One-on-one or group rehabilitation classes will be hugely beneficial to the patient provided strict social distancing and sanitising procedures can be followed.

Key Components of Rehabilitation Programmes After Covid-19 (18*) Exercise Exercise is likely to be needed by all patients, to overcome deconditioning, improve pulmonary and cardiac function and any neuromuscular complications. Graded exercise therapy is also a key element of CFS management.

Respiratory Exercises Pulmonary rehabilitation is a key treatment strategy to reduce symptoms of breathlessness and improve lung function and capacity. It is welldocumented to increase walking capacity and quality of life. Practice of Activities Re-establishing patient autonomy in important activities, either undertaken

REHABILITATION WILL REQUIRE A PERSONCENTRED APPROACH, BUT IS LIKELY TO INVOLVE IMPROVING PHYSICAL STRENGTH AND STAMINA ALONGSIDE OPTIMISING PSYCHOLOGICAL HEALTH, AND ADDRESSING NEUROLOGICAL REHABILITATION NEEDS WHEN NECESSARY 19

as before or done differently with/ without equipment and aids.

management and goal-setting skills to patients and families.

Emotional Support Psychological input to offer cognitive behavioural therapy, acceptance and commitment therapy, and other input to help patients with the likely emotional sequelae – anxiety, depression, sleep disturbance, etc.

Equipment/Adaptations Some patients may need equipment or adaptations, at least in the shortterm.

Education and Information Provision of high-quality information both about the person’s situation and about their future. Teaching self-

References

1. Singhal T. A review of coronavirus disease-2019 (COVID-19). The Indian Journal of Pediatrics 2020;87:281–286 Open access https://bit.ly/2LJmByZ 2. Conti P, Ronconi G, Caraffa A et al. Induction of pro-inflammatory cytokines (IL-1 and IL-6) and lung inflammation by Coronavirus-19 (COVI-19 or SARS-CoV-2): anti-inflammatory strategies. Journal of Biological Regulators and Homeostatic Agents 2020;34(2):doi:10.23812/ CONTI-E Open access https://bit.ly/2TgqqQm 3. Mehta P, McAuley D, Brown M et al. COVID-19: consider cytokine storm syndromes and immunosuppression. The Lancet 2020;395(10229):1033–1034 Open access https://bit.ly/2Td9IS4 4. Poggiali E, Bastoni D, Ioannilli E et al. Deep vein thrombosis and pulmonary embolism: two complication of COVID-19 pneumonia? European Journal of Case Reports in Internal Medicine 2020;7:doi:10.12890/2020_001646 Open access https://bit.ly/2z6fAFO 5. Yang M, Hon KL, Li K et al. The effect of SARS coronavirus on blood system: its clinical findings and the pathophysiologic hypothesis. Zhongguo Shi Yan Xue Ye Xue Za Zhi 2003;11(3):217–221 6. Zhai Z, Li C, Chen Y et al. Prevention and treatment of venous thromboembolism associated with coronavirus disease 2019 infection: a consensus statement before guidelines. Thrombosis and Haemostasis 2020;doi:10.1055/s-0040-1710019 Open access https://bit.ly/369opuJ 7. Chen T, Wu Di, Chen Huilong et al. Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study. BMJ 2020;368:m1091 Open access https://bit.ly/2X1QG2c 8. Huang C, Wang Y, Li X et al. Clinical 20

2. sports and exercise medicine; 3. neurorehabilitation and neurological disability services; and/or 4. vocational rehabilitation.

Rehabilitation from Covid-19 will entail a combination of treatment strategies, customised to the patient’s needs depending on any comorbidities from the virus. They may require (18*): 1. cardio-pulmonary rehabilitation;

Specialist rehabilitation should be delivered by coordinated multidisciplinary rehabilitation teams comprising rehabilitation medicine, psychiatric and neuropsychiatric support, rehabilitation nursing, physical therapy, occupational therapy, clinical psychology/neuropsychology, speech and language therapy, dietetics and social work.

features of patients infected with 2019 novel coronavirus in Wuhan, China. The Lancet 2020;395(10223):497–506 Open access https://bit.ly/3ga88dI 9. 11. Zu ZY, Jiang MD, Xu PP et al. Coronavirus disease 2019 (COVID-19): a perspective from China. Radiology 2020;200490 Open access https://bit.ly/2z0xvOq 10. Pan F, Ye T, Sun P et al. Time course of lung changes on chest CT during recovery from 2019 novel coronavirus (COVID-19) pneumonia. Radiology 2020;200370 Open access https://bit.ly/3cHjmEp 11. Tse GM, To KF, Chan PK et al. Pulmonary pathological features in coronavirus associated severe acute respiratory syndrome (SARS). Journal of Clinical Pathology 2004;57(3):260–265 Open access https://bit.ly/3dToc1t 12. Geier MR, Geier DA. Respiratory conditions in coronavirus disease 2019 (COVID-19): Important considerations regarding novel treatment strategies to reduce mortality. Medical Hypotheses 2020;140:109760 Open access https://bit.ly/2Za74QW 13. Parikh SM, Mammoto T, Schultz A et al. Excess circulating angiopoietin-2 may contribute to pulmonary vascular leak in sepsis in humans. PLoS Medicine 2006;3(3):e46 Open access https://bit.ly/2z6gkuA 14. Essig M, Matt M, Massy Z. The COVID-19 outbreak and the angiotensinconverting enzyme 2: too little or too much? Nephrology Dialysis Transplantation 2020;pii:gfaa113 Open access https://bit.ly/2LCkdu1 15. Kim DY, Lee JS, Park SY et al. Systematic review of randomized controlled trials for chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME). Journal of

Translational Medicine 2020;18(1):7 Open access https://bit.ly/36aeRiZ 16. Maes M, Twisk FN. Chronic fatigue syndrome: Harvey and Wessely’s (bio)psychosocial model versus a bio(psychosocial) model based on inflammatory and oxidative and nitrosative stress pathways. BMC Medicine 2010;8:35 Open access https://bit.ly/3cL8N2U 17. Landry MD, Tupetz A, Jalovcic D et al. The novel coronavirus (COVID-19): making a connection between infectious disease outbreaks and rehabilitation. Physiotherapy Canada 2020;e20200019 Open access https://bit.ly/2LFW4CV 18. Philips M, Turner-Stokes L, Wade D et al. Rehabilitation in the wake of Covid-19 - a phoenix from the ashes. British Society of Rehabilitation Medicine 2020;1 27.4.2020 Open access https://bit.ly/2ThJ6PV 19. Carda S, Invernizzi M, Bavikatte G et al. The role of physical and rehabilitation medicine in the COVID-19 pandemic: the clinician’s view [Letter; not peer reviewed]. Annals of Physical and Rehabilitation Medicine 2020;pii:S1877-0657(20)30076-2 Open access https://bit.ly/2WIb7SE 20. Ahmed H, Patel K, Greenwood D et al. Long-term clinical outcomes in survivors of coronavirus outbreaks after hospitalisation or ICU admission: a systematic review and meta-analysis of follow-up studies. medRxiv 2020;doi:https://doi.org/10.1101/2020. 04.16.20067975 [Pre-print; not peer reviewed] Open access https://bit.ly/2LJmByZ 21. Simpson R, Robinson L. Rehabilitation After Critical Illness in People With COVID-19 Infection. American Journal of Physical Medicine & Rehabilitation 2020;doi:10.1097/ PHM.0000000000001443 [Epub ahead of print] Open access https://bit.ly/3cV97vg.

Conclusion

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KEY POINTS

lC ovid-19 is not simply a pneumonia or respiratory virus. lT he pathophysiology shows infiltration of inflammatory cells and elevated responses to inflammatory proteins, such as cytokines, resulting in damage to internal organs and acute respiratory distress syndrome. lC ovid-19 causes disseminated intravascular coagulation, disrupting blood clotting resulting in thrombotic events, such as deep vein thrombosis, pulmonary embolism and stroke. l I n some patients who recovered from Covid-19 pneumonia, lesions within lung tissue were gradually absorbed but left extensive ground-glass opacity and subpleural parenchymal bands. lT he main repercussions of Covid-19 infection are respiratory, central nervous system and cognitive, deconditioning, critical-illness myopathy and neuropathy, dysphagia, joint stiffness and pain, and psychiatric problems. lS ARS survivors, at 1-year follow-up, had both significant reductions in lung function and reduced exercise capacity. lA potential long-term risk of developing chronic fatigue syndrome has been raised. Common ‘triggers’ of this include severe viral infections and emotional stress, a dysregulation of immune and autonomic nervous system, not unlike Covid-19 survivors. lP hysical therapy can mediate the deleterious pulmonary, respiratory, and immobility complications following Covid-19 using graded exercise, respiratory exercises and manual hands-on therapy when necessary. lR ehabilitation is complicated by the infectious nature of the virus whereby telehealth devices or teleconsultations may be the first option available. lA team of medical services may be required including physical therapy, occupational therapy, social work, psychiatry, specialist physicians, and speech therapy.

RELATED CONTENT

lC ovid-19 Social Media and Lead Generation Campaign https://bit.ly/2WKZiLT l Rehabilitation Following COVID-19 Part 2: Practical Applications https://bit.ly/3cMU334 lP atient Information Leaflet: Physical Activity and Chronic Fatigue Syndrome (CFS) [Printable leaflet] https://bit.ly/2LFH3kx

DISCUSSIONS

l Given the pathophysiology of the virus, what conditions and patient complaints do you feel are going to present most frequently in survivors seeking rehabilitation? l Do you fear there has been little focus and/or an underestimation on the long-term medical requirements still needed in rehabilitating Covid-19 patients? l What do you believe will be the biggest barrier in the recovery of Covid-19 patients?

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Tweet this: Covid-19 can be more than just a respiratory disease bit.ly/2Aj8dLO Tweet this: Infection with the Covid-19 virus can cause the disruption of blood clotting and thrombotic events bit.ly/2Aj8dLO Tweet this: Lung CT scans can be abnormal even in asymptomatic Covid-19 patients bit.ly/2Aj8dLO Tweet this: Rehab from Covid-19 will entail a variety of treatment strategies customised to the patient’s needs bit.ly/2Aj8dLO 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 21

Disclaimer: Given that the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, which causes Covid-19) is a novel coronavirus, etiopathology of Covid-19 remains incompletely understood, as do the long-term consequences and recovery from the disease. It is important to note that the current approaches to care described below are based on treatments extrapolated from diverse underlying health conditions and that the literature on this topic is evolving rapidly. COVID-19 | 20-07-COKINETIC FORMATS WEB MOBILE PRINT All references marked with an asterisk are open access and links are provided in the reference list

he focus of the initial response to Covid-19 has been saving lives. Rightly so; be it in the hospital and ICU or preventing transmission and developing treatments or vaccines. For the majority, (81%) (1*), infection with the Covid-19 virus will confer a mild to moderate disease; however, for a significant minority, the infection may have very serious consequences. In those patients requiring hospitalisation, a relatively high proportion (20.3%) have required management in an ICU environment, the most common reason being the development of acute respiratory distress syndrome (ARDS) (32.8%) (2*). Less commonly, patients may develop acute liver injury, acute cardiac injury, acute kidney injury, and viraemic septic shock (3*). The leading cause of death following Covid-19 is acute respiratory failure, and disseminated intravascular coagulopathy has been reported in 71% of non-survivors (3*). Rehabilitation is a core component of patient-centred care in responding to disasters. Rehabilitation professionals and facilities will play an important role in helping speed the recovery of those survivors with residual impairments after ICU

REHABILITATION FOLLOWING COVID-19 PART 2: PRACTICAL APPLICATIONS Having read Part 1 of this article, you will be aware of the complex and varied nature of conditions that Covid-19 survivors might face. Reading this article will enable you to assess all the needs of your patients and to prepare individualised rehabilitation programmes. Additionally, advice and ideas are provided to allow you to decide how best to deliver these programmes, whether in person or online, to minimise any spread of infection. Read this article online https://bit.ly/3cLMYQ8 By Kathryn Thomas BSc MPhil treatment, and also a critical role in providing an appropriate outlet for acute services, creating space for newly affected patients to receive the acute care they need (4*). Ideally rehabilitation should be routinely incorporated into pandemic response plans early on, rather than in retrospect only after widespread disability becomes apparent (4*). Early intervention for successful rehabilitation is key. Many patients will not have had access to this owing to fears of infection/reinfection and lockdown status in their area. Patients who have been hospitalised may have had respiratory therapy with a physical therapist. But has their care continued

FOR ANY PATIENT RECOVERING FROM COVID-19, WE MUST BE COGNISANT THAT REHABILITATION WILL NOT ONLY BE FOR THE PHYSICAL HEALTH OF THE INDIVIDUAL BUT PSYCHOLOGICAL AND SOCIAL TOO 22

since discharge? What about the millions of mild to moderate cases of Covid-19 survivors who werenâ&#x20AC;&#x2122;t admitted to hospital? They too will have residual lung tissue damage with reduced exercise capacity, which could affect their lifestyle and work ability in the future. Our knowledge of the range of impairments and disabilities is still evolving; however, Covid-19 is a multisystemic condition and some of the effects will be long lasting (5*,6*). A third of patients being discharged from hospital require assistance in activities of daily living and a similar proportion have significant neurological sequelae (5*,6*). Physical therapy can mediate the deleterious pulmonary, respiratory and immobility complications that are common. Moreover, rehabilitation can offer a cost-effective strategy that can restore physical activity capacity, as well as mental and emotional quality of life (6*). Persistent mental health impairment is commonly described following treatment in the ICU, with Co-Kinetic Journal 2020;85(July):22-31

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pooled estimates reporting high prevalence rates of depression (29%), PTSD (22%) and anxiety (34%) affecting survivors at 1 year (4*). Beyond this, pandemics are associated with high levels of emotional distress across society (4*). On the individual level, dyspnoea is generally recognised as a distressing experience in its own right (4*). For patients and families, admission to hospital with a Covid-19 diagnosis may raise fears for survival. So, for any patient recovering from Covid-19, no matter the severity, we must be cognisant that rehabilitation will not only be for the physical health of the individual but psychological and social too. Owing to the diversity in potential conditions that could result from Covid-19, rehabilitation will have to be tailored depending on the needs of each patient. Cardiopulmonary rehabilitation including respiratory exercises and a graded exercise routine will be required for most patients. However, hands-on specialist care for patients recovering from any neurological deficits, severe weakness acquired from prolonged bedrest may be necessary. Awareness of chronic pain syndromes and chronic fatigue syndrome (CFS) should be kept in mind, as these biopsychosocial conditions may evolve as a consequence of survival. As we have needed an army of medical personnel to get through the acute phase of this virus, so too will we need a team of rehabilitation specialists to ensure a successful long-term outcome. That team will potentially comprise of physicians, psychiatric and neuropsychiatric support, rehabilitation nursing, physical therapy, occupational therapy, clinical psychology/neuropsychology, speech and language therapy, dietetics and social work.

Modifications to Rehabilitation Pulmonary rehabilitation (PR) is a firstline management strategy in patients with respiratory diseases as it reduces breathlessness, increases exercise capacity and improves health-related quality of life (HRQoL). A small but significant increase in physical activity in patients with chronic obstructive Co-Kinetic.com

pulmonary disease (COPD) has also been shown following PR (7*,8*). However, 8–50% of those referred to PR never attend, and 10–32% of those who commence do not complete the programme (9*). Barriers to attendance and completion include difficulty accessing the programme, poor mobility, lack of transport and cost of travel (8*). Home-based PR may overcome the barriers to attendance at a centrebased programme and resolve some of the concerns regarding Covid-19 patients interacting with other people. One-to-one or group rehabilitation classes would be hugely beneficial to the patient provided that strict social distancing, the use of masks and sanitising procedures can be followed (10*). Some of the interventions, including breathing exercises are aerosol-generating procedures, which pose a significant health risk to the professionals who treat patients, as well as a risk of spreading infection to others (10*). A recent study showed that supervised pulmonary telerehabilitation produced equivalent results to standard hospital-based group PR (7*). More participants, however, completed the telerehabilitation, where better compliance may result in better outcomes over the long term. Previous clinical trials comparing standard PR versus online, web-based sessions have shown to be neither inferior nor superior to face-to-face therapy (11*,12*,13*). Therefore, in the context of the Covid-19 pandemic, virtual-care outpatient consultations may be preferable to face-to-face interactions for multiple reasons. Firstly, in order to take care of patients, healthcare providers must themselves be in good health – fear for your own (and your family’s) safety or exposure to Covid-19 is understandable. Secondly, from a patient, family and wider societal perspective, delivering healthcare in settings where groups of people gather, such as ‘waiting rooms’ or a group rehabilitation class, is actively discouraged for fear of further community spread. In this context, it is also possible that a healthcare provider may be carrying

IN THE CONTEXT OF THE COVID-19 PANDEMIC, VIRTUAL-CARE OUTPATIENT CONSULTATIONS MAY BE PREFERABLE TO FACE-TO-FACE INTERACTIONS Covid-19 asymptomatically; in such a case the healthcare provider may then inadvertently become a ‘super spreader’ (4*). Regular and repeated testing for Covid-19 will be necessary to support segregation (of those still positive, from those being negative) and it is essential that staff have access to all the necessary personal protective equipment to be able to treat patients safely (4*,10*). Suggestions for your practice or clinic include the following. 1. Patients should be unaccompanied where possible. Family or friends are not to wait in a waiting area but remain in their vehicles or outdoors. 2. Appointments should be staggered, with 15-minute intervals between, to allow time to sanitise equipment and prevent congestion of people. 3. Therapists and patients should wear masks and practise social distancing where possible. 4. Temperature checks on arrival, as well as a short questionnaire checking patients’ symptoms, should be done routinely. 5. Therapists and patients should hand sanitise on arrival. 6. Patients can bring their own linen or towels to use during treatment and take home for their own washing. 7. Each therapist should have their own designated working area or cubicle to avoid cross-over within the practice. Virtual care circumvents these issues and allows personalised consultation and treatment via telephone, live internet connections, or via pre-recorded sessions for more generic materials. In some countries, well-developed, secure virtual-care platforms already exist; in others, media such as Zoom, Skype, Facetime and others may be suitable alternatives. You may be 23

able to have a group rehabilitation class through a video conference or Zoom facility. Patients gain support and encouragement from each other (albeit through a screen), plus seeing others during this lonely time may boost morale. Additionally, having a set ‘appointment’ time may keep patients motivated to do their rehabilitation exercises. However, virtual care also has many limitations, such as availability of equipment, technical malfunctions, potential for inadvertent personal data disclosure, limited scope for physical examination, and the process largely relies upon the patient being able to attend sessions, handle the technology, communicate and interact accordingly. This may not be possible for all patients. Rehabilitation providers should start to consider the scope and limitations of virtual physical examinations and make patients expressly aware of this accordingly (4*,10*). Programmes already exist and are available online for cardiac rehabilitation (www. activateyourheart.org.uk) and COPD (www.spaceforcopd.co.uk) that may be beneficial to some patients.

Baseline Testing

There are many tests that can be performed to assess the pulmonary function and exercise tolerance of a patient recovering from Covid-19. As Covid-19 is such a complex disease, components of all aspects of a biopsychosocial model may need to be incorporated. These too may have to be selected depending on your and the patients’ access to clinics/ hospitals and equipment for testing. Tests can form part of a baseline score from which PR can progress, as well as monitoring improvement and motivating patients over the weeks ahead. Specific strength tests or neurological assessment may be necessary for Covid-19 patients who may have suffered deep vein thrombosis, stroke or prolonged bed-

rest in ICU, for example. The majority of patients may follow a form of graded PR programme, which physical therapists are familiar with. However, combining patients into different levels of ability/disability may be required if group sessions, be it face-to-face or online, are to be effective.

Tests may Include:

1. Pulmonary Function Test Spirometry [forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC)], diffusing capacity of the lung for carbon monoxide (DLCO) and static lung volumes by body plethysmography may be performed according to the guidelines (9*,14*,15*). Lung disease severity of each patient can then be classified according to the Global Initiative for Obstructive Lung Disease spirometric criteria (16*). 2. Exercise Test Exercise capacity can be assessed by the 6-minute walk test (6MWT) (17*) (see p.51), the incremental shuttle walk test (ISWT) and the endurance shuttle walk test (ESWT) according to standardised protocols (18*,19*,20*,21*). A primary outcome for patients may be endurance exercise capacity, measured by the ESWT. Modifications may be necessary for 6MWT as the distance recommended of a 30–45m long, straight course may not be possible depending on the patient’s location. This may become a 20m (or even less) distance along the lounge floor or corridor that the patient repeats loops of for the 6-minute duration. Provided the distance and space remains the same with each test/ re-test, improvement can be monitored based on distance or number of laps in the given 6-minute time. Ideally two tests should be performed for each walk test over two visits/sessions within 7 days of each other, separated by at least 30-minutes’ rest. The better test result can then be used in the baseline. SpO2 (peripheral capillary oxygen

BREATHING CONTROL EXERCISES AND RESPIRATORY MUSCLE TRAINING CAN BE USED TO IMPROVE BREATHLESSNESS 24

saturation) and heart rate (HR) should be monitored with a pulse oximeter, where possible. Dyspnoea and rate of perceived exertion should be assessed before and after each exercise test using the modified 0–10-point Borg category-ratio scale (22*). Reference values for the 6MWT are based on an Australian study of healthy individuals (23*). 3. Quality of Life The Chronic Respiratory Disease Questionnaire (CRDQ) can be used to measure HRQoL. The minimal important difference for the four domains in this questionnaire are 2.5 for dyspnoea, 2 for fatigue, 3.5 for emotional function, 2 for mastery and 10 for the total score (24*). 4. Physical Activity The use of smart phones, Fitbits, and watches with activity or fitness trackers that monitor step counts, calorie expenditure and activity levels can be helpful in recording and motivating a patient’s physical activity. 5. Physical Performance Physical performance can be assessed by using the Functional Performance Inventory – Short Form (FPI-SF) which evaluates the level of difficulty respondents have in six domains including body care (five items), maintaining the household (eight items), physical exercise (five items), recreation (five items), spiritual activities (four items), and social interaction (five items). For ease of use, activities assessed are organised according to these domains. For each item/ activity, respondents are asked to rate how difficult the activity is for them to perform on a simple three-point scale: ‘no difficulty’, ‘some difficulty’, or ‘much difficulty’. If respondents do not perform an activity, they can select one of two options: ‘don’t do for health reasons’ or ‘choose not to’ (25*,26*). 6. Health Status COPD health status can be assessed using the COPD Assessment Test (CAT) which quantifies the impact of COPD on well-being (https://bit.ly/3d0rwIa) (27*,28*).

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TABLE 1: MEDICAL RESEARCH COUNCIL (MRC) AND MODIFIED MRC (MMRC) SCALE AND SEVERITY OF DYSPNOEA (Sourced 30*,31*,32*) Description

Disease severity

Breathless with strenuous exercise

Mild

Short of breath when hurrying on the level or walking up a slight hill

Moderate

Walks slower than people of the same age on the level or stops for breath while walking at own pace on the level

Stops for breath after walking 100m

Too breathless to leave the house or breathless when dressing

MRC grade

mMRC grade

Severe

Care must be taken not to confuse the grading scale from the original MRC (grades 1–5) to the modified MRC (grades 0–4). 7. Dyspnoea Dyspnoea can be assessed with the modified Medical Research Council (mMRC) dyspnoea scale (Table 1). The mMRC assesses dyspnoea as part of the BODE (BMI, airway obstruction, dyspnoea, exercise capacity) index which has been determined in this study (29*). The MRC dyspnoea scale has been proven to be a reliable index of disease severity and health status in elderly COPD patients which should prove useful for remote monitoring of COPD and for rating health status for epidemiological purposes (30*). 8. Psychological Status Anxiety and depression can be measured using the Hospital Anxiety and Depression Scale (HADS) (33*). 9. Self-efficacy The Pulmonary Rehabilitation Adapted Index of Self-Efficacy (PRAISE) tool can be used to measure self-efficacy (Fig. 1) (34,35*) (downloadable questionnaire available with the online version of this article).

Exercise Training

Exercise training has been acknowledged as the cornerstone of a comprehensive PR programme (36*). Eight to ten weeks of exercisebased PR can lead to clinically relevant improvements in daily symptoms (dyspnoea, fatigue, anxiety and/or depression), physical capacity, physical activity and quality of life in patients with COPD, without a significant Co-Kinetic.com

change in the degree of airflow limitation. Indeed, if exercise training is lacking, there is no significant improvement in physical activity tolerance (36*). Most training studies focused on

the effects of whole-body endurance exercise training (ie. treadmill walking and/or stationary cycling). Nevertheless, not all patients are able to exercise for a continuous period of 20 minutes or more at a training intensity of 60% or more of the predetermined maximal exercise tolerance (36*). Therefore, many other exercise training modalities and settings have been studied, ranging from Nordic walking for patients with a relatively well-preserved exercise tolerance to neuromuscular electrical stimulation for the most dyspnoeic, weakened and perhaps even mechanically ventilated patients (36*). Even though multiple training modalities and settings are available, a true personalisation of the exercise training based on the prerehabilitation assessment is often lacking. A one-size-fits-all approach is common practice, but may not be successful in the Covid-19 arena with such a range of ages, disease severity and comorbidities affecting patients’ rehabilitation.

Statement

Score

1 I can always manage to solve difficult problems if I try hard enough.

2 If someone opposes me, I can find the means and ways to get what I want.

3 It is easy for me to stick to my aims and accomplish my goals.

4 I am confident that I can walk for a good distance, at my own pace, despite it making me breathless.

5 I am confident that I could deal efficiently with unexpected events.

6 Thanks to my resourcefulness, I know how to handle unforeseen situations.

7 I feel confident that I will be able to perform the exercises asked of me during the course of rehabilitation, even if I find them difficult.

8 I can solve most problems if I invest the necessary effort.

9 I feel that I have an adequate amount of knowledge about my lung disease, despite it being a complex condition.

10 I can remain calm when facing difficulties because I can rely on my coping abilities.

11 When I am confronted with a problem, I can usually find several solutions.

12 I feel positive that I will be able to complete the exercises at home, despite there being no supervision from a health professional.

13 If I am in trouble, I can usually think of a solution.

14 I can handle whatever comes my way.

15 On a day-to-day basis I feel in control of my lung disease and how that affects my lifestyle, even when my symptoms become distressing.

Response: Please circle the number that reflects how you feel now: 1 = Not at all true 2 = Hardly true 3 = Moderately true 4 = Exactly true Figure 1: Pulmonary rehabilitation adapted index of self-efficacy (PRAISE) tool [Vincent E, Sewell L, Wagg K et al. Measuring a change in self-efficacy following pulmonary rehabilitation: an evaluation of the PRAISE tool. Chest 2011;140(6):1534–1539 (34)]

Reasoning from traits that are modifiable during exercise training, there are multiple options. Resistance training (training small muscle groups at 70–80% of the one repetition maximum (1RM), 4 sets of 8–12 repetitions) should be considered for patients with lower limb muscle weakness/atrophy and a moderate degree of dyspnoea (mMRC 2) (36*). For weakened patients with (very) severe dyspnoea, resistance training may still be too burdensome to their weakened ventilatory system, and

neuromuscular electrical stimulation should be considered as a substitute for resistance training (36*). Wholebody vibration has also been suggested as a useful means of increasing lower limb muscle strength but seems not to be used very often in daily clinical rehabilitation practice (36*). Whole-body exercise training can be considered for patients with a clear exercise intolerance. 1. Patients who are mainly restricted

by reaching their maximal HR during the cardiopulmonary exercise test, should be offered whole-body exercise training (at 60% to 80% of the predetermined maximal cycling load/walking speed, for 20–30min), which can range from treadmill walking to stationary cycling, and outdoor walking, including Nordic walking, elliptical trainer (36*). 2. Patients who are mainly restricted by the ventilatory system, should undergo a constant work rate cycling endurance test (CWRT) at

TABLE 2: EXAMPLE OF CONVENTIONAL GROUP PULMONARY REHABILITATION PROGRAMME. Table first published as Supplementary Table 9 in Hansen H, Bieler T, Beyer N et al. Supervised pulmonary tele-rehabilitation versus pulmonary rehabilitation in severe COPD: a randomised multicentre trial. Thorax 2020;75:413-421 (7*. Exercise type

Exercises

Intensity

Progression

Warm-up (duration 5–10min)

Sitting or standing: l heel uprisings (unilateral or bilateral) l knee extension l rear deltoid row l chest-press movement l vertical shoulder-press (unilateral or bilateral)

Non-specific intensity

None

Purpose: l increase body temperature l cardiorespiratory warm-up l muscle and tendon tissue warm-up

Standing: l walking various l leg-curl l leg-swing l squats Endurance training (duration 20–30min)

Walking or Cycle or Treadmill or Circuit training or Activity games

Borg CR-10 dyspnoea 4–7 Exercises performed in intervals or continuously

Every 2nd to 4th week load adjustment individualised

Resistance training (duration 20–30min)

Machine: l leg-press l knee extension l pull-down and/or chestpress (vertical)

40–80% of 1RM corresponding to 8–25 repetitions 2–3 sets

Every 2nd to 4th week load adjustment individualised (repetition counting by supervisor)

Non-specific intensity

Non-specific

Other equipment for strength circuit training: l elastic band l dumbbells l weight cuff Cool-down (duration 5–10min)

breathing exercises pursed-lip breathing relaxation exercises yoga exercises

Health professional responsible: Physiotherapist Monitoring of intensity may vary, but it is expected that hospitals use either objective (pulse or Watt monitoring) or subjective (Borg scale for dyspnoa) measurements for intensity monitoring. Resistance training will be evaluated for progression by counting the maximum repetitions and estimating a new optional weight/ resistance within 8–25 repetitions. Workout logs from every training session are recommended to be registered by the authorisation law.

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75% of the peak cycling load. If the CWRT lasts ≥10min, endurance training (starting at 60%) is still an option. If the CWRT lasts <10min, interval training (at >80% of the predetermined maximal cycling load/walking speed, for 30–60s per exercise bout, for 20 to 40 bouts) using treadmill walking or stationary cycling should be

proposed. Interestingly, patients who cycle <10min also have weaker quadriceps muscle (36*). 3. I n turn, interval training should most probably be combined with resistance training. 4. T he rehabilitation goals of the patient should be taken into the equation, as interval training matches to a greater extent the

metabolic load of activities of daily living than endurance training (36*). Tables 2 and 3 give examples of a conventional group PR programme and a home-based group rehab programme using tele-communication, respectively (7*). Suggestions for patient education topics in both group hospital/clinic/

TABLE 3: EXAMPLE OF TELECOMMUNICATION OR GROUP HOME-BASED (USING ONLINE CONFERENCING FACILITY) PULMONARY REHABILITATION PROGRAMME. Table first published as Supplementary Tables 11, 12 and 13 in Hansen H, Bieler T, Beyer N et al. Supervised pulmonary tele-rehabilitation versus pulmonary rehabilitation in severe COPD: a randomised multicentre trial. Thorax 2020;75:413-421 (7*). Exercise no.

Exercise name

Body position

Time/volume min, minutes s, seconds

Exercise load

Warm-up

Sitting or standing: l heel uprisings (unilateral or bilateral) l knee extension l rear deltoid row l chest-press movement l vertical shoulder-press (unilateral or bilateral)

5min

Non-specific intensity Purpose: l increase body temperature l cardiorespiratory warm up l muscle and tendon tissue warm-up

Standing: l walking on site l side to side walking l leg curl l leg swing l squats 1

Sit-to-stand

Sitting and standing Lower extremity, bilateral

Active: 80–160s Rest: 160–80s Total: 240s

Body weight and dumbbells

Biceps curl, shoulder-press

Standing Upper extremity, bilateral

Active: 80–160s Rest: 160–80s Total: 240s

Dumbbells or any homeadapted hand-held weight

Step-up

Standing Lower extremity, bilateral

Active: 80–160s Rest: 160–80s Total: 240s

Body weight, dumbbells and stepbox/step

Bent-over rowing

Standing with upper body bent slightly forward Active: 80–160s Upper extremity, unilateral Rest: 160–80s Total: 240s

Static-dynamic squat

Standing Lower extremity, bilateral

Active: 80–160s Rest: 160-80s Total: 240s

Body weight and dumbbells

Dumbbell front-raise

Standing Upper extremity, bilateral

Active: 80-160s Rest: 160–80s Total: 240s

Dumbbells or any homeadapted hand-held weight

Progression for home-based rehabilitation Week number

Working volume

Rest volume (in seconds)

Number of sets for each exercise

Familiarisation

1–2

Progression 1

3–6

Progression 2

7–10

Phase

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COVID-19 SURVIVORS MIGHT EXPERIENCE PERSISTENT FATIGUE; THIS CAN OFTEN BE HELPED WITH ACTIVITY-BASED BEHAVIOURAL INTERVENTIONS practice-based rehabilitation and individual or group home rehabilitation via online portal include (7*): 1. welcome, individual introduction or presentation 2. Covid-19, the disease, treatment and management 3. early signs of exacerbation, chronic fatigue and action plan 4. medication, use of any devices, inhalers, oxygen support; breathing techniques 5. physical activity and exercise 6. food, nutrition and the importance for health and immune system 7. smoking cessation 8. anxiety, stress, depression - a venues for coping mechanisms, support, therapy and help - i dentify vulnerable individuals to refer for counselling, include education on relaxation techniques. In all these education topics allocate approximately 20 minutes for information, discussion and reflection. A number of sessions may be required for each topic to allow adequate time for questioning and practising breathing/ relaxation techniques for example.

TABLE 4: BORG DYSPNOEA SCALE Scale

Description of dyspnoea by patient

Nothing at all

0.5

Very, very slight, just noticeable

Very slight

Slight

Moderate

Somewhat severe

Severe

6 7

Very severe

8 9

Very, very severe (almost maximal)

Maximal

A number of studies have been conducted comparing the traditional face-to-face PR to a home-based programme (8*,11*,12*,13*). The home-based programme can be delivered in a number of ways (real-time, online pre-recorded sessions, website based, telephone monitoring or interactive group video conferencing) all of which have been shown to improve exercise tolerance and physical activity capacity; this in turn improves patients’ symptoms of fatigue, dyspnoea and ability to carry out daily chores. Some programmes run for 6 weeks whereas others for 10 or 12 weeks or even up to 4 months; you may choose to alter these timelines depending on the severity of the patient’s symptoms and their rehab progress. In addition to this there are many ways one can exercise at home or in a clinic depending on equipment available. Provided it has an element of cardiovascular endurance work and some strength training, sessions could include: l A ‘basic level’ of programme consisted of 15–25min of exercise with mini-ergometer without load and 30min of callisthenic exercises, performed three times/week and free walking twice a week. The ‘high level’ consisted of 30–45min of mini-ergometer with incremental load (from 0 to 60W), 30–40min of muscle reinforcement exercises using 0.5kg weights and pedometerbased walking, performed from 3 to 7 days/week (13*). l 10 exercises increased by 30 s, starting from 60s in week 1, to 3.5min in week 6. Exercises included biceps curls, squats, push-ups against a wall, leg extensions in a sitting position, upright row with weights, sit-to-stand, arm swings with a stick, leg kicks to the side, arm punches with weights and step-ups. Both the online and faceto-face programmes also included warm-up and cool-down sessions (11*). l Lower limb cycle ergometer, 15–20min at 60–80% of peak work rate estimated from the best 6-minute walk distance at baseline using an algorithm for cycle exercise

prescription (37*). Progressing in increments of 5W. Followed by 5min rest and a further 15–20min walking at 80% of best 6-minute walk test. Followed by 5min rest and strength training involving squats and sit-tostand (3 sets of 10 repetitions each) (8*). Exercise monitoring and progression should be based on both the modified Borg dyspnoea (Table 4) and rate of perceived exertion 0–10 categoryratio scales (22*, 38*) with participants encouraged to exercise with symptoms between moderate to somewhat severe (a score of 3–4). A simple visual analogue scale (VAS) consisting of a line, usually 100mm in length, placed either horizontally or vertically on a page, with anchors to indicate extremes of a sensation can also be used. The anchors on the scale have not been standardised, but ‘not breathless at all’ to ‘extremely breathless’; and ‘no shortness of breath’ to ‘shortness of breath as bad as can be’ are frequently used. Scoring is accomplished by measuring the distance from the bottom of the scale (or left side if oriented horizontally) to the level indicated by the subject. The reliability and validity of the VAS as a measure of dyspnoea has been reported (39*). If there are clear signs of exerciseinduced oxygen-desaturation during the cardiopulmonary exercise test, the rehabilitation team may want to consider the use of oxygen supplementation during the wholebody exercise training, although its use has been questioned recently. Indeed, Alison et al. showed that a 10-week exercise training programme was safe and effective in patients with mild exercise-induced O2desaturation who were training with oxygen supplementation or room air supplementation (40). SpO2 and HR can be monitored via the finger-tip pulse oximeter intermittently during training. If SpO2 falls below 88% and/or HR increases above 80% of predicted maximum HR (predicted by age) then participants should rest with the pulse oximeter continuing to record. Participants can resume exercising when the SpO2 reaches 88% Co-Kinetic Journal 2020;85(July):22-31

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or above and HR drops to below 80% of maximum predicted HR. Participants should be asked to report the pulse oximeter readings either by presenting it in front of the camera or by verbally reporting it to the physiotherapist supervising the session (8*). To prevent exercise-induced oxygen-desaturation, again, interval training should be considered. Moreover, patients with severely exercise-induced lung hyperinflation may be in need of ventilatory support during whole-body interval training. This can be provided using non-invasive ventilation (36*). This requires fewer patients per therapist compared to ‘regular’ supervision of exercise training, which may be an organisational challenge. Obviously, the first step here is to teach patients to use pursed-lips breathing, which may partly prevent dynamic lung hyperinflation (36*). Besides stationary biking (instead of treadmill walking), water-based walking seems also a valid option for patients with obesity and/or arthrosis of hip/knee/lower back. To date, exercise training generally results in an improved exercise tolerance in patients with COPD and two-thirds of patients achieve a clinically relevant improvement in physical capacity (36*). It is possible to consider that these benefits will be conferred to recovering Covid-19 patients. A further personalisation of the exercise training intervention(s) as part of a comprehensive PR programme may be required depending on the patient’s needs.

Respiratory Training

Following Covid-19 infection there appears to be residual alveolar damage and possible fibrosis of lung tissue, even after resolution of symptoms. This may result in long-term respiratory issues such as breathlessness or dyspnoea at rest or on exertion affecting a patient’s ability to carry out daily chores, work or physical activity. In a vicious cycle, reduced physical activity due to dyspnoea actually leads to increased symptoms of breathlessness owing to reduced exercise tolerance and muscle weakness. The difficulty is to motivate patients on the importance of Co-Kinetic.com

exercise training when it is perceived to exacerbate their symptoms. Patients may be fearful, anxious, fatigued and have depression. Breathing exercises can address issues of panic, anxiety and depression as well as improve breathlessness by strengthening respiratory muscles. As the result of peripheral airway obstruction, air may become trapped in the lungs (i.e. hyperinflation). The respiratory rate may increase because of inspiration, which is initiated before emptying the lungs of air. Adjustment of rapid shallow breathing may lead to fatigue of the respiratory muscles. Hyperinflation may lower the dome of the diaphragm, shorten respiratory muscle fibres, and impair the possibility of muscle contraction. In addition, gas exchange may be inefficient. Hence, patients develop symptoms of breathlessness or dyspnoea (41*). Various breathing control exercises (BCEs) and respiratory muscle training (RMT) are being used to improve breathlessness. For example, BCEs include diaphragmatic breathing, pursed-lip breathing, relaxation techniques, and body position exercises. BCEs aim to decrease the effort required for breathing and assist relaxation by deeper breathing, which may result in an improved breathing pattern through decreased respiratory rate and reduced breathlessness (41*,42*). In regard to RMT, the aim is to improve muscle strength and endurance where the respiratory muscles are impaired, hopefully resulting in a greater ability to control the breathing pattern and reduce breathlessness (41*,42*). RMT requires a training programme using an adjusted breathing resistance device (41*). Active expiration is another exercise requiring contraction of abdominal muscles, increasing abdominal pressure during active expiration, which lengthens the diaphragm and contributes to operating the diaphragm close to its optimal length. In addition, active expiration increases the elastic recoil pressure of the diaphragm and the ribcage, the release of which after relaxation of the expiratory muscles

assists the next inspiration (43*). A description of BCEs and RMT is shown in Figure 2 (41*). The goal of breathing or respiratory exercises should be to (42*): 1. reduce dynamic hyperinflation of the ribcage and improve gas exchange; 2. increase strength and endurance of the respiratory muscles; 3. optimise the pattern of thoracoabdominal motion; and 4. induce psychological effects (such as controlling respiration) that might also contribute to the effectiveness of controlled breathing.

Fatigue

Fatigue is a symptom common to many illnesses, such as cancer, depression, autoimmune diseases, hormonal disorders and infections, and it is associated with poorer health outcomes. Most health conditions that cause fatigue, such as fatigue secondary to deconditioning, cancer and neuromuscular disorders, have aetiologies that are attributable to specific pathologies that may respond favourably to various forms of intervention, such as physical therapist management. However, some people may demonstrate fatigue related to causes that remain unclear. It is not clear or understood as yet, why many patients recovering from Covid-19 have reported fatigue. This may improve with time and simply be delayed symptom resolution. However, it is speculated that with the complex nature of Covid-19 (and the manner in which it attacks multiple systems within a patient’s body, combined with the psychological and social impact of the virus) persistent fatigue may become more sinister. In clinical practice, many individuals presenting with the

TREATMENT OF THE VARIED AND COMPLEX CONDITIONS THAT A COVID-19 SURVIVOR MIGHT FACE MAY REQUIRE THE CARE OF A MULTIDISCIPLINARY TEAM 29

common symptom of persistent fatigue may benefit from activitybased behavioural interventions, as suggested by Friedberg et al. (44*). However, persistent fatigue is not equivalent to the multisymptom debilitating illness of ME/CFS. Despite the lack of approved treatments or a fully articulated standard of medical care, there are still many actions physical therapists can take to help. Clinicians can help patients to better manage a major illness challenge: how to minimise debilitating post-exertional malaise by learning to stay within their ‘energy envelope’ (45). The energy envelope delineates the amount of energy that a myalgic encephalomyelitis (ME)/CFS patient has available to perform all activities. The size of this energy envelope can

vary from day to day and between patients, with some patients lacking energy for basic activities of daily living. When patients exceed their limited energy levels, they experience postexertional worsening of symptoms and functioning. Medical providers can teach patients how to recognise their own personal energy limits and use ‘pacing’ (dividing symptomproducing activities into smaller parts with interspersed rest intervals) to stay within those limits (45,46*). Once pacing is effectively used, some patients may be able to use an individualised exercise plan to increase available energy and functioning while avoiding post-exertional worsening (45,46*). Standard of care for ME/CFS has been cognitive behaviour therapy and

Description of breathing control exercises and respiratory muscle training

Breathing control exercises

Respiratory muscle training

Diaphragm breathing or slow and deep breathing is performed by breathing with the diaphragm muscles. The work of the accessory muscles during inspiration is reduced at the same time.

Inspiratory muscle training can be performed by: l normocapnic hyperpnea: the patient trains the respiratory muscles at a high level for an extended time (approx. 15min) l inspiratory resistive loaded breathing: inhalation is performed ‘through a mouthpiece with an adapter with an adjustable diameter’ l inspiratory threshold loaded breathing: performed through a flow of independent resistance.

Yoga breathing involves instruction on breathing, relaxation and body position.

Body position exercises or relaxation exercises are favourable positions of the body that encourage the upper chest, shoulders and arms to relax, allowing movement of the lower chest and abdomen. These exercises are often used during diaphragmatic breathing. Examples of such positions may be: l high side lying l relaxed sitting l forward lean standing l knee leaning positions.

Pursed-lip breathing is performed by breathing out with pursed lips (half-opened lips). The expiratory mouth pressure is approx. 5cm HttO using this technique.

Expiratory muscle training can be performed by low-intensity strength training or high-intensity strength training. Figure 2: Description of breathing control exercises and respiratory muscle retraining. Figure first published in Borge CR, Hagen KB, Mengshoel AM et al. Effects of controlled breathing exercises and respiratory muscle training in people with chronic obstructive pulmonary disease: results from evaluating the quality of evidence in systematic reviews. BMC Pulmonary Medicine 2014;14:184 (41*) and reproduced under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0)

graded exercise therapy (47*). Both interventions had been recommended by the US Centres for Disease Control and the UK NICE guidelines. Multiple literature reviews have reported that these therapies are not only effective at improving fatigue and, to a lesser extent, physical function in ME/ CFS but are also safe. It would seem obvious then that good clinical care of these patients would include these behavioural interventions (47*). A paper by Davenport et al. illustrates pacing and load introduction/ adaptation over time with CFS patients as well as ideas on graded exercise intervention (48*). A brief self-management intervention for patients with unexplained chronic fatigue or CFS appeared to be clinically effective for reducing the impact of fatigue on functioning (44*). In the long term, however, using the guided exercise self-help booklet alone is unlikely to be adequate to support patients sufficiently. Additional guidance from skilled physiotherapists/health professionals who demonstrate an understanding of what it is like to cope with ME/CFS is also important (49). Pharmacological interventions for pain and unrefreshing sleep can be prescribed. If needed, patients can be referred for counselling to improve coping with the severe impacts of ME/CFS on quality of life. Essentially, optimal patient care will require a multidisciplinary team.

Conclusions

Without a clear picture of exactly what each Covid-19 survivor will look like, it is hard to plan ahead to be fully prepared. Based on the pathophysiology of the virus and case reports of patients, it is reasonable to assume a degree of pulmonary, even cardiopulmonary, rehabilitation will be required together with breathing exercises. It will be critically important to be aware of the chronic manifestations of pain and fatigue and dealing with these complex biopsychosocial issues may require the involvement of a multidisciplinary team. In addition to this, patients may require specific musculoskeletal or neurological rehabilitation, so Co-Kinetic Journal 2020;85(July):22-31

COVID-19

programmes will have to be tailored to the individual. Traditional therapy will need to be adapted to account for social distancing, lockdown regulations and fear of infection. These are unprecedented times; your requirement to deliver treatment to these patients is vital, while still protecting your health as a primary priority. Creativity may be the key word for long-term Covid-19 care.

RELATED CONTENT

lC ovid-19 Social Media and Lead Generation Campaign https://bit.ly/3cMU334 lR ehabilitation Following Covid-19 Part 1: Theoretical Considerations https://bit.ly/2Aj8dLO lP atient Information Leaflet: Physical Activity and Chronic Fatigue Syndrome (CFS) [Printable leaflet] https://bit.ly/2LFH3kx

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://bit.ly/2C0Obq3

KEY POINTS

lR ehabilitation is a core component of patient-centred care in responding to disasters, and early intervention for successful rehabilitation is key. lO ur knowledge of the range of impairments and disabilities is still evolving; however, Covid-19 is a multisystemic condition and some of the effects will be long lasting. lP hysical therapy can mediate the deleterious pulmonary, respiratory and immobility complications that are common, as well as conditions arising from venous thromboembolism and the stress, anxiety and depression of having survived Covid-19. lP ulmonary rehabilitation (PR) is a first-line management strategy in patients with respiratory diseases as it reduces breathlessness, increases exercise capacity and improves health-related quality of life (HRQoL). lA ssessment may include 6MWT, ISWT, ESWT, FEV1, FVC, Borge scale of dynspnoea and Medical Research Council (MRC) dyspnoea scale, questionnaires for quality of life (CRDQ) and physical performance (FPI-SF), neuromuscular assessment, as well as psychological (HADS) and selfefficacy testing (PRAISE). lE xercise training has been acknowledged as the cornerstone of a comprehensive PR programme. lW hole-body endurance exercise training and strength training can be progressed over 6 weeks or more. lS upervised home-based PR has been proven to be equivalent in efficacy to traditional group clinic/hospital-based PR. lV arious breathing control exercises (BCEs) and respiratory muscle training (RMT) are proven to improve breathlessness. lM odifications in PR delivery will need to be made accounting for social distancing, and lockdown regulations, including telerehabilitation, video conferencing and online portals. lW ith the complex nature of Covid-19, one should be aware of possible developments of biopsychosocial syndromes such as chronic pain and chronic fatigue syndrome.

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DISCUSSIONS

l What are your thoughts or plans to make rehabilitation of Covid-19 patients safe for everyone involved? lH ow can you make pulmonary rehabilitation effective and fun to ensure participation, compliance and success even when performed in the virtual setting? lW hat other rehabilitation protocols do you feel will be beneficial for a Covid-19 survivor?

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Tweet this: Rehab professionals can help the recovery of Covid survivors with impairments after ICU treatment https://bit.ly/3cLMYQ8 Tweet this: Pulmonary rehabilitation is a first-line management strategy in patients with respiratory disease https://bit.ly/3cLMYQ8 Tweet this: Exercise training is crucial in a comprehensive pulmonary rehabilitation programme https://bit.ly/3cLMYQ8 Tweet this: All pulmonary rehab programmes, whether in person or online, improve physical activity capacity https://bit.ly/3cLMYQ8 THE AUTHOR Kathryn Thomas BSc Physio, MPhil Sports Physiotherapy is a physiotherapist with a master’s degree in Sports Physiotherapy from the Institute of Sports Science and University of Cape Town, South Africa. She graduated both her honours and master’s degrees Cum Laude, and with Deans awards. After graduating in 2000 Kathryn worked in sports practices focusing on musculoskeletal injuries and rehabilitation. She was contracted to work with the Dolphins Cricket team (county/provincial team) and The Sharks rugby teams (Super rugby). Kathryn has also worked and supervised physios at the annual Comrades Marathon and Amashova cycle races for many years. She has worked with elite athletes from different sporting disciplines such as hockey, athletics, swimming and tennis. She was a competitive athlete holding national and provincial colours for swimming, biathlon, athletics, and surf lifesaving, and has a passion for sports and exercise physiology. She has presented research at the annual American College of Sports Medicine congress in Baltimore, and at South African Sports Medicine Association in 2000 and 2011. She is Co-Kinetic’s technical editor and has taken on responsibility for writing our new clinical review updates for practitioners. Email: kittyjoythomas@gmail.com

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MANUAL THERAPY

MANUAL THERAPY AND THE PELVIS, HIP AND SACRUM References

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HAMSTRING INJURY PART 1: ANATOMY, FUNCTION AND INJURY Hamstring injuries are common and may represent up to 12% of sports injuries. So you are likely to see many patients with these injuries. After reading this article you will have refreshed your knowledge of the anatomy and function of the hamstring muscles, as well as the common mechanisms and grades of injury. This will allow you to get the maximum benefit from Part 2, which discusses the rehabilitation of hamstring injury and will be published in the October journal. Read this article online https://bit.ly/2XMH5Og

HAMSTRING | 20-07-COKINETIC FORMATS WEB MOBILE PRINT All references marked with an asterisk are open access and links are provided in the reference list

By Dr Chris Norris PhD, MCSP

Incidence

Hamstring injury is common in sport and these injuries frequently recur. Up to 12% of sports injuries may be to the hamstrings (1*), and it is the most common muscle injury in male footballers (2*). Recurrence rates vary between 12% and 63% depending on the site of injury and severity, and the first month after return to sport sees the greatest risk of reinjury (3*). Highquality rehabilitation is a key factor for recovery from hamstring injury and can affect both recurrence and return to play (RTP). The hamstrings consist of three muscles, the biceps femoris (BF) laterally, and the semimembranosus (SM) and semitendinosus (ST) medially. The BF is more commonly injured than the ST and SM with rates of 80% compared to 10% respectively (1*). The ischial portion (vertical fibres) of adductor magnus is sometimes considered within the hamstring group, and involvement of this muscle is sometimes seen alongside hamstring injury (4). The anatomy of this region is an important factor in the varying injury incidence between the various hamstring components.

Anatomy

HAMSTRING INJURY IS COMMON IN SPORT AND THESE INJURIES FREQUENTLY RECUR 32

The three hamstring muscles attach to the ischial tuberosity â&#x20AC;&#x201C; the SM from the superior-lateral aspect, the ST and BF from the infero-medial portion below the sacrotuberous ligament (Fig. 1). The ST and long head of BF have a combined attachment on the lower medial facet of the ischial tuberosity, the two muscles travelling together for a short distance until they form fusiform muscle bellies. The ST almost instantly forms into a long slender tendon, and travels around the medial condyle of the tibia to attach to the medial surface of the tibia below gracilis. The BF has two

proximal attachments; the long head, as described above, and the short head from the lower linea aspera of the femur. The muscle swings downwards and laterally across the posterior aspect of the thigh and around the lateral ligament to insert into the head of the fibula. From this point it has a strong fascial attachment to the peroneus (fibularis) longus and the iliotibial band as part of the lateral and spiral fascial lines (5). The hamstrings as a group are innervated by the sciatic nerve (tibial branch), but the BF has a dual innervation (tibial and peroneal branch), and asynchronous stimulation of the two heads has been described as a factor in injury (6). The SM comes from the lateral facet of the ischial tuberosity and travels down and medially, becoming flattened and broader as it does so. The SM is deep to both the ST and BF, and divides into five components when it reaches the knee. The principal insertion is to the posterior aspect of the medial tibial tubercle, with attachment into the oblique popliteal ligament and medial meniscus. The proximal tendon of the BF extends into the muscle by 60% of its length, and the distal tendon by 66%, while for the SM the tendon extension is 78% and 52% (7). The continuity between the two tendons into the centre of the muscle constitutes the central tendon (intramuscular myotendon), which is often a region of disruption in persistent injuries (8*).

Function

The hamstrings have functions over the pelvis, hip and knee. They are twojoint (biarticular) muscles, and (as with all muscles) contribute force through active (contraction) and passive (recoil) means. In open chain motion the muscles will flex the knee and extend Co-Kinetic Journal 2020;85(July):32-36

MANUAL THERAPY

the hip, but the short head of BF has an action (flexion) over the knee alone. When the knee is flexed, SM and ST medially rotate the tibia and the BF laterally rotates. In closed chain action the hamstrings will assist in knee extension by drawing the femur into extension over the fixed foot.

Two-Joint Muscles

As biarticular muscles, the hamstrings are unable to permit full movement simultaneously at both joints they span. Full movement may be limited during stretch (passive insufficiency) for example knee extension combined with hip extension, or contraction (active insufficiency) such as knee flexion and hip extension. Biarticular muscles are arranged as agonist and antagonist: in the case of the thigh, the hamstrings being grouped opposite the rectus femoris. Because both biarticular muscle-sets are not long enough to permit movement at both joints simultaneously, the tension in one muscle is transferred to the other. Using the hip as an example, as the hamstrings contract to extend the hip, passive tension is transmitted to the rectus femoris creating a knee extension force. This type of action, involving either extension or flexion at both joints at the same time, is called concurrent movement. The muscle shortens at one end but lengthens at the other, and so maintains its length with a range of 100% to 130% resting length to conserve tension (9*). When the hip is flexed but the knee extended, the rectus femoris is shortened and rapidly loses tension, while the hamstrings are lengthened and rapidly gain tension, an example of countercurrent movement (10). Two-joint muscles provide a number of mechanical advantages over monoarticular equivalents. Firstly, they couple movement at both joints. For example, in the upper limb shoulder and elbow flexion occur together in a feeding pattern, and both actions have a contribution from biceps brachii (11). Biarticular muscles also allow the transfer of power from proximal to distal segments (8*), allowing bulky musculature to be kept closer to the trunk, reducing the mass Co-Kinetic.com

THE FIRST MONTH AFTER RETURN TO SPORT SEES THE GREATEST RISK OF REINJURY of the extremity and facilitating limb acceleration. Secondly, the shortening velocity of a two-joint muscle is less than that of a single-joint muscle (12), contributing to more rapid limb movement. By shortening less than two equivalent monoarticular muscles, a biarticular muscle demonstrates lower contraction velocities and higher force development. For instance, the contraction velocity of the hamstrings during vertical jumping is said to be one quarter of that required by a monoarticular muscle. As force and velocity are linked during muscle performance (force velocity relationship) biarticular muscles can generate approximately three times the force of their monoarticular counterparts (13). Thirdly, two-joint muscles are said to redistribute muscle force throughout the limb (14). For example, if hip flexion is performed by rectus femoris, recoil of the lengthening hamstrings will tend to flex the knee.

Equally recoil of the lengthening rectus femoris in hip extension will tend to extend the knee. A biarticular muscle will also enhance joint stability by allowing co-contraction of the agonist and antagonist muscles without reducing tension, as would occur with monoarticular muscles at both joints. The hamstrings, as biarticular muscles, have an important function during both running- and lifting-type actions.

Bending

Forward bending is a coupled movement combining lumbar flexion and pelvic rotation (lumbarpelvic rhythm), which results from a coordinated action between the back-extensor muscles (erector spinae) and the hip extensors (gluteals and hamstrings). Towards end-range forward bending, both the backextensor muscles and the hip extensors show reduced electrical activity, a phenomenon called the flexionâ&#x20AC;&#x201C; relaxation response (FRR). As the body

Ilium

Gluteus medius muscle

Sacrum

Gluteus maximus muscle

Ischium Ischial Tuberosity

Femur

Figure 1: Anatomy of the hamstring muscles

Adductor magnus muscle Gracilis muscle Vastus lateralis muscle Biceps femoris muscle Semitendinosus muscle

Tibis

Semimembranosus muscle

Fibula

THE HAMSTRINGS, AS BIARTICULAR MUSCLES, HAVE AN IMPORTANT FUNCTION DURING BOTH RUNNING AND LIFTING-TYPE ACTIONS bends forwards, its descent is initially controlled by eccentric action of both the spinal extensors and hamstrings; however, towards the end of midrange, activity of the spinal extensors ceases and elastic resistance of the spinal extensors and posteriorly placed spinal soft tissues limits movement range (8*). Near end range, activity of the hamstrings also ceases and the final angle of pelvic tilt is limited by elastic resistance of these muscles and tension of other posteriorly placed soft tissues. At the initiation of body lifting, little muscle contraction is seen, the trunk being raised by elastic recoil of the posterior tissues. The point at which this occurs (critical point) varies, and the FRR of both the erector spinae and hamstrings may be altered or obliterated in subjects with chronic low back pain (CLBP), perhaps representing an inability to relax the muscles as part of pain behaviour. EMG biofeedback training has been used to decrease lumbar paraspinal muscle activity and increase motion range in patients with CLBP. In this study a decreased fear of movement was noted leading the authors to suggest that initial movement limitation may have been modulated by fear avoidance (15*). Surface EMG has also successfully been used to assist a home-based stretching programme aimed at lengthening the paraspinal muscles in CLBP subjects (16), again suggesting that increased tone in these muscles may be part of the pain phenomenon of CLBP. There are several important considerations with respect to injury recovery and rehabilitation with the bending action. Firstly, the lumbar spine and pelvis must work in a coordinated fashion and following injury this coordination often breaks down and must be retrained. Secondly, although both the back muscles and hamstrings must be strong enough to 34

lift a subject’s own body weight and the weight of any object being held (these muscles often weaken after injury), they must also be able to relax at the right point when bending. If they stay active throughout the bending action, without switching off, they will tire and become painful.

Running

During the running cycle, the hamstrings are said to contract eccentrically to decelerate the leg in late forward swing, an action which also helps to stabilise the knee. Although lengthening (as the distance between the muscle insertion points increases), tension in mid forward swing is primarily through recoil of parallel and series elastic components within the muscle. In later forward swing an isometric contraction occurs at knee extension (17). During the support phase, the hamstrings act concentrically to extend the hip, and continue to stabilise the knee by preventing knee extension. During push-off, the hamstrings and gastrocnemius, both biarticular muscles, paradoxically extend the knee. EMG studies have demonstrated differences between the medial and lateral hamstrings during knee flexion (isokinetic dynamometry) with BF showing maximal activation early on (15–30°) and SM and ST later (90–105°) in knee flexion (18). BF is subjected to the greatest muscle-tendon stretch in the terminal swing phase of highspeed running, perhaps explaining the increased incidence of injury to this muscle. BF and ST are maximally active eccentrically throughout the swing phase of running, but their neuromuscular coordination patterns show BF more active in the middle-tolate swing and ST in the terminal swing phase only (19). It has been suggested that a reduced endurance capacity of the ST is compensated by increased activity of the BF, as muscle functional MRI (mfMRI) has shown increased metabolic activity in the ST compared to BF following injury (2*).

Injury

Hamstring injuries tend to occur in two main categories: high-speed running, which typically involves

the BF long head; and slower extended lengthening (high kick or splits action), which often implicates the proximal tendon of SM (20). In addition, posterior thigh pain showing no local structural injury (MRI-negative injury) may be due to referred pain from the lumbar spine or pelvis (21*). The orientation of fibres within the hamstrings is an important consideration in both injury and rehabilitation. The ST and BL have a common origin with the ST fibres originating close to the ischial tuberosity. The BF long head has fibres which originate from the common tendon but 5–6cm below the ischial tuberosity. The semimembranosus has a long proximal free tendon some 10cm long, with the short head attaching from the linea aspera of the femur (and as such has no direct action on the hip). The proximal and distal tendons of the BF extend to almost 60% of the total muscle length, so that the muscle-tendon (MT) junctions are in two parts. The proximal MT junction is along the medial aspect of the muscle, the distal MT junction along the lateral. An area of overlap is seen in the centre of the muscle belly. The muscle fascicles (bundles of fibres) attach at an angle (pennation angle) to the tendon with effects on pennation angle and fascicle length often being important outcome measures of exercises in research studies. The injuries may be classified according to the Munich consensus statement (22*). Muscle injury may be direct or indirect, and graded from 1 to 4. Grades 1 and 2 are functional muscle disorders due to overexertion and/or fatigue, with grade 2 representing delayed onset muscle soreness (DOMS) or MRI-negative injury resulting from referred posterior thigh pain. Grade 3 injury is a minor or partial tear, whereas grade 4 is a total or complete tear or avulsion. Grades 3 and 4 represent structural injuries (Table 1). The Munich consensus muscle classification system has been extended into the British Athletics system with reference to MRI views of hamstring injuries (23). Grades 1–4 of the Munich consensus are still applied, but the site and depth of the injury are assessed on MRI and given a suffix. Co-Kinetic Journal 2020;85(July):32-36

MANUAL THERAPY

Where the injury is to the superficial aspect of the muscle (myofascial injury) the suffix ‘a’ is used, ‘b’ for an injury extending into the muscle belly and ‘c’ for injuries extending to the tendon. Further, the site of the injury is described (proximal, central or distal third). Recovery from injury and return to the activities of daily living or RTP may partially be determined by the site of injury and the amount of tissue damage. However, although studies suggest that closer proximity to the ischial tuberosity is likely to imply greater recovery time (24*,25*), MRI and US studies show no association between scan findings and RTP (26,27). RTP before full rehabilitation has taken effect can be an important factor in reinjury. Reduction of eccentric strength and delayed rate of torque development may suggest neural function change following injury, especially at longer muscle lengths (28). Pain inhibition following injury may produce a structural and functional maladaptation within the muscle, meaning that early pain management may be important to reduce inhibition and encourage early muscle activation (21*). Healing rates of different portions of the hamstring unit vary and responses to rehabilitation may be different (23). Fascia consists of collagen tissue layers with hyaluronic acid between the layers to enable sliding. Healing is through inflammation followed by fibrosis, with collagen synthesis peaking at 7 days post-injury and full strength returning after 21 days (29*). Little damage occurs to the contractile portion of the muscle in this type of injury, with the main effect being oedema, which tracks between the fascial layers. Pain may occur locally to palpation, but manual muscle testing often demonstrates full strength. Where muscle tissue is affected, manual muscle testing will usually show pain and weakness. Healing of muscle is through satellite cell activity with the healing tissue maximising after 10 days (For a review of muscle healing see 30). Intratendon injuries typically occur in high-force movement (running or ballistic stretching), and present with significant loss of both Co-Kinetic.com

Table 1: Munich classification of muscle injuries in sport (Modified from MuellerWohlfahrt et al. Terminology and classification of muscle injuries in sport: The Munich consensus statement. British Journal of Sports Medicine 2013;47:342–350 (22*)) Indirect Functional Type 1: overexertion related

1A: fatigue induced 1B: DOMS

Type 2: neuromuscular

2A: spine related 2B: muscle related

Structural Type 3: partial tear

3A: minor 3B: moderate

Type 4: (sub)total

Subtotal or complete tear Tendinous avulsion

Direct

Contusion Laceration

ROM and strength. Tendon tissue heals more slowly than either fascia or muscle. Healing is through deposition of extracellular matrix followed by collagen type III synthesis. Remodelling occurs as collagen type III is replaced by collagen type I after about 6 weeks post-injury. During this time, highload eccentric actions (which increase fascicle length) should be delayed avoiding excessive elastic strain on healing tendon tissue (25*). References

1. Ekstrand J, Healy JC, Waldén M et al. Hamstring muscle injuries in professional football: the correlation of MRI findings with return to play. British Journal of Sports Medicine 2012;46:112–117 Open access https://bit.ly/3glFJkU 2. Schuermans J, Van Tiggelen D, Danneels L et al. Biceps femoris and emitendenosus --teammates or competitors? New insights into hamstring injury mechanisms in male football players: a muscle functional MRI study. British Journal of Sports Medicine 2014;48(22):1599–1606 Open access https://bit.ly/3glFEO8 3. Brukner P, Nealon A, Morgan C et al. Recurrent hamstring muscle injury: applying the limited evidence in the professional football setting with a seven-point programme. British Journal of Sports Medicine 2014;48:929–938 Open access https://bit.ly/2LYTZSO 4. Askling CM, Tengvar M, Saartok T et al. Acute first-time hamstring strains during slow-speed stretching: clinical, magnetic resonance imaging, and recovery characteristics. American Journal of Sports Medicine 2007;35(10):1716–1724 5. Myers TW. Anatomy trains: myofascial meridians for manual and movement therapists, 3rd edn. Churchill Livingstone 2013. ISBN 978-0702046544 (Print £45.38 Kindle £22.84) Buy From Amazon https://amzn. to/3cZveBC

6. Burkett LN. Investigation into hamstring strains: the case of the hybrid muscle. Journal of Sports Medicine 1975;3(5):228–231 7. Garrett WE Jr, Rich FR, Nikolaou PK et al. Computed tomography of hamstring muscle strains. Medicine and Science in Sports and Exercise 1989;21:506–514 8. Brukner P, Connell D. ‘Serious thigh muscle strains’: beware the intramuscular tendon which plays an important role in difficult hamstring and quadriceps muscle strains. British Journal of Sports Medicine 2016;50:205–208 Open access https://bit. ly/3c4E8fU 9. Burkholder TJ, Lieber RL. Sarcomere length operating range of vertebrate muscles during movement. Journal of Experimental Biology 2001;204:1529– 1536 Open access https://bit.ly/3d2RWbZ 10. Rasch PJ, Burke RK. Kinesiology and applied anatomy: the science of human movement. Lea and Febiger 1989. ISBN 978-0812111323 11. Enoka RM. Neuromechanical basis of kinesiology, 2nd edn. Human Kinetics 1994. ASIN B005P2FT40 12. van Ingen Schenau GJ, Bobbert MF, van Soest AJ. The unique action of bi-articular muscles in leg extensions. In: Winters JM, Woo SL-Y, Delp I (eds) Multiple muscle systems: biomechanics and movement organisation. Springer 1990. ISBN 9780387973074 (£149.99) Buy from Amazon https://amzn.to/2yzjk2w 13. Cleather DJ, Southgate D, Bull AM. The role of the biarticular hamstrings and gastrocnemius muscles in closed chain lower limb extension. Journal of Theoretical Biology 2015;365:217–225 14. Toussaint HM, van Baar CE, van Langen

HEALING RATES OF DIFFERENT PORTIONS OF THE HAMSTRING UNIT VARY 35

PP et al. Coordination of the leg muscles in backlift and leglift. Journal of Biomechanics 1992;25:1279–1289 15. Pagé I, Marchand AA, Nougarou F et al. Neuromechanical responses after biofeedback training in participants with chronic low back pain: An experimental cohort study. Journal of Manipulative and Physiological Therapeutics 2015;38:449– 457 Open access https://bit.ly/30oB2Bn 16. Moore A, Mannion J, Moran RW. The efficacy of surface electromyographic biofeedback assisted stretching for the treatment of chronic low back pain: a case series. Journal of Bodywork and Movement Therapies 2015;19(1):8–16 17. Van Hooren B, Bosch F. Is there really an eccentric action of the hamstrings during the swing phase of high-speed running? Part I: A critical review of the literature. Journal of Sports Science 2017;35(23):2313–2321 18. Onishi H, Yagi R, Oyama M et al. EMGangle relationship of the hamstring muscles during maximum knee flexion. Journal of Electromyography and Kinesiology 2002;12(5):399–406 19. Higashihara A, Ono T, Kubota J et al. Functional differences in the activity of the hamstring muscles with increasing running speed. Journal of Sports Sciences 2010; 28(10):1085–1092 20. Askling CM, Malliaropoulos N, Karlsson J. High-speed running type or stretchingtype of hamstring injuries makes a difference to treatment and prognosis. British Journal of Sports Medicine 2012;46(2):86–87 21. Brukner P. Hamstring injuries: prevention and treatment—an update. British Journal of Sports Medicine 2015;49:1241–1244 Open access https://bit.ly/2zkjc7z 22. Mueller-Wohlfahrt HW, Haensel L, Mithoefer K et al. Terminology and classification of muscle injuries in sport: The Munich consensus statement. British Journal of Sports Medicine 2013;47:342– 350 Open access https://bit.ly/2ZvUuvz

KEY POINTS

23. Macdonald B, McAleer S, Kelly S et al. Hamstring rehabilitation in elite track and field athletes: applying the British Athletics Muscle Injury Classification in clinical practice. British Journal of Sports Medicine 2019;53(23):1464–1473 24. Askling CM, Tengvar M, Thorstensson A. Acute hamstring injuries in Swedish elite football: a prospective randomised controlled clinical trial comparing two rehabilitation protocols. British Journal of Sports Medicine 2013;47:953–959 Open access https://bit.ly/3el8f47 25. Silder A, Sherry MA, Sanﬁlippo J et al. Clinical and morphological changes following 2 rehabilitation programs for acute hamstring strain injuries: a randomized clinical trial. Journal of Orthopaedic and Sports Physical Therapy 2013;43:284–299 Open access https://bit.ly/2zjd7Iv 26. Reurink G, Brilman EG, de Vos RJ et al. Magnetic resonance imaging in acute hamstring injury: can we provide a return to play prognosis? Sports Medicine 2015;45:133–146 27. Petersen J, Thorborg K, Nielsen MB et al. The diagnostic and prognostic value of ultrasonography in soccer players with acute hamstring injuries. American Journal of Sports Medicine 2014;42:399–404 28. Fyfe JJ, Opar DA, Williams MD et al. The role of neuromuscular inhibition in hamstring strain injury recurrence. Journal of Electromyography and Kinesiology 2013;23:523–530 29. Zügel M, Maganaris CN, Wilke J et al. Fascial tissue research in sports medicine: from molecules to tissue adaptation, injury and diagnostics: consensus statement. British Journal of Sports Medicine 2018;52(23):1497 Open access https://bit.ly/2AWXQgJ 30. Norris CM. Muscle injury and rehabilitation. sportEX medicine 2012;51(January):22–27. https://bit.ly/30qdR9A.

lH amstring injuries are common in sport and frequently recur. lG ood rehabilitation is key for recovery from hamstring injury. lT he hamstrings consist of three muscles: the biceps femoris, the semimembranosus and semitendinosus. lT he hamstrings are biarticular muscles and have functions over the pelvis, hip and knee. lB iarticular muscles do not allow full movement simultaneously at both of the joints that they span; however, they do have advantages over monoarticular equivalents. lA s the hamstrings are part of the hip extensors, and so are involved in forward bending, correct functioning of these muscles may be needed in rehabilitation with a bending action. lH amstring muscle injuries are graded 1–4 on the Munich consensus statement and the British Athletics system adds further information according to the part of the muscle that is injured and the site of injury. lH ealing rates vary, but return to play before full rehabilitation has happened may be a factor in reinjury. 36

RELATED CONTENT

lR ole of the Thorax in Treatment of Recurrent Hamstring Injury [Article] https://bit.ly/2LT8zex l The Hamstring Hustle: Rapid Return to Sport Versus Recurrence [Article] https://bit.ly/2yALD0A l Hamstring Injury Patient Information Resources https://bit.ly/2yuUiS2

DISCUSSIONS l Refresh your knowledge of hamstring anatomy. Can you describe the hamstring muscles (and their insertion and attachment points) and innervations from memory? l Discuss what is meant by a biarticular muscle. What are their advantages over monoarticular muscles? l Discuss the common mechanisms of hamstring injury – which have you most often seen in your own patients? THE AUTHOR Dr Chris Norris PhD, MCSP is a physiotherapist with over 35 years’ experience. He has an MSc in Exercise Science and a PhD in Backpain Rehabilitation, together with clinical qualifications in manual therapy, orthopaedic medicine, acupuncture, and medical education. Chris is the author of 12 books on physiotherapy, exercise, and acupuncture and lectures widely in the UK and abroad. He is a visiting lecturer and external examiner to several universities at postgraduate level. He runs private clinics in Cheshire and Manchester and his postgraduate courses for therapists are on his website. Email: cmn@norrishealth.co.uk Twitter: https://twitter.com/NorrisHealth YouTube: https://www.youtube.com/channel/ UC0VExulacEqFW7gahk98Tuw Website: http://www.norrishealth.co.uk/

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Tweet this: Hamstring injury is common in sport and it is the most common muscle injury in male footballers https://bit.ly/2XMH5Og Tweet this: Good rehab is key in hamstring injury recovery, affecting both recurrence and return to play https://bit.ly/2XMH5Og Tweet this: The site of a hamstring injury and amount of tissue damage may affect the time to return to play https://bit.ly/2XMH5Og Co-Kinetic Journal 2020;85(July):32-36

MANUAL THERAPY

MANUAL THERAPY AND THE PELVIS, HIP AND SACRUM Introduction

This article provides an overview of the structures that make up the pelvic girdle. It summarises the main joints, their functions and ranges of motion; the associated common injuries and red-flag signs; and the necessary tests allowing you to make an accurate diagnosis of your patientâ&#x20AC;&#x2122;s pain. This article has been extracted from chapter 9 of the authorsâ&#x20AC;&#x2122; book Advanced Osteopathic and Chiropractic Techniques for Manual Therapists. Read this article online https://bit.ly/3hayxs9 By Giles Gyer BSc, Dip. Medical Acupuncture, Dip. Sports & Remedial Massage and Jimmy Michael BSc, BTEC Dip. Sports & Remedial Massage, Dip. Medical Acupuncture of any treatment. This article aims to provide therapists and associated professionals with brief descriptions of the joints of the pelvis, hip and sacrum, their ranges of motion and special diagnostic tests for detecting serious pathology. Later sections give an overview of common injuries to these structures and red flags to be aware of. The approach taken aims to aid development of knowledge for the target audience, with information that is both succinct and actionable.

Joints

Range of motion

PELVIS | HIP | 20-07-COKINETIC FORMATS WEB MOBILE PRINT All references marked with an asterisk are open access and links are provided in the reference list

ALTHOUGH THE SIJ HAS A LIMITED RANGE OF MOTION, IT IS NOT COMPLETELY IMMOBILE AS PREVIOUSLY BELIEVED 37

TABLE 1: JOINTS OF THE PELVIS AND SACRUM [Sources: OpenStax (8), Standring (9), Vleeming et al. (10)] Joint name

Description

Function

Acetabulofemoral joint

l Commonly known as the ‘hip joint’ l A synovial, ball-and-socket joint l Found between the head of the femur with the acetabulum of the hip bone l Forms a connection between the lower limb and the pelvic girdle l Serves as a connection of the lower extremity with the axial skeleton of the trunk and pelvis

l Facilitates body-weight-bearing in both dynamic and static postures l Maintains balance of the body

Sacroiliac joint

l A matchless diarthrodial joint made up of the sacrum and the ilia of the pelvis l Forms a connection between the spine and the pelvis (ilium bones) l Usually formed within the sacral segments of S1, S2 and S3 l Consists of fibrocartilage in addition to hyaline cartilage l Is a less mobile, well-innervated joint; thus, very strong and stable

l Functions as a shock absorber for the spine l Conveys the weight of the upper extremity to the pelvis and legs l Offers steadiness to the spine and pelvis l Facilitates in the maintenance of body balance during walking (push-off phase)

Lumbosacral joint

l A cartilaginous, multifunctional joint that connects the lumbar spine with the sacrum l Provides articulation between the vertebral bodies of the last lumbar vertebra (L5) and the first sacral segment (S1) l Consists of several interconnected components, including a disc between the two articulating vertebral bodies and two facet joints

l Provides a strong and stable base for the vertebral column l Permits the trunk of the body to twist and bend in almost all directions

BOX 1: HIP MANIPULATION TECHNIQUE: SUPINE PROXIMAL FEMORAL HEAD MANIPULATION l Ask the patient to lie supine with their head supported using a pillow. l Flex the patient’s hip to 90° and fully flex the knee. l Place a towel over their upper thigh, as shown. l Interlace your fingers around the thigh with the ulnar border over the joint line. l Ask the patient to inhale and exhale. l As the patient exhales, increase hip flexion while distracting the hip to engage the barrier. l On the engagement of the barrier, perform the manipulation by pulling your hands towards you. Key to Note: l If the patient cannot flex the knee, rest the knee on your shoulder bent ideally to 90° or whatever the patient can manage. l You may want to place a towel over the midline of the body for modesty and the addition of a barrier. l If you are unable to interlace your fingers around the patient’s upper thigh as shown, use a towel and hold both ends. l You can add bias to internal and external rotation by placing the hip into either position and perform the technique the same way, as described above. l Remember not to keep the patient at the barrier for too long.

rotation, abduction, adduction and hyperextension (11*,12). The greatest motion occurs at the external pelvic platform. Table 2 summarises the estimated ranges of motion in the hip for weight-training participants. The SIJ has a limited range of motion in contrast to the hip. Although in past times many in the medical community believed it to be immobile, studies have demonstrated rotation of less than 4° and translation of up to 1.6mm (2*).

Common Injuries

A major injury to the pelvis and

the sacrum is often caused by a fall, motor vehicle accident, violent activity, sporting accident or penetrating trauma. These injuries are common in all populations, including male and female, the very young and old, and athletes of numerous sports (13) (Table 3).

Red Flags

It is always important for therapists to check for red-flag symptoms as these may indicate emergent medical conditions requiring immediate attention (19) (Table 4). While individual red flags do not necessarily point to a specific pathology, they have great

TABLE 2: HIP RANGE OF MOTION VALUES FOR RECREATIONAL WEIGHT-TRAINING PARTICIPANTS [Source: Cheatham et al. (11*)] Movement Flexion

Right hip

Left hip

P-value

120.4±14.5° 121.3±13.8° 0.50

Extension

12.6±5.9° 12.6±7.6° 0.95

Internal rotation

36.4±9.5°

36.1±8.7°

0.82

External rotation

32.2±8.7°

32.0±9.4°

0.78

Abduction

42.6±11.3°

43.2±12.3°

0.64

Co-Kinetic Journal 2020;85(July):37-42

MANUAL THERAPY

TABLE 3: COMMON INJURIES OF THE PELVIS AND SACRUM [Sources: Laslett (2*); Foulk and Mullis (14); Johansen et al. (15); Rashbaum et al. (16); Russell and Jarett (17); Schmidtt, Sciulli and Altman (18)] Common Injuries Incidence

Characteristics

Pelvic fracture

l 37 cases per 100,000 person- years (USA) l 19 cases per 100,000 person-years (UK)

l Typically, a fracture of the bony structures of the pelvic region that often includes the hip bone, sacrum and coccyx l Often results from traumatic events such as road traffic accidents or falls l The severity of pelvic fractures varies along a continuum from mild to life-threatening as a function of the amount of force applied

Sacroiliac joint dysfunction

l Accounts for 13–30% of back pain cases

l Commonly refers to anomalous position or movement of SIJ structures that may or may not result in pain l Can result from motor vehicle accidents, falls or other traumatic events that apply force to the SIJ region l Common indications include pain in the lower back, buttock(s), hip or groin as well as a sensation of numbness, sciatic leg pain and a frequent urge to urinate

Hip dislocation

l Accounts for 5% of traumatic joint dislocations

l Usually results from dissipation of a large amount of energy directed along the axis of the femur l Posterior dislocations are the most common (>90%) but may also be anterior or central l Motor vehicle accidents are implicated in a majority of cases l May be associated with fractures of the femoral head or neck

THE THERAPEUTIC GOAL OF MANIPULATIVE TECHNIQUES FOR PAIN RELIEF IN PATIENTS WITH PELVIC AND SIJ DYSFUNCTION IS TO PROVIDE A NON-INVASIVE, WELL-TOLERATED PROCEDURE THAT PRODUCES THE BEST RESULTS TABLE 4: RED FLAGS FOR SERIOUS PATHOLOGY IN THE PELVIS AND SACRUM [Sources: Gibbons and Tehan (1);

Boissonnault (21); Gabbe et al. (22); Henschke, Maher and Refshauge (23); Meyers et al. (24); Reiman et al. (25); van den Bruel et al. (26)] Condition

Signs and symptoms

Pathologic femoral neck fractures

l Elderly females (>70 years) with hip, groin or upper thigh pain l Severe, constant hip, groin or knee pain that worsens with motion l History of trauma such as a blunt force to the upper thigh or falling from a standing position

Osteonecrosis of the femoral head

l History of prolonged use of corticosteroids l History of trauma l History of alcohol abuse l History of slipped capital femoral epiphysis l Slow, consistent onset of pain l Pain in the groin, thigh or knee that increases with load bearing

Cancer

l Past or present history of malignancy (eg. prostate, breast or any reproductive cancer) l Family history of cancers of the pelvic region (eg. colon, prostate or any reproductive cancer) l Rectal disturbances and bowel anomalies (eg. bleeding in the rectal/anal region, black stool) l Chronic, localised, progressive pain independent of position

Infection

l Fever, chills l History of infections of the urinary tract or skin l Burning sensation when urinating l Persistent pain at rest l No recovery following 6 weeks of conventional therapy

Slipped capital femoral epiphysis

l Obese adolescent l History of trauma l Pain in the groin that increases with weight-bearing l Limited internal rotation and abduction of the hip resulting in the involved leg being held in external rotation

Legg-CalvéPerthes disease

l Young boy (aged 5–8) with groin/thigh pain l Antalgic gait l Pain intensified with abduction, internal rotation or other movements of the hip

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TABLE 5: SPECIAL TESTS FOR PELVIS AND SIJ DYSFUNCTION [Sources: Kahn and Xu (19); Innes, Dover and Fairhurst (27); Ganderton et al. (28); Goodman and Snyder (29); Gross, Fetto and Rosen (30); Hattam and Smeatham (31); Lee et al. (32*); Magee (33); Olson (34); Rahman et al. (35*); Reiman et al. (25)] Test

Procedure

Positive sign

Interpretation

Test statistics

Trendelenburg test

he patient stands facing the therapist. T The therapist then asks the patient to transfer their weight to the affected leg while slowly raising the unaffected foot off the ground, flexing both the hip and knee. The therapist observes the movement as the weight is shifted towards the symptomatic side

l Pelvis drops on the non-weight-bearing side (ie. hemipelvis falls below the horizontal)

✓ Gluteal dysfunction ✓ Hip subluxation or dislocation

Specificity: 0.76 Sensitivity: 0.72

Patrick or FABER test

The patient assumes a supine posture with one leg extended and the test leg is placed in a flexed, abducted, externally rotated (FABER) position. The therapist gently applies overpressure of the hip by pressing the test leg knee towards the table while stabilising the anterior superior iliac spine ASIS

l Pain elicited on the groin/ipsilateral side anteriorly

✓ Hip joint dysfunction

Specificity: 0.71 Sensitivity: 0.57

l Pain elicited on the buttock/contra lateral side posteriorly

✓ SIJ irritation

Gaenslen’s test

The patient assumes either a supine or side-lying posture. The therapist asks the patient to draw both legs up onto their chest before slowly lowering the test leg into extension

l SIJ pain

✓ SIJ dysfunction

Specificity: 0.26 Sensitivity: 0.71

Ober test

The patient assumes a side lying position with the test leg on top. The affected knee is flexed to 90° and the therapist passively abducts and pulls the patient’s upper leg posteriorly, until the thigh is in line with the torso

l Leg remains in abduction and fails to fall to the table

✓ Extreme tension of the iliotibial band

Specificity: 0.98 Sensitivity: 0.13

Thomas test

The patient begins the procedure seated at the edge of the foot of the treatment table. The therapist then guides the patient into a supine posture with the knees and hips fully flexed With the non-test leg in full flexion, the therapist guides the test leg into hip extension. The therapist then flexes the test leg to 90°

l Straight leg lifting off the treatment table

✓ Flexion contracture of the hip

Specificity: 0.92 Sensitivity: 0.89

Log roll test

The patient lies supine with both lower limbs extended. The therapist passively rotates both fully extended legs medially and laterally to end range

l A painful sensation in the anterior hip or groin

✓ Intraarticular hip pathology ✓ Piriformis syndrome ✓ Slipped capital femoral epiphysis

Specificity: 0.33 Sensitivity: 1.00

Femoral nerve tension test (Ely’s test)

The patient lies prone while the therapist passively flexes the test leg to 90° before lifting the hip into full extension. The therapist monitors the ipsilateral hip for uplift from the table

l Ipsilateral hip flexion and anterior rotation of the pelvis

✓ Irritation of femoral nerve ✓ Rectus femoris contracture

Specificity: 1.00 Sensitivity: 0.63

Co-Kinetic Journal 2020;85(July):37-42

MANUAL THERAPY

BOX 2: HIP MANIPULATION TECHNIQUE: SUPINE PROXIMAL FEMUR MANIPULATION WITH EXTERNAL ROTATION l Ask the patient to lie supine with their head supported using a pillow. l Flex the affected hip to approximately 90° or as much as they possibly can. l Stand with an asymmetrical stance, as shown. l Your left hand enters the medial aspect of the distal femur and exits at the proximal lateral tibia. l Your right hand contacts the proximal femoral head, as shown. l Externally rotate the affected hip until you engage the barrier. l Ask the patient to inhale and exhale. l As the patient exhales, engage the barrier by creating external rotation of the affect hip. l On the engagement of the barrier, perform the manipulation by pushing the proximal head of the femur oblique and inferior, as shown Key to Note: l You may want to place a towel over the patient’s adductors as a barrier and a broader contact for you to push against. l You can perform this technique for bias towards internal rotation by switching the directions shown. l Remember not to keep the patient at the barrier for too long. utility in outlining the need for further investigation. Multiple red flags, when present, do require further investigation (20*).

Special Tests

Table 5 is not an exhaustive list of special tests but gives you, the therapist, a guide for this area. If you are unsure of the interpretation of any test that you complete with your patient, we advise that you refer to the

most appropriate medical professional for further investigations.

Treatment

After making your diagnosis, you can begin treatment; Boxes 1 and 2 show two examples of hip manipulation techniques. Both of these techniques aim to improve the quality and quantity of movement of the hip. These techniques enable you to change the angle of the hip in order to

Advanced Osteopathic and Chiropractic Techniques for Manual Therapists Giles Gyer and Jimmy Michael Singing Dragon 2020; ISBN 978-0857013941 Buy it from Amazon https://www.amazon.co.uk/ Advanced-Osteopathic-Chiro-Tech-Giles/ dp/0857013947 Develop your knowledge of chiropractic and osteopathy with this comprehensive guide to advanced skills and peripheral manipulation techniques. This practical handbook takes into account the latest research, highlighting the neurophysiological effects of these techniques, and providing clear, step-by-step guidance from experienced manual therapists. Covering key topics such as the effects of manipulation on organs, working in sports settings, and motion palpation misconceptions, the book demonstrates how to work with a range of joints with advice on diagnostics, contraindications and safety precautions. This is an expert collaboration between professions and can be used as the go-to clinical handbook for all manual therapists.

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reduce any discomfort that the patient is experiencing and limiting the amount of force and reducing the risk of increasing the patients symptoms. It is advisable to know as many techniques as possible in order to adapt to any pathology that you are presented with. Further hip manipulation techniques can be seen in chapter 9 of the authors’ book Advanced Osteopathic and Chiropractic Techniques for Manual Therapists.

CONTENTS Chapter 1: Spinal Manipulation Therapy: Is it all about the brain? A current review of the neurophysiological effects of manipulation Chapter 2: Can Manipulation Affect the Visceral Organs? Chapter 3: Motion Palpation Misconceptions Chapter 4: The Cervical Spine Cervical spine manipulation techniques Temporomandibular joint manipulation techniques Chapter 5: The Thoracic Spine Cervico-thoracic junction manipulation techniques Thoracic spine manipulation techniques Chapter 6: Shoulder and Rib Cage Shoulder manipulation techniques Rib manipulation techniques Chapter 7: Elbow, Wrist and Hand Elbow manipulation techniques Wrist manipulation techniques Chapter 8: The Lumbar Spine Lumbar spine manipulation techniques Chapter 9: Pelvis, Hip and Sacrum Hip manipulation techniques Chapter 10: Knee, Ankle and Foot Knee manipulation techniques Foot and ankle manipulation techniques

IT IS ALWAYS IMPORTANT FOR THERAPISTS TO CHECK FOR RED-FLAG SYMPTOMS KEY POINTS

lM anual manipulation techniques may be used to provide temporary relief from pelvic and sacroiliac joint (SIJ) pain. lC ombining different approaches may provide effective treatment. lT he knowledge and skill of the therapist is important in the treatment outcome. lT he joints of the pelvic girdle, the acetabulofemoral joint, the SIJ and the lumbosacral joint, fulfil complex roles of providing both structure and stability as well as allowing movement and, at the same time, balance. lM ajor injuries to the pelvis and sacrum are common in all populations. lC ommon injuries of the pelvis and sacrum include pelvic fracture, SIJ dysfunction and hip dislocation. lE nsure that the red-flag signs are checked, conduct further investigations and refer the patient as necessary. lT here are a number of specific tests that can be done for pelvic and SIJ pain, including (among others) the Trendelenburg, Patrick, Gaenslenâ&#x20AC;&#x2122;s and Ober tests.

RELATED CONTENT

lC linically Effective Manual Therapy for the Hip [Article] https://bit.ly/2McBIRR lF emoroacetabular Impingement Syndrome Part 1: Diagnosis and Morphology [Article] https://bit.ly/3eBJFMS lF emoroacetabular Impingement Syndrome Part 2: Management [Article] https://bit.ly/2TQDfRK l Manual Therapy Student Handbook: Assessment and Treatment of the Hip - Part 5 [Article] https://bit.ly/3ewS6bX

DISCUSSIONS

l Revise the anatomy of the pelvic girdle. l Think about any recent patients with hip pain. Having read this article would you do anything differently in your assessment of them? l Discuss the red-flag signs of pelvic pain. What would you do if you encountered them?

Want to share on Twitter? Here are some suggestions

Tweet this: Combining different manipulative approaches provides effective treatment for pelvic pain https://bit.ly/3hayxs9 Tweet this: The fused bones of the pelvis provide a loadbearing scaffold to sustain the weight of the body https://bit.ly/3hayxs9 42

THE AUTHORS Giles Gyer BSc (Hons) Osteopathy, Dip. Medical Acupuncture, Dip. Sports & Remedial Massage is a British trained specialist musculoskeletal osteopath who has worked within health and fitness for over 14 years. Having started off with qualifications in personal training and strength and conditioning, he progressed into medical acupuncture and then completed a 5 year degree in Osteopathy with the College of Osteopaths. Giles graduated with awards in clinical distinction and special achievement, as a strong structural osteopath he combines rehabilitation exercises and multiple techniques within his treatments and has worked with patients from office workers to international athletes. When he is not treating patients, Giles is part of a training company lecturing and teaching Medical Acupuncture, Manipulative therapy and Clinical Kinesiology taping to a range of manual therapists and doctors throughout the United Kingdom and is published in Medical and ElectroAcupuncture, Osteopathic Spinal and Peripheral Joint Articulations and Osteopathic and Chiropractic Techniques. Jimmy Michael BSc (Hons) Sports & Exercise Science, BSc (Hons) Osteopathy, BTEC Dip. Sports & Remedial Massage, Dip. Medical Acupuncture began his career in the health industry after graduating from his degree in Sports & Exercise Science working in the personal training and strength and conditioning area. It was at this point he found an interest in injuries and rehabilitation. Jimmy added sports and remedial massage to his skill set and found it a fantastic addition for his clients as he could support their training through treatment to try and prevent problems before they arise. As a registered Osteopath Jimmyâ&#x20AC;&#x2122;s treatments focus combining hands on therapy with exercise to get you back to your activity as quickly as possible. Jimmy has extensive experience from working with premier league football clubs to Formula One drivers. Jimmy has extensively added to his training through continual professional development and combines multiple skills in his treatments where necessary. Jimmy has been lecturing in the field of manual therapy for a number of years and this keeps him at the forefront of all new and adaptive techniques. He has lectured professionals from all fields of manual therapy and he travels the UK teaching others from single practitioners to premier league football medical teams. As part of a small team Jimmy is published in Medical and ElectroAcupuncture, Osteopathic Spinal and Peripheral Joint Articulations and Osteopathic and Chiropractic Techniques. Email: bookings@omttraining.co.uk LinkedIn: www.linkedin.com/in/jimmy-michael-980b2011a/ and www.linkedin.com/in/giles-gyer-88975863/ Instagram: www.instagram.com/omttraining_official/ Website: www.omttraining.co.uk Facebook: www.facebook.com/OMTtraining/

Co-Kinetic Journal 2020;85(July):37-42

ENTREPRENEUR THERAPIST

A Short Reflection on What Covid-19 May Mean for the Therapist in 2020 and Beyond

Co-Kinetic.com

thank you to each one of you, for giving me that opportunity to learn, develop and improve. With that in mind, we come to the article that will follow this one (and the topic of my new webinar). Like it or not, our lives have changed, and the normal we knew up to March this year, is now gone, certainly for the foreseeable future. I don’t think I’m alone in anticipating that the normal we knew then, is now a thing of the past. Our job is now to move into the next era of physical and manual therapy delivery. The increased uptake of telehealth, due to Covid-19, may have just caused the single biggest change in the way we deliver MSK services, that any of us will ever experience in our lifetime. I think back to my days studying as a physio at Addenbrookes Hospital in Cambridge and how I bemoaned that the days of the “old school” hands-on physio were over, because students graduating since then, did nothing like the hands-on work that I trained to deliver. And now, ironically, I find myself thinking what a mixed blessing it is that things did move on, because those hands-on skills are the ones that have, and will continue to suffer most, as a result of this virus. What I’m in absolutely no doubt about, is that in order to survive, and eventually once again thrive, we have to move as many of our skills online as we feasibly can. We also need to find a way we can scale, ie. build our businesses without always requiring our physical presence in that process.

By Tor Davies, Co-Kinetic founder 20-07COKINETIC FORMATS WEB MOBILE PRINT

WE HAVE TO MOVE AS MANY OF OUR SKILLS ONLINE AS WE FEASIBLY CAN

have been blown apart. OK he can’t get his hands on me physically, but as we all know, a lot of rehabilitation is based on getting the right diagnosis, prescribing the right rehab, and then making sure your patient follows through and does that rehab. And guess what, you can do all that online. Sure, I don’t get the immediate satisfaction or relief, of some deep tissue massage to ease the aching muscles in my back, that are having to compensate for my injury and resulting muscle imbalances. However, if the rehab works, those tight muscles, will start to loosen and I’ll hopefully become pain-free. The scary (or exciting) thing from a practitioner perspective is that suddenly you’re in competition with the wider national and even international physical therapy world for patients. If you view it from that exciting perspective, the whole world’s patient population has suddenly become your oyster. But in order to benefit from this new opportunity, you’re going to need a ninja marketing plan, and that’s exactly what I’m going to give you, in my next article. From a patient perspective, there are some definite advantages to doing this stuff online. Even with my training, I still forget what I’ve been told to do after the first day or two but now I have a recording of my session, so I can go back any time and revisit it. In addition, I haven’t had to get in my car, drive to the clinic, find and pay for a parking spot and then sit in a waiting room, when I could be working. Part of my job I feel now, is to

help you to educate your patients and clients, on the upsides of telehealth, so that you can encourage more people to get more from their rehab. Let’s face it, despite knowing that my long-term situation is only going to improve through my own commitment to my rehab exercises, there’s something about a good, strong, deep massage, that almost makes me advocate responsibility for my own recovery. The ‘here I am, I’ve made the effort to turn up and pay you, now you fix me’ attitude, which we all know, will end in failure. So now, in order to deliver the very best for our patients, we need to hone our diagnostic skills so we can be as sure as clinically possible that we’re rehabbing the right thing, and then become better at motivating our patients to stick with, and progress, their rehabilitation so that they achieve the outcome they’re looking for. Most of all, they need to understand that once you’ve given them the tools and knowledge they need, the responsibility for their own rehabilitation lies with them. You can be there to motivate and cheer from the sidelines, but no longer can they delegate responsibility for their rehab, to your physical hands-on treatments. I appreciate this is much harder if you’re a dedicated manual therapist, and where the primary offering is the hands-on component. Where this is the case, the strategies I outline in the next article, will help you diversify and find new ways to use your manual therapy skills online. Regardless of whether you’re a

physical or manual therapist, the more you can start to widen your revenue streams, with a focus on going online wherever possible, the better the chance of building a thriving physical or manual therapy business going forward. You never know, maybe this is the ideal opportunity to bring physical and manual therapists closer together, where physical therapists can work in partnership with a manual therapist to supplement their online diagnosis and rehabilitation. Instead of having a rushed physical therapy appointment because an osteopath, or physio is trying to get up to speed with what you’ve done in the last week, offer some exercise progressions AND deliver a hands on treatment all in 40-45 minutes, you get an online appointment which is a more focused assessment, and includes more time for condition explanation, Q+A and the necessary motivational kick up the back-side to keep the rehab going. From a patient perspective, my face-to-face physio sessions would always leave me feeling less physical pain, but I was also emotionally drained from the physical treatment. As a physio, you forget what it’s like to be a patient. I didn’t experience that emotional reaction during my telehealth session (thankfully because I can’t say I enjoy it), because I was in my own safe space and instead of feeling wary of what was about to happen next, I felt less emotionally exposed. Instead all I had to do was focus on what Chris was telling me I needed to do to get stronger. So in the following article and accompanying webinar, I’m going to look at as many ways as possible that you can monetise, ie. earn revenue, using your physical and manual therapy skills online. Not only that, I’m going to explain how you formulate and then execute the plan. As usual, it’s a ‘hands-on’ practical guide that is designed to help you build a much stronger business, whatever the future brings. I may not be able to predict much but what I can assure you, is that I will be here every step of the way to support and help you. Co-Kinetic Journal 2020;85(July):43-44

How to Monetise Your Therapy Skills Online

ENTREPRENEUR THERAPIST

By Tor Davies, Co-Kinetic founder 20-07-COKINETIC FORMATS WEB MOBILE

In this article I’m going to look at how you can use your physical and manual therapy skills to generate revenue online, and discuss briefly why I think this is so important. There is a very small amount of cross-over with my Covid Survival Strategies webinar, but most of the content of this article (and my new webinar) is fresh and better informed, as a result of having four months of hindsight, and not being in emergency survival mode! The key to business survival is diversity. It’s about spreading the risk so that not all our eggs are being held in one basket, and we are not so reliant on one source of income. I don’t have the space here to talk you through how to implement this strategy step-bystep (or how to prime your strategy to give you the best results), I’ve left that for the webinar. The idea of this article is to let you mull over which of the following ideas could work best for you, and then through the webinar, I’ll explain how you create a marketing funnel, prime it so your funnel is full of people who need the service you’re going to offer them, and designed to move people through it in a completely unsalesy way, towards a purchase, while continuously adding value to your prospects. To sign up to the webinar click/or visit this link (https://bit.ly/30J3dev). Co-Kinetic.com

Introduction

Covid-19 spreads more effectively than most, if not all, other viruses we’re aware of, at least outside the scientific community. And, while it’s not the deadliest virus we’ve seen (Ebola takes that prize with fatality rates of over 40%), in addition to affecting those with immunity vulnerabilities, it has also affected seemingly random people with no obvious signs of a compromised immune system. Understandably, this, accompanied by such a gaping hole in our knowledge about this virus, makes us all fearful that either ourselves or our loved ones, might fall into that minority. We can’t afford to underestimate this fear. The fact that we also don’t yet have a vaccine for so many of these viruses (despite Ebola being first discovered in 1972 (nearly 50 years ago), SARs in 2002 and MERs in 2012), it feels like a scary and unknown future. On the plus side, the extent of the worldwide economic destruction wreaked by Covid-19, puts finding a vaccine at the highest priority level possible, not only with plenty of funding available for the endeavour, but also an international effort in play, like we’ve never seen before. However, all this still leads me to the conclusion that as a profession, which relies almost exclusively on face-to-face contact to make our living, we have no choice but to diversify on a more permanent basis. To state the obvious, nobody knows what the

future holds and 4 months ago, none of us ever believed anything like this could happen, and yet here we are. If we don’t adapt our businesses now, there’s a very good chance they won’t survive what the future brings. As a former physio, I understand that prospect may, at least at first glance, seem extremely depressing and demotivating. I also understand first-hand the deep motivation each of you has, to help people feel better and I understand how satisfying, even exhilarating, it is to deliver hands-on treatments that help to heal not only the body, but also the mind, and in doing so having such a motivating impact on people’s quality of life. And I’m not saying we should give up on that, quite the contrary. I’m just saying that we need to add more strings to our bows (and more permanent ones than just filling the gap temporarily), so that we’re not as financially vulnerable if one source of income suddenly disappears, just as it did in March. In this article, I cover the income revenue ideas, but I tackle practical implementation of how to generate the revenue, in my webinar.

What Have We Learnt?

There are a few key lessons that hopefully we’ve all learnt over the last few months. 1. As a business, we rely too heavily on face-to-face appointments as our primary, if not only, revenue stream 2. We probably didn’t have much of 45

a cash-buffer to help tide us over when this situation hit 3. Our marketing was in most cases, in extremely poor health a. Without an email list, we lost the ability to communicate with our existing patients overnight b. Without an ongoing nurture email process in place (ie. we weren’t sending regular valueadded emails to our email list), we didn’t have an engaged audience, which we could leverage at short notice, to build new revenue streams c. We weren’t prioritising the importance of growing an email list. That in a nutshell, should be EVERYONE’S PRIMARY MARKETING PLAN right there, building an email list, and nurturing and building engagement with that list. I’ve said it before, and I’ll say it again. It may not seem sexy or exciting, but it’s real, it’s reliable, it’s proven and it’s something that healthcare professionals will find second nature if you know how to do it, and you approach it with the right mental mindset.

Telehealth: Opportunity or Threat?

In my view, the increased uptake of telehealth due to Covid-19, may have just caused the single biggest change in the way we deliver MSK services, that we’ll ever see, at least in our lifetime. Telehealth creates a whole host of new opportunities, but as with all new opportunities, come a host of new threats. If you build a reputation for being a 5-star therapist to runners, or cyclists, or in women’s health, the ability to deliver online consultations means you can transcend geography. The trouble is, on the flip side, being local may soon not be enough of a draw or convenience to bring people through your physical clinic doors. What this means, is that having a solid, reliable and effective marketing strategy, that is also being implemented on a regular and consistent basis, suddenly becomes a LOT more important, business critical in fact. 46

A Summary of Ways to Generate Revenue Online

1. Take Your Services Online Most of you I’m guessing will have done this in some form or another over the last 3-4 months. The downside is that you have to be physically available (albeit online) which will always restrict your capacity to deliver (there are only so many hours in the day). It’s also not as satisfying as face-toface treatments, but you should definitely plan to set some hours aside in your week to provide a service through online channels, and focus on what you can deliver most effectively through the online medium. Some things lend themselves to being delivered online, especially if you can use animations or demonstrations on your screen that you wouldn’t realistically use during a face to face appointment. Think about, and implement, ways you can add value to your appointments. 2. Sell Therapy Products We covered this in my Covid Survival Strategies webinar. Sign up with affiliate programmes, run weekly or monthly promotions, work with your suppliers, and give your (growing ) email list easy ways to purchase these products through your regular email communications. 3. Produce an Online Course or Deliver Online Workshops/ Webinars This could be for patients or fellow therapists. Can you provide a unique offering based on your particular skill set? Research what’s out there. Is there a niche you can fill, or something you can do better than what’s already done? Frankly, it doesn’t matter if you can’t find something unique, you’ve just got to be good at doing it. 4. Create Digital Content You Can Sell I give LOTS of examples and ideas in my webinar. It could range from eBooks, Advice Guides, Cheat Sheets or even templates for things. It also doesn’t necessarily have to be clinical. Have you

developed something really useful for running your business like a spreadsheet, or set of email templates, or even something you use regularly in your personal life? I discuss how you monetise these in my webinar. 5. Hire Yourself Out Do a search on some of the wellknown ‘freelance’ sites like Fiverr or Upwork, or People by the Hour – search for physiotherapy, or fitness, or massage or nutrition and see what comes up. If there’s nothing for your sector, but you can find things under a similar discipline like fitness, could you use those ideas to create something similar for massage or physical therapy? 6. Consultancy/Mentoring Have you got useful knowledge you can share to help people achieve an outcome either clinically or in a business setting that you’d prefer to do that one-to-one or in small groups? If so, consider hiring yourself out as a consultant or a mentor (ideally use online as a major part of your delivery). Do you have other skills from previous jobs like project managing, HR, accountancy, business planning that you can throw into the mix? 7. Question and Answer Sites Similar to hiring yourself out, can you find Q+A websites like justanswer.com where the site will pay you to answer questions specific to your expertise? You can find more info about similar sites at this link https://bit.ly/2URxfst 8. Start a Peer-to-Peer Online Discussion Group This could involve an ongoing fee and offer anything from continuing education outcomes to peer-topeer support on any topic you like. You could invite guest speakers (online interviews). Make sure to record the sessions so you can provide this as an ongoing, growing archive. 9. Online Membership Group/ Community Similar to the peer-to-peer group but client/patient-facing. For a relatively small amount of work each month, potentially one or two new presentations/interviews/ Co-Kinetic Journal 2020;85(July):45-47

PHYSICAL THERAPY

resources, and maybe a private Facebook group where members can ask questions or get support for ongoing issues, you could charge a recurring subscription fee which will build nicely over time – I offer some financial models in my webinar. 10. Create or Teach a Therapeutic Technique This could be something that’s exclusive to you or something that’s difficult to learn, if you can build on the skills it becomes an ongoing proposition/membership/ course. 11. Collaborate with Other Professionals Why not team up with fellow professionals, again geography no longer has to be an issue, it could be a friend or colleague who has skills that ideally complement your own, to create one of the above offerings. In addition to giving you a wider scope and a more unique offering, by combining your audiences, you also have a bigger (combined) audience to market to, than you would if you went solo. 12. Turn Hobbies into Money Always wanted to paint? Or make cosmetics? Or take photographs? Or teach people how to train dogs? Now’s the time to try it out! Sites like Etsy help people to sell all sorts of craft-related products. Whatever your skill set there will be a website out there to help you monetise it. 13. Generate Cash from Everyday Activities OK admittedly ideas 12 and 13 are not necessarily therapyspecific but as they can potentially generate a meaningful amount of cash, I figured they were worth including. Ideas here include using a cash-back credit card both personally as well as for your business and paying on these cards wherever possible (make sure to set up a direct debit for full payment so you don’t incur nasty interest fees). Use cashback websites to make purchases, you’d be surprised at how quickly this can add up. Topcashback.com is one Co-Kinetic.com

of the world’s biggest and best known sites. A friend of mine has earnt several thousand pounds by using this site to make purchases she’d normally make anyway. Each time she buys any form of insurance, she does it through this site, as well as phone contracts, clothes shopping, hotel bookings, electricals, or shopping on most of the online stores (with the exception of Amazon). If you do it through this site, it will result in you earning cashback. We know this last one, but how often do we do it? Regularly compare utility rates, or if you’re based in the UK, use this Dragon’s Den record-breaking service called Look After My Bills (if you’re outside the UK Google and see if there is an equivalent service in your country) who will do the comparing and the switching for you. I just saved myself £500 a year by switching to a different energy supplier, but better than that, I switched to a 100% renewable energy source too, so not only did I save money, but I feel much better about my choice of provider too! 14. Affiliate Programmes This can include therapy-specific products as well as general everyday products but if you have a company you use that you love (or maybe you don’t even use them yet but you love what they do), use your engaged email list to tell people about them. Other companies I use and enjoy promoting, mainly because I like their ethics, is my new utility provider Octopus Energy [share. octopus.energy/sand-rose-104] mentioned above, because their energy comes from 100% renewable sources, they’ve been recommended 3 years in a row by Which and they have an amazing customer service reputation. You’ll find that pretty much any provider you use will have some sort of affiliate programme. I’m not suggesting you shove it in people’s faces, but there’s nothing wrong on occasion in recommending companies that

you feel are doing good work and deserve the recommendation, and if you earn a few pounds from it, all’s well and good. 15. Other Ideas I didn’t really want to spend too much time on this category because they either take a lot of time to build or require a relatively large amount of input/investment in order to generate revenue, but ideas include starting a podcast, building a YouTube channel and writing a blog (the latter is relatively easy to do). For these to be successful, you also need a decent-sized audience to appeal to.

The Accompanying Webinar to This Article

In the accompanying webinar, I go into specific detail about how to actually generate revenue from these ideas and specifically how to build a funnel, which adds value at each level, and increases the chance of converting your prospects into paying customers. As with all my webinars, I show you how to do this in a completely unsalesy way, while adding value to your prospects at each level of the funnel. I look forward to joining you there. For more info and to register, visit this link (https://bit.ly/30J3dev).

TO SIGN UP TO THE WEBINAR click/or visit this link (https://bit.ly/ 30J3dev)

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

PATIENT ADVICE

Recovering from Coronavirus T

A Long and Unclear Road to Recovery

WHEN WILL I BE BETTER?

Medically, a person must be fever-free without fever-reducing medications for three consecutive days. They must show an improvement in their other symptoms, including reduced coughing and shortness of breath. And it must be at least seven full days since the symptoms began. In addition to those requirements, the United States CDC (Centres for Disease Control and Prevention) guidelines say that a person must test negative for the coronavirus twice, with the tests taken at least 24 hours apart. But is that really recovery? Can you say then that you have recovered from Covid-19? We think not, surviving the virus may take you to this point but recovering from it may still be a much longer and more complex process. Recovery time will depend on how ill you became in the first place. Some people will shrug off the disease quickly, but for others it could leave lasting problems. The more invasive the treatment you receive, and the longer it is performed, the longer recovery is likely to take.

WHY DON’T I FEEL ‘RIGHT’?

Many patients report waves of symptoms over a period of weeks following recovery – from heart palpitations to headaches, shortness of breath and fatigue. Decreased lung capacity is observed by doctors during follow-up consultations. All this impacts on your ability to return to ‘normal’ life, be it

WILL CORONAVIRUS AFFECT MY HEALTH LONG-TERM?

We don’t know for sure as there are no long-term data, but we can look at other conditions. Acute respiratory distress syndrome (called ARDS) develops in patients whose immune systems go into overdrive, causing

damage to the lungs. There are really good data that, even five years down the line, people can have ongoing physical and psychological difficulties. People also need mental health support to improve recovery. Doctors report how they tell patients, “You’re having difficulty breathing, we need to put you on a ventilator, we need to put you to sleep. Do you want to say goodbye to your family?”. PTSD (post-traumatic stress disorder) in these most severely ill patients is not surprising. There will be significant psychological scars for many, not just the most severe cases. Sometimes even mild cases of the disease may leave patients with longterm mental health problems – issues from concerns over stress and anxiety of surviving the illness, job security, depression, family and financial worries during lockdown.

WHAT CAN BE DONE?

Having a team of medical professionals working with you will get you through this. Physical activity will be critical to re-build your strength and fitness. Pulmonary rehabilitation may be key to improving your exercise tolerance which will improve your ability to do daily chores and return to normal life sooner. Pulmonary rehabilitation is proven to work with patients’ chronic lung disease or individuals recovering an acute lung illness or lung surgery. As Covid-19 primarily attacks the lungs, this may be a good starting point that a physical therapist can guide you through. In combination with this, seeking counselling, speaking to professionals and social workers may assist in dealing with stress, anxiety and depression. There are also instances where patients have suffered from deep vein thrombosis (DVT) and strokes

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with Covid-19; in which case doctors and physical therapists will provide you with a personalised rehabilitation plan depending on your needs. Shortness of breath or feeling breathless with even the smallest task (such as getting dressed or doing some housework) can result in a cascade of thought, emotions, behavioural and physical responses that can be unhealthy physically and mentally. Below in the solid blue smaller circles are techniques you can use to control and improve your breathlessness – coping techniques that can be taught to you by a physical therapist. Being breathless often leads to inactivity. The more inactive you are, the more breathless you become and the vicious cycle continues. Being inactive also leads to weight gain, also making you more breathless. Being inactive can increase your risk of developing a DVT. You have the ability, with help, to change this. The most important thing is not to be complacent in your recovery, thinking that Inefficient breathing Increased work of breathing

EVENT Doing house work Walking ouside Getting dressed

SHORTNESS OF BREATH

THOUGHTS “There’s no point in trying” “This is dangerous” “What if...?” PHYSICAL SYMPTOMS Feeling light-headed Fatigue Sleep problems Chest pain

EMOTIONS Depressed, worthless Anxious, worried, Guilty, ashamed BEHAVIOUR Inactivity, passivity Avoidance Maladaptive behaviours (eg. smoking)

Relaxation Mindfulness

Addressing concerns and expectations

Anxiety management

Breathing Increased respiratory rate Use of accessory muscles Dynamic hyperinflation

Fan

Thoughts about dying Misconceptions Attention to the sensation Memories, past experiences

Thinking Breathlessness Anxiety, distress Feelings of panic

Breathing control

Functioning Deconditioning of limb, chest wall and accessory muscles

Reduced activity Tendency to self-isolate More help from others

Activity pacing

Encourage exercise

Walking aids

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PATIENT ADVICE

this is simply the flu and ‘I will feel better soon’. This can often lead to a downward spiral of prolonged symptoms which can result in the development of chronic complications in lung function, exercise intolerance and even chronic fatigue syndrome (formally

called ME or myalgic encephalomyelitis). Be pro-active and ask for help, most of which can be even done over telehealth calls, virtual consultations and group exercise or support sessions via Zoom or Skype, for example. You do more activity to help your breathlessness

You do less activity

You avoid those activities which make you breathless

You become fearful of activity that makes you breathless

Vicious cycle of inactivity

Your muscles become weaker

You’re motivated to continue being active

You feel better Weak muscles use more oxygen and are less efficient

You feel breathless

here are many breathing exercises you can do which can help you to relax and destress, but also improve your lung function, particularly if you’ve suffered from a recent respiratory illness. The following exercises are designed to help you to increase your lung function and capacity. Where possible dedicate 10 minutes, preferably twice a day, but once is better than nothing, and particularly anytime you’re are feeling anxious, stressed or overwhelmed. Caution: Breathing exercises can make some people dizzy or lightheaded, especially if they are new to you. So, always work safely by lying down or sitting while you perform the exercises. Also take it slowly, do 1-2 exercises at a time initially and perform them 2-3 times through the day. 1. Lions Breath This exercise is good for strengthening the diaphragm. l Take a deep breath in through the nose l As you exhale open your mouth and push your tongue out as far as possible. l Repeat 8 times 2. Forced Exhalation This is a good exercise to strengthen your diaphragm and improve your deep breathing mechanics. l Breathe in through your nose pushing your belly up and out l Then open your mouth and breathe out hard in a shot sharp blow. Remember to pull your stomach in as the same time as you exhale. l Repeat 8 times.

Your muscles become stronger

Positive cycle of activity

Your muscles use oxygen more efficiently You’re less breathless and tasks become easier

3. Huff Cough This is a progression from forced exhalation and is more for someone who has been ill or has experienced a build-up of mucus in their chest. The huff cough is a breathing exercise designed to help you cough up mucus effectively without making you feel too tired. It should be less tiring than a traditional cough, and it can keep you from feeling worn out when coughing up mucus. lP lace yourself in a comfortable seated position. Inhale through your mouth, slightly deeper than you would when taking a normal breath. lA ctivate your stomach muscles to blow the air out in 3 even breaths while making the sounds “ha, ha, ha.” Imagine you are blowing onto a mirror to cause it to steam. lT ry this 3 times as it should elicit a productive cough and relieve you of any mucus. This can be done anytime during the day when you feel there is mucus build-up. 4. Forced Inhalation This is a good exercise for strengthening your diaphragm and improving your deep breathing mechanics. l Open your mouth and take a fast hard breath in. Don’t forget to push your stomach out as you breathe in l Slowly relax breathing out l Repeat 8 times

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PATIENT ADVICE

What is the 6 6-Minute Walk Test? T

he 6-minute walk test is a submaximal (meaning less than the full effort you are capable of) exercise test that measures the distance walked during 6 minutes. The 6-minute walk distance provides a measure for the integrated global response of the multiple cardiopulmonary (heart/lung) and musculoskeletal (muscle/bone) systems involved in exercise. The 6-minute walk test provides information regarding functional lung capacity, response to therapy and prognosis across a broad range of chronic cardiopulmonary conditions. The main strengths of the 6-minute walk test stem from its simplicity. It is easily understood and performed, meaning that most patients are happy to do it, including those who are unfit, elderly or frail. It is also a very low-cost test and the results are easy to understand.

ABOUT THE 6-MINUTE WALK TEST

Turn point

This test can help monitor your response to treatments for heart, lung and other health problems. This test is commonly used for people with pulmonary problems or chronic lung disease to assess lung function. The results of this test may lead your doctor or therapist to do more tests. They may also do further tests of your heart and lung function.

WHAT TO EXPECT

Preparing for your test: l Wear clothes and shoes that are comfortable. l Itâ&#x20AC;&#x2122;s OK to eat a light meal before your test. l Take your usual medications. l Do not exercise during the 2 hours before your test. During the test: l The person conducting the test will measure your blood pressure, pulse and oxygen level before you start to walk. l You can use your usual walking aids, such as a cane or walker, if needed. l If you typically use oxygen while walking, you can use it during your test. l Let the testing staff know if you are having chest pain or breathing difficulty. l You can slow down, rest or stop at any time during the test. After every minute, the tester will tell you how much time remains.

Path of Walk Distance 30 metres

Start point

You will be given the following instructions: l The purpose of the test is to walk as far as possible within 6 minutes. l Walk at your normal pace to a chair or cone, turn around and walk back to where you started. l Continue to walk back and forth for 6 minutes. Ideally the length of each lap should be 30 metres. However, this may need to be adjusted and made shorter depending on available space, especially if you are performing a test at home or during lockdown with limited access to facilities. So the length of each lap may be shorter, but you continue to walk for the 6 minutes and then calculate how far you have travelled by multiplying the number of laps with the length of 1 lap. Provided the ground is level and flat and the same distance/route is used for re-testing then the results can be compared. Safety: l The tester will watch you for any difficulty breathing or chest pain. l Oxygen and other supplies will be nearby if you need them.

UNDERSTANDING THE RESULTS

The results of your test are compared with results that are typical for healthy people at your weight, height, sex and age. The test results can help estimate how well you are responding to treatment. Often, your therapist will ask you to repeat the 6-minute walk test after 6 months or a year. Your therapist may change your exercise programme based on your test results.

WHAT ARE THE RISKS?

This is a low-risk medical evaluation. Medical help is available during the test.

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New Webinar from Tor

How to Monetise Your Therapy Skills Online l 14 strategies you can employ to generate ongoing online revenue using specifically your therapy skills l The focus is on building scalable revenue streams which don’t depend on you being physically present and which can thrive despite Covid-19 l I show you step-by-step how to monetise your online strategies and explore a couple of different revenue models l And I’ll explain how to build a marketing funnel from scratch, and then fill it specifically with people primed to want your offering l Finally we look at how you can use a blended online and offline approach, which plays to the strengths of each environment, and helps you to deliver a better overall customer experience

To survive we need to learn to diversify without losing focus on our strengths I’ve listened to 2 of Tor’s webinar’s on marketing and surviving Corvid-19 she is passionate about supporting physios and small practices in making to most of our time and providing added value for our clients. If you are looking at growing your business you wouldn’t be wasting your time listening to one of these.

Great webinar and really informative resources which I am now using within my Subscription to get new leads for my clinic. Highly recommend!!!

To Register click here https://bit.ly/30J3dev

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