Co-Kinetic Journal Issue 86 - October 2020 by Co-Kinetic

1999 202

ISSUE 86 OCTOBER 2020 ISSN 2397-138X

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what’s inside PRACTICAL

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ENTREPRENEUR THERAPIST

THE BENEFITS OF OFFERING MEMBERSHIP PACKAGES IN YOUR THERAPY BUSINESS

The Benefits of Offering Membership Packages in Your Therapy Business 20-10-COKINETIC FORMATS WEB MOBILE

emberships have been around a long time in all sorts of business settings, and they’re now slowly making an appearance in the therapy world, which is good thing. We’re all familiar with the concepts like gym memberships, but in this article I’m going to dig into what a membership can look like for your physical or manual therapy practice, the benefits of them, and the different models you can choose from. Memberships can provide the option for clients to become a member and get VIP services, special rates or extras included in their membership fee. It builds loyalty and stability in your business, making it the natural next step for your regular clients. A lot of therapists don’t even consider the option of a membership package or get overwhelmed by what to choose. Starting simple and with limited places is the best plan, and then build out the offerings and places over time.

Why Memberships are SO Important for any Business

Before we dive into the specifics, let’s

In this article, Vicki explores the benefits of offering a membership subscription option within a physical or manual therapy business. She discusses why memberships are so valuable, explores some different membership models, offers some suggestions regarding what you can include and then reviews briefly the ways in which you can take payments and manage the memberships. Read this article online By Vicki Marsh, Massage Therapist, Clinic Owner and Business Coach quickly cover WHY memberships are so important for any business. The first, and biggest reason is that they create reliable recurring income. You can actually PLAN your finances knowing there is a guaranteed payment coming in next month. For most clinics, if we look ahead in the dairy for even just 2 months, the number of committed bookings won’t even cover the basic running costs of the business, and you have no actual guarantee that anyone else will book. In practice, we know that clients often leave it to the same day to book, but without that commitment in the dairy, you can never be 100% certain of your income. This leads onto how memberships can deliver you improved diary management. I ALWAYS recommend that all your members are treated like VIPs and their appointments are booked in advance. This secures their

preferred appointment time, creates a much clearer snapshot to your capacity and allows you to make confident decisions about when to hire or expand. By getting those appointments in advance, it also encourages other regular clients to get their appointments in too, building an increasingly robust diary with a clearer ability to predict your income over the coming months. And arguably most importantly,

MEMBERSHIPS CAN PROVIDE THE OPTION FOR CLIENTS TO BECOME A MEMBER AND GET VIP SERVICES, SPECIAL RATES OR EXTRAS INCLUDED IN THEIR MEMBERSHIP FEE

Co-Kinetic.com

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MEMBERSHIP MAGIC – HOW YOU CAN BUILD RECURRING REVENUES INTO YOUR BUSINESS

THE THREE CORNERSTONES TO MARKETING AND SALES

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FASCIAL STRETCH THERAPY™ FOR THE LOWER BODY

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12-13 PHYSICAL & MANUAL THERAPY AND HEALTH & WELLBEING INFOGRAPHICS

RESEARCH INTO PRACTICE

Journal Watch Physical Therapy

CLICK ON RESEARCH TITLES TO GO TO ABSTRACT

WHEN HEEL PAIN IS NOT PLANTAR FASCIITIS. Fullem B. Podiatry Today 2020:33(6):36–39

OPEN

= OPEN ACCESS

ADDUCTOR LONGUS INJURY AFTER ELECTROMECHANICAL SELFTREATMENT: A CASE REPORT. Rosado-Velazquez D, Gestoso-Campos M, Medina-Porqueres I. Physical Therapy in Sport 2020;46:7–13

OPEN

This is described as the author’s personal treatment algorithm. He argues that although plantar fasciitis is a common diagnosis, if the pain is not occurring at the attachment of the plantar fascia, then one should consider other possible diagnoses. However, the first treatment of his plan is to apply kinesiology-type tape to the bottom of the foot. If this improves the symptoms it conforms a diagnosis of plantar fasciitis. Then, follow up with supporting the foot via taping and sometimes an over-the-counter or custom orthotic device, icing with a frozen water bottle, extracorporeal shockwave therapy, calf stretching, massage of the arch and flexor hallucis tendon, proprioception exercise and exercises for the core intrinsic foot muscles. The stretches should concentrate on the calf muscles and not the foot otherwise traction is put onto the plantar fascia attachment. If none of this works, consider other conditions. A couple of case studies are included that suggest plantar fascia tears, bone spurs and fractures.

Co-Kinetic comment As a guide to treating plantar fasciitis this is useful piece of work. It is not as clear on what to do either diagnostically or for treatment if it’s not plantar fasciitis. Bottom line is try the given treatment algorithm first, then start thinking about MRIs and X-radiography.

This is about injury prevention for high-performance aviators. They are exposed to musculoskeletal risk relating to the extreme environments in which they operate. These include, high-gravitational force equivalents (g-forces), altered gravitational vectors, vibratory loading, and interaction with equipment. Injuries to the cervical and lumbar spine, and the extremities are common to aviators and astronauts, and occur in training and operational environments. Stress on the spinal column secondary to gravitational loading and unloading, and the vibration of the craft are implicated in the development of pain syndromes and intervertebral disc pathology. Astronauts in training have reported pain and injury to hands, shoulder, feet, arms, legs, neck, trunk, groin, and head owing to overuse in association with their protective suits. Constraints include its planar hard upper torso, difficulty in donning, glove 4

CREW-FRIENDLY COUNTERMEASURES AGAINST MUSCULOSKELETAL INJURIES IN AVIATION AND SPACEFLIGHT. O’Conor DK, Dalal S, Ramachandran V et al. Frontiers in Physiology 2020;11:837 moisture and fingertip loading, and limited scapulothoracic motion. For astronauts, the second most reported in-flight complaints are musculoskeletal issues with an incidence of 3.34 events/ person-year. The most reported complaint was sleep disturbance. Crew support equipment, such counterbalanced helmets, head mounted electronic communications systems and anti-vibration seats, can contribute to musculoskeletal strain or trauma by adding to the overall weight of the helmet. Pain in flight leads to impaired concentration and situational awareness, impaired motor control and posture and an inability to perform in-flight manoeuvres. Evidence suggests that many pilots do not report pain or injury and continue to fly because of fear of losing flight

OPEN

status. Crew-focused injury prevention measures such as stretching, exercise, and conditioning programmes have demonstrated the potential to prevent pre-flight, in-flight, and post-flight injuries. Equipment countermeasures, especially those addressing helmet mass, centre of gravity and spacesuit ergonomics, are also key in injury prevention.

Co-Kinetic comment Spaceflight medicine, now there is a speciality that is out of this world. Is it only for highflyers? Seriously though, this is another must-read (we have a lot of them in this edition) if you are involved with this patient population (or want to be). How scary is the thought that the crew of that low-flying fast jet that just passed overhead may in a degree of pain that impairs their judgement? Do not worry, help is at hand. There are some examples of interventions to reduce in-flight pain such as neck strengthening exercises using resistance bands which, this being the military, get an acronym of PCED (portable cervical spine resistive exercise device). Military speak means that the flight crew are not exercising, they are practising musculoskeletal effects countermeasures. Co-Kinetic Journal 2020;86(October):4-7

This case involves a 27-year-old male, professional soccer player who had a 24h history of what is described as ‘adductor longus overload’. It did not require him to stop physical activity, which is also not described but let’s assume it was football. To combat the condition, he self-applied a 1h treatment with a hand-held vibratory electromechanical massage device. As a result, the original overload sensation turned into pain and functional impairment. He presented with difficulties when actively adducting his leg in both the flexed and extended positions of the hip. Diffuse tenderness was elicited on palpation over the

superomedial part of the medial upper third of his thigh with acute moderate pain throughout the entire area but no palpable gap nor mass at any site throughout the adductor longus. No ecchymosis appeared during the whole process. Passive abduction and resisted adduction resulted in pain. Manual strength testing indicated weakness of the adductors. Passive joint mobility was normal in all axes of mobility, with a loss of 10 to 20° in maximum amplitudes during active mobilisation in abduction. Along with the clinical presentation, MRI and ultrasonography (US) showed a loss of continuity in muscle fibres in

This is a guest editorial in which the authors warn clinicians about allowing unverified claims and online discussions involving negative comments about cryotherapy to affect their treatment plans. The purpose of this editorial is to provide the reader with clarification in the hope that it improves the effectiveness of cryotherapy when used in the sports healthcare setting. Its main points are as follows. l Many of the negative comments come from detractors who do not support the therapy and often they come from a biased source whose purpose is to support or market a product or technique. l Evidence quoted in the text says that cryotherapy reduces localised pain and pain atherogenic muscle

21ST CENTURY ATTACKS ON CRYOTHERAPY IN SPORTS HEALTH CARE—CLINICIAN BEWARE. Long BC, Jutte LS. Athletic Training and Sports Health Care 2020;12(3):99–101 inhibition in all stages of healing. l It is not the only treatment modality available and its use depends on individual treatment goals and may be contraindicated in some patients. l It does not eliminate inflammation nor does contrast hot and cold. l Applying an ice bag directly to a patient’s skin does not cause frostbite in patients unless they have a preexisting vascular condition. l Read the small print. Look at studies closely and determine for yourself if the methods really are getting the results the headlines say and are the subjects tested are similar to your patient population.

the central area in the affected muscle, suggesting intramuscular oedema and a partial rupture of the thigh adductor muscle. He was rehabbed back to full fitness by the professionals.

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JOURNAL WATCH

Co-Kinetic comment Some say that the two most common elements in the world are hydrogen and stupidity.

OPEN

Co-Kinetic comment False news gets everywhere. This editorial makes a very good point about myths being promulgated. It’s hard to believe that you will still hear people stating, ‘there is no evidence massage or other hands-on therapy’ even though we report on it in every edition. As for cryotherapy, it reduces pain and muscle inhibition. What more do you want? Actually it does do more. Never underestimate the psychological aspects of what you do. Putting a bag of ice on a player who has just been injured does three things. It acts an analgesic, it instils in the player the idea that something is being done so that the healing process has started, and finally it makes the therapist feel that they have done something positive at a time when, to a large extent, nature needs time to take its course and there is not much else you can do.

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HAMSTRING INJURY PART 2: REHABILITATION

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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CLICK ON RESEARCH TITLES TO GO TO ABSTRACT

WHEN HEEL PAIN IS NOT PLANTAR FASCIITIS. Fullem B. Podiatry Today 2020:33(6):36–39

OPEN

= OPEN ACCESS

OPEN

This is described as the author’s personal treatment algorithm. He argues that although plantar fasciitis is a common diagnosis, if the pain is not occurring at the attachment of the plantar fascia, then one should consider other possible diagnoses. However, the first treatment of his plan is to apply kinesiology-type tape to the bottom of the foot. If this improves the symptoms it confirms a diagnosis of plantar fasciitis. Then, follow up with supporting the foot via taping and sometimes an over-the-counter or custom orthotic device, icing with a frozen water bottle, extracorporeal shockwave therapy, calf stretching, massage of the arch and flexor hallucis tendon, proprioception exercise and exercises for the core intrinsic foot muscles. The stretches should concentrate on the calf muscles and not the foot otherwise traction is put onto the plantar fascia attachment. If none of this works, consider other conditions. A couple of case studies are included that suggest plantar fascia tears, bone spurs and fractures.

Co-Kinetic comment As a guide to treating plantar fasciitis this is a useful piece of work. It is not as clear on what to do either diagnostically or for treatment if it’s not plantar fasciitis. Bottom line is try the given treatment algorithm first, then start thinking about MRIs and X-radiography.

This is about injury prevention for high-performance aviators. They are exposed to musculoskeletal risk relating to the extreme environments in which they operate. These include high-gravitational force equivalents (g-forces), altered gravitational vectors, vibratory loading, and interaction with equipment. Injuries to the cervical and lumbar spine and the extremities are common to aviators and astronauts, and occur in training and operational environments. Stress on the spinal column secondary to gravitational loading and unloading and the vibration of the craft are implicated in the development of pain syndromes and intervertebral disc pathology. Astronauts in training have reported pain and injury to hands, shoulder, feet, arms, legs, neck, trunk, groin and head owing to overuse in association with their protective suits. Constraints include its planar hard upper torso, difficulty in donning, glove moisture and fingertip 4

CREW-FRIENDLY COUNTERMEASURES AGAINST MUSCULOSKELETAL INJURIES IN AVIATION AND SPACEFLIGHT. O’Conor DK, Dalal S, Ramachandran V et al. Frontiers in Physiology 2020;11:837 loading, and limited scapulothoracic motion. For astronauts, the second most reported in-flight complaints are musculoskeletal issues with an incidence of 3.34 events/person-year. The most reported complaint was sleep disturbance. Crew support equipment, such as counterbalanced helmets, head mounted electronic communications systems and anti-vibration seats, can contribute to musculoskeletal strain or trauma by adding to the overall weight of the helmet. Pain in flight leads to impaired concentration and situational awareness, impaired motor control and posture and an inability to perform in-flight manoeuvres. Evidence suggests that many pilots do not report pain or injury and continue to fly because of fear of losing flight status.

OPEN

Crew-focused injury prevention measures, such as stretching, exercise, and conditioning programmes, have demonstrated the potential to prevent pre-flight, in-flight and post-flight injuries. Equipment countermeasures, especially those addressing helmet mass, centre of gravity and spacesuit ergonomics, are also key in injury prevention.

Co-Kinetic comment Spaceflight medicine, now there’s a speciality that is out of this world. Is it only for highflyers? Seriously though, this is another must-read (we have a lot of them in this edition) if you are involved with this patient population (or want to be). How scary is the thought that the crew of that low-flying fast jet that just passed overhead may be in a degree of pain that impairs their judgement? Do not worry, help is at hand. There are some examples of interventions to reduce in-flight pain such as neck strengthening exercises using resistance bands which, this being the military, get an acronym of PCED (portable cervical spine resistive exercise device). Military speak means that the flight crew are not exercising, they are practising musculoskeletal effects countermeasures.

Co-Kinetic Journal 2020;86(October):4-7

RESEARCH INTO PRACTICE

Journal Watch Physical Therapy

ADDUCTOR LONGUS INJURY AFTER ELECTROMECHANICAL SELFTREATMENT: A CASE REPORT. Rosado-Velazquez D, Gestoso-Campos M, Medina-Porqueres I. Physical Therapy in Sport 2020;46:7–13

This case involves a 27-year-old male, professional soccer player who had a 24h history of what is described as ‘adductor longus overload’. It did not require him to stop physical activity, which is not described but let’s assume it was football. To combat the condition, he self-applied a 1h treatment with a hand-held vibratory electromechanical massage device. As a result, the original overload sensation turned into pain and functional impairment. He presented with difficulties when actively adducting his leg in both the flexed and extended positions of the hip. Diffuse tenderness was elicited on palpation over the

superomedial part of the medial upper third of his thigh with acute moderate pain throughout the entire area but no palpable gap nor mass at any site throughout the adductor longus. No ecchymosis appeared during the whole process. Passive abduction and resisted adduction resulted in pain. Manual strength testing indicated weakness of the adductors. Passive joint mobility was normal in all axes of mobility, with a loss of 10 to 20° in maximum amplitudes during active mobilisation in abduction. Along with the clinical presentation, MRI and ultrasonography showed a loss of continuity in muscle fibres in the central

21ST CENTURY ATTACKS ON CRYOTHERAPY IN SPORTS HEALTH CARE—CLINICIAN BEWARE. Long BC, Jutte LS. Athletic Training and Sports Health Care 2020;12(3):99–101

Co-Kinetic.com

inhibition in all stages of healing. l It is not the only treatment modality available and its use depends on individual treatment goals and may be contraindicated in some patients. l It does not eliminate inflammation nor does contrast hot and cold. l Applying an ice bag directly to a patient’s skin does not cause frostbite unless the patient has a pre-existing vascular condition. l Read the small print. Look at studies closely and determine for yourself if the methods really are getting the results the headlines say and if the subjects tested are similar to your patient population.

area in the affected muscle, suggesting intramuscular oedema and a partial rupture of the thigh adductor muscle. He was rehabbed back to full fitness by the professionals.

Co-Kinetic comment Some say that the two most common elements in the world are hydrogen and stupidity.

OPEN

Co-Kinetic comment False news gets everywhere. This editorial makes a very good point about myths being promulgated. It’s hard to believe that you will still hear people stating, ‘there is no evidence for massage or other hands-on therapy’ even though we report on it in every edition. As for cryotherapy, it reduces pain and muscle inhibition. What more do you want? Actually it does do more. Never underestimate the psychological aspects of what you do. Putting a bag of ice on a player who has just been injured does three things. It acts as an analgesic, it instils in the player the idea that something is being done so that the healing process has started, and finally it makes the therapist feel that they have done something positive at a time when, to a large extent, nature needs time to take its course and there is not much else you can do.

BIOMECHANICAL ANALYSIS OF LONG DISTANCE RUNNING ON DIFFERENT SPORTS SURFACES. Shen SQ, He YQ, Zhang Y et al. Journal of Biomimetics, Biomaterials and Biomedical Engineering 2020;45:31–39 The objective of this study was to investigate the differences in ground reaction forces (GRFs) and kinematic parameters between longdistance runners before and after longdistance running on a treadmill (TM), asphalt road (AR) and plastic track (PT). An eightcamera Vicon motion analysis system was used to measure the hip, knee and ankle motion parameters of 10 healthy male subjects at a speed of 2.8±0.2m/s. The hip, knee and ankle kinematics and the relationship of joint angles of lower limbs in the sagittal plane, coronal plane and transversal plane were analysed. GRF data were collected using an AMTI force platform. The results showed that there were no significant differences in GRFs and average loading rate.

This is an essay on positive pain with a research study questioning swimmers’ attitudes to non-injury pain added to prove the points made. Despite the predominance of negative connotations associated with pain, not all sporting pain is experienced as unwelcome, nor is it always associated with injury or illness. In fact, in certain contexts (for example,

There was no significant difference in ankle and hip ROM after longdistance running on three surfaces compared to pre-test. Compared with the stance-period of pre-test, the stance-period of AR and PT were significantly longer. Post hoc analyses exhibited the stanceperiod of AR and PT were longer than TM. In conclusion, runners can adjust the angles of different joints to maintain a similar GRF during long-distance running on different sports surfaces.

IS GENU VARUM A RISK FACTOR FOR THE PREVALENCE AND SEVERITY OF ACHILLES TENDINOPATHY? A CROSSSECTIONAL STUDY OF NIGERIAN ELITE TRACK AND FIELD ATHLETES. Aiyegbusi AI, Tella BA, Sanusi GA. Nigerian Postgraduate Medical Journal 2020;27(2):87–92

Co-Kinetic comment It was a very small sample with only 10 runners, but it appears that the surface doesn’t make any difference to the GRF.

OPEN

Eighty‑five (56 male and 29 female) elite professional Nigerian track and field athletes, who specialised in running, long jump or high jump, participated in this study. Some of them took part in more than one event. Biomechanical variables of Q angle, tibial torsion, limb‑length discrepancy (LLD) and foot posture index (FPI) were evaluated. The presence of Achilles tendinopathy (AT) was confirmed with ultrasonography and clinical assessments, and the severity was evaluated with the VISA‑A questionnaire. Thirteen of the athletes tested positive for AT on both the clinical tests and ultrasound and one tested positive clinically but this was not confirmed by ultrasound. The results showed that there was no significant association between AT and LLD, tibial torsion and FPI. However, most of the participants with AT had genu varum (as measured by

“YOU ALWAYS WANNABE SORE, BECAUSE THEN YOU ARE SEEING RESULTS”: EXPLORING POSITIVE PAIN IN COMPETITIVE SWIMMING. McNarry G, Allen-Collinson J, Evans AB. Sociology of Sport Journal 2020;doi:https://doi.org/10.1123/ssj.2019-0133

during intense exercise or while receiving a deep tissue massage) pain can actually be associated with positive feelings and consequences. Examples of positive pain include the structured hardships endured by athletes during training and bodybuilders who ‘learn to enjoy’ non-injurious pain during training – this pain is constructive and contributes to the sustainability of bodybuilding as a physical culture. There is a similar culture in Mixed Martial Arts. In swimming, the ‘discomfort’ and ‘good pain’ of performance are described and an example given of marathon swimmers who come to understand pain as a

positive part of hard training, in which they push the limits of their physical capacities, producing physiological and psychological training effects. The discomfort of tired or sore shoulders is often considered evidence of an effective swim, with fatigued muscles equating to an embodied sign of training progression.

Co-Kinetic comment This is a must-read for anyone involved with athletes who train themselves to breaking point. Training is seen as ‘work’ in the pursuit of athletic improvement. Discomfort and ‘good pain’ become perceived as by-products of training, providing swimmers with important embodied information on pace, energy levels and other bodily indicators of performance. The problem for coaches and physical therapists is finding the point at which good pain becomes an overuse injury. Co-Kinetic Journal 2020;86(October):4-7

RESEARCH INTO PRACTICE

their Q angle) that was associated significantly with both the prevalence and severity of AT.

Co-Kinetic comment They went a long way to get there but, in the end, showed that none of the variables made much difference except being a bit bandy. Sadly they do not examine why their athletes have the condition. A big plus for this paper is that they talk about optimal sample size in medical research and use the open access paper by Pourhoseingholi et al. to work out how many they needed (Pourhoseingholi MA, Vahedi M, Rahimzadeh M. Sample size calculation in medical studies. Gastroenterology and Hepatology from Bed to Bench 2013;6(1): 14â&#x20AC;&#x201C;17; https://bit.ly/3bU3zm5). If you read this and similar papers, you realise that the majority of studies do not have a large enough number of subjects. If you are thinking of doing research, there are online calculators.

CONSERVATIVE TREATMENT OF MENISCUS INJURIES COMPARED TO SURGICAL INTERVENTION. Bingham G. Poster presentation 2020 This is a poster presentation that reviews the current state of play for meniscus tears. It describes the findings from seven primary research studies to compare conservative and surgical treatment in an age group of subjects from 30 to 60 years old, where there was a surgical group and a control group of conservative treatment and follow-up evaluation data for at least 12 months. Collectively the studies showed similar results for both surgical intervention and conservative treatment. Patients have improved evaluation scores quicker with surgical intervention; however, if patients can adhere to physical therapy and exercise regimens, they show slightly better outcomes in the long run. If patients do not show any improvement within the first 3 months of conservative treatment it appears that they would benefit from surgery. As with most soft tissue injuries, the more severe the tear, the more likely the patient is to require surgery. Injuries such as displaced bucket handle or displaced flap tears are examples. In those papers that described the conservative treatment, it generally consisted of early intervention to control swelling followed by progressively increasing ROM and strength.

Co-Kinetic comment We donâ&#x20AC;&#x2122;t usually review poster presentations but this one is clear, concise and it points in the direction of a treatment path. Its take-home message is to give the conservative treatment a go before you send your patients to the surgeons.

RISK FACTORS OF OVERUSE SHOULDER INJURIES IN OVERHEAD ATHLETES: A SYSTEMATIC REVIEW. Tooth C, Gofflot A, Schwartz C et al. Sports Health 2020;doi:https://doi.org/10.1177/1941738120931764 This is a systematic review aimed at identifying the risk factors of overuse shoulder injury in overhead athletes. The search involved the years 1970 to 2018 using two electronic databases: PubMed and Scopus. It looked for studies, written in English, that described at least one risk factor associated with overuse shoulder injuries in overhead sports (volleyball, handball, basketball, swimming, water polo, badminton, baseball and tennis). The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist was used to gauge the quality of this systematic review. Data was extracted from 25 studies. Study methodology quality was evaluated using the Modified Coleman Methodology Score. The findings were that intrinsic factors, previous injury, ROM (lack or excess) and rotator cuff weakness (isometric and isokinetic) highly increase the risk of future injuries. Additionally, years of athletic practice, BMI, sex, age and level of play seem to have modest influence. As for the effect of scapular dysfunction on shoulder injuries, it is still controversial, though these are typically linked. Extrinsic factors, field position, condition of practice (match/ training), time of season, and training load also have an influence on the occurrence of shoulder injuries.

Co-Kinetic comment The number of papers found on the initial search always comes as a bit of a shock. This time it was 1214 on PubMed and 2059 on Scopus. From this number the authors read the title and abstract and whittled it down to 198 papers, of which 180 were dumped. We are drowning in research! As to this study, it is a must-read for those involved with overhead athletes and a template for anyone thinking of doing their own literature search. Just to repeat, 198 papers read and 25 subjected to analysis. You had better get started now! Co-Kinetic.com

CLICK ON RESEARCH TITLES TO GO TO ABSTRACT PHYSICAL MANAGEMENT OF SCAR TISSUE: A SYSTEMATIC REVIEW AND META-ANALYSIS. Deflorin C, Hohenauer E, Stoop R et al. The Journal of Alternative and Complementary OPEN 2020;doi:10.1089/acm.2020.0109 This a systematic review of the various treatments for dealing with surface scar tissue. Most research concentrates on hypertrophic scars or keloids after burn injury but this study examined scars on adults with any kind of scar tissue. The outcome looked at pain ratings, pigmentation, pliability, pruritus, scar surface area and scar thickness. Most of the papers examined included combination treatments. The authors found that physical scar management has a significant positive effect influencing all of the outcomes compared with control or no treatment. Of interest is that massage therapy (sometimes alone and sometimes with other treatments) is effective in the management of pain and scar thickness of hypertrophic and burn scars.

Co-Kinetic comment At the time of writing, the Chartered Society of Physiotherapists in the UK is going through a review of its four pillars of practice which were established in 1920 and are described as Massage/Manual Therapy, Exercise/Movement, Electrotherapy, and what is described as ‘Kindred Methods of Treatment’. Without pre-empting the findings of the review, there has been a movement in recent years against hands-on treatment and massage in particular. Papers such as this show that it still has a place in the therapy tool box.

OPEN

THE EFFECTS OF ONE SESSION OF ROLLER MASSAGE ON RECOVERY FROM EXERCISE-INDUCED MUSCLE DAMAGE: A RANDOMIZED CONTROLLED TRIAL. Medeiros FVA, Bottaro M, Martins WR et al. Journal of Exercise Science & Fitness 2020;18(3):148–154 This is a randomised controlled study in which 36 healthy males (aged 21.1±2.1 years) with no experience of roller massage, completed four sets of six eccentric actions of elbow flexors at 90°/s with a 90s rest interval between sets in order to induce DOMS. They were assigned into one of three groups: roller massage (n=12), sham (n=12), and control (n=12). The roller massage was applied using a rubber coated stick (Tiger Tail, USA), with an inbuilt strain gauge to measure force. The action a constant stroking rhythm going from distal to proximal of the elbow flexors, at a frequency of 60 beats per minute for 5min, controlled by a metronome with magnitude force of 4–5kgf, corresponding to the pain perception of 6–7 on a numeric rating scale. The sham massage was applied for

5min using an ultrasound probe which was off. The ultrasound transducer was moved smoothly, taking care not to compress the tissue, using an identical procedure to the roller massage. Participants of the control group were kept at rest for 5min. They were all tested at 4, 48, and 72h post-exercise. There was no significant group by time interaction for maximal isometric voluntary or ROM. There was a significant group by time interaction for muscle thickness, but no significant difference between groups. There was no significant difference between groups for DOMS at any time.

THE GUIDELINES FOR APPLICATION OF KINESIOLOGY TAPE FOR PREVENTION AND TREATMENT OF SPORTS INJURIES. Andrýsková A, Lee JH. Healthcare 2020;8(2):144 Originally, kinesiology tape was developed and used for the treatment of injuries, joint stabilisation and pain reduction. However, nowadays, it is particularly valued for its injury prevention and performance enhancement properties. Kinesiology taping, in comparison to many other treatments, is non-invasive, simple, affordable, does not cause pain, and a relatively small amount of time is required for the application. This paper lays out a set of guidelines for its application.

OPEN

l Don’t just apply to the affected area. Consider the stability of the kinetic chain and that movement of one body part influences another one. l The skin to be taped must be clean, without any dirt, oils or sweat. l Shave longer body hairs. l In order to prevent skin problems in some body parts (eg. anterior aspect of the acromion), it is recommended to apply hypoallergenic undertape (50×75mm) to the origin and insertion areas before applying kinesiology tape.

Co-Kinetic Journal 2020;86(October):8-11

RESEARCH INTO PRACTICE

Journal Watch Manual Therapy

Co-Kinetic comment Did you know that the deprecated unit kilogram-force (kgf) or kilopond (kp) is the force exerted by 1kg of mass in standard earth gravity (defined as exactly 9.80665m/s²) and that 1kgf is equal to exactly 9.80665N? If you did then you will be interested to know that the strain gauges were attached to the roller’s inner rod to monitor the force applied. The signal was below 7Hz and was transmitted via Bluetooth to a computer that had a ‘human– machine interface’, allowing control of the force applied. Is a human–machine interface a keyboard and a monitor? Forget the fact that this paper shows that a single session of foam roller massage makes no difference to the athlete, the game changer here is using the roller to measure force applied. The applications for gauging dosage in massage research are endless.

l It is not recommended to apply kinesiology tape to the abdominal area immediately after food consumption. Otherwise, mild digestive troubles can be generated. l After the application of tape, it is necessary to ensure that the tape adheres to the skin properly, but vigorous rubbing of the tape should be avoided to prevent skin irritation. l Give at least 10min for the body to adapt to the taping before any activity. l Apply tape for only 24h because of possible adverse skin reactions caused by the glue and sweat, the constantly changing physical condition of a subject and the loss of

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SIGNIFICANCE OF INTENSITY OF SWEDISH MASSAGE COURSE IN IMPROVEMENT OF HEALTH STATUS. Veseta U, Gulbe A, Onževs O. Proceedings of the International Scientific Conference 2020;4:445–455

The criteria for inclusion in this study were to: be physically and psychologically healthy, be aged 18 to 35 years old, be a non-smoker, not have taken more than a glass of wine or its alcohol equivalent per day within the last 6 months, not have used drugs, not have worked night shifts, not be pregnant, not have failed to follow a special diet, have a BMI within the normal range of 18.5 to 24.9kg/m2 and have full blood test results consistent with the generally accepted normal values of a healthy person. Somehow, they managed to find 30 women who fitted the profile. They were split into equal groups, one receiving massage twice per week for 5 weeks and the other once a week for 10 weeks. The treatment was recorded as ‘Swedish back massage’ performed from C7 to S5 gliding, rubbing, kneading and vibration for 25min. Before and after each massage,

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salivary cortisol level, total antioxidant capacity, blood pressure and heart rate were measured; in addition emotions were assessed using FaceReader 6.0™. The results showed that there was no difference between groups and that the effect of a single massage was weak, but the impact analysis of each massage session showed minor changes in determinations of physiological and emotional factors.

Co-Kinetic comment Studies like this are deeply frustrating. It was a great idea and the results are positive, if marginal, for massage but it could have been so much more if the authors had included a control group and some idea of the massage dose. The subjects were super healthy and clean living in the first place so there was never going to be much change. The use of a computer program to judge emotions by classifying facial expressions is a bit ‘Big Brother’ and what if your subject is a great poker player? According to a validation study, the software is 89% accurate. Also, there are cultural differences regarding the meaning of facial expressions, especially smiles. Incidentally the coding for an insincere and voluntary smile is a ‘Pan Am Smile’ – no wonder the airline went bust!

tape elasticity. l Remove the tape immediately after showering as the wet tape can provoke undesirable skin effects.

Co-Kinetic comment According to the reference list of this paper, most of it is attributed to a 2016 publication by Lee and Choi that we couldn’t access. There are a couple of points that are obvious such as cleaning the skin and removing long hair and a couple that are in contravention to the majority of training such as the application of under wrap and the 24h period. Going back to the Lee and Choi item, it is a book titled Balance taping: clinical application of elastic therapeutic tape for musculoskeletal disorders (https://amzn.to/2R9JAGr). We did manage to find a website called ‘Balance Taping International’ (http://balancetaping.net/02/01.php) who cite Lee and Choi for the definition ‘Balance taping is a method for providing structural and functional balance to the body by simply and accurately evaluating structural and functional imbalances of muscles or joints, locally or across the whole body, and applying kinesiology tape to areas that cause pain or muscular or joint dysfunction’.

PROGRESSIVE REHABILITATION OF THE SPRAINED ANKLE: A NOVEL TREATMENT METHOD. Maetzler M, Ruescher M, Punzenberger F et al. The Foot 2020;43:101645 Measurements were taken before and after treatment via a standardised lateral view photograph from 19 subjects, 5 female and 14 male, who presented with grade 1–3 ankle sprains. The treatment follows the concept of the Fascial Distortion Model® (FDM), which appears to be basically a variation of myofascial release, soft tissue release and ischaemic pressure. The results showed that after one treatment session 13 of the 19 subjects were walking pain-free and 3 of the 19 were walking with only little pain. The highly significant mean improvement of ankle dorsiflexion was 7.9° (±5.8°). All, apart from one subject, who were walking pain-free after treatment

The aim of this study was to determine the influence of the sex of the therapist and of the athlete on the athlete’s current emotional state after a sports massage, as sexual attraction or dislike are among the causes of nonspecific effects of a treatment. One hundred and sixty-eight highperformance male and female amateur athletes received a sports massage from 15 male and female trained therapists. The current emotional state of the athletes was measured before and

showed a minimum of 4° increased dorsiflexion.

Co-Kinetic comment FDM, a trademarked technique, was developed by Dr Stephen Typaldos, DO. It is a treatment model in which soft tissue injuries, or musculoskeletal complaints, are viewed through one or more of six different types of alterations to the body’s connective tissues. They are trigger bands, continuum distortions, cylinder distortions, herniated trigger points, folding distortions and tectonic fixations. FDM has its own website (https://www.fascialdistortion.com/). They will teach you all about it in an

online course for a couple of thousand US dollars and/or six seminars at over a grand each. They do seem to use the thumbs a lot which may be good for the tissue but is very bad for the thumbs.

DOES THE THERAPIST’S SEX AFFECT THE PSYCHOLOGICAL EFFECTS OF SPORTS MASSAGE? A QUASI EXPERIMENTAL STUDY. Reichert B. Brain Sciences 2020;10(6):376 after intervention using the BSKE-EA17 adjective scale, whose items can be assigned to five categories of emotional state. The results showed that sports massages resulted in an improvement in all the categories (an increase in elevated mood and, level of activation, and a decrease in the responses for low mood, level of deactivation and level of excitation) after the massage compared

to before the massage. No differences were attributable to either the sex of the therapist or athlete except that when male athletes were treated by female therapists, where an increase in ‘elevated mood’ was observed.

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Co-Kinetic comment That’s a relief. Sports massage improves mental status and the question of sex is clearly irrelevant to the outcome.

STRATEGIES TO INCREASE ANKLE DORSIFLEXION RANGE OF MOTION. Howe LP, Waldron M, North JS et al. The Sport and Exercise Scientist 2020;63(Spring):24–25 OPEN

This is an essay that discusses various strategies for increasing ankle dorsiflexion (DF) ROM, giving research evidence and an example of the exercise. Its main points are that: l Static stretching performed three times per week for a total weekly duration of 5min is sufficient to increase ankle DF ROM. Other timings don’t seem to make much of a difference. l Eccentric exercise performed daily for 6 weeks resulted in significant increases in ankle DF ROM. The increase was not different with the knee extended or flexed. l There is little evidence specifically relating to the ankle for self-myofascial release using equipment such as foam rollers. Self-massage to the calf muscles with a roller stick for three sets of 30s at a perceived pain level of 7 out of 10, resulted in a significant improvement in ankle DF ROM, and one that was comparable to static stretching. When the dosage for self-massage was doubled, no additional acute gains in ankle DF ROM were seen. A caveat is added that attention needs to be given to the correct execution of the exercises. l Manual joint mobilisation has been shown to increase ankle DF ROM in both previously injured and healthy populations.

Co-Kinetic comment Well worth a read if you treat the ankle, which probably means everybody. A full reference list for the papers used is included if you want to explore the protocols. 10

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RESEARCH INTO PRACTICE

THE IMPACT OF SOFT TISSUE TECHNIQUES IN THE MANAGEMENT OF MIGRAINE HEADACHE: A RANDOMIZED CONTROLLED TRIAL. Rezaeian T, Mosallanezhad Z, Nourbakhsh MR et al. Journal of Chiropractic Medicine 2020;doi:https://doi.org/10.1016/j.jcm.2019.12.001 This study involved 46 participants with a neurologist-diagnosed history of migraine as defined by the International Headache Society criteria and with the presence of active trigger points in the upper trapezius, suboccipital and sternocleidomastoid muscles. The presence of active trigger points was confirmed if ‘there was an area of focal muscle tenderness that was activated by palpation and that, when activated, referred pain replicating the patient’s headache complaint’ and ‘there was a jump sign that was the characteristic behavioural response to pressure on a trigger point’. All subjects were required to complete a daily headache diary for 2 weeks before being randomly divided into two groups and for 30 days after treatment, which, for both, involved 20min sessions three times a week for 2 weeks. Immediately before and

Patellofemoral pain syndrome (PFPS) is characterised by diffuse anterior knee pain. Forty subjects with PFPS were recruited. Inclusion criteria were: (1) age between 18 and 50 years; (2) male or female; (3) VAS rating of at least 30mm on a 100mm scale over the previous week; (4) anterior knee or retropatellar pain during at least three of the following activities: such as stair ascent or descent, squatting, kneeling, hopping, jumping and prolonged sitting; (5) gradual onset of symptoms; (6) subject experiences pain during palpation of patellar facets or while performing a 25cm step-down test or double-legged squat. Exclusion criteria was anything that could be easily identified as the pain source, such as hip, meniscus, cruciate ligaments issues or quadriceps tendinopathy. Evaluation of fascial restriction was assessed using the therapist’s elbow. Any restrictions felt were given treatment. In the experimental group (n=20), treatment was myofascial chain release to the quadriceps, iliotibial band and tibialis anterior for 5 to 10min duration, 3 days in a week for a period

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after the treatment and at the 30-day post-treatment time point, they were assessed for disability due to headache and pressure pain threshold. The soft tissue group (n=23) received ischaemic pressure to identified trigger points in the three muscles and stretches to the upper trapezius and sternocleidomastoid. The control placebo group (n=23) received a ‘soft and superficial massage’ while in the supine position. Compared with baseline and the control group, the treatment group showed a significant reduction in headache parameters, drug consumption, and Headache Disability Index score immediately after the intervention and after a 1-month follow-up period. Pressure pain threshold levels increased in the treatment group in comparison with the control group.

Co-Kinetic comment Google ‘athletes who have missed games due to migraine’ and you hit a lot of star names including basketballer Scottie Pippen, quarterback Troy Aikman, 100m Olympic gold medallist Gail Devers, multi-tennis major winning Serena Williams and Arsenal’s Freddie Ljungberg, to name but a few. In fact, according to the NHS, in the UK it affects around 1 in every 5 women and around 1 in every 15 men. The exact cause is unknown although common triggers include certain foods such as eggs, dairy products and wheat; drinks, especially red wine; the start of a menstrual cycle; environmental factors, such as bright lights, flickering screens and loud noises; stress; and tiredness. This is not an exhaustive list. These few may explain why high achieving athletes get them. Hot off the press at the American Headache Society Annual Meeting 2020, a smartphone app, which consists of progressive muscle relaxation therapy assistance and an electronic headache diary, reduced headache days in patients with migraine [Minen MT et al. Smartphone delivered progressive muscle relaxation (RELAXaHEAD) for the treatment of migraine in primary care: a pilot randomized controlled study. Presented at the American Headache Society Annual Meeting 2020, Virtual meeting].

EFFECT OF RELEASING MYOFASCIAL CHAIN IN PATIENTS WITH PATELLOFEMORAL PAIN SYNDROME – A RANDOMIZED CLINICAL TRIAL. De Souza IG, Kumar PG. International Journal of Current Research and Review 2020;12(08):5 of 4 weeks. They were also given an exercise programme of stretching and strengthening the knee musculature. A control group (n=20) were given only the exercise programme. Outcome measures were the Kujala knee pain questionnaire, VAS and a patient specific functional scale. Both groups showed statistically significant change in all the three outcome measures. The experimental group showed the greater change.

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Co-Kinetic comment A tick in the ‘exercise works’ box and another in the ‘it works better with a bit of manual therapy’ box. The exercise routine is well described. The myofascial release less so but the routine used is referenced as coming from The myofascial release manual, 3rd edn by Manheim CJ, Slack 2000; p194. Much of the assessment and treatment depends on the therapist’s ability to discern tissue restriction and that takes practice, but this study used a treatment technique that only took a few minutes so it is worth giving it a go in order to gain experience. They used the therapist’s elbow which in most people is not as sensitive as the hands but it does have the ability to work deeper without risking therapist injury.

THE 10 MOST DISCUSSED PIECES OF RESEARCH IN PHYSICAL & MANUAL THERAPY (JUL - SEPT 2020) TELEHEALTH FOR MUSCULOSKELETAL PHYSIOTHERAPY

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INTRA-ARTICULAR SALINE INJECTION AS EFFECTIVE AS CORTICOSTEROIDS, PLATELET-RICH PLASMA AND HYALURONIC ACID FOR HIP OSTEOARTHRITIS PAIN: A SYSTEMATIC REVIEW AND NETWORK META-ANALYSIS OF RANDOMISED CONTROLLED TRIALS

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DRY NEEDLING COMBINED WITH GUIDELINE-BASED PHYSICAL THERAPY PROVIDES NO ADDED BENEFIT IN THE MANAGEMENT OF CHRONIC NECK PAIN: A RANDOMIZED CONTROLLED TRIAL

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HAMSTRING INJURY PART 2: REHABILITATION By Dr Chris Norris PhD, MCSP

HAMSTRING | 20-10-COKINETIC FORMATS WEB MOBILE PRINT All references marked with an asterisk are open access and links are provided in the reference list

Hamstring injuries are common in sport, as are injury recurrence rates. Hamstring injury rehabilitation requires a multifactorial approach involving the lower spine and pelvis, neuromobilisation and hamstring lengthening and strengthening. This article sets out the aspects that need to be addressed and how to address them so that you will be able to create a personalised hamstring rehab programme that will give your patient the strength and confidence for the best quality return to play. Read this article online https://bit.ly/33p2fUu

e have seen in Part 1 of this article that the structure and function of the hamstrings is used to guide the rehabilitation process. To be truly effective, hamstring rehabilitation must be multifactorial, and a number of factors are important, as shown in Table 1 (1*). Let’s begin by looking at changes in the lumbar spine, pelvis and neural systems.

Lumbo-Pelvic Manual Therapy and Neurodynamics

Addressing the lumbar spine and pelvic joints may be important as the presence of pain referred into the leg can change hamstring strength, muscle contraction timing and willingness to bend. Manual pain provocation tests may be used to clear the lumbo-pelvic region in the hamstring-injured patient, and the slump test may be used to differentiate hamstring and sciatic nerve symptoms as the primary source of posterior thigh pain. Additionally, the slump movement may

be used as a treatment technique to facilitate nerve length and mobility (neurodynamics). Neural tension may both increase stretch resistance and limit total movement range. The slump test is positive where the patient’s posterior thigh pain is reproduced in the final slump position and reduced with cervical extension – an action which has no effect on the hamstrings but does change tension in the neural structures of the posterior thigh. The test has been shown to be positive in sportsmen and women (rugby players) who have suffered a number of hamstring tears in the past 2 years (2*). In addition, quality of return to play (RTP) is enhanced (fewer missed matches) when the test is used as a stretch within a rehabilitation programme (3*). Including the slump test modified as a neuromobilisation technique (slider exercise) has been recommend for athletes who have suffered a hamstring injury and feel a lack of free movement when running even in the presence of a negative straight leg raise (SLR) and slump test (1*). Nerve sliding (gliding) of this type involves movement of at least two joints with one lengthening the nerve and the other shortening it. The combination of lengthening and shortening maintains the overall nerve length but improves nerve motility. In the case of

the posterior thigh, we move the distal tissues (limb) while maintaining the position of the proximal tissues (spine) and then reverse the sequence. Whereas sustained nerve tension increases intraneural (within the nerve) pressure and reduces local blood flow, sliding (by maintaining overall nerve length) avoids these changes. For the classic slump test or stretch, the subject sits on a stool and links their arms behind their back (Fig. 1). The action is to gently flex the spine, beginning with the neck. At the same time one leg is straightened and the foot and ankle pulled up (dorsiflexed). Components of this action may be used individually at first, then built up into a full sequence. If one leg is very tight, the knee on that side can be bent and gradually worked towards straightening, easing into the tightness but not forcing the movement. Supporting the foot of the tight leg on the floor by placing it on a shiny piece of paper is also helpful. With the weight of the leg taken through the floor, the subject slides the foot forwards and backwards, again gradually working towards the fully extended position. Maintain this position for 20–30 seconds and then release. To perform the nerve slide (seated straight leg slider; Fig. 2), the subject begins in the classic slump position described above, ensuring that the subject’s feet are clear of the floor. Keeping the spine flexed throughout

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PHYSICAL THERAPY

the exercise the neck is bent (flexed) to bring the chin down towards the breastbone (sternum). At the same time the knee is kept bent and the toes and foot are pointed (plantarflexion). To reverse the action, straighten the knee and draw the foot and toes up (ankle dorsiflexion and toe flexion) and at the same time look up at the ceiling (cervical extension). The sliding action is repeated rhythmically for 10 repetitions. Where there is a high degree of tightness, or where pain occurs, the exercise can be performed in two parts. Firstly, keeping the head still and moving the leg, and secondly keeping the leg still and moving the head. When both actions are pain free the two actions may be combined. This straight leg sliding technique has been shown to increase range of motion (ROM) of the hamstring muscles (measured by SLR) without the need for separate hamstring stretching. Looking at a group of soccer players Castellote-Caballero et al. (5) used straight leg sliding for three periods over 1 week. Each exercise was practised for 60s for 5 repetitions. Average scores for SLR testing for the control group (no sliding) went from 58.9° to 59.1°, whereas the intervention group (neural sliding) went from 58.1° to 67.4°. Mobilisation of the lumbar spine has been shown to increase ROM in the SLR test and change sympathetic nervous system activity in the limb (6), and it is recommended that this technique be used to modify patient symptoms with a view to pain

modulation. Although lumbo-pelvic examination and treatment may be appropriate for any patient with hamstring injury, it is likely that the MRInegative patient (that is, one where there is no visible muscle damage on an MRI scan) may especially benefit because of the presence of posterior thigh pain in the absence of local tissue change.

TO BE TRULY EFFECTIVE, HAMSTRING REHABILITATION MUST BE MULTIFACTORIAL

Lumbo-Pelvic Neuromuscular Control

Research studies have consistently supported the notion that various forms of eccentric hamstring exercise are essential for prevention and rehabilitation of hamstring muscle injury. Injury commonly occurs at the end of the swing phase of sprinting when the hamstring muscles are lengthening either through eccentric contraction or isometric contraction with passive stretch (see Part 1 of this article). Rehabilitation must match this muscle contraction type and joint angle position, so eccentric work (high loads at longer muscle–tendon lengths) and/or isometric work at lengthened positions would seem logical.

Improvement in lumbo-pelvic control has been suggested to reduce hamstring demand and, therefore, potential for injury (1*). In addition, a trunk-stabilisation programme has been shown to reduce hamstring injury recurrence rate (7*) and a balance training programme to reduce hamstring injury rate in women’s professional football (8). Although many athletes successfully compete at very high levels with suboptimal static and dynamic postures, in elite sport where fractions of a second matter, optimising control of the lumbo-pelvic region onto which the hamstrings take attachment would seem logical. Control of lumbo-pelvic alignment in the frontal plane can focus on actions based around the Trendelenburg test (pelvic alignment in single-leg standing). In the sagittal plane forward bending and lifting actions (above) can be used to optimise pelvic tilt. These actions should be progressed in terms of overload and complexity but must be paralleled with good exercise instruction and neurobiology

Table 1: Multifactorial components of hamstring rehabilitation. After Brukner 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 2013;48(11):929–938 (1) Component

Clinical reasoning

Biomechanics

Foot, lower limb and lumbo-pelvic alignment

Neurodynamics

Single leg raise and slump testing

Neuromuscula control of lumbar spine

Lumbo-pelvic control and strengthening

Eccentric-biased strengthening

Varying movement range and muscle length

Running overload

Varying direction and speed; Task/sport specific

Stretching Restoration of symmetry of motion range in static and dynamic task/sport-specific actions

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re-education to reduce the chance of hypervigilance following injury.

Eccentric-Biased Strengthening

Figure 1: Slump test (a) Start position

(b) End position

Figure 2: Straight leg slider

Nordic Hamstring Exercise

The Nordic hamstring exercise (NHE) has been shown to reduce injuries by 60% and reinjury by 85%, when used in a progressive 10-week programme (9). Progressive eccentric strengthening of this type is thought to address eccentric strength deficits, muscle– tendon atrophy and scar tissue within the hamstrings (10*). The NHE may shift the optimum angle for torque generation towards a longer hamstring length, mimicking the limb position at terminal swing just before heel contact, a point at which injury has been shown to occur (11). The NHE has also been shown to be preventive of hamstring injury in male soccer players. Looking a 259 players, Hasebe et al. compared a NHE group to a control group not using the NHE but matched for all other training variables (12). Over a 27-week period the injury rate per 10,000 playing hours of the control group was 1.04/10,000 h but down to 0.88/10,000 h in the NHE group, resulting in a significant reduction in time lost. A recent systematic review and meta-analysis showed a reduction in the injury risk ratio (relative risk) of 0.49† when programmes included the NHE, demonstrating that programmes which include the NHE reduce hamstring injuries by up to 51% (13*). The method by which the (a) Start position in high kneeling with the ankles fixed

NHE prevents injury would seem to be a combination of increased eccentric strength and increased biceps femoris long head fascicle length (13*). Shorter length of the biceps femoris long head has been associated with increased hamstring muscle injury (14), and (as highlighted above) hamstring muscle injury is more common in late forward swing of a sprinting action when the hamstrings are acting eccentrically. Isometric hip extension using the single-leg Roman chair hold may be used together with, or as an alternative to, the NHE depending on subject requirements as both have been shown to increase biceps femoris long head fascicle length (15). The hip extension is more suited to endurance (isometric holding time) whereas the NHE is more demanding for repetitions. In addition, high-load isometrics may improve motor unit recruitment within the hamstrings (16). The NHE is an intense muscle contraction, giving rise to muscle adaptation but with the likelihood of delayed onset muscle soreness. Progressive programmes should begin cautiously with one session each week initially (weeks 1–3) building to two sessions per week (weeks 2–5) and finally three per week (weeks 3–10) with one session per week for maintenance thereafter. Variation in the prescription is dependent on subject reaction to the exercise intervention.

(b) NHE using Swiss ball

Although the NHE is a vital component of rehabilitation it should not be used in isolation as it has a number of disadvantages. In general, it is practised bilaterally, not reflecting the unilateral nature of hamstring injury. Also, it is a single-joint (uniarticular) action whereas the hamstring muscles as a group are biarticular, and normally the NHE is performed at slow speeds. Progression of exercise must include training volume (frequency, intensity, time and type) and velocity at multiple joint angles. Slow controlled eccentrics should progress in parallel with general lower limb and lumbo-pelvic resistance training and motor control complexity. Ultimately power and speed-based actions (plyometrics) should be used together with skill-based actions reflecting the sport or employment of the subject. The NHE begins in high kneeling with the ankles fixed (Fig. 3 and Video 1). The traditional action is to keep the hip fixed and angle the body forwards

Figure 3: The Nordic hamstring exercise (NHE)

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(a) Start position

(b) End position

Video 1: Nordics. Nordic hamstring exercise with variation for re-strengthening hip extensor musculature (Courtesy of YouTube user Norris Health) https://youtu.be/zVC9x9fcWZg

Figure 4: Box drop

from the knee. The aim is to lower the body under control into a prone position, taking the final body weight of the final degrees of movement onto the hands. The action may be unloaded using a fixed strap (partner), elastic power loop (fixed point), or with the subject placing their hands on a Swiss ball and rolling it away from themselves. From the same starting position, a bent knee back extension action may be performed, pulling from the hip and keeping the spine straight to begin. This action targets the hamstring higher up into the buttock, using an active pelvic tilt. It may be combined with or used separately to the traditional eccentric only version.

Deceleration Drops

Deceleration drills involve dropping into a bent-hip and -knee (squat) position either unilaterally or bilaterally. Initially this may be achieved by standing tall and simply dropping into a half-squat position. Firstly, this is performed on both legs together (squat position) and then progressed to one leg leading (lunge position). These actions may be progressed to lunge, hop and jogging actions to eventually mimic the straight-leg heel contact position of terminal swing phase of running. The flat floor position may be changed to a box-drop position, when the action is to jump down and initially Co-Kinetic.com

hold the position (Fig. 4). This action progresses to drop, land and move in forward, sideways, or rotary actions. These actions represent in-place (staying on one spot), short-response (2 or 3 hops or steps) or long-response (multiple steps or hops) plyometrics. These actions can emphasise force generation (acceleration) or force acceptance (deceleration) depending on training requirements.

General Exercises Deadlift Variations

The straight-leg (Romanian) deadlift uses a fixed leg position either with the legs straight (knees locked) or slightly bent (knees soft) (See deadlift technique in Video 2). The action is to keep the spine straight and lift the body from the hip. Initially body weight alone is used (arms behind the tail or behind the head), but resistance may be added from a barbell, kettlebell or dumb-bells. As an alternative, the arabesque may be viewed as a singleleg version of the straight-leg deadlift. The leg to be trained stays with the foot on the floor (leg vertical) and the other leg lifts (leg horizontal). There are a number of versions of this action. In yoga, this is one of the warrior poses and the final position is with the lifted leg, trunk and arms horizontal to emphasise balance. This action may be performed standing on one leg with the arms lifted above the head. The movement is to keep the lifting leg,

Video 2: Re-educating bending following low back pain (Courtesy of YouTube user Norris Health) https://youtu.be/-kGdwtfdRwY

trunk and arms rigid and tip forwards into a â&#x20AC;&#x2DC;Tâ&#x20AC;&#x2122; position. The hands may be placed on a wall for balance. The diver is the same action, but the arms reach downwards to touch a stool or gym bench and then the body is moved back to the starting position focusing on repetitions and strength (Fig. 5 and Video 3).

Bridge-Type Movements

Bridging actions use the hip extensors and spine extensors from a supine lying position. For the slide-board leg-curl, the subject lies on their back with their foot on a slide board, piece of shiny paper on a carpet, cloth on a wooden floor, or seat of a rowing machine. The action is to slide the foot out from a bent knee position to straight leg and return. Single-leg or

ADDRESSING THE LUMBAR SPINE AND PELVIC JOINTS MAY BE IMPORTANT 17

(a) Arabesque using kettlebell

(b) Warrior 3

Video 3: Hamstring rehabilitation. Diver, extender, and slider exercise used for rehabilitation & training of hamstrings injury (Courtesy of YouTube user Norris Health) https://youtu.be/cVyZqMcrbok bilateral-leg action may be used (Fig. 6 and Video 4). The high bridge (gym-ball bridge) is performed from a crook (hook) lying position with one heel on a bench or chair, or a gym ball to provide an unstable surface. The action is to press the heel down to dig into the bench and lift the hips upwards. Again, unilateral or bilateral actions may both be used. Where the unilateral action is used, the pelvis must be kept level, not allowing the hip on the nonactive side to trail. This action may be modified into the eccentric leg-curl on a gym ball. The action now is to press the heels into the gym ball to lift the pelvis and to straighten the legs and then lower the trunk (eccentric only) or to straighten the legs and then bend them again (eccentric-concentric). The loaded bridge may be performed with the shoulders on a gym bench and the knees bent. A weight disc is placed on the lap, or a

Figure 5: Single-leg actions

(a) Slide on rowing machine

(b) Bridge on Swiss ball

Video 4: Bridge exercise & variations (Courtesy of YouTube user Norris Health) https://youtu.be/dd1AR1gzsX8 18

Figure 6: Bridging actions

barbell is placed over the pelvis with the bar (padded) level with the top of the pelvis. The action is to lift the pelvis into a bridge position, finishing with the thigh horizontal. The foot must press directly downwards (hip extension) rather than outwards (knee extension).

Overload Running

Initially following injury, active muscle lengthening may be imposed by walking (treadmill or set distance/ time when land based). At this stage, pain tolerance can be used to limit training intensity and volume with short timescales of 5â&#x20AC;&#x201C;10 minutes and pain intensity of 3 or 4 out of a maximum of 10 (numerical rating scale). Early activity of this sort (from day 1 with more minor grade 1 or 2 functional injuries) prevents the neuromuscular inhibition which is often seen following muscle injury. Progression can be by time and/or distance, speed, stride length and incline. Table 2 outlines a programme of progressive phases from simply treadmill walking through to full running. Treadmill walking gives way to gentle pain-free jogging and then scout pace (walk-jog-walk). Manual resistance is used as isometric exercises progress to concentric exercises using both bent-leg (prone lying knee flexion) and straight-leg (SLR position) actions. The running speed increases gradually ensuring that the subject can tolerate the increase load on the injured leg. Graded exposure is used, increasing and reducing distance and speed depending on symptoms initially. Manual concentric strength work is progressed to assisted bodyweight work using concentrics and eccentrics. Deadlift actions (straight leg and bent leg) are performed to reduced range (bench or stool level) and using band assistance initially. NHE can be begun with belt/resistance band assistance, progressing to Swiss ball roll-out as pain allows. Running gradually increases for pace, distance, and incline. As function improves the symptom contingent nature of training can progress to time contingent work. Treadmill work gives way to normal running on a runway in the gym or sports field. Longer (50m) runs at Co-Kinetic Journal 2020;86(October):14-21

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slower pace gradually progress to shorter (30m, 20m) at increased pace. The next progression is to focus on acceleration and deceleration drills and to introduce sagittal (side step) and multidirectional (zig-zag and cutting) loading. The final progression before RTP will depend on the sport and player’s position, or subject’s work time and daily living actions. Functional progressions are used to replicate the actions to be encountered in sport/ daily living with the aim of building final load tolerance and confidence in the limb.

Hamstring Stretching

Current practice in both prevention and rehabilitation of hamstring injury places less emphasis on stretching than in previous years as the evidence for its importance is limited. Interestingly, the active SLR has been used as an assessment of both flexibility and feelings of general insecurity in the limb following injury. The test (H-test) is performed by the subject lying supine with the upper body and contralateral leg stabilised and the ipsilateral knee locked and held immobile in a brace. The subject performs a maximum number of rapid SLR actions and rates their experience on a VAS scale. The H-test was shown to be sensitive to detect remaining signs of injury in MRI-confirmed acute hamstring strain when standard clinical examination (palpation pain, manual strength tests and passive SLR) had failed to do so (17). ROM should be restored to that required by the subject’s activities to ensure pain-free unrestricted movement. The use of ROM combined with controlled contraction (eccentrics) more accurately reflects the functional requirements of the hamstrings than static stretching alone. A series of three lengthening actions (L-protocol) were compared to traditional contraction

Table 2: Progressive walk/run programme for hamstring rehabilitation Phase

Activity

l Isometrics to prevent neuromuscular inhibition l Reduce pain maintain ROM l Walk on treatment 4–6mph until able to jog

l Run at speed without symptoms – patient led rehab l Introduce concentric exercises using manual resistance bent/straight leg l Swing through within comfortable range l Increase running speed progressively

l Increasing speed on treadmill to higher speed l Concentric eccentric RDL low weight pull through with band l NHE using Swiss ball roll-out l 1km run outside l 4min high speed (4.5m/s)

l Treadmill higher speed, 30s on, 30s off ×6 reps – build to 5m/s and 6m/s l Band-assisted NHE l Increase rate of force development using weights

l Runway work 20m acceleration, 20m hold, 20m deceleration l Increase speed and reduce distance to 15m, then 10m l Use acceleration/deceleration to progress rate of torque development l Sagittal training, progressing to cutting and multidirectional work l Return to protected training and limited RTP l Focus on load management

NHE, Nordic hamstring exercise; RDL, Romanian deadlift; ROM, range of motion; RTP, return to play

and static stretching (C-protocol) in elite sprinters and jumpers (18). The L-protocol gave a mean time for return to competition of 49 days compared to 86 days for the C-protocol. The three exercises used are shown in Table 3 and Video 3. Activity-specific actions of this type can be designed using basic movement analysis of sports and daily actions with an emphasis on ‘strengthen and lengthen’ exercise. These can progress to functional activities pre-competition which involves all types of muscle work. Where traditional stretching exercises are used, they must take account of pelvic action and the action of the two-joint muscle. In addition, relative flexibility may dictate that the majority of the stretching force is imposed on the lumbar spine in toetouching type movements.

RESEARCH STUDIES HAVE CONSISTENTLY SHOWN THAT ECCENTRIC HAMSTRING EXERCISES ARE ESSENTIAL FOR PREVENTION AND REHABILITATION OF HAMSTRING MUSCLE INJURY Co-Kinetic.com

Table 3: Hamstring lengthening exercise protocol (L-protocol) Adapted from Askling et al. Acute hamstring injuries in Swedish elite sprinters and jumpers: a prospective randomised controlled clinical trial comparing two rehabilitation protocols. British Journal of Sports Medicine 2014;48(7):532–539 (18) Extender: Active knee extension exercise holding the thigh still (90° hip flexion) and extension of the leg for 3 sets of 12 repetitions. Diver: Modified arabesque exercise. Single-leg standing on injured side, with knee soft (10–20° flexion). Reach forwards, flexing at the hip and stretch the arms out and free leg backwards, allowing back leg to bend: 3 sets of 6 reps. Glider: Modified front splits. Stand with the injured leg forwards holding onto a bar. Slide the unaffected leg backwards using a cloth/slide pad beneath the foot keeping the body weight on the front (injured) leg. Move back to the starting position using the arms, not pulling through the injured leg.

Flexibility may begin with active knee extension described above. The advantage of this movement is the reciprocal innervation gained from quadriceps action, and the control that the athlete has over the movement. In addition, the back is supported throughout the action. The tripod stretch is also a useful exercise which requires a combination of pelvic stability with hamstring flexibility in a sitting position. The arms support the spine and encourage an upright body position.

Closed Chain Actions

Closed chain exercises for the hip extensors may be performed by modifying many common exercises. Leg rowing is a useful exercise. The athlete sits on a towel (on a wooden floor) or plastic tray (on a carpeted floor) with the feet fixed. The action is to pull the body forwards by hamstring action, mimicking a rowing position. Sitting astride a gym bench or ‘form’, the athlete digs the heels into the ground and again pulls the body forwards using leg strength alone. Both of these actions may be performed unilaterally or bilaterally. The slide trainer may also be used for sagittal leg-pumping actions with the knees straight or bent. The sitting leg-press weighttraining apparatus may be used for the sprint kick exercise. Instead of sitting on the bench, the athlete turns

around and places the shoulder against the chair back, and the ball of the foot on the machine pedal. The action is to press the machine pedal with a combined hip and knee extension action. Bridging actions may be performed with the foot on a moving surface (skateboard), bench, or Swiss ball as above for variety and resistance increased by adding weight to the hips (barbell) and placing the shoulders on a bench.

RTP Criteria

As rehabilitation progresses, functional training increases with actions that mimic the demands of an activity or sport. The question then arises as to when a person can resume their sport/activity or when a player is fit for competition. Criteria for RTP following hamstring muscle injury have been agreed in a consensus statement involving 58 experts in the field of hamstring injury management in soccer (19*). RTP is a shared decision between those involved in player management (physician, physiotherapist, fitness trainer and coach) and both physical and mental attributes are involved. Firstly, there should be an absence of pain to palpation, and an absence of pain during strength and flexibility tests. In addition, there should be no pain during or after sport-specific functional testing. Hamstring strength and flexibility should be similar on both the injured and non-injured sides. Functional performance on field testing should be positive, reaching preinjury levels (able to perform tasks selected relevant to sports and sport position). Maximal sprints and sprints under fatigue conditions are usually included as part of functional training and testing to

RETURN TO PLAY IS A SHARED DECISION AND INVOLVES BOTH PHYSICAL AND MENTAL ATTRIBUTES 20

mimic match play. Finally, psychological readiness to play must be established with the player demonstrating a positive mental attitude and no avoidance behaviour. References 1. 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 2013;48(11):929–938 Open access https://bit.ly/2LYTZSO 2. Turl S, George K. Adverse neural tension: a factor in repetitive hamstring strain? Journal of Orthopaedic & Sports Physical Therapy 1998;27(1):16–21 Open access https://bit. ly/3iVdslM 3. Kornberg C, Lew P. The effect of stretching neural structures on grade one hamstring injuries. Journal of Orthopaedic & Sports Physical Therapy. 1989;10(12):481–487 Open access https://bit.ly/2CKawZM 4. Norris C. Sports and soft tissue injuries, 5th edn. Routledge 2018 ISBN 978-1138106598 (Print £44.55 Kindle £42.32). Buy from Amazon https://amzn.to/2CLySSY 5. Castellote-Caballero Y, Valenza M, MartínMartín L et al. Effects of a neurodynamic sliding technique on hamstring flexibility in healthy male soccer players. A pilot study. Physical Therapy in Sport 2013;14(3):156– 162 6. Szlezak A, Georgilopoulos P, BullockSaxton J et al. The immediate effect of unilateral lumbar Z-joint mobilisation on posterior chain neurodynamics: a randomised controlled study. Manual Therapy 2011;16(6):609–613 7. Sherry M, Best T. A comparison of 2 rehabilitation programs in the treatment of acute hamstring strains. Journal of Orthopaedic & Sports Physical Therapy 2004;34(3):116–125 Open access https://bit.ly/3g8dTr7 8. Kraemer R, Knobloch K. A soccer-specific balance training program for hamstring muscle and patellar and Achilles tendon injuries. The American Journal of Sports Medicine 2009;37(7):1384–1393 9. Petersen J, Thorborg K, Nielsen M et al. Preventive effect of eccentric training on acute hamstring injuries in men’s soccer. The American Journal of Sports Medicine 2011;39(11):2296–2303 10. Thorborg K. Why hamstring eccentrics are hamstring essentials. British Journal of Sports Medicine 2012;46(7):463–465 Open access https://bit.ly/3iVeA90 11. Schache A, Kim H, Morgan D et al. Hamstring muscle forces prior to and immediately following an acute sprintingrelated muscle strain injury. Gait & Posture 2010;32(1):136–140 12. Hasebe Y, Akasaka K, Otsudo T et al. Effects of Nordic hamstring exercise on hamstring injuries in high school soccer

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players: a randomized controlled trial. International Journal of Sports Medicine 2020;41(03):154–160 13. van Dyk N, Behan F, Whiteley R. Including the Nordic hamstring exercise in injury prevention programmes halves the rate of hamstring injuries: a systematic review and meta-analysis of 8459 athletes. British Journal of Sports Medicine 2019;53(21):1362–1370 Open access https://bit.ly/34atxzP 14. Timmins R, Bourne M, Shield A et al. Short biceps femoris fascicles and eccentric knee flexor weakness increase the risk of hamstring injury in elite football (soccer): a prospective cohort study. British Journal of Sports Medicine 2016;50(24):1524–1535 15. Bourne M, Duhig S, Timmins R et al. Impact of the Nordic hamstring and hip extension exercises on hamstring architecture and morphology: implications for injury prevention. British Journal of Sports Medicine 2017;51(5):469–477 16. 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 17. Askling C, Nilsson J, Thorstensson A. A new hamstring test to complement the common clinical examination before return to sport after injury. Knee Surgery, Sports Traumatology, Arthroscopy 2010;18(12):1798–1803 18. Askling C, Tengvar M, Tarassova O et al. Acute hamstring injuries in Swedish elite sprinters and jumpers: a prospective randomised controlled clinical trial comparing two rehabilitation protocols. British Journal of Sports Medicine 2014;48(7):532–539 19. van der Horst N, Backx F, Goedhart EA et al. Return to play after hamstring injuries in football (soccer): a worldwide Delphi procedure regarding definition, medical criteria and decision-making. British Journal of Sports Medicine 2017;51(22):1583–1591 Open access https://bit.ly/328TL2O.

† The risk ratio is a measure of association between two items (variables). If the risk ratio is close to 1 the incidence is about the same in both groups. Where the risk ratio is greater than 1 (>1) it suggests an increased risk, and where it is less than 1 (<1) the risk is reduced.

KEY POINTS

lH amstring rehabilitation must be multifactorial. lT esting the lumbar spine, pelvic joints and neural systems is important to rule out these structures as the primary source of pain referred to the posterior thigh. lT he slump test can be modified to a neuromobilisation exercise, which improves quality of return to play when used as part of a hamstring rehab programme. l I mprovement of lumbo-pelvic control through a trunk-stabilisation programme seems to reduce hamstring demand and hamstring injury recurrence. lE ccentric hamstring exercises are essential for hamstring injury prevention and rehab. lT he Nordic hamstring exercise is very effective for reducing hamstring injury and reinjury rates. lO verload running, hamstring stretching and closed chain actions can all form part of the hamstring rehab programme. lR eturn to play should be through shared decision-making and criteria have been set out in the consensus statement concerning return to play after hamstring injuries in football (soccer).

DISCUSSIONS

l If you had a patient complaining of posterior thigh pain, what tests/checks would you do to determine the cause of that pain? l How would you prepare a hamstring rehabilitation programme tailored to an individual patient? l How would you assess when a patient is ready to return to their activity?

Co-Kinetic.com

Acknowledgement All Figures are published with permission from Norris C. Sports and soft tissue injuries. Routledge 2018 (4)

RELATED CONTENT

lH amstring Injury Part 1: Anatomy, Function and Injury [Article] https://bit.ly/2UncJj8 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

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/

Want to share on Twitter? Here are some suggestions

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HOW TO PLAN AND EXECUTE A TELEHEALTH PHYSICAL THERAPY SESSION:

Don’t Just Natter, Make it Matter

COVID-19 | 20-10-COKINETIC FORMATS

WEB

MOBILE

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

By Kathryn Thomas BSc MPhil

Covid-19 and the physical distancing measures introduced to help reduce its spread have spurred many businesses to find new ways of working. Many occupations, even ones traditionally believed to need face-to-face contact, are being done successfully remotely and physical therapy is no exception. This article discusses the conditions that are most suited to a remote healthcare service as well as the considerations for implementing a telehealth service, allowing you to provide physically distanced healthcare to new and existing patients and perhaps even reaching patients who can’t access in-house services for reasons other than Covid-19. Read this article online https://bit.ly/2Re9Xe6 22

usculoskeletal conditions have been identified by the 2018 Global Burden of Disease Study (1*) as a leading cause of global morbidity. Although not considered to be life-threatening, these conditions can place profound restrictions on an individual’s ability to participant in daily activities, employment and recreational activities. They subsequently account for one-fifth of the world’s total ‘years lived with disability’ (YLDs) (1*). International guidelines recommend that in the absence of sinister ‘red flag’ pathology (eg. fracture, neoplasm), first-line interventions for the majority of musculoskeletal conditions should involve simple non-surgical management, where interventions are tailored to the individual’s needs and clinical presentation (2*). Despite these recommendations, the timely, affordable and equitable access to such healthcare services can be

severely limited for some. Traditionally these access barriers are associated with geographical issues due to a significantly reduced health workforce capacity in regional and remote communities (3). However, access barriers are not only the result of geographical isolation. Cost, cultural or religious differences, access to transport, commitments to the home or work environment restricting absenteeism can all be limiting factors to an individual attending physical therapy. A new indisputable barrier to face-to-face hands-on care is the strict social-distancing policies initiated in response to the Covid-19 pandemic. The rapid and ongoing presence of the Covid-19 pandemic has forced medical professionals to rethink how traditional healthcare services can be delivered, providing care to new and existing patients. Rapidly adopting telehealth service delivery methods (where possible and most often)

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has been the result. Although safe, effective and convenient, there are complex challenges to implementing video outpatient consultations in organisations or to people that are hesitant to change (4*). We must not forget that telehealth is a medical service and not just a technology (5*). There are many definitions circulating regarding this ‘new form’ of healthcare service. From electronic (e)Health to telemedicine, telehealth, eSEM (sports and exercise medicine) or teleSEM to mHealth (mobile device) (6*). Without becoming overly caught up in the semantics for the purpose of this article we are looking at how you, the physical therapist, can be confident in providing optimal, effective care to your patients, from a distance.

What is Telehealth?

The term ‘telehealth’ can be thought of as an umbrella term to describe the provision of healthcare at a distance using information and communication technology (ICT) sources and is inclusive of all healthcare professions. Over more recent years, there has been an explosion of new terminology that aims to describe the healthcare profession involved (eg. telepsychiatry, teleradiology), the type of interaction (eg. telerehabilitation, teleconsultation), or be more inclusive of the ways in which health information can now be exchanged digitally (eg. eHealth, digital practice) (2*,7*). Specific to the field of physiotherapy, the term ‘telerehabilitation’ has been used in much of the literature to date and is defined as ‘the delivery of rehabilitation services via information and communication technologies.’ (2*). The choice of ICT also determines whether the healthcare interaction takes place either asynchronously or in real-time. Asynchronous (commonly referred to as ‘store-andforward’) telehealth is where there is a temporal delay between the sending and viewing of health information. Common store-and-forward ICT includes secure messaging services and email; however, newer applications such as wearables, virtual reality and activity trackers are increasingly being used within the health setting. In contrast, real-time telehealth Co-Kinetic.com

implies that information is exchanged instantaneously between all users, with telephone and videoconferencing being the most prevalent forms of ICT (2*).

What is the Research Behind Musculoskeletal Telehealth?

Literature investigating the use of telehealth for the management of musculoskeletal conditions continues to grow. The validity and reliability of undertaking a physiotherapy assessment via telehealth has been investigated. A systematic review by Mani et al. found that telerehabilitation assessments demonstrated good concurrent validity for pain, swelling, range of motion, muscle strength, balance, gait and functional assessment (8). However, only low to moderate concurrent validity was found for several special orthopaedic tests, neurodynamic tests and lumbar posture (8). From assessment, diagnostic agreement between telehealth and in-person assessments has been investigated for a variety of musculoskeletal conditions and ranged from 59.7% to 93.3% (9,10,11,12,13*). In a recent study by Cottrell et al., participants underwent two consecutive assessments by different physiotherapists: in-person assessments were conducted as per standard clinical practice; telehealth assessments took place remotely via videoconferencing. The results of the study showed substantial agreement (83.3%) between therapists using the two different delivery mediums regarding clinical management pathways (14). Moderate to near perfect agreement was reached for referral to individual allied health professionals. Diagnostic agreement was 83.3% between the two delivery mediums, and there was substantial agreement (81%) when requesting further investigations (14). Several systematic reviews have demonstrated that telehealth can provide improvements in pain, physical function and disability that are similar to that of usual care for individuals with musculoskeletal conditions such as osteoarthritis, non-specific low back pain or following total knee arthroplasty (15,16*,17,18,19*,20).

THERE ARE MANY REASONS WHY PEOPLE STRUGGLE TO ACCESS FACETO-FACE HEALTHCARE, ALL OF WHOM CAN BENEFIT FROM THE EXPANSION OF TELEHEALTH PROVISION THAT COVID-19 HAS PROMPTED The use of telehealth has also been shown to increase exercise adherence for a variety of musculoskeletal conditions (21,22*). Within these systematic reviews the studies included have vast heterogeneity with respect to the healthcare interventions provided and the selected ICT, highlighting the need for further large, high-quality controlled trials to be undertaken to strengthen findings (2*,23*). Although not unique to musculoskeletal physiotherapy, it seems individuals place a high value on being able to access care via telehealth. Research on telehealth in the field of musculoskeletal physiotherapy has universally reported high levels of patient satisfaction (2*,24*,25), where satisfaction can also be significantly higher compared with those receiving in-person care (26). Although more work needs to be done to confirm the economic implications of providing musculoskeletal services

MEDICAL ETHICS STILL FORM A KEY PART OF TELEHEALTH; REMEMBER THAT YOU ARE STILL PROVIDING A HEATHCARE SERVICE, NOT SIMPLY DEALING WITH A TECHNOLOGY via telehealth, research to date has shown telehealth services to be costeffective with cost-savings to the health service generally favouring telehealth over usual inperson care (2*,27,28,29).

Implementing a Telehealth Consultation

A telehealth consultation has three important stages each with its own considerations (6*): 1. planning the consultation; 2. performing the consultation; and 3. actions after the consultation.

1. Planning a Remote Consultation

1.1 Establish the Need for a Remote Consultation (6*)

The obvious need for a remote clinical consultation exists where a patient needs clinical care but cannot access such a service in person. This might be due to: l geographical challenges; l safety issues for patient and clinician

(war, pandemics); l mobility issues (relevant to patient and clinician); and/or l sports medicine where individual athletes or teams travel to training camps and competitions without medical support staff. It is important to consider what can and what cannot be done in the telehealth context.

1.2 Decide on the Consultation Participants

Clinicians should exercise care when selecting patients for telehealth consultations. Telehealth consultations have been shown to work better when the clinician and patient know and trust each other; however, this may not be the case or choice in the current Covid-19 situation. With ongoing social distancing or lockdown regulations people are bound to need care for a new condition or for the first time with a new therapist. Although there are distinct advantages to telehealth consultation, patients that require examination or have complex or sensitive problems

(eg. disability) may still require consultation in the traditional faceto-face method (6*). It may be that the first telehealth consultation is an initial assessment or screening in order to create an ongoing management plan. Knowledge of the patient’s age, ethnicity and gender are important factors that should be, and invariably are, taken into account in any consultation (6*). Additional considerations for consultation participants include the following points. l The need for an interpreter or advocate, provided by someone in the room or remotely accessed by dial-in, and with suitable introduction to the patient. A medical interpreter, a relative or other person who is with the patient can fulfil this role. l The use of multidisciplinary teams in conference-call situations may be required for team athletes and more complex cases. l In the case of a minor or male– female patient–client interaction it may be advisable to have an adult or witness present during the consultation. l A carer, family or friend may be required to help move patients to aid in assessment or treatment, especially if the patient is disabled, or elderly where safety is critical. A ‘helper’ may be required to assist in videoing or photographing postures, movements and gait patterns, for example, or simply assisting with the technology.

Table 1: The tele-sport-and-exercise-medicine (teleSEM) process Dijkstra HP et al. Remote assessment in sport and exercise medicine (SEM): a narrative review and teleSEM solutions for and beyond the Covid-19 pandemic. British Journal of Sports Medicine 2020;doi:10.1136/bjsports-2020-102650 (6*) Planning the remote consultation

Performing the remote consultation

After the remote consultation

l Establish the need for a remote consultation. l Decide on the consultation participants. l Choose wisely between text, audio or video. l Know the technology. l Ensure remote access to the electronic health record. l Apply ethical guidelines.

l Have the condition-specific teleSEM guide ready (if you know the type of condition) l Connect, introduce yourself (and other team members) and confirm the patient’s identity l Perform an initial rapid health status assessment l Take a history (condition, general, sport, performance goal) l Perform a remote SEM physical examination l Consider options; discuss a care plan l Communicate decisions and actions

l Make accurate and comprehensive notes in the patient’s health record l Arrange further investigations, follow-up, referral to other members of the multidisciplinary team (physiotherapist, podiatrist, etc), discharge, urgent hospital admission for further care

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Documenting who is present during the telehealth consultation will aid in continuity, privacy or ethics issues and the ultimate success of the programme.

1.3 Choosing Wisely Between Text, Audio or Video

Evidence for the indications, selection of telehealth type, patient satisfaction and success of clinical outcomes is poor (6*). The patient’s preference and ability to access technology and the patient’s expectations from the interaction and intended clinical outcomes are some considerations when choosing the medium of choice. Telephone conversations are easy, readily accessible and most people are familiar with them. Video may be less accessible in less-resourced areas, or because of adversity or ignorance of technology. However, some benefits of video consultations are that it adds a visual dimension to the consultation permitting a certain level of enhanced interaction to gauge non-verbal cues and visualise external physical signs. Text messaging with WhatsApp is a cheap and efficient tool for communications in patient care, for example, between therapists and athletes. A patient’s rehabilitation progress can be tracked and adapted at any time.

1.4 Know the Technology

The use of telehealth is dependent on access to technology in the population where it is applied. More than 52% of the world’s population use the internet, 97% live within reach of a mobile cellular signal and 93% within reach of a 3G (or higher) network (6*). Many digital aids are available to assist healthcare provider–patient communication in the telehealth context. There are purpose-specific apps as seen in some National Health Care Systems, dedicated sports medicine apps, rehabilitation websites and non-specific social media platforms such as VSee, WhatsApp, Skype or Zoom, and a plethora of exercise ‘gurus’ on Twitter, Instagram and YouTube (helpful or not – patients may have access to them!) Co-Kinetic.com

Table 2: Preparing the physical environment Cottrell MA, Russell TG. Telehealth for musculoskeletal physiotherapy. Musculoskeletal Science and Practice 2020;48:102193 (2*) Feature

Notes

Physical environment

l Select a physical space that is: l large enough to perform necessary tasks, eg. perform an exercise; l free from clutter and potential trip hazards; and l private to reduce unwanted distractions and maintains a level of privacy and confidentiality. l Ensure necessary furniture (eg. bed, chair) and/or equipment (eg. light weights) is available.

Acoustic environment

l Eliminate as much background noise as possible – close doors/windows; turn off television/radio; move to a room near the back of the house. l A headset (with microphone) can be worn to further reduce background noise while maintaining privacy and confidentiality. l Physical spaces with soft furnishings (eg. carpet) can minimise echoing and other audio distortions.

Visual environment

l Encourage backgrounds that are stationary and neutral in colour. l Choose artificial lighting over natural light that is positioned in front and above the computer device to avoid glare and shadows.

Appropriate clothing

l Encourage clothing that is plain and light in colour; clothes with heavy patterns or stripes can create visual distortions. l As per an in-person consult, ensure that the patient is wearing clothing that allows for necessary movement or de-robing as part of the examination.

1.5 Preparing the Physical Environment

communication methods; l recommending appropriate and practical treatment options; l ensuring that patient feedback mechanisms are in place; and l implementing strategies to evaluate and ensure patient satisfaction.

1.6 Ensure Remote Access to the (e)Health Record

Medical ethics play an important role in adhering to these principles. The five key components of an eHealth medical ethics code include mutual respect, promoting open communication and consent, informed care and shared treatment decisions, access to health information and physician autonomy and responsibilities (6*). A final note on planning and preparation for a telehealth consultation would be your fee for service considerations. Telehealth billing varies widely depending on the involved government’s regulations and policies or on the patient’s health insurance. Not every government or private care provider provides reimbursement for telehealth services, in which case you and the patient must be prepared for this. Services might be free, fully covered by the insurer or the patient, with or without a co-payment.

Aside from the technology requirements, both therapist and patient need to consider their environment and surroundings in order to enhance the telehealth consultation.

In an ideal setting the therapist (and medical team) would have access to all medical records, results from investigations, etc, via integrated electronic health records. The reality is this is probably not the case for many. Where possible, paper-based clinical records should be sent over/scanned or emailed, bearing in mind patient confidentiality and online security concerns.

1.7 Apply Ethical Guidelines

Fundamental ethical responsibilities apply in every kind of care, including ‘new-age’ telehealth consultations. Core ethical principles for healthcare providers engaged in telehealth should include (6*): l ensuring patient safety; l using secure and effective

EVEN THOUGH THE ASSESSMENT IS BEING DONE REMOTELY, MANY SPECIAL TESTS CAN BE CARRIED OUT BY THE PATIENT THEMSELVES OR WITH THE AID OF A THIRD PARTY PRESENT WITH THE PATIENT It is also possible for certain billing codes not to be covered. These factors contribute to the challenges associated with telehealth services (6*).

2. The Remote Consultation

The Covid-19 challenges are unprecedented, and therapists must be agile and flexible to adapt their traditional clinical assessments. It is reasonable to assume that most patients who present for a telemedicine consultation will at some point require a face-to-face or handson clinical consultation. However, depending on the situation or the condition, this face-to-face meeting does not necessarily have to be the initial consultation. Triage in SEM can most often be determined through telehealth,

based on history alone. Other musculoskeletal conditions that may need more information during triage are, for example (2*): l medical co-morbidities; l mobility/balance deficits; l language barriers and visual/ hearing/cognitive impairments that may determine the eligible criteria for telehealth; and l the patient’s clinical presentation including symptom severity, chronicity, urgency to access care, and the presence of (potential) red and/or yellow flags may further impact their suitability for telehealth. In case of uncertainty (and where appropriate), initial special investigations may be arranged, followed by a face-to-face consultation for examination and review of the results. It may even be possible to provide initial advice and a rehabilitation plan, followed later by a face-to-face follow-up consultation. In the current Covid-19 world, the goal of telehealth is to provide optimal care with minimal or no

Table 3: Five key components of a telehealth medical ethics code Dijkstra HP et al. Remote assessment in sport and exercise medicine (SEM): a narrative review and teleSEM solutions for and beyond the Covid-19 pandemic. British Journal of Sports Medicine 2020;doi:10.1136/bjsports-2020-102650 (6*) Element

Details

Mutual respect

The patient–physician relationship must be based on mutual trust, respect and safety. It is therefore essential that the physician and patient be able to identify each other reliably when using telehealth services.

Promoting open communication and consent

A telehealth consultation must be treated like any other outpatient consultation, safeguarding sensitive or confidential information at all times.

Informed care and shared treatment decisions

Telehealth consultations are ideal in situations where a physician cannot be physically present in a safe and timely manner. Telehealth consultations do not allow for the performance of a physical examination; most nonverbal clues usually present in face-to-face meetings will be absent. These might affect the quality of telehealth communication. The principles of shared decision-making are similar in physical or eHealth consultations. However, it might be more challenging in the telehealth setting to confirm the patient’s understanding of the pathology and treatment options. If there is any doubt, a face-to-face consultation should be offered as an alternative. Inform the patient about the nature and limitations of the telehealth consultation and document informed consent. It remains a vital healthcare provider’s responsibility to consider language barriers and to ensure the right to an interpreter or health advocate.

Access to health information

Patients have the right to access all electronic health record information, unless the attending physician specifically restricts access in consultation with a family representative, legal or surrogate guardian. This can be for medical or legal reasons.

Physicians’ (or therapists’) The normal ethical and professional standards apply to all aspects of a physician’s practice. A physician should autonomy and responsibilities not participate in telehealth services if it violates the country’s legal or ethical framework. Physicians should only practice telehealth in countries/jurisdictions where they are licensed to practice. This is an essential consideration for team physicians when travelling with a team to competitions and training camps in another country. Physicians should also ensure medical indemnity that covers telehealth.

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PHYSICAL THERAPY

physical contact where possible. While this is a reversal of the usual steps in clinical assessment, it may be the only reasonable way to provide a service in a ‘lockdown’ or similar situation. Patients will generally understand and appreciate this. Many conditions (such as tendinopathies) are more suitable to this type of consultation, where the physical assessment or imaging add very little additional value to the clinical history, and management is based mainly on progressive exercise therapy which can be achieved remotely. Acute musculoskeletal injuries can be managed remotely with education and advice on the importance of Peace and Love (the newest protocol for immediate care following an acute injury; see Related Content), which will guide the patient through the first 72 hours of care, before requiring further assessment or treatment (30). Similarly, telehealth is ideal to discuss results following the initial face-to-face clinical consultation in cases where the follow-up would not involve further or a repeated patient examination (eg. where there are no contradictory imaging findings). Physical therapists working with sports teams or a specific cohort of athletes can offer telehealth for routine athlete health monitoring (in those without any new injury or illness), or initiate injury prevention programmes. A potential new area of SEM telehealth service is consultation for general health advice, not specific to a particular patient or pathology. In such a consultation, a patient/client will engage with you and ask one-onone questions about health issues, without requiring a specific clinical examination. For example discussing the benefits of physical activity, or falls prevention. An SEM telehealth consultation can be facilitated by condition-specific guidelines based on a downloadable generic template (Fig. 1) from Dijkstra et al. (6*): Figure 1: A quick generic sport and exercise medicine (SEM) guide to assessing an athlete with a sports injury remotely (teleSEM) (https://bit.ly/3lHcM5I).

2.1 Connection and Introduction

The consulting team should be ready Co-Kinetic.com

to connect with the patient using the agreed technology at the time of the scheduled appointment. Ensuring that you stick to your appointments and time is a key component to committing to treatment, and this applies to both the therapist and the patient. Timemanagement will be essential and challenging. Isolation and ‘lockdown’ has resulted in loneliness for many. Socialising and having that connection with you may be critical to the patient’s mental health. Identifying this and being sensitive to the patient, while maintaining subsequent appointments, could be challenging and require delicate referral to a counsellor who could assist. Quick pointers for beginning a telehealth consultation include (6*): l introduce yourself; l check the video and/or audio connection; l ask for the patient’s phone number in case the connection fails; and confirm the patient’s identity (name, date of birth, identity (ID) or medical record number). It is important to confirm that the patient is in a comfortable and quiet place and whether they are alone or with someone they trust.

2.2 Initial Rapid Assessment

Do a quick assessment of the patient’s general health status: are they injured/ ill or less injured/ill? Can they walk? Ask the patient what they want from the consultation. This might include a clinical assessment, reassurance or referral, a certificate or health advice. Some of your patients may be those recovering from Covid-19 and requiring rehabilitation. Referring to our article on long-term rehabilitation following Covid-19 Part1 (https://bit.ly/379wArx) and Part 2 (https://bit.ly/2YcNjWT)) may be helpful and is supported with many patient advice and exercise leaflets (https://bit.ly/2CYgDJP). Bear in mind how far reaching this virus is: the reality may be that a patient attending telehealth consultations for some other condition may one day present poorly. Using the downloadable quick reference guide (https://bit. ly/3lzuacg) from Greenhalgh et al.

Figure 1: A quick generic sport and exercise medicine SEM) guide to assessing an athlete with a sports injury remotely (teleSEM). Download from Dijkstra HP et al. Remote assessment in sport and exercise medicine (SEM): a narrative review and teleSEM solutions for and beyond the Covid-19 pandemic. British Journal of Sports Medicine 2020;doi:10.1136/bjsports-2020-102650 (https://bit. ly/3lHcM5I) (6).

during your consultation may be helpful in identifying a suspected Covid-19 patient or to monitor the progress of a patient confirmed with Covid-19 (Fig. 2) (5*). It does not cover every clinical eventuality, and should not be used as an official guideline for the management of a Covid-19 patient. Referral to a doctor and contact with your national health care department/Covid action team would be necessary if this is a suspected new case (5*).

2.3 History

The history-taking structure is similar to a normal face-to-face consultation; a

THE USE OF TELEHEALTH HAS ALSO BEEN SHOWN TO INCREASE EXERCISE ADHERENCE FOR A VARIETY OF MSK CONDITIONS 27

brief history of the current injury/illness, additional history on medication, allergies, previous medical and surgical history, sport performance/physical activity level and training history (recent and past) as well as the patient’s performance goal(s) (6*).

2.4 The Remote Physical Examination (6*)

Figure 2: Covid-19 remote consultations: a quick guide to assessing patients by video or voice call download from Greenhalgh T et al. Covid-19: a remote assessment in primary care. BMJ 2020;368:m1182 (https://bit.ly/3lzuacg) (5).

l Assess the patient’s physical and mental function as best as you can. l Ask the patient: “Where does it hurt? Can you point/show me?” l Observe for colour, swelling, bruising and any obvious deformity. l Test the involved and contralateral joint range of movement (active and if possible, passive with the help of a carer/health advocate). l Ask the patient or if possible, a third party to carefully palpate the injured area while you observe. l Consider special tests based on the condition and what is possible. The patient may be able to perform their own special test(s) (eg. empty can test for shoulder pain or a flexion adduction internal rotation test for hip pain), or measurements at home (eg. glucose, blood pressure, pulse,

A POTENTIAL NEW AREA OF SEM TELEHEALTH SERVICE IS CONSULTATION FOR GENERAL HEALTH ADVICE

step count for the day/past week, girth/diameter of swelling).

2.5 Agreeing on a Care Plan Including Shared DecisionMaking

Shared decision-making is not so much a step as it is a way of conducting a consultation. But it is most tangible in the final step of the consultation, agreeing on a care plan. As in a face-to-face consultation, the following steps are important (6*). l Team talk: inform the patient that a choice must be made, that they may consult with significant others and you are there to support them. l Option talk: discuss the options and communicate the risks and benefits of each. l Decision talk: listen to the patient to help them go from preferences to informed decisions.

2.6 Decision and Action: Working Diagnosis and Red Flags

The working diagnosis and the presence/absence of any red flag symptoms or signs will all determine the treatment plan. This might be further investigations, a follow-up, a referral, discharge with advice or urgent hospital admission for further care (6*).

3. After the Consultation

Document the telehealth consultation, including all patient instructions and the agreed care plan. Complete the relevant (paper)work for an exercise prescription, a referral for further special investigations, or to another healthcare provider. Ensure the appropriate arrangements are in place for a follow-up consultation if required (6*). Support and education are paramount for success. Using evidence-based materials/resources shared with your patient will reinforce your consultation.

Conclusion

Covid-19 may have been the rocket up the (you know where) to get telehealth implemented and moving; and I am sure it will remain a key component to the healthcare system 28

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PHYSICAL THERAPY

in the future, no matter what that future looks like. The rapid uptake of telehealth in response to the strict social-distancing policies associated with Covid-19 has cut through many of the traditional barriers to telehealth adoption (lack of control, no ‘hands-on’ assessment or treatment, inability to use certain equipment or devices, perceived depersonalisation of care, cost, level of education or computer literacy in patients, privacy concerns) (6*). For many organisations, a rapid shift to telehealth has been the only option to generate income and for patients to receive services during this time. Key elements in successfully running a telehealth consultation involve a combination of planning, professionalism and structure, while at the same time being flexible with technology challenges, and conducting assessments and treatments through ‘space!’ 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/35FcmqZ

DISCUSSIONS

l Have you engaged in telehealth yet? How confident do you feel in planning and executing a consultation? l What common tests (consider a knee, shoulder, ankle or lower back) do you feel confident the patient can perform by themselves to assist in your assessment? l Have you used any aids (quick reference tables, charts, diagrams, etc) that have assisted you and your patient during a telehealth assessment or treatment?

RELATED CONTENT

lR ehabilitation Following Covid-19 Part 1: Theoretical Considerations [Article] https://bit.ly/379wArx l Rehabilitation Following Covid-19 Part 2: Practical Applications [Article] https://bit.ly/2YcNjWT lC ovid-19 Patient Rehabilitation and Recovery Resources https://bit.ly/2CYgDJP l Immediate Treatment of Soft Tissue Injuries is all about PEACE and LOVE Poster and Patient Leaflet https://bit.ly/34SQIyK

Co-Kinetic.com

KEY POINTS

lC ovid-19 has led to the rapid adoption of telehealth by many healthcare professions. lT elehealth should be implemented to meet specific needs of the healthcare service. lC ovid-19 has cut through many of the traditional barriers to telehealth adoption. lT elehealth is a viable alternative for managing many musculoskeletal conditions. lS tudies have shown that physical therapy with telerehabilitation has the potential to increase quality of life, is feasible, and is at least equally effective as usual care. lP atients have stated that they were satisfied with most of the aspects of telehealth, including the access to services, the relationship developed with the therapist, the exercise programme, the technology and the support provided. lM any factors need to be considered to implement a sustainable telehealth service. lT elemedicine is a clinical service and not a technology. lT he organisational and operational aspects that need to be in place to support an effective telemedicine service are vital and complex.

Want to share on Twitter? Here are some suggestions

Tweet this: The presence of Covid-19 has forced the rapid adoption of telehealth service delivery methods https://bit.ly/2Re9Xe6 Tweet this: We must not forget that telehealth is a medical service and not just a technology https://bit.ly/2Re9Xe6 Tweet this: Telehealth has also been shown to increase exercise adherence for a variety of MSK conditions https://bit.ly/2Re9Xe6 Tweet this: Telehealth can provide improvements that are similar to that of usual care for some MSK conditions https://bit.ly/2Re9Xe6 Tweet this: Research in telehealth for MSK physiotherapy has reported high levels of patient satisfaction https://bit.ly/2Re9Xe6 Tweet this: In a remote exam, there are some special tests that the patient can perform themselves https://bit.ly/2Re9Xe6 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

References

1. GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018;392:1789–1858 Open access https://bit.ly/2QzRdWp 2. Cottrell MA, Russell TG. Telehealth for musculoskeletal physiotherapy. Musculoskeletal Science and Practice 2020;48:102193 Open access https://bit.ly/3lH0Oci 3. Cottrell MA, Hill AJ, O’Leary et al. Service provider perceptions of telerehabilitation as an additional service delivery option within an Australian neurosurgical and orthopaedic physiotherapy screening clinic: a qualitative study. Musculoskeletal Science and Practice 2017;32:7–16 4. Greenhalgh T, Shaw S, Wherton J et al. Real-world implementation of video outpatient consultations at macro, meso, and micro levels: mixed-method study. Journal of Medical Internet Research 2018;20(4):e150 Open access https://bit.ly/3lvcbE3 5. Greenhalgh T, Koh GCH, Car J. Covid-19: a remote assessment in primary care. BMJ 2020;368:m1182 Open access https://bit.ly/3lzuacg 6. Dijkstra HP, Ergen E, Holtzhausen L et al. Remote assessment in sport and exercise medicine (SEM): a narrative review and teleSEM solutions for and beyond the COVID-19 pandemic. British Journal of Sports Medicine 2020;doi:10.1136/ bjsports-2020-102650. Open access https://bit.ly/31IHRxY 7. World Confederation for Physiotherapy and International Network of Physiotherapy Regulatory Authorities. Report of the WCPT/INPTRA digital physical therapy practice task force. 2019, 15 May Open access https://bit.ly/34N14Ac 8. Mani S, Sharma S, Omar B et al. Validity and reliability of internetbased physiotherapy assessment for musculoskeletal disorders: a systematic review. Journal of Telemedicine and Telecare 2017;23(3):379–391 9. Lade H, McKenzie S, Steele L et al. Validity and reliability of the assessment and diagnosis of musculoskeletal elbow disorders using telerehabilitation. Journal of Telemedicine and Telecare 2012;18(7):413–418 10. Richardson BR, Truter P, Blumke R et al. Physiotherapy assessment and diagnosis of musculoskeletal disorders of the knee via telerehabilitation. Journal of Telemedicine and Telecare 2017;23(1):88–95 11. Russell TG, Blumke R, Richardson B et al. Telerehabilitation mediated physiotherapy assessment of ankle disorders. Physiotherapy Research International 2010;15(3):167–175 12. Russell T, Truter P, Blumke R et al. The diagnostic accuracy of telerehabilitation for nonarticular lower-limb musculoskeletal disorders. Telemedicine Journal and 29i

HOW TO PLAN AND EXECUTE A TELEHEALTH PHYSICAL THERAPY SESSION:

Don’t Just Natter, Make it Matter eHealth 2010;16(5):585–594 13. Steele L, Lade H, McKenzie S et al. Assessment and diagnosis of musculoskeletal shoulder disorders over the Internet. International Journal of Telemedicine and Applications 2012;2012:945745 Open access https://bit.ly/34Kjkdx 14. Cottrell MA, O’Leary SP, Swete-Kelly P et al. Agreement between telehealth and inperson assessment of patients with chronic musculoskeletal conditions presenting to an advanced-practice physiotherapy screening clinic. Musculoskeletal Science and Practice 2018;38:99–105 15. Cottrell MA, Galea OA, O’Leary SP et al. Real-time telerehabilitation for the treatment of musculoskeletal conditions is effective and comparable to standard practice: a systematic review and meta-analysis. Clinical Rehabilitation 2016;31(5):625–638 16. Dario AB, Moreti Cabral A, Almeida L et al. Effectiveness of telehealth-based interventions in the management of non-specific low back pain: a systematic review with meta-analysis. Spine Journal 2017;17(9):1342–1351 Open access https://bit.ly/3gBZB24 17. Jiang S, Xiang J, Gao X et al. The comparison of telerehabilitation and face-to-face rehabilitation after total knee arthroplasty: a systematic review and metaanalysis. Journal of Telemedicine and Telecare 2018;24(4):257–262 18. van Egmond MA, van der Schaaf M, Vredeveld T et al. Effectiveness of physiotherapy with telerehabilitation in surgical patients: a systematic review and meta-analysis. Physiotherapy 2018;104(3):277–298 19. Kairy D, Tousignant M, Leclerc N et al. The patient’s perspective of inhome telerehabilitation physiotherapy services following total knee arthroplasty. International Journal of Environmental Research and Public Health 2013;10(9):3998–4011 Open access https://bit.ly/3hI6Gzz 20. Bennell KL, Nelligan R, Dobson F et al. Effectiveness of an internet-delivered exercise and pain-coping skills training intervention for persons with chronic knee pain. Annals of Internal Medicine 2017;166(7):453–462 21. Bennell K, Marshall C, Dobson F et al. Does a web-based exercise programming system improve home exercise adherence for people with musculoskeletal conditions?: a randomized controlled trial. American Journal of Physical Medicine & Rehabilitation 2019;98(10):850–858

22. Lambert TH, Harvey LA, Avdalis C et al. An app with remote support achieves better adherence to home exercise programs than paper handouts in people with musculoskeletal conditions: a randomised trial. Journal of Physiotherapy 2017;63(3):161–167 Open access https://bit.ly/2Gf0YYd 23. Pastora-Bernal JM, Martín-Valero R, Barón-López FJ et al. Evidence of benefit of telerehabitation after orthopedic surgery: a systematic review. Journal of Medical Internet Research 2017;19(4):e142 Open access https://bit.ly/2EPppdK 24. Lawford BJ, Delany C, Bennell KL et al. “I was really sceptical...But it worked really well”: a qualitative study of patient perceptions of telephone-delivered exercise therapy by physiotherapists for people with knee osteoarthritis. Osteoarthritis and Cartilage 2018;26(6):741–750 Open access https://bit.ly/34MPrt6 25. Moffet H, Tousignant M, Nadeau S et al. Patient satisfaction with inhome telerehabilitation after total knee arthroplasty: results from a randomized controlled trial. Telemedicine Journal and eHealth 2017;23(2):80–87 26. Cottrell MA, O’Leary SP, Raymer M et al. Does telerehabilitation result in inferior clinical outcomes compared with in-person care for the management of chronic musculoskeletal spinal conditions in the tertiary hospital setting? A non-randomised pilot clinical trial. Journal of Telemedicine and Telecare 2019;doi:10.1177/135763 3X19887265 27. Cottrell M, Judd P, Comans T et al. Comparing fly-in fly-out and telehealth models for delivering advanced-practice physiotherapy services in regional Queensland: an audit of outcomes and costs. Journal of Telemedicine and Telecare 2019;doi:10.1177/135763 3X19858036 28. Nelson M, Russell T, Crossley K et al. Cost-effectiveness of telerehabilitation versus traditional care after total hip replacement: a trial-based economic evaluation. Journal of Telemedicine and Telecare 2019;doi:10.11 77/1357633X19869796 29. Pastora-Bernal JM, Martín-Valero R, Barón-López FJ. Cost analysis of telerehabilitation after arthroscopic subacromial decompression. Journal of Telemedicine and Telecare 2017;24(8):553–559 30. Dubois B, Esculier J. Soft-tissue injuries simply need PEACE and LOVE. British Journal of Sports Medicine 2020;54:72–73. Co-Kinetic Journal 2020;86(October):22-29

FASCIAL STRETCH THERAPY ™ FOR THE LOWER BODY

FASCIA | 20-10-COKINETIC FORMATS WEB MOBILE PRINT

Fascial Stretch Therapy™ (FST) is a technique that involves painless assisted stretching that focuses on the neuromyofascial net of the body as a whole for improving flexibility and function. This article explains how to implement the Ten Principles of FST as well as how to perform the initial general assessment of the lower body, allowing you to understand the concepts of FST and to see how it can benefit your patients. This article is an excerpt from Chapter 5 ‘FST – Lower Body Technique’ of the authors’ book Fascial Stretch Therapy. Read this article online https://bit.ly/2GTUPB3 By Ann Frederick ATSI and Chris Frederick PT ATSI

Fascial Stretch Therapy™

Fascial Stretch Therapy™ (FST) is a painless assisted-stretch and full body mobility system for improving flexibility that was created in 1995 and developed by us over 25 years. Initially aimed at improving flexibility and performance in professional sports, FST was quickly found to benefit people of all ages with a variety of chronic, unresponsive pain conditions, strength and mobility imbalances and other common musculoskeletal

disorders. FST is a neuromyofascial manual therapy that focuses on the fascia rather than isolated muscle treatment. We assess passive, active and resisted movements in functional positions as well as on the treatment table. The approach starts with specific assessment of regions called ‘fascia nets’ so that treatment is individualised to the needs of the person. FST starts at the deepest part of the connective tissue system – the joint capsule. It progresses through all the layers of fascia, ending with the superficial layer. Where the central or peripheral nervous system is restricted or not optimal in movement, proper neural mechanics is restored. Muscles that were inhibited are activated while those that are over-activated are normalised. We are very pleased to have just had the second edition of

our book Fascial Stretch Therapy™ published and this article is an extract from Chapter 5, discussing the key concepts for applying FST to the lower body (Part 1) as well as how to perform the initial general assessment (Part 2).

Part 1: Key Concepts Introduction

For experienced practitioners, some of the concepts in this article will be familiar. We share our philosophy, our tips for success, proper body mechanics, and specific instructions on how best to perform our technique. We use our Ten Principles (Box 1) to correlate these concepts for better understanding (these are described in detail in Chapter 3 of our book). All of the principles are applied to the technique and are not done in any specific order. When we teach our

Box 1: The Ten Fundamental Principles of Fascial Stretch Therapy™ 1. Synchronise breathing with movement. 2. Tune nervous system to current conditions. 3. Follow a logical order. 4. Achieve range of motion gain without pain. 5. Stretch neuromyofascia, not just muscles. 6. Use multiple planes of movement. 7. Target the entire joint. 8. Get maximal lengthening with traction. 9. Facilitate body reflexes for optimal results [proprioceptive neuromuscular facilitation (PNF)]. 10. Adjust stretching to current goals.

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MANUAL THERAPY

hands-on workshop we demonstrate the practical relevance of these guidelines. They are not just theoretical but have an extremely useful application as well. The philosophy and theory of the principles were described in Chapter 3 of our book. Here they will be outlined differently for the specific practice of FST technique. If you truly embrace all of the principles when you perform the technique, you will have excellent results. They have stood the test of time not only for us but also for thousands of our students. A term we use is the StretchWave™. This is a metaphor used to help people visualise a stretch as being made up of undulations of movement coordinated with proper breathing. It comes from observing that many physiological and kinesiological processes in the body occur in waves, from the light waves that stimulate the retina in vision to the pulsing waves of the blood in arteries and veins.

Practical Guide to Implementing the Ten Principles 1. Breathing Breathing is a crucial component in successful stretching, for both the client and the practitioner. Breathe together and be aware that if the practitioner is not breathing well it often translates to the client not breathing well.

2. Nervous System We use a combination of movement that we refer to as TOC in order to ‘talk’ to the tissue. This stands for: traction, oscillation and circumduction. It uses a combination of breathing cues to either relax (down-regulate) or excite (up-regulate) the client’s nervous system. TOC is used in a slow or fast manner, just like the StretchWave™. Traction Physically decompress and create space in the joint using your hands or body. Contact with the entire neuromyofascial net through traction lengthens the tissue. Oscillation Movement that has a vibratory effect Co-Kinetic.com

with a rhythmic motion: it can be back and forth, side to side, up and down, in and out, or any combination of these. It can be used to calm down a nervous system, moving the client into the parasympathetic state, or amp up a nervous system, shifting the client into the sympathetic state. Most pain that arises from factors such as unintentionally overstretching or pinching a structure can be relieved in seconds with immediate oscillation. Circumduction There are six reasons why we use circumduction in FST: 1. T o warm up and thin out synovial fluid in the joint. 2. T o assess the feel of the joint and possible impingements. 3. To assess feel of the tissue and check for imbalances. 4. T o see if the client is going to give up control and allow us to move them. 5. T o increase overall relaxation in joint and entire body. 6. T o build trust and rapport with the client. This is very important! Smooth oscillations calm the nervous system. Jiggling, gyrating, yanking movements are jarring to the nervous system. Rapid movement wakes up the nervous system. 3. Order l Begin at the core of the body to unlock the restrictions first before moving to the extremities. l Stretch one-joint muscles (bent) before two-joint muscles (straight). l Start at the deepest innervated structures of the body – the joint – and progressively move all the way through to the distal ends of neuromyofascial chains. 4. Gain without pain l The risk of causing pain means possibly losing trust and potential injury. There should be a stretch awareness, but never pain. l ‘No pain, no strain!’ is one of our fundamental credos. Movement is gained through finesse, not force. l Less is more – don’t overstretch and cause the rebound effect. l We believe that it is important for the client to understand what a

FASCIAL STRETCH THERAPY™ (FST) IS A NEUROMYOFASCIAL MANUAL THERAPY THAT FOCUSES ON THE FASCIA good stretch should feel like and not that it should never hurt. l You always want the client making ‘aahs’ (happy sounds) before they make ‘oohs’ (stretch awareness). 5. Neuromyofascia Consider the following when practising FST: l Think neuromyofascia and shift out of the mindset of engaging with specific muscles. l When stretching, think global not local. Consider entire continuities of neuromyofascial lines and all the tissue contained within, not just isolated regions. l Look at the body from a three dimensional perspective – from the inside out. Think: micro macro and macro micro. l The irrefutable fact that it is impossible to separate one tissue from another – it is all intertwined and interdependent. l Think of adding layers as you stretch into and across tissue: joint capsule, one joint, multiple joints, fascial, neural all the way to two or more practitioners stretching a client along multiple planes, in opposite directions. 6. Multiple Planes of Movement l Explore all possible movements – remember it is a dance! l Play with angles to find all of the tight fibres. l Change the angle or level to find different fibres and tissue restrictions. l Move in 3–5° increments around the body, like the sweep hand on a watch. 7. Joint l Proprioceptively, the knee specifically needs contact – hand 31

WHEN IN DOUBT, TRACTION IT OUT!

and/or body placement around the knee – for a sense of security. This makes the joint feel safe and stable, rather than hanging unsupported in space. l Gently cradle the knee instead of grabbing or gripping it. l In side lying moves, make sure you are supporting the client’s knee and ankle. Keep the ankle in line with the tibia–knee–femur, as dropping the ankle below the knee can cause tweaking in the knees. l If the joint has been stretched open for a while, then close it; or if it has been closed for a while, open it. Joints don’t like to be in one position for too long.

l Traction can be done at varying degrees and angles – through multiple planes. l Hand placement during traction (ie. under versus over) is important, especially during the straight leg segment. l When tractioning through any joint, make sure to target only the intended joint and be cautious of hypermobile joints. l We like to say, ‘When in doubt, traction it out!’. This means use traction when: l the client feels joint or tissue pinch l you forget what to do next l the client cannot relax l the client gets a spasm, etc.

8. Traction Traction is the cornerstone of FST (Tip 1). Consider the following features and benefits of traction, which: 1. opens the joint capsule and space, decompresses the joint; 2. creates conditions for optimal mobility of all joint structures; 3. releases adhesions in joint capsule and other connective tissues; 4. achieves neuro-reflexive release of the joint capsule being tractioned, as well as neighbouring structures – some of which may also cross that joint; 5. increases endorphin release; 6. reduces pain; 7. allows maximal lengthening of all the connective tissues; 8. eliminates joint compression (jamming or pinching) while stretching; 9. targets fascial components deep inside joint capsule, ligaments, tendons, muscles, and neural tissues; and 10. dramatically improves the effectiveness of ROM increases and flexibility gains.

Don’t use traction on acute injuries or in conditions of hypermobility or laxity.

Traction Points l Use traction in all positions to find ROM. l Use your body to traction and very rarely your arms. l Use it to transition and move from one position to the next. l Slow down, make sure your angle/ position is correct for both you and your client. 32

9. Proprioceptive Neuromuscular Facilitation (PNF) Described in detail earlier in the book, PNF is the flowing dance of two people and their respective neuromyofascial systems moving in therapeutic harmony. Each dance is unique to the practitioner and the client. It uses specific simple cues (verbal, tactical, importance of hand placement). It is key not to touch the opposite side of the body or you send a neurological signal to the wrong area. 10. Current goals l Know what the current goal is and keep treatments on track with it. l Change the goals in order to continue moving ahead to successfully achieve them. l Adapt sequencing to your client and what their tissue needs are at a particular moment, not to what is on your agenda. l Apply asymmetrical dosing of stretching, for example, 2:1 (or, if needed, 3 or 4:1) ratio to correct side-to-side ROM imbalances, where ROM unilaterally is remarkably decreased.

Range of Motion Evaluation

Explanation of Resistance of the Tissue Feel The purpose is to get a passive sense of soft tissue resistance to movement and to identify the type of tissue (joint

capsule, ligament, neuromyofascial unit or chain) that is responsible for movement restrictions or other aberrations. The ROM assessment will give you a sense of when soft tissue starts to resist the passive movement being directed by the practitioner. The first response of passive resistance to passive (P)ROM is called Resistance 1 or simply, R1. This occurs when the practitioner feels or senses the first barrier encountered, as one takes up increasingly more PROM. R1 can occur at the relative start of the ROM or may occur toward the expected end or anywhere along that spectrum. The feel of R1 can be soft or hard or somewhere in between. It can have a gooey, almost nondescript feel, as in some long-practising yoga practitioners who have reduced the gamma gain of the muscle as well as over-lengthened their connective tissue by excessive stretching. R1 in this body type will occur toward the expected end of the ROM and, in some, it will actually coincide with the anatomical limit of joint motion. On the other side of the spectrum, R1 can have a wiry, guitar string feel, such that it springs into your hand almost suddenly, which usually occurs at the relative beginning of the ROM. We generally see this in the following client types: highly strung, massively stressful life, cannot give up being the one in control, highly nervous and or anxious, distrustful. Many disorders of the nervous system or some diseases of the connective tissue system may also have these or similar characteristics, but those topics are beyond the scope of this book. R2 or Resistance 2, is the second response to the PROM evaluation. After you note where R1 occurs, proceed to increase the ROM until you feel the tissue suddenly start to slow down the movement. Any further movement after this point will elicit maximal resistance (R3) from the tissue (and probably a look of pain or high alert from the client) and possibly a reflex reaction that contracts the muscle to prevent further lengthening of the tissue. Naturally, this scenario is undesirable and can be avoided if the practitioner is attentive to the feel of tissue under tension, as well as to the reaction and response of the client.

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Resistance to traction (RT) occurs during the actual stretching phase of the session, not during the evaluation or ROM phase. RT can conceptually be thought of as ‘enhanced R2’, meaning that the second barrier felt during PROM is explored with the addition of two simultaneously occurring components, traction and increased ROM. For example, when working to increase bent knee hip flexion at R2, we first micro-traction, then add more flexion while maintaining the traction. For example: l Move into starting position for ROM without being in a rush to get into the stretch. l The ROM check needs to be just that, a check – no stretching yet. l It needs to be the client’s end-ROM, not what is shown in the book. l Know where R1 is for your client and stay there during the evaluation and warm-up. Check in with your client if you are not certain. Breathing Technique The importance of using the breath to maximise gains in the tissue and also to help control the desired nervous system is the second of the Ten Principles. This can be easily achieved by the practitioner and client breathing together to achieve synchronised movement and flow. The basic rule with FST is to exhale into all movements, be it finding the ROM or into the stretch after PNF contraction. An inhalation is taken for both the brief concentric and then isometric contraction component during PNF. The following is a detailed explanation of how FST PNF is performed for the first move in the routine. We use part of the Superficial Back Net as one example, which targets the gluteus maximus and proximal attachment hamstrings. It represents how it is executed through the entire technique. PNF Technique This technique uses a modified form of PNF we call FST PNF to help differentiate it from traditional and other forms of PNF. In FST PNF, the client contracts targeted muscles with as little as 5% of their strength and up to 20% (versus traditionally Co-Kinetic.com

50–100%) and holds the contraction for approximately 3 to 4 seconds (versus 6 to 10 seconds), for a more effective relaxation response. We use comfortable straps to stabilise the limb that is not being worked on, thus facilitating complete relaxation of the person being stretched and enhancing the effectiveness of the actions of the practitioner. Other key differences are that traction is used to assess the ROM in the tissue before the stretching begins. It is also gently used throughout the stretching. Pain is never allowed and is considered a negative response. The practitioner and client move together as if in a dance, with perpetual undulating movements through the session. For a list of 18 reasons that make FST PNF different, please see Principle 9 in Chapter 3 of our book. FST PNF Sample Sequence 1. Begin with the client’s leg placed comfortably on your body, draped over your shoulder and with the weight of their leg resting on your back. Their other leg is normally secured by stabilisation straps for this routine (Tip 2). 2. Make sure your own body mechanics are good (you are also relaxed and in a comfortable position). 3. The client and practitioner both inhale together. You will breathe together for the entire session. 4. Using your body (not just your hands) to lift their leg, traction their femur up out of the socket and then take their leg into their barrier of resistance (R1). Their knee remains bent, as the focus in this case is proximal tissue. 5. The practitioner gives a gentle hand tap to the back of their hamstring for the PNF cue. Ask them to inhale and press back and meet your resistance. The client performs a slow and gradual concentric contraction of the hamstrings and gluteus maximus for just a few degrees of movement into hip extension and with as little as 5–20% of their strength for the duration of the inhalation (Note 1). 6. After the concentric contraction is performed for a few degrees, the

IF YOU TRULY EMBRACE ALL OF THE TEN PRINCIPLES WHEN YOU PERFORM THE TECHNIQUE, YOU WILL HAVE EXCELLENT RESULTS client continues the same inhalation while being cued to hold an isometric contraction, as they firmly meet the resistance provided by the practitioner for about two more seconds. The contraction is then ramped down smoothly until the targeted region completely relaxes. 7. On the exhalation, the practitioner increases the traction of the femur upward out of the hip joint and creates space between the pelvis and the femur, maintaining the traction while increasing the stretch to the next tissue barrier, R2. 8. This is where the concept of the StretchWave™ is used – like the rise and fall of a wave. The traction up is the rise and movement forward into flexion is the fall. 9. Increased ROM in hip flexion is gained by hooking and carrying the femur upward with your body and hands, thereby enabling deeper and further hip flexion motion. This should look like the StretchWave™ (described in Chapter 3 of our book). The traction should be applied at the peak of the wave movement. Flowing into the newfound ROM is likened to the sea washing over the shore after the wave builds into a peak. Use words such as ‘up, out, and down’ when you move in unison with your client.

2 IF YOU DON’T HAVE STRAPS, YOU WILL HAVE TO MODIFY YOUR PRACTICE ACCORDINGLY: USE YOUR OTHER HAND TO STABILISE WHEN POSSIBLE, USE AN ASSISTANT, OR HAVE THE CLIENT PERFORM ACTIVE STABILISATION.

Note 1 The reason there is such a large variance in the percentage of the contraction is because it depends on the strength of the client as well as the practitioner. The area of the body being targeted also influences it; for example, the neck will use a lighter contraction than the leg. Finally, there is a spectrum of contraction intensities that the practitioner will need to experiment with in order to find the best response to whatever the intent is – increase ROM, reduce tone, etc. This ‘experiment time’ is greatly reduced with practice and experience.

10. Repeat PNF two or more times as indicated by client response, moving a few degrees out into abduction with each PNF pass to a new angle and targeting different, adjacent fibres of tissue. Repeat the series until you have moved through all the possible angles and fibres to get an optimal fascial stretch of the tissues. Remember: never cause pain or push past appropriate levels of indicated stretch movements. Less is more and patience is important. Always listen to the client’s tissue! The treatment table routines in Chapters 5 and 6 of our book are presented in the way we progress through an actual session with a client. They can be done in entirety or in smaller segments for emphasis. What makes the patterns unique is the flow and sequence of movements from the core of the body out to the extremities. There are also several signature moves such as the ‘Sack of Buns’ and the ‘Glute Swoop’. While developing the technique in the world of athletics, I discovered that it was all about unlocking the tightness around and in the hips. This is why I focused so intently on the four key muscle groups of the lower body. This group consists of the gluteal complex including

the six deep rotators, iliopsoas complex, quadratus lumborum and latisimus dorsi.

Tips for the Practitioner’s Success

The two most important tips are: 1. Listen to your intuition and never, ever go against your gut feelings! 2. Our brain is wired for survival first and foremost, so it is imperative the client always feels safe and that the practitioner is never perceived as a threat. Trust takes time to develop and can be broken in an instant.

listening and working together as a team. l Be clear in your intention. l Be clear about the client’s goals or concerns for each session. Check in with your client. l Pay attention to client’s verbal cues, facial expressions, and body language. l Let the client’s tissue tell you what it needs. It will talk to you; your job is to listen. l Don’t let the client convince you to deepen a stretch because they think they can go farther when your sense is that the stretch is already at the correct intensity for the best results. l Be clear and simple in your cueing of PNF. l Ask for feedback from client. Give communication cues to get specific information: l Where do you feel that stretch? l On a scale of 1–10? l Any pinching? l Use different ways to elicit feedback (because people don’t necessarily know what they’re supposed to feel like or be experiencing). l There is a difference in brain wave patterns between talking and silence. Encourage clients to be where they need to be to accept what you’re doing. If their eyes are closed, don’t talk; listen to what their bodies are telling you. Let them find their happy place.

More Tips l Less is more. You can always increase the stretch but it is difficult to undo overstretching. l It takes time and patience to learn to listen and understand the tissue. Go easy on yourself and your skill level. It has taken 30 years to develop this technique and we are still learning every single day from each and every client and student! l Patience and practice … slow down and keep listening. l Listen with your heart, not just your brain to tune into your clients’ bodies. l Don’t let your eyes do all your seeing; close them and see what happens. l When you are in the right position, the stretch movement comes naturally and just flows. If not, it feels awkward to you and to the client! l Remember to visualise the StretchWave™ throughout the session. Think of moving heel to toe (like tai chi movement) as you move through the stretch wave. l If you feel like you’re working too hard, you are. l It takes energy, patience and skill to pay attention – not just physical force. l Own the technique. Play with it. Keep it within the general context and make it yours. l Remember, we are just bringing our client’s bodies back into balance.

Body Mechanics l The golden rule is: if the practitioner feels comfortable and relaxed in their position and the client is relaxed and not in pain – everything works. l Make the technique your own and don’t worry about getting into the perfect position as this will change depending on the size and flexibility of each client as well as the practitioner.

Communication l Work with your client not against them. Practitioner intent is a crucial component. Know the power is in

Personal Adaptations There are no exact hand or leg placements for the practitioner. Position Co-Kinetic Journal 2020;86(October):30-38

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Note 2 Please note that the majority of the photos in the practical section show a petite practitioner and a tall client. The instructions are also for the biomechanics of a petite practitioner and a tall client. Therefore, make necessary adjustments of table height, body mechanics and client positioning to make it work for you.

yourself for your ease and comfort. Find what works for you. If you are uncomfortable or in pain, the client will sense it and be unable to relax Note 2). Position tips for body, legs, and hands have many possible variations: l The closer your body is to, and the more contact you have with, the client, the better you will be able to read the tissue. l Use your whole body (feet, hip action, etc.) – not just your hands. This enhances the client’s sense of security and thus their ability to relax. l Always adapt your own body positions according to each client. Your positioning may change

Figure 1: Hip clearance

Figure 2: Leg length check

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LESS IS MORE. YOU CAN ALWAYS INCREASE THE STRETCH BUT IT IS DIFFICULT TO UNDO OVERSTRETCHING depending on the size and flexibility of your client. l Positioning is KEY – small adaptations can make a huge difference. l Use soft, relaxed hands. Don’t grip roughly. l You are not just moving your client, you are moving with them. l For better results, and less soreness and fatigue in your own body, use leverage rather than pulling and pushing (strong arming) your client. Always release the stretch through a neutral pathway and a different plane – don’t re-contract what you have just lengthened. l Remember always: finesse not force. The text in the practical sections (Chapters 5 and 6 of the book) is broken down into logical steps for you to follow: Goal: What is the intent of the specific movement and target tissue? Client position: What is the position of the client on the table (or couch)? Practitioner: What is the practitioner’s position and what do they do? ROM: What is the movement needed to find ROM? Traction: What is the target area and how does the practitioner achieve it? PNF: What does the client do? PNF cues: What does the practitioner say to the client to verbally cue contraction? Stretch: What is the target area? What is the movement needed and what does the practitioner do to increase the stretch or vary other parameters? For simplicity’s sake, we have placed all of the same key components at the beginning of this chapter. They apply to the entire technique of the FST system outlined in the rest of the chapter. So for instance, instead of writing the breathing cues for each stretch, they are stated once from the start. The same is true for PNF sequences.

Part 2: General Assessment of the Lower Body

The final two chapters of the book Fascial Stretch Therapy contain a detailed step-by-step methodology of how FST is applied to the lower and upper body to provide full body mobility and stretch therapy as well as to provide regional manual therapy. Here, we describe how to perform the general assessment of the lower body, which would be done before beginning a therapy session. Please refer to the book for details of how you would continue to treat your patient after doing this initial assessment.

1. Major Observations

Goal: To look at the client from the overall perspective. To assess the client’s body before beginning a session. Client position: Supine and relaxed on table. Arms are down, alongside the client’s body. Practitioner: Standing at the foot of the table.

2. Hip Clearance Move (Fig. 1)

Goal: To ensure the client is aligned correctly on the table. To assess the passive flexion of lumbar spine, pelvis, and hips. Client position: Supine. Practitioner: l Grasp the heels and lift both of the client’s legs off the table. l Bend both knees toward their chest, then straighten out the legs and slowly bring them back down to the table. l Make sure client remains relaxed and does not help you as you return to the starting position. l Reason for move: eradicates falsepositive leg length discrepancies (LLD) due to poor positioning on table.

3. Leg length check (Fig. 2)

Goal: To check bilateral medial malleoli for LLD. 35

TRACTION IS THE CORNERSTONE OF FST Client position: Supine with arms down at their sides. Practitioner: l Standing at the foot of the table. l Place your thumbs under medial malleoli edges, resting other fingers on feet. l Look straight down to check leg length and compare. l Frequently, the short leg is the dominant leg, especially in athletes.

4. Double leg traction (Fig. 3)

Goal: To feel for tension and restrictions throughout client’s entire fascial net. Client position: Supine and relaxed with arms at their sides. Breath: Both the client and practitioner inhale to prepare for the movement and then exhale into the movement together. Practitioner: l Hold both heels in the palms of your

hands and gently wrap your fingers around the rest of the feet. l Lift both of the client’s extended legs with traction at 10–20° hip flexion. l Engage your core and bend your knees slightly. l Lean back with your body, stay relaxed. l Where do you feel the client’s tension and/or lack of tissue yield/ elasticity? Traction: Through both legs.

5. Single Leg Traction (Fig. 4)

Goal: To assess the hip joint capsule by performing moderate traction until slight elastic give is felt in the tissue. To find their specific ‘sweet spot’ which is the optimal open joint position for traction. To decompress joint and create more space. Client position: Supine and relaxed with arms at their sides. Practitioner: Standing at the foot of the table. l Position client’s leg approximately 20° flexion and abduction, with a slight external rotation of the femur.

Note 3 1. Do not pull, yank or try to ‘pop’ the hip. If the hip spontaneously manipulates during traction, do not repeat this specific traction again. 2. Do not try to manipulate the other hip (unless you are licensed to do so); just repeat same on other side as noted above. 3. Hypermobile and/or painful ankle joints require the practitioner to anchor hands above the joint or otherwise stabilise it manually.

Figure 3: Double leg traction

Figure 4: Single leg traction

l Hold their heel with the outside hand and wrap your other hand around the inside of their mid-foot moving foot into dorsiflexion. If this hand position does not feel secure to you, or the client’s ankle is hypermobile and/or painful, try another variation by wrapping both hands around the malleoli and above the ankle joint (See Figs 1 and 2). Traction: Relax your own body. Lean back with your body to achieve the traction. Do not pull with your arms; rather, let your body do the work. Repeat traction three times with a bit more force each time, as indicated (Note 3). Hip capsule end-feel for different joint mobilities: l normal: ±50% elastic give l hypomobile: <50% l hypermobile: >50%. Repeat: On the other leg. Oscillate: Both legs before moving on to the lateral line check for relaxation. Gently move legs in and out of internal and external rotation. Gently and slightly shake legs up and down.

6. Check Lateral Movement (Moving to the Practitioner’s Left Side)

Stage 1 (Fig. 5) Goal: To assess the client’s ROM on the lateral side of their body and to ascertain where they may be

Figure 5: Lateral net check – walking to the right

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restricted as you move them laterally. Client position: Supine with arms at their side. Practitioner: l Lift both of the client’s extended legs with traction at 10–20° again. l Hold both of their heels in the palms of your hands and gently wrap your fingers around their heels. l Engage your core and bend your knees slightly. l Move slowly to the left until the client’s movement stops. l If their hip begins to roll up off the table you have reached the end of their ROM. Traction: Lean back with your body, stay relaxed. Stage 2 This stage progresses from the last position (Fig. 6). Goal: To increase ROM in lateral lumbopelvic hip region, especially lateral QL, TFL/IT band and all tissue along lateral net. Practitioner: l Place the client’s left leg (the bottom one) on your hip or quad as you move to your left. l Lift their top leg higher, holding at their heel. l Place your inside hand on their medial malleolus and anchor it to your thigh on your inside leg. l Increase ROM by increasing lateral flexion of their opposite side.

Figure 6: Lateral net check with crossed legs

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l Use your body to lean way from the table and not your arms to feel the tissue response and end-feel. Traction: Keep tractioning out as you move. Think of the traction as if you are moving together in an arc away from the table, then up toward the top of the table. Repeat: On the other side. Caution: Return to start position if anything like the following occurs: any sensation of pain or paresthesias which may come from unidentified disc or nerve issues.

7. ROM Check (Fig. 7)

Before you begin stretching, it is important to have a good benchmark for improvement before treatment commences. Goal: To assess initial ROM for later re-assessment Client position: Supine. Practitioner: l Perform a straight leg raise (SLR) PROM to R1. l Use the heel of your hand to lift the client’s leg, keeping your fingers relaxed. l Use your lats; keep your arm straight to help. ROM: Make a note of what the ROM is to start off with. Repeat: On the other leg.

therapist would then go on to work on the lower body as a whole or to provide regional manual therapy as detailed in the book.

Fascial Stretch Therapy™

Ann Frederick and Chris Frederick Handspring Publishing 2020; ISBN 978-1912085-67-5. Buy it from Handspring https:// www.handspringpublishing.com/product/ fascial-stretch-therapy-second-edition/ The beautiful new edition of this highly successful book, written by Ann and Chris Frederick, directors of the Stretch to Win® Institute, is packed with theory and practice, including a host of beautifully illustrated assisted stretches. Fascial Stretch Therapy™, Second edition is a practical and highly applicable manual for any massage therapist, movement instructor, physical or occupational therapist, athletic or sports trainer, fitness instructor or osteopath – in fact for any hands-on practitioners who wants to learn new skills and improve therapeutic outcomes. It clearly demonstrates how FST™ assessment, treatment, and training are used in a variety of common circumstances encountered in manual therapy and athletic training.

CONTENTS

Chapter 1: The Emergence of Assisted Stretching Chapter 2: Research and the Science of Stretching Chapter 3: Fascial Stretch Therapy Dissected Chapter 4: Assessment Chapter 5: FST – Lower Body Technique Chapter 6: Upper Body Technique

After performing this general assessment of the lower body, the

Figure 7: Straight leg raise (ROM check)

RELATED CONTENT

lA ssessment of Fascial Dysfunction [Article] https://bit.ly/3m0OTWE lO ptimising Therapeutic Outcomes [Article] https://bit.ly/359KdId l Connectivity: Fascia-Related Therapies [Article] http://spxj.nl/2h9ii4i

DISCUSSIONS

l Describe the Fascial Stretch Therapy™ (FST) system and its Ten Principles to a colleague. What is its aim and what structures does it target? l Think about the manual therapy that you usually do for your clients to improve stretch and flexibility. In what ways is it similar to or different from the FST approach described here? l What do you see as advantages to the patient of the FST approach?

THE AUTHORS Ann Frederick ATSI is a former professional dancer, having grown up in her mother’s dance studio, starting to dance at the age of four and to teach dance at 14. She has practised her particular brand of stretch therapy since 1995, which includes both individual and assistedstretching and group stretch instruction. Ann originally created a unique system of neuromyofascial manual therapy called Fascial Stretch Therapy™ for the USA Men’s Olympic Wrestling Team of 1996. Besides improving professional athletic performance, she soon discovered that FST also rapidly helped other clients with a variety of chronic, unresponsive pain conditions, strength and mobility imbalances and other common musculoskeletal disorders. Chris Frederick PT ATSI has been a physical therapist/ physiotherapist since 1989, focusing on manual therapy – particularly with integration of Fascial Stretch Therapy and Anatomy Trains® Structural Integration – along with personalised movement prescription to restore function. He has an extensive background in dance, both as a professional dancer of contemporary ballet, as well as being a practitioner in the specialty of dance physical therapy/physiotherapy. Chris is also well versed as an instructor and practitioner of the movement and healing arts of tai chi and qigong. He is a co-author with Thomas Myers of the chapter on stretching in the seminal book Fascia: The tensional network of the human body edited by Robert Schleip, Leon Chaitow et al. Ann and her husband Chris are both certified by Thomas Myers in Anatomy Trains® Structural Integration (ATSI) and are the authors of the popular book Stretch to Win, now in its second edition. Ann and Chris directed their own highly successful centre for Fascial Stretch Therapy, physical therapy/physiotherapy, Structural Integration, chiropractic, acupuncture, sports massage and Pilates for nearly 20 years. They are now Directors of the Stretch to Win Institute, where they offer certification training workshops in Fascial Stretch Therapy. Email: stwinstitute@stretchtowin.com Website: www.stretchtowin.com Twitter: https://twitter.com/stretchtowinfst LinkedIn: https://www.linkedin.com/in/annfrederickstretchtowin/ and https://www.linkedin.com/in/chrisfrederickstretchtowin/ Facebook: https://www.facebook.com/StretchToWinInstitute Instagram: @stretchtowin

KEY POINTS

lF ascial Stretch Therapy™ (FST) is a neuromyofascial manual therapy that focuses on the fascia rather than isolated muscle treatment. lF ST starts with assessment and treatment where needed at the deepest part of the connective tissue system – the joint capsule – before progressing through all the layers of fascia. lF ST is a therapy based around Ten Principles to achieve maximum benefit. lF ST is painless – movement is created through finesse, not force. lE xplore all possible movements and angles to find all the tight fibres. lT raction is the cornerstone of FST, but should not be used in conditions of hypermobility or laxity. lC ommunication with your client is key – work with them, patiently, as a team. l A dapt the position of your body according to each client. l A pplying FST begins with a general assessment of the client’s body before providing regional manual therapy if necessary.

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ENTREPRENEUR THERAPIST

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Why Memberships are SO Important for any Business

Before we dive into the specifics, let’s Co-Kinetic.com

In this article, Vicki explores the benefits of offering a membership subscription option within a physical or manual therapy business. She discusses why memberships are so valuable, explores some different membership models, offers some suggestions regarding what you can include and then reviews briefly the ways in which you can take payments and manage the memberships. Read this article online https://bit.ly/3ilWPzA By Vicki Marsh, Massage Therapist, Clinic Owner and Business Coach quickly cover WHY memberships are so important for any business. The first, and biggest reason is that they create reliable recurring income. You can actually PLAN your finances knowing there is a guaranteed payment coming in next month. For most clinics, if we look ahead in the dairy for even just 2 months, the number of committed bookings won’t even cover the basic running costs of the business, and you have no actual guarantee that anyone else will book. In practice, we know that clients often leave it to the same day to book, but without that commitment in the dairy, you can never be 100% certain of your income. This leads onto how memberships can deliver you improved diary management. I ALWAYS recommend that all your members are treated like VIPs and their appointments are booked in advance. This secures their

MEMBERSHIPS CAN PROVIDE THE OPTION FOR CLIENTS TO BECOME A MEMBER AND GET VIP SERVICES, SPECIAL RATES OR EXTRAS INCLUDED IN THEIR MEMBERSHIP FEE 39

members get better results – their appointment attendance rates are higher, their overall compliance with self-care advice is better, PLUS they are your most loyal supporters, because they are now ‘part of the team’ and they are more invested in you as a business.

What Types of Membership Options are There?

There are lots of different ways to build memberships into a therapy business, and this is the topic Tor explores in her new webinar called How to Monetise your Therapy Skills Online and Create a Recurring (Subscription) Revenue Stream. For the purposes of this article, I’m going to talk through two of the most common membership models that I’ve had specific experience with. Each one has different pros and cons, and the decision about which one to use is a personal preference. You can, of course come up with your own variations on a theme.

1. One-Off Upfront Fee

Unsurprisingly, this involves the client paying a one-off fee to become a member. Paid up-front this could literally be a single payment or an annual payment and simply allows them to access all the members benefits. It is by far the simplest model, but in reality is likely to give you the lowest benefits of client compliance and income for your business.

2. Subscription Model

The most familiar model is where a client prepays every month for their appointments. By automating the regular payments using your booking system, the new functionality provided through the Co-Kinetic website, direct debit (like GoCardless) or card payments (like Stripe/Paypal), you will have a higher commitment level, higher attendance rate and better results. This is the best guarantee of income and if you are planning on selling your business eventually, this model is the one that gives your business the highest value because of guaranteed future income. 40

What Can I Include in My Membership?

I would absolutely recommend starting with the simplest membership options possible. We can often want to overplease our clients to the detriment of the business. By starting small you can ensure you have priced the membership correctly and you are not running at a loss. Also, you want to ensure you are including things in the membership that your clients ACTUALLY want. Don’t bombard them with lots of added bonuses (and work for you) that they never actually use.

1. Appointments

This is the most obvious core offering of your membership. At our clinic we offer 30-minute or 60-minute appointment memberships with either one, two or four appointments per month at a slightly discounted rate than our Pay as You Go sessions. This is how I launched our memberships, it was simply an appointment budget per month at a slight discount with no extras included, and our clients loved it. So don’t worry about feeling pressure to include extras – remember to let your clients know how they can use their membership (see the Setting Up Your Membership section below) and the Price Lock alone is often enough to seal the deal.

2. Self-Care Kits or Product Discounts

Products like mobility balls, ice packs, mini-bands, or extras like tape that you may charge for or which could be included within a membership package if you choose. In reality, we very rarely give this equipment out, but members like to know that the cost is included if they ever need it.

3. Online Classes or Online Groups

So this could include things like classes, workshops or private community groups – like Facebook. During lockdown we added live online classes and an online library of tutorials, workshops and pre-recorded classes. We included these for free and with unlimited access to our

‘in-person’ members. Alternatively you could create a more highly priced membership to include online and in-person, with a lower cost option for online-only. Again, I would definitely recommend you watch Tor’s new webinar as she discusses all the different options available and has now also built the ability to manage these memberships into her Co-Kinetic system.

4. Other Discounts

A lot of memberships also include extra discounts on additional appointments booked but we found this was difficult to manage from an administration point of view, with our system, and it was easier to get the commitment on the number of appointments upfront from a client. I’ve come across practices in the USA who also allow these to be used for friends and family as well, which helps to get more clients into your practice who otherwise wouldn’t have given your services a try.

Setting Up Your Membership

Now we get to the nitty gritty of the membership. So far, we’ve covered what is commonly referred to as the deliverables, now let’s move into the set-up and administration side of things. l Do you want a fixed number of appointments a month or the option to add on more? l Is a price lock included? Do you want to explicitly say prices will stay ‘locked in’ at that rate for as long as they are a member? If so then I would suggest limiting the number of member places available at any given time. l Can clients pause their membership? We decided on a 3-month pause for no fee, then one month’s membership would be charged (with the appointments added to their account to use) and then a pause can happen again. We have a lot of people who travel for work or studies so this worked best when a potential member was concerned they may be called away for more than a month. l Appointment rollover? Will you

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allow for unused appointments to rollover? If you do then make sure you have a system to check in if clients are doing this and get them reactivated or cancelled if not. Or find a way to give them tokens for rolled-over appointments that they have to hand in to redeem their rolled-over appointments.

Legal and Paperwork

Memberships are a great idea, but this step is often what holds therapists back from taking any action. In reality if someone doesn’t want to pay their membership fee it’s no different from enforcing a noshow or late cancellation fee. You’re unlikely to retrieve the payment unless you do have a card on file, and ideally you want to resolve any issues peacefully so you don’t receive any unnecessary negative reviews. The best way to protect yourself from this, is through clear terms and conditions, making the terms of the membership very obvious (ours is a 12-month commitment, with a rolling monthly commitment thereafter). We also outline in detail when they can/ can’t cancel. If you stay ahead of things, pre-book clients and deliver a great service, the reality is you’ll experience very few problems anyway. But do create clear guidelines of what to do in certain scenarios (like illness, or an unexpected move out of area for example, or situations like Covid!). This will give you consistency as well as confidence in the situation, and you can easily pull out the info from the terms and conditions if there is a problem or dispute. We don’t have a signed contract but do have the terms and conditions on the website when they sign up. Card payment is done in advance and our booking system allows us to remove or add appointments depending on what we need. Of course, it’s always a good idea to get legal advice if you are creating contracts for your memberships – you can also research other therapy and fitness terms and conditions to create some that work for your business. Co-Kinetic.com

Why our Membership Programme Saved our Business During Lockdown

I love our membership and our members. Knowing that every month we have a guaranteed income, rebooked diaries and knowing our team have committed clients gives you wonderful peace of mind. I don’t plan on selling the business anytime soon, but I know the memberships and the systems will significantly increase the value of my business, when compared with a business without this structure. But it wasn’t until lockdown that I realised how important our membership really was. Yes, the income played a huge part in saving the business and keeping us going, and the team morale was boosted by having loyal clients willing to take the jump to trying online appointments, but more importantly we had a community of clients who were really ‘with us’ in the whole journey, sharing our posts on Facebook, and offering technology and financial help. It was amazing. They do say that the customer lifetime value of a ‘subscriber’ to a business is considerably more than a non-subscriber but, as I came to realise, the benefits extend far beyond the financial. Our members enthusiastically joined our online classes, which made it much more appealing for new clients to try them out too, and with the security of knowing we had the memberships, we were able to take the risk of NOT furloughing the team and continuing to deliver appointments throughout lockdown. All of this has meant that our practice has not only bounced back but we’ve even been able to hire another full-time therapist. I would definitely encourage everyone to register for Tor’s new webinar which discusses an even broader range of membership types and models, as well as showing you how to implement these models. Tor has also just recently added the ability for you to take sign ups to your membership packages, manage these sign-ups, process the payments and even manage the memberships. There’s no reason to be limited

to just physical offerings in your membership packages either, by combining online and offline components, you have the opportunity to: l build greater customer trust and investment in your business; l increase your bottom line; l add financial stability; l build a more robust and reliable diary; l mitigate the risks for any future Covid-lockdowns; l earn a greater business resale value; l increase the lifetime value of your customers; and l …arguably most importantly, provide an even better service and experience for your customers. Nobody knows what the future will bring, and there is no doubt that this is an uncertain time for all physical and manual therapists, but we all know now that securing our businesses financially is more real and more necessary than ever.

Further Resources

lS ign up to Tor’s webinar How to Monetise your Therapy Skills Online and Create a Recurring (Subscription) Revenue Stream at the following link https://bit.ly/2ZnCItl l Come learn more about what I do and who I help over at https://www.massagetherapistbusinessschool.com

RELATED CONTENT

lY ou can find the author’s series on Running Successful Open Clinic Events at the following link https://bit.ly/35B5j2w l And the full list of articles written by Vicki for Co-Kinetic at this link (https://www.co-kinetic.com/profile/9705) THE AUTHOR Vicki Marsh teaches massage therapists and clinic owners how to start, grow and scale their business freeing up their time, building confidence and earning more money. She is the founder of the Massage Therapist Business School, hosting the Massage Therapists’ Business & Marketing Podcast and running the Clinic Business Growth Membership site which provides actionable business advice tailored to massage therapists & clinic owners. To find out more visit www.massagetherapistbusinessschool.com or www.massagetherapistbusinessschool.com/ clinicbusinessgrowth to get your 7 day trial of Clinic Business Growth.

By Tor Davies, Co-Kinetic founder 20-10- COKINETIC FORMATS WEB MOBILE

Membership Magic

Membership packages, purchased on a regular recurring payment basis, are extremely valuable to all businesses at all times, but with the challenge presented by a situation like Covid-19, they can be the lifeline that makes the difference between a business surviving or not. This article details the advantages of creating recurring revenue streams and then goes into more detail about the sorts of packages you could create within a physical or manual therapy business. Download the PDF of this article at the following link https://bit.ly/33wJiiE.

f you’ve been on my latest webinar How to Monetise your Therapy Skills Online and Build New CovidResistant Online Recurring Revenue Streams you will already know that I’m strongly encouraging as many people as possible to start building recurring revenue memberships into their businesses, as soon as feasibly possible. Why? Because I believe Covid-19 will remain with us for the foreseeable future, and we’re very unlikely to have a reliable vaccine available to us within the next 6-12 months at the very least, which leaves businesses like ours, which are almost solely reliant on being face-to-face with our clients to earn our living, extremely vulnerable and exposed. Until we develop some new alternative streams of revenue, our businesses and all the time, effort and money we’ve invested in them to date, will be hanging from the gallows, with each of us hoping fervently that the trap door below doesn’t suddenly spring open. But is it worth gambling everything you’ve invested in your business to date, on that not 42

happening? I really hope not. Having built and run my own business for 22 years on a 100% subscription-based model, I know at first hand the strengths and advantages of this business structure. Here are just some advantages of a recurring revenue business model: 1. Recurring customers have a significantly higher lifetime value, in fact they spend more than twice as much as a pay-as-you-go customer 2. You get a greater opportunity to build a longer term relationship with a recurring revenue customer which builds trust and makes them more loyal and therefore more likely to refer to you 3. It allows you to predict ahead of time the demand for capacity, allowing you to plan more reliably and smooth out demand 4. Regular subscription/membership income is more reliable and predictable 5. There’s no need for invoicing which makes cashflow easier to manage 6. It creates ‘stickier’ customers who stay around for longer, and this gives you more opportunities to upsell

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and cross sell other services and products 7. By increasing the services you provide online, or by offering a blend of online and offline services as part of a membership package, you are better able to mitigate the impact of Covid-19 on your business 8. Recurring revenue streams (ie. subscriptions/memberships) have a 3-4 times greater resale value than non-recurring revenue if/when you come to sell your business. Even without Covid-19 threatening our livelihood, developing and diversifying your streams of revenue is a good idea for any business. After all, we’ve just witnessed exactly what happens when we don’t, and forewarned needs to be forearmed, because most businesses won’t get a second shot at this.

Memberships in Physical Therapy Businesses

This isn’t a new concept and I know several practices who offer ‘physical’ membership packages, although far too few in my view. It could constitute anything from buy five sessions for 10% off the price of one-off appointments, through to much more complex offerings. Vicki Marsh’s article on pages 38-41 focuses mainly on these more ‘hands-on’ clinic membership offerings. What I’m proposing is to focus on building a much stronger online element into these packages, so that we’re not so heavily reliant on delivering physical treatments. In fact you could create a completely hands-on package or a completely (hands-off) online package or a combination of both. What you do is down to what you feel most comfortable with and what fits your skill set best. A fully online offering, such as an online special interest group perhaps, based around an ongoing medical condition, is going to be much more resistant to any further waves of Covid-19, but even a combination of both an online and offline offering, can help you maintain ongoing revenue as well as bolster the delivery of your physical services. Co-Kinetic.com

EVEN WITHOUT COVID-19 THREATENING OUR LIVELIHOOD, DEVELOPING AND DIVERSIFYING YOUR STREAMS OF REVENUE IS A GOOD IDEA FOR ANY BUSINESS Types of Memberships

I cover this in detail in my webinar, so I would encourage you to register for, and watch that webinar (see Further Resources for details) but there are three main types of membership: a fully online offering; a fully offline offering ie. physical delivery; and then a blended online and offline approach. You could charge monthly or weekly for a specific period of time, or for an ongoing undefined period (the latter would be my recommendation). Financially, an ongoing model is much stronger as you’ll see from my Recurring Revenue Business Planning spreadsheet (which you can download from Further Resources below). The end goal is to put a package of services together, with as much of it being online as possible (if you want the greatest protection against the impact of Covid), that will add value to your members and help them to solve a very real pain or problem in their life, that you are ideally suited or qualified to solve and by harnessing the tools that you feel most comfortable using.

A Fully Online Membership

This could be a predominantly online group, where you publish or provide access to content that can help solve a problem, or provide support for a community of people with a common ‘pain’ or problem – this could include people for example who are suffering from long term conditions like chronic pain, specific forms of arthritis, mental health issues, dietary or nutritional issues, MS…the list goes on. The sorts of content you could include might be: l Reviews or write ups on newly published research l Online presentations by yourself, colleagues or third parties l Interviews with other specialists in related areas l Specially curated YouTube playlists

l Group Zoom discussions or Q+A sessions l One-to-one online sessions l Online classes eg. management techniques, stretching/strengthening programmes, stress management l Book club-type discussions around different types of treatment or management strategies l Links to publicly available resources, articles, leaflets. Once you let your imagination run free, you’ll probably think of all sorts of things you could incorporate to help support an online community. Even the community itself, can help to support each other. You don’t have to generate everything yourself, but in order to justify a monthly fee, there should be a component of the content that is unique and private to your community. This is my first choice recommendation, because it is based purely online and therefore completely Covid-resistant. So during lockdown, I built the technology into existing subscriptions to allow you to do everything you needed to run one of these groups, including taking sign-ups to your group, processing automated payments (both one-off and recurring) and managing memberships. So if you like this revenue idea, I’d definitely recommend you watch my webinar and visit the Help section on Co-Kinetic to see how it all works (see Further Resources). There’s no extra cost for this added functionality, I built it into the current subscriptions for free. The premise was that you would charge a monthly fee (depending on the value of the content you were providing) to provide ongoing content and support to this community. You can use the Business Planning spreadsheet (in Further Resources), to set targets, and create a financial model or plan for this kind of community. It doesn’t need to be an ongoing community (although this is a more 43

robust financial proposition), it could be a fixed time-period programme to deal with a given injury instead. It doesn’t matter what the structure, my system will let you designate exactly how many weeks or months you want to set up a payment plan for.

A Blended (Online and Offline) Membership

This approach could include all the things I’ve covered above, but could also incorporate more traditional hands-on offerings. For example, you could decide to charge a monthly membership fee of say £50 and include a monthly hands-on treatment along with some additional value content as I’ve described above. This would help take the pressure off creating lots of unique content but you still need to offer compelling enough value, to make it worth subscribing to, rather than sticking with pay-as-you-go. You could email each customer a coupon which they present at their treatment to redeem that appointment. It doesn’t stop them booking their normal treatments, it just means you’ve incorporated a component of your treatments, into a recurring membership package, which makes it more stable and reliable.

Obviously the more incentivised this price is, compared with the normal prices you’d charge, the greater the incentive to sign up. The coupon doesn’t necessarily have to be an appointment with you. You could partner up with people with complementary skill sets so that your subscriber could choose the treatment they wanted that month as a sort of bonus extra. For example if your group was focused on back pain, you could offer yoga or Pilates sessions or even Tai Chi or a personal guided meditation. You could strike a deal with the people you team up with, to agree a proportion of the fee. All your subscriber would need to do is hand in their paper coupon at the time of their appointment, and that practitioner would send it to you for payment. That way all the money comes to you and then you pay out what you’ve agreed. These third-party appointments don’t need to necessarily be offline either, they could also be online classes, or one-to-one sessions. You get the idea. Basically you could construct whatever package you wanted, as long as it is well-designed to solve the problem or pain of the group you’ve built the package for. If someone was prepared to commit to weekly sessions, you could set this up using these same payment plans, just make sure to keep a note of how many sessions they’re buying, in case there is any

USE THAT TIME TO CREATE A PIECE OF CONTENT THAT WILL GENERATE YOU £70+ EVERY MONTH? 44

disruption in being able to deliver or redeem these sessions.

Offline Membership

Lastly you could offer a completely offline package, ie. physical treatments only, much like those discussed in Vicki’s article on page 38. The only downside here is that it can easily be disrupted by local or national lockdowns and people may be a little more reluctant to make that commitment based on what we’ve been through. Regardless of whether you offer hands-on treatments as part of a purely offline membership, or a blended membership, make sure to have reasonable ‘use-by’ dates on your treatments. Don’t make it too tight a time frame (particularly given the fear of repeat local or national lockdowns), but equally don’t make it such a long redemption period that they leave it, forget about it and then come back to you asking for a refund. So what’s stopping you?

How Can I Find The Time?

If this is what you’re thinking, I’ll bet you a Cornish Cream Tea that you’re currently making a very ineffective and inefficient use of your time, sorry, but I’m not one to sit on the fence! Do you think it’s better to spend 40 minutes giving a treatment, and getting £50 in the hand today, or is it better to spend 40 minutes investing in creating a piece of content that 10 new people a month would pay £7 a month to access? In other words, instead of a one-off £50 payment, you’d get £70 every month right there, for that same 40 minutes of invested time. And if you had 100 people accessing it, that 40 minutes would be worth £700 (14 times more than your payment for the one-off treatment). In fact, invest just one of your hands-on sessions a week (ie. see one less patient) on creating high value content, and you could be creating 3-4 unique pieces a month, and building a growing, evergreen library resource, that will continue to give value many months, or even years, into the future. And the greater the value of your resources within your community, the greater the amount you can charge to access it.

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On top of that, it doesn’t matter whether you have 10, 100, or 1,000 people signed up to your group, you don’t have to do any more work, or create any more content for 1,000 members as you would for 10. In other words the model is scalable, your input is not affected by quantity of customers, and this is the very best, most profitable, most cost-effective business model out there. It gives you the choice of whether to use the extra money you generate to support your family, your business, to bank it for future rainy lockdowns or invest further in your offering (which is always my choice). The better the product you have, the more desirable and useful it is, and the more people will want it. The more you invest, the more it will be worth in the longer term, it’s as simple as that.

But Managing Memberships Sounds Complicated

That’s where you’re wrong. Give me a pain or a problem to solve, and I’ll do exactly that! I’ve built a super-simple way that you can use the blank web page templates on the Co-Kinetic site to build a great looking sign up page, set your membership payment requirements, process automated payments and manage membership to a private Facebook group. If there’s one thing I understand, it’s managing subscriptions and more importantly in the simplest and quickest way possible to do it, which is why I’ve created a new membership management section within the CoKinetic site. And building the sign up pages and taking payments is literally as simple as filling a few form fields in. Check out the Help section in Further Resources to see exactly how easy it is.

How Would I Find Enough Content?

This often seems the biggest hurdle before people get started, and yet it actually ends up being the easiest part once you’re going. The key is to build a content calendar for maybe a couple of months and let the content evolve based on what your community wants and responds to. Start with things you can create or find easily. These could be as simple as links to CoCo-Kinetic.com

Kinetic patient resources, it could be a playlist you put together of exercises on YouTube, a link to a piece of newly published research with your own take-home message. I cover a whole host of ideas in my webinar (and on my private Facebook Group – see Further Resources). It’s actually amazing how much good quality content is out there. Then focus your efforts on producing 2 or 3 really good quality pieces of content like a short PowerPoint presentation or an interview or Q+A session on Zoom, with a colleague or other specialist. It could be exercise sheets or a discussion about a certain exercise that is frequently done badly or incorrectly, or alternatively an exercise that is one of the most effective for the group you’re working with. There is so much content out there. This is exactly the kind of thing I’ll be covering in my own Private Facebook group which I’ve set up using exactly the same technology that I’ve created for you in your subscription. You can join my group for a very small recurring monthly fee at the following link https://bit.ly/32uD6bK. Not only will you be able to see what the sign up pages look like, and how you might use them for your own customers, but once you join the group, we will be discussing all sorts of ideas and suggestions for helping you put a group like this together. We’ll look at different ideas of what you can include in your membership packages and discuss the types of content that work best.

In Conclusion

As you’ll see from my Business Planning spreadsheet included in the resources below, even a very small monthly subscription charge of £10 per month, growing at just 10 new members a month (which is virtually nothing), can result in an extra £6k in revenue in the first year, and no less than £21k in the second year. That is a significant amount of additional revenue for very little time and cost investment. It is also based on an online-only offering. Incorporate some higher-value content like online classes, physical treatments, or maybe even a short one-to-one online consultations

and you could easily double or triple that monthly membership cost. You can use the spreadsheet to model different variations. Start with promoting it to your existing email list and customer base, and you can get off to a great start right there with very little cost (maybe even no cost). I have no vested interest in this process. I make nothing from you using the Co-Kinetic system in this way, I added this value to Co-Kinetic purely to help you build more robust businesses that were better able to survive the Covid onslaught. All I can hope is that you will take my advice, and at the very least, explore the further resources below in more detail. And if you choose to join my private Facebook group at the link in the resources box, I will be there to share the journey with you.

Further Resources

l Register for my free webinar How to Monetise your Therapy Skills Online and Build New Covid-Resistant Online Recurring Revenue Streams at https://bit.ly/2ZnCItl l Co-Kinetic Help Section on building new revenue streams using Co-Kinetic at this link https://bit.ly/3iytlP5 l Tor’s Recurring Revenue Business Planning spreadsheet https://bit.ly/3kidwfP l Health Professionals Building Recurring Revenue Communities – subscription-based private Facebook group – more details at this link https://bit.ly/32uD6bK 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 45

The Three Cornerstones to Marketing and Sales Too many people overcomplicate marketing. In reality, everything can be based around three principal pillars, which should combine to form a funnel of people who you intend to convert into paying customers. If you focus on the right things at the right time, it’s hard to go wrong. Unfortunately, the number of marketing activities out there, can make it difficult to know where to start and what to focus on. The goal of this article is to help you identify what matters, and why, so you can focus on the right activities, instead of wasting time on ones that are likely to be unproductive. You can download the PDF of this article at the following link https://bit.ly/2E3nrGR.

efore we launch into specifics, there are some marketing foundations you need to have in place, before starting an ongoing marketing strategy.

Marketing Set Up (one-off jobs)

l A Google My Business account/ listing l A regularly updated Facebook Business page that promotes authority, confidence in your skill set and adds value to your page viewers l A ‘fit-for-purpose’ website to ensure people know who you are, what you do, and how to book and attend an appointment (you could also use your Facebook page for this purpose if you wanted to) l Google Analytics and the Facebook Pixel analytics code installed on your website to help you track activities when you begin your more detailed marketing. By Tor Davies, Co-Kinetic founder 20-10COKINETIC FORMATS WEB MOBILE PRINT 46

Ongoing Marketing Priorities (‘steady-state marketing’)

1. Creating as many opportunities to build your email list 2. Sending regular nurture emails to your growing email list 3. Ongoing collection of customer reviews on Google/Facebook. Once you have those foundations in

place, you’re ready to plan a strategy that can generate sales from your marketing activities. Just so we’re clear on the distinction between marketing and sales: l Marketing = is the process of getting people interested in the goods and services being sold l Sales = describes the activities that lead to the selling of goods and services. Marketing and sales are two different sides of the same coin, particularly if your end objective is sales, which in the case of most small businesses it should be. Most of us are not The Coca Cola Company who can afford to invest in a wider marketing strategy, involving goals like raising brand awareness. There are better ways for most small businesses to spend hard earned marketing money, than on raising brand awareness. You can do marketing without sales (and you should be doing this regularly regardless of whether you need sales), but you can’t do sales without marketing. Unfortunately, this is exactly what most people attempt to do, and is the reason why most people get very poor results from their marketing efforts.

For most of us, our marketing efforts must be much more pragmatic, we need to prioritise sales. So whenever you spend marketing money, think very carefully about whether it fits into the strategy you’ve built. Whatever your so-called ‘marketing expert’ tells you, a greater number of page followers, page engagement or Likes on Facebook or Instagram very rarely, if ever, result in the ability to generate more revenue. They’re known as vanity metrics for a reason, read this excellent article from the Content Marketing Institute entitled The Right and Wrong Ways to Use Vanity Metrics to learn more (1). The goal here is to make sure we’re implementing the 20% of marketing activities that we need, in order to give us 80% of our results. This is all about focusing on the right things.

The Marketing Funnel

There are three cornerstones to every marketing (and sales) strategy, and together these three cornerstones form a funnel. The idea is to fill this funnel with a specific group of people, who are primed to ‘buy’ from you, with a structure of marketing activities in place within the funnel, to move these people towards a purchase. The three cornerstones to a sales and marketing funnel are:

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The first two parts are marketing, the third part is sales. Most ongoing ‘marketing’ activities that you undertake, would ideally fit within these three cornerstones (see Figure 1).

Strategy

Audience

Let’s just recap on the objective definition I gave you earlier, marketing

NEW LEADS/ BUILD EMAIL LIST

COLD

AUDIENCE

NURTURE STEADY-STATE MARKETING

RU ST &

Co-Kinetic.com

STRATEGY

If the answer is Yes, you do need to generate sales in the short term, then you need to identify your ‘sale’, or in other words part 3 of this article, the real and specific pain or problem that you are going to solve for a specific population group. And then you need to create the solution to that pain, which those people are going to pay you to provide. We’ll come back to this in a minute, but first let’s discuss Audience because in order to have a good chance of successfully making sales, we need to build an audience of people who are likely to want what we offer, and that’s all part of the preliminary marketing process.

D BUIL

The first thing to decide is, what is your strategy? There’s absolutely no point in doing any marketing or trying to generate any sales, if you don’t first have a strategy. You’ll just be wasting time, effort and money. If you’ve got to get from A to B without knowing where you’re going ie. what A and B are, you need a map to help you do it. Without a map, you’re going to waste a ton of time, going in the wrong direction and down dead-ends, and this is a perfect analogy for most people’s marketing efforts. This is equivalent to 80% of effort with 20% results (and that’s if you’re lucky, in reality you’ll probably get less than 20% results despite your 80% effort level). You need to KNOW what ‘success’ is and in case you’re unsure, this needs to be a sale of your ‘solution’ to a prospect who needs it. How many times have you posted social media on your social network pages, without actually being clear what you’re looking to achieve from those posts? Let alone whether those efforts are guided by good business sense, like getting a return on your investment (ROI). How many of these following activities have you done in the last 6 months? l Spent an hour posting random social media posts on your business Facebook page – what was your ROI? l Spent 2-3 hours writing a customer email – did you get a ROI? l Spent 2 hours writing a blog post – what was your ROI? l Spent money on boosted Facebook posts (regardless of the goal) – what was your ROI?

I’m guessing most of you will have done at least one or two of the above. There’s a quote by John Jantsch, the founder of the excellent small business marketing podcast, Duct Tape Marketing, which goes: “Marketing without strategy is like noise before failure”. You’ve got to know what your end goal is before you start. And then you need a clear map for getting to that end result. So what’s your strategy? Well that depends on the answer to the question, “do you need this strategy to result in direct sales in the short term?” If the answer is No, then your focus should be on ‘steady-state marketing’ ie. building an email list and nurturing that email list through regular valueadd emails.

TH OR ITY

1. Strategy 2. Audience 3. A (paid for) solution to a pain or problem (ie. the end sales goal)

LEAD TEMPERATURE

PAIN 1

AU H ESTABLIS PAIN 2

PAIN 3

SALES (CONVERSION EVENT)

HOT Figure 1: The Three Cornerstones to Marketing

SOLUTION TO PAIN = SALE 47

prospective customers, unless there’s a very good reason for it and strategy behind it. It can feel a little desperate and cheap, and I doubt that’s what you want to be seen as?

MARKETING IS SIMPLY ABOUT BUILDING RELATIONSHIPS, AND AS WITH MOST THINGS IN LIFE, THE MORE EFFORT YOU INVEST, THE MORE YOU’LL GET BACK is the process of getting people interested in the goods and services being sold. You could add to this, it’s also the process of convincing them that you are the right person to deliver that service. Here’s where I’m going to deviate away slightly from that very objective view of marketing, because as physical and manual therapists, we can and should look at this a little differently. Marketing is best likened to the same process we go through when we’re getting to know a new friend or partner. It’s about talking, sharing information, doing things together, getting to know each other, it’s about building trust and establishing confidence, in the professional context, in you. It’s about becoming someone they trust, and like, and want to engage with, in order to help them solve a problem. When it comes to solving pain and injury, which has often become chronic by the time someone takes the leap to come and see you, that trust is particularly important, as is the confidence that you are the right person to help them, and that’s something that many marketers, not familiar with the ‘therapy approach’ might overlook, under-appreciate or under-value.

Does the shoe fit you?

Something that holds so many therapists back when it comes to their marketing is an incongruence, or feeling of discomfort, between what you feel as a therapist and what you feel you’re supposed to do with your marketing. Most of the time this is a very uncomfortable fit, even though it doesn’t have to be. I’ve had many calls from people who tell me they’re spending anything from £500-£2000 a month on Facebook ad specialists to generate them new leads for their clinics. This is how the strategy works. 48

A marketer creates an offer, usually some kind of lead magnet or a direct offer to sign up for a half price appointment (which they usually do through a Facebook or Google ad). When someone signs up to that lead magnet or offer, they share their phone number, and they are then coldcalled by a member of that marketing team, to book the appointment into the diary. When that happens, the marketing person gets a fee, and the therapist gets a half-price appointment booking. The goal is then for the practitioner to convert that half-price visit into full-paying repeat visits. This process can definitely work, as long as you feel OK with the quite blunt cold-call approach, but there are some downsides (most of which are based around not taking time to build trust in the relationship): 1. Many people find the approach too salesy and ‘in your face’ 2. It results in customers who are more focused on the financial transaction than investing in their own health or a healthy outcome 3. Rebooking rates are generally only around 25%, meaning 3 out of 4 of those customers who take up the half price offer, you’ll never see again after that first appointment 4. You’ll probably get a sub-optimal clinical outcome because the individual knows less about you and therefore has less confidence in your skills and authority 5. The customer’s loyalty won’t be as strong, nor will their inclination to recommend or refer you 6. You have less opportunity to upsell or cross sell other products of services (because there’s less trust) 7. For all the reasons above the customer lifetime value (CLV) is likely to be much lower (there’s a good article here on CLV (2)) 8. Doing discounts and deals (particularly on a regular basis) just doesn’t look that good to

It’s simple rules of investment and loyalty. Give someone a cheap offer and you may get lots of take ups, but as the saying goes ‘easy come, easy go’. Take the time to invest in that relationship, and continue adding value to it, even when you’re not asked to, and that person is very much more likely to stick around your business, and refer more people to you, than the ‘discount-hunter’ ever will. At the end of the day however, we still have to pay our bills, so sometimes the quick wins may be necessary, but it’s important to start putting the right processes in place from the start, so we can move to the more considered, intelligent, trust-building approach, as soon as we’re able to. So the moral of marketing? As I say in all my webinars, marketing is simply about building relationships, and as with most things in life, the more effort you invest, the more you’ll get back. The better the relationship you have with your prospects (and this can be as simple as regular value-added communications with your email list), the greater your opportunity to convert these relationships into a tangible return on your investment. There are therefore two parts to marketing: 1. Building your audience (ie. an email list) 2. Establishing trust, demonstrating authority and developing a relationship with that audience Exactly who those people are depends on, and should be directed by, your strategy and whether or not you have an end sales goal. If you’re NOT looking to generate specific sales in the short term, then you still need to be building that audience and developing those relationships, you just can’t be quite so focused about it, but you should still have a good idea of your ideal customer, who is most likely to want the solution your expertise can provide.

Co-Kinetic Journal 2020;86(October):46-50

ENTREPRENEUR THERAPIST

If you ARE looking to generate specific sales in the short term, then you need to be building an audience of, and developing those relationships with, people who are specifically likely to want the solution to the problem you’re going to solve. In other words, if you need to generate business now, you need to figure out what it is you want to sell, and then your marketing task is to build and develop relationships with an audience of people who are likely to want what you’re offering, giving you the best likelihood of converting them from a prospect to a paying client. The important thing to remember here, is that we’re going to do this in a way that consistently adds value to your readers and prospects. In other words, in a way that is likely to be a much better fit with both your personal, as well as your business, ethos. That leads us neatly to the ‘sales’ component (stay with me here, it’s not as difficult or as cringey as it sounds).

The Problem 3 Define You’re Going to Solve (aka The Sale)

So again, this is important. You need to think of this as a problem or pain you’re going to solve which happens to have a commercial component. As much as most of us would love to do everything for free, that doesn’t pay the bills. The important thing is that your solution delivers value and helps to improve the quality of peoples’ lives, making it worth paying for. This is what I regularly refer to in my articles as a ‘conversion event’. Traditionally we’ve looked at handson therapy ie. face to face treatments, as the paid solution, but this solution could take many different forms, or in fact a combination of forms. In fact, it doesn’t actually matter what the solution is, as long as it has the desired outcome and it solves a genuine problem for a big enough audience, to generate the income you need. With Covid-19 on the scene for the foreseeable future, in my view the more online components you can incorporate into your solution, the better. For example, I have a bad back so if I think about the kind of things I’d like Co-Kinetic.com

it could be a combination of elements such as: l A regular coupon for a massage because I know the erector spinae muscle on one side of my back gets incredibly tight l It might be an online yoga class (or recording/s) I can attend, or refer to regularly, to stretch problem areas l It could be leaflets on stretches I should do in the morning when I get up, or at night before I go to bed, to reduce the pain when I’m lying down and improve my sleep l It could be leaflets and advice about posture during the day and how to set up my desk or standing desk (with affiliate links to appropriate products) l It could be guidance on meditation to reduce stress l Or advice on nutrition to promote wellbeing and reduce pain l It could be online interviews with back pain specialists or people with (preferably not whacky) but possibly less well-known approaches to dealing with chronic pain l And joining a group of people who share the same pain who can also share resources and ideas of things that have helped them, which also provides social support could also be good. You get the idea. Once you get the imagination flowing there’s a whole host of content you could organise, link to, build, or create, to help people solve a problem. Even just being a part of a community with a shared pain, can be a psychological comfort, particularly in times of isolation like lockdown, and we all know that managing chronic pain is most effectively managed with a biopsychosocial approach. You can decide what you want to include in your solution. If you don’t deliver yoga or meditation, or Pilates, why not partner with someone who does and agree a referral fee or buy those sessions at a reduced ‘bulk’ price for your clients and include a cut for you in your monthly membership fee. You can email your members their coupon each month, make sure the terms of the agreement are clear, and the coupons have a reasonable redemption period, (particularly

taking into account potential future lockdowns) and then charge a monthly membership fee for that package. Through your Co-Kinetic subscription, you can now process one-off or regular recurring payments, take sign ups, manage memberships and automate the payment processing. If you partner with other people, you can strengthen your offering way beyond just what you’re capable of delivering alone and more to the point you can take much of your offering online, and make it a recurring revenue income stream which will help you bring predictability, stability and a reliable income, to your business, even with the existence of Covid-19. Once you’ve defined your product/ service/solution, you have your funnel, and then it’s time to build it. This is my tried and tested funnel, that I use very effectively in my own business: 1. A relatively simple, low commitment offer of something that adds value for people with that problem, but doesn’t require a big effort to sign up to – this is where lead magnets come in useful. Give a piece of information away, in return for an email address, which you collect through an email lead collection page. The primary purpose of this stage, is that it ensures you’re building an audience of people with an interest in the right topic or problem. 2. A next level commitment might be to encourage those people to sign up to a more detailed product or basically make a bigger commitment to you. I personally like the webinar/online presentation approach. It allows you to express your personality, helps people to get to know you, establishes your authority on a given topic, and gives you the chance to go into more detail helping your defined audience towards solving a problem (without giving away your entire solution obviously). It requires your viewer to make a bigger time investment in you, taking them another stage down the funnel. In that presentation or webinar, you 49

lead them towards your solution explaining why in value and benefit terms, it can help them solve their problem, which by now, if they’re still with you, you can be fairly confident, they’ll be interested in. 3. The final stage, is to offer the sale/service/product/package/ membership/solution while at the same time giving them a worthwhile incentive to sign up within a meaningful timeframe ie. encourage some form of deadline or scarcity (short availability). It’s important to ‘strike while the iron is hot’ and while it’s present and fresh in their consciousness. It doesn’t have to stop them signing up to the same ‘product’ at a later date (if you want to make it available), but make the reason for them to sign up today, compelling. This may well require testing different offers to see which ones convert the best. You can also now do everything I’ve described through your Co-Kinetic subscription.

The Power Move – Paid Advertising

I tend to refer specifically to Facebook Ads because that’s what I’m trained in, but the same could equally go for Google Ads if you know what you’re doing (or you know someone else who does – be careful here as this is fertile ground for being taken advantage of). Facebook Ads specifically is very good at helping you to build very targeted audiences, even within a very specific local area, with a specific interest or issue. Facebook knows A LOT about its users and you can take advantage of this but you do have to pay Facebook for the privilege. The reality is that you won’t collect many email leads by using organic (unpaid posts) published to your Facebook pages because for quite a few years now, Facebook has been throttling (restricting) the number of people who see your Facebook Business Page posts. Firstly, Facebook prioritises person-to-person posts, that have been specifically written by you on Facebook, and secondly, to put it bluntly, they want you to pay for people to see content that is going to help your business – so it’s not in Facebook’s 50

interests to publish your free content to other people and help you collect email addresses if you’re not paying for it! But as the saying goes, if you can’t beat them, then join them! The best way by a long shot, to building up a targeted email list of people with a very specific interest area or problem, is to set up native (inbuilt) lead generation ads and pay Facebook to deliver these ads to the people you designate. And if that all sounds very complicated, don’t worry, that is exactly why I created a very cheap bolt-on Facebook Ads product that you can either subscribe to (which gives you access to all the campaigns at any time), or buy individual topicspecific campaigns for. I give you all the content you need to build a very targeted ad pitched at a very specific group of people, all the content for which has already been through Facebook’s approval process. Not only that, I show you step-bystep how to set up each ad and more importantly how to build the custom audience that you need, so that you are collecting the email addresses of exactly the right group of people. Facebook ad specialists may be a little annoyed as this essentially bypasses the need for you to pay them to collect those leads. All that it leaves you to do, is pay Facebook to put that ad in front of the right people. My goal was to save you money, so you could spend more on building your audience (more details in the Further Resources section below). That lead collection stage represents Stage 1 in your funnel. The next step is to introduce those leads to Stage 2 (the next level commitment) in your funnel which you will already know they are interested in, as they have already indicated an interest in Stage 1 of the funnel. And then in Stage 2, you present the final paid offer/solution to the pain and that in a nutshell is your funnel. If you want to explore this idea then I’d recommend you sign up for my latest webinar How to Monetise your Therapy Skills Online and Create a Recurring (Subscription) Revenue Stream (3.

The Final Word

Successful conversion for any kind of positive sales or marketing outcome, is all about building relationships with people, who have a problem, which you can provide a solution to, that those people want, and more importantly, for those people to trust and recognise that you are the right solution to that problem. That’s marketing and sales in a nutshell. It doesn’t require any arm twisting or cringey sales pitches. It’s all about establishing a need and delivering a solution to that need.