Co-Kinetic Journal Issue 89 - July 2021 by Co-Kinetic

1999

2021

ISSUE 89 JULY 2021 ISSN 2397-138X

Discover the 20% of Marketing Activities That Will Give You 80% of Your Marketing Results

UPDATED

Post 9 Covid-1

Tired of working all the hours in the day for a physical therapy business that feels like it only just survives? Or fluctuating between “feast or famine” with your clinic bookings? Well, it’s time to change all that. Sign Up to My Free Webinar

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

Take Action Today

You’ll discover a unique three-step formula for attracting new patients, that allows you to attract only motivated prospects, who understand the value of what you are offering, and are predisposed to trust you. By using this formula you can increase your earnings by over £6,000 a month - more than enough to move into a new premises, take on another therapist, or even open a new clinic.

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sportEX journal 2015;66(October):0-0

what’s inside PRACTICAL

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21-07-COKINETIC FORMATS WEB MOBILE PRINT

Technology

By Tor Davies, Co-Kinetic Founder

1999

2021

APRIL ISSUE 88

SOFT R N FO I AT I O TS SSOC RAPIS THE A E THE TISSU SOFT

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co-kinetic.com/compendium

2397-138X 2021 ISSN

The Co-Kinetic Compendium of Marketing and Clinic Growth for Physical and Manual Therapists

Published in April, this Compendium is both a marketing guide and a handbook helping you to get the very best value from your Co-Kinetic subscription as well as your marketing activities. It’s a long overdue, all-in-one-place

outline of the full range of services at your disposal – including several new features developed to help you adapt to the post-Covid business landscape. As well as detailed descriptions of everything available to you, you’ll find tips on how to use your social media, run successful live events, attract new customers with discount vouchers and more. You’ll also find handy marketing ‘cheat sheets’ to help make sure you’re

Business Growth Campaigns – NEW for 2021

Who Can Access this Content? As of June, it is fully open-access. Visit co-kinetic.com/compendium.

Open Clinic Event Clinic Growth Campaign

Introductory Offer/Taster Appointment Clinic Growth Campaign

All the content you need to run an Introductory Offer/Taster Session business growth campaign to jumpstart the conversion of prospects into paying clients, and generate revenue. It includes a range of editable content, such as a pre-written web sign-up page, ready-to-post social media, and printable artwork including posters and leaflets that you can use to promote your campaign. If you wish to charge for your introductory session, you can also set your web page up to take payments. Login with an existing account or register a free one below for more details and an accompanying video showing you what’s included in the campaign and how to implement it. Ideal times to use a campaign like this are when people take ‘first step’ actions such as: l signing up to your email newsletter (or any other lead magnet resource); l following one of your social media pages; l signing up to a lead magnet; l making an enquiry off your website (that’s maybe a little tenuous and

doesn’t look like a willingness to commit to a fully paid appointment at that point); and l meeting you (or your team) at local events. All you need to do is include the link to your web sign-up page in any material you distribute. You can watch a video demonstration of this campaign at the following link https://bit.ly/3gmoJ0l. It’s a great way to jump-start the process of turning a prospect into a paying client at an early opportunity. Who Can Access this Content? l Full Site subscribers – included in your subscription l Anyone else – this content is purchasable individually for £90+vat at the following link https://bit.ly/3gmoJ0l

This campaign includes all the content and technology you need to run an Open Clinic event to generate new clients and bookings. It includes a ready-to-use, editable web signup page allowing you to take sign-ups to your event, along with some pre-designed artwork including social media, a ticket/coupon and printable promotional material including a poster and postcard (which can be mailed) to existing and past clients. All the content can be edited to add your specific event details. If you wish to charge for your event, you can also set up the web page up to take payments. In short, we’ve done almost everything for you, all you need to do is decide what your event will be, pick a time/ date to run it and then use the various pieces of artwork provided, to promote it. This is a great way to introduce new equipment, new therapists, new clinic areas or facilities and to reduce barriers to booking paid appointments in the future. It could be combined with offering free sessions to increase attendance. The goal of the event is to offer exclusive packages or incentives to book paid appointments. You can watch a video demonstration of this campaign at https://bit.ly/3sCenvP

50-52 NEWLY RELEASED CONTENT & TECHNOLOGY

Who Can Access this Content? l Full Site subscribers – included in your subscription l Anyone else – this content is purchasable individually for £90+vat at the following link https://bit.ly/3sCenvP.

Co-Kinetic Journal 2021;89(July):50-51

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ENTREPRENEUR THERAPIST

TIMELESS TESTIMONIALS It’s easy for some (although admittedly not all), to brag about themselves and the services and products they offer, but there’s honestly no better way to build trust and demonstrate authenticity and validity than by using customer testimonials. This article discusses the evidence behind why testimonials and reviews can have such an impact both on your bottom line as well as the ability to be found, and then looks at some practical ways to implement what we discuss. Read this article online https://bit.ly/3vRqeHN

estimonials take the spotlight away from you the ‘seller’, and shine it on the client. Once a potential new patient hears from someone they can actually relate to – someone who isn’t being paid to say great things – it deepens their trust and increases the chances of them buying into you. Anyone who has listened to just about any of the marketing presentations I’ve given will know that I consider Reviews/Testimonials to be a marketing super-power. Add growing your review and testimonials count to email list building and email list nurturing, and you have the three most powerful and influential marketing activities available to any business, of any size, in any industry, anywhere in the world. But why are reviews and testimonials so powerful?

The Influences of Reviews and Testimonials 1. Testimonials Build Trust

Testimonials, case studies, reviews and star ratings are all designed to build trust and confidence by communicating a real customer’s experience. This also gives prospective customers a more personal insight into you and your business, so they can decide whether it’s a good fit for them (social networks can also help here). l 92% of customers read online reviews before buying (Big Commerce). l 72% of consumers say positive testimonials and reviews increase their trust in a business (Big Commerce). l 70% of people trust reviews and recommendations from strangers

The of Powerws Revie

TIMELESS TESTIMONIALS: THE POWER OF REVIEWS

21-07-COKINETIC FORMATS WEB MOBILE PRINT

By Tor Davies, physiotherapist-turned Co-Kinetic founder (Nielsen). l 88% of consumers trust online testimonials and reviews as much as recommendations from friends or family (Big Commerce). l 72% of consumers will take action only after reading a positive review (Search Engine Watch). But numbers do matter. Ten or more reviews can increase search traffic (Big Commerce) and 40+ reviews are needed before consumers will consider a star-rating accurate (Opt-In Monster).

2. Testimonials Drive Revenue

Testimonials are perfect for resolving customers’ objections, which reduces buying resistance and increases confidence in you and your service. This, in turn, increases the likelihood of them becoming a customer. l Using customer testimonials regularly can generate approximately 62% more revenue (Strategic Factory). l Customer testimonials placed alongside more expensive items increased conversion rates by 380% (Power Reviews). l On average, testimonials on sales pages increase conversions by 34% (Impact). l Customers who interact with reviews are 58% more likely to buy (Big Commerce).

3. Testimonials Improve Website Traffic and Search Engine Optimisation Search engine developers want their

customers to find the best results for their queries and the best possible businesses that most accurately answer that query, which is why reviews and testimonials play a role in which businesses come up for which search queries. Testimonials also create fresh, ever-changing and relevant content that proves to search engines that customers are interacting with your brand, and reviews are naturally filled with long-tail keywords that customers are actually searching for. Here are some testimonial statistics that demonstrate clearly how using reviews and testimonials can improve search engine optimisation (SEO) and help you to win more search traffic. l Websites using testimonials saw a 45% increase in traffic compared to those who didn’t (Yotpo). l Listing 10 or more reviews increased traffic by 15 to 20% on Google Business listings (Big Commerce). l Improving star ratings from 3 to 5 stars can increase clicks on Google up to 25% (Bright Local). l Businesses with 5 stars earned 69% of total clicks amongst top Google listings (Bright Local). l Reviews account for nearly 10%, or 1 in 10 of total search engine ranking factors (Search Engine Watch).

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JOURNAL WATCH

The customer review software platform Yotpo performed their own research to see how testimonials could impact SEO rankings. They tested 30,000 ecommerce businesses of all sizes and industries to “see how SEO

Co-Kinetic.com

33-43 ONCOLOGY MASSAGE: THE LYMPHATIC SYSTEM

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PHYSICAL & MANUAL THERAPY AND HEALTH & WELLBEING INFOGRAPHICS

MARKETING METRICS THAT MATTER (AND WHICH DON'T)

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WORKING WITH THE LONG COVID CLIENT: A MASSAGE THERAPIST'S PERSPECTIVE

14-21

PAIN DOES NOT ALWAYS INDICATE INJURY

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PAIN IN THE ATHLETE

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

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

CLICK ON RESEARCH TITLES TO GO TO ABSTRACT

OPEN

= OPEN ACCESS

KNEE KINEMATICS DURING LANDING: IS IT REALLY A PREDICTOR OF ACUTE NONCONTACT KNEE INJURIES IN ATHLETES? A SYSTEMATIC REVIEW AND META-ANALYSIS. Romero-Franco N, Ortego-Mate MDC, Molina-Mula J. Orthopaedic Journal of Sports Medicine 2020;8(12):2325967120966952 Studies were eligible for this review if they examined variables of the knee in the frontal plane during vertical jump landing tasks and their relationships with knee injuries. The specific kinematic and kinetic variables considered were knee abduction moment, maximum knee valgus angle or medial knee displacement during landing, knee valgus angle at initial contact, knee valgus during the stance phase, and other variables derived from the aforementioned variables (ie. the lower extremity stability score). Additionally, kinematic and kinetic variables of the knee in the sagittal plane during vertical jump landing tasks were considered. A search of the medical databases

This blog post reviews common and rare adverse events (AEs). It quotes an RCT that says that common AEs in manual therapy are local tenderness followed by tiredness. Tiredness on the day of treatment presented the highest attributable risk. Other AEs were rare (less than 1%), and no serious AEs occurred. Local tenderness was the most common AE followed by tiredness and headache. Other non-serious AEs were uncommon (less than 5%), but did include muscle spasm, dizziness, fainting and nausea. There were, however, some other AEs in manual therapy, but they are very rare. Reported serious AEs include spinal cord injuries with severe neurological consequences and cervical arterial dissection (CAD). The rarity of serious AEs can be evidenced by the large national survey conducted in the United Kingdom that assessed all AEs in 28 807 chiropractic

revealed a total of 13 studies, capturing 333 acute non-contact knee injuries in 8689 participants. The results showed that no kinetic or kinematic variables from landing tasks had a significant association with acute non-contact knee injuries. The authors conclude therefore that “the role and application of the landing assessment for predicting acute non-contact knee injuries are limited and unclear, particularly given the heterogeneity and risk of bias of studies to date”.

Co-Kinetic comment Variables of the variables!! This review recalls to mind a quote from Donald Rumsfeld, the USA Secretary of Defence in 2002, “As we know, there are known knowns; there are things we know we

know. We also know there are OPEN known unknowns; that is to say we know there are some things we do not know. But there are also unknown unknowns – the ones we don’t know we don’t know”. The lack of a link between knee biomechanics on landing and subsequent knee injuries doesn’t sound right. The authors complain that most of the studies referred to showed high risk of bias regarding study attrition and moderate to high risk related to study participation and study confounding. Come on researchers. We need to know what we don’t know and if you leave big question marks around the validity of your research we are never going to know.

COMMON AND RARE ADVERSE EVENTS IN SPINAL MANIPULATIVE THERAPY. Chaibi A. Journal of Orthopaedic & Sports Physical Therapy 2020; November 18 [online blog] treatment consultations, which included 50 276 cervical spine manipulations, and reported no serious AEs. The risk estimate that spinal manual therapy will cause a clinically worsened disc herniation or cauda equina syndrome in a patient presenting with lumbar disc

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herniation has been calculated to be less than 1 in 3.7 million, while CAD reportedly constitutes as few as 1 per 8.1 million office visits and 1 per 5.9 million cervical manipulations by practising chiropractors in Canada.

Co-Kinetic comment The author says that this is written aiming to “promote professional cooperation between general practitioners and manual therapists, improve the efficiency of musculoskeletal healthcare, and sharpen clinical decision-making regarding risk– benefit factors when considering SMT [spinal manual therapy] in sports-related practice, in which the clinician is often under pressure to return the athlete to sport quickly”. That might be a tad ambitious but it does show that AEs in manual therapy appear to be substantially lower than acceptable thresholds in any medical context. The bottom line is that AEs from manual therapy are few, mild and transient, and if you warn your patients about this (and document the warning), you, and hopefully the patient, will be fine. If you want to look up the original papers that are discussed, they are all referenced.

Co-Kinetic Journal 2021;89(July):4-11

RESEARCH INTO PRACTICE

Journal Watch CLASSIC SPORTS MASSAGE VS. CHINESE SELF-MASSAGE. WHICH ONE IS MORE EFFECTIVE IN WARM-UP? Boguszewski D, Adamczyk JG, Hanc A et al. Biomedical Human Kinetics 2021;13(1):97–102

Fifty-five students (42 female, 13 male) aged 19 to 22, who were not engaged in competitive sports participated. They performed a functional movement screen without a warm-up consisting of running (running exercises – skips, reverse gear, crossings, etc.) and dynamic stretching exercises (circulations, bends, turns) over a time span of approximately 10min. A week later they were randomly divided into two groups. One performed a warm-up preceded by a pre-workout, stimulating sports massage for 10min. The strokes were described as intensive rubbing and kneading and were performed on the muscles of the lower, upper and dorsal extremities. The second group performed a warm-up with Chinese self-massage, described as stroke and rubbing movements, longitudinal and circular, 16 repetitions each. It

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started with hand rubbing, followed by energetic stroking and rubbing the arms and whole upper limbs. Then the chest and abdomen were stroked. Finally, the lower limbs were worked on longitudinally (whole limbs) and circularly (knee joints). After these interventions the functional movement screen was repeated. The results showed that both groups improved their screening scores but there was no statistically significant differences between the two groups.

Co-Kinetic comment This looked quite promising at first and the results showed improved movement function scores for both groups, which is always welcome. However, the warm-ups, test and interventions are only described in general; for further details the reader needs to dig out three other papers, which is a bit of a pain and doesn’t help the busy practitioners looking for the evidence-based medicine grail.

EFFECTS OF MULLIGAN CONCEPT IN CLASSICAL BALLET DANCERS WITH PAIN IN THE LOWER LIMBS. Aguiar LL, Dos Santos Araújo VA, De Andrade Mesquita LS. Manual Therapy, Posturology & Rehabilitation Journal 2020;18:1–6 This was a study of four ballet dancers aged between 12 and 30 years with at least 4 years’ dancing experience who presented with painful knees. An evaluation of their pain level was performed using a digital algometer pre- and post-intervention at the patellar ligament, medial collateral ligament, and lateral collateral ligament. The Mulligan concept of mobilisation with movement was performed actively, painlessly, with adjustments by the therapist in the direction that the dancer felt pain and maintained at the end of the knee amplitude for 10 seconds. This protocol was repeated 3 times in the first attendance, in the second 10 times, in the third there were 2

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repetitions of 10 slides and in the subsequent attendances there were 3 repetitions of 10 slides. The results showed an increase in the average of the pain threshold in patellar, medial collateral and lateral collateral ligaments in all participants of the study, when comparing the initial values of the first care and the final values of the 12th Mulligan session. The lateral collateral ligament presented the most significant result.

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Co-Kinetic comment There were originally 12 dancers in the study but 8 of them did not turn up enough to maintain the programme. Four subjects makes it a case study rather than a trial of the technique but it does add to the literature supporting manual therapy.

EFFECTIVENESS OF MANIPULATION AND MOBILIZATION IN CHRONIC BACK PAIN – A SYSTEMATIC REVIEW. Almushaiqeh NA, Almeshari OM, Almarshad SA et al. International Journal of Recent Innovations in Medicine and Clinical Research OPEN 2020;2(4):84–91

The data for this review came from a search of Google Scholar, PubMed and PEDro from 2010 to 2019. The search resulted in 50 articles but only 5 were selected for the study based on criteria which were RCTs on adult humans published in English. The main outcome measures used were lumbar range of motion, pain scales, catastrophic thoughts scale and the Oswestry disability index version 2. The selected studies included Maitland, McKenzie and Mulligan techniques. The conclusion was that there is low to intermediate quality proof that different forms of manipulation and/or mobilisation can alleviate pain and improving function for chronic back pain compared to other treatments.

Co-Kinetic comment Did you know that globally one out of three people suffer from low back pain at some time in their life? The prevalence rates of low back pain in athletes range from 1% to 40%. Back injuries in the young athlete occur in 10% to 15% of participants. One of the exclusion criteria for the study was that the full text was not available. Authors (and publishers) please take note. If you want your work plugged it needs to be available in full – not just the abstract.

RELATIONSHIP BETWEEN REACTIVE AGILITY AND PLAYING POSITIONS IN AMATEUR FOOTBALL PLAYERS. Chinta A, Bisen R, Kalra K. International Journal of Health Sciences and Research 2020;10(5):40–44 This study aimed to verify if reactive agility is influenced by the playing positions of amateur footballers. Forty-two players between the ages of 11 and 21 years were selected for this study. The participants included 14 attackers, 14 midfielders and 14 defenders. A soccer-specific reactive agility test was performed by all the players. This began with a 2m forward sprint, after which the timing started. At this point, the participant was faced with four cones, each with an LED light

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on top, situated at lateral and diagonal positions. Then, one of the LED lights lit up and the subject had to assess and sprint towards that cone and kick the ball placed in front of it and return back to the original starting position. There was a significant difference in the times recorded from players of different positions. When multiple comparisons between the groups were analysed it showed that midfielders performed significantly better than attackers and defenders.

Co-Kinetic comment This is a first: a paper about football that starts with a description of the game, “Football also known as soccer is a game in which two teams of eleven players each play whose objective is to invade the opposition’s area and try to manoeuvre the ball into the opponent team’s goal”. Wow, do we really need a description of the game? According to the FIFA website (FIFA.com), 250 million people play football worldwide and there are another 5 million referees and officials. That is 1 in 25 of the world’s population. This is probably not an up-to-date figure. Go to https://www. worldometers.info/world-population/ where you will find a set of dials counting daily births and deaths and the subsequent minute-by-minute increase in the world’s population. It’s a bit scary. As to the paper, reactive ability is described as “a rapid whole-body movement with change of speed or direction in response to a stimulus”. This may guide coaches to allocating players to a particular position or in improving the reactive agility of the slower ones.

CONCUSSION DISCLOSURE: FEARS PRESENTED BY FOOTBALL STUDENTATHLETES. Craig DI, Lininger MR, Lane T. Athletic Training and Sports Health Care 2021;https://doi.org/10.3928/19425864-20200424-02 This was a survey of 205 American collegiate football student-athletes from three National Collegiate Athletic Association (NCAA) Division I institutions regarding their attitude to reporting concussions: l 51.9% feared that they would lose playing time if they reported the concussion. l 16.3% feared that they would be considered weak. l 7.5% feared that their football career would be over. l 11.3% feared hearing about potential health impacts. On the plus side, in comparison with similar questions in Kroshus et al.’s 2014 study [NCAA concussion education in ice hockey: an ineffective mandate. British Journal of Sports Medicine 2014;48(2):135–140 (https://bit.ly/3pt5LHI)], the current study’s results indicate a positive increase in thinking that their teammates will think they made the right decision if they disclose a concussion (47% agree) and that they will be better off in the long run (59% agree).

Co-Kinetic comment The authors believe that the results show that team norms around concussion reporting may be shifting towards a more positive trend. From here it looks like a disaster waiting to happen.

EFFECT OF MULLIGAN SUSTAINED NATURAL APOPHYSEAL GLIDES ON THORACIC COBB ANGLEIN SUBJECTS WITH THORACIC KYPHOSIS. Elgendy MH, Mohamed SR, Abuelkasem ST et al. Egyptian Journal of Applied Science 2020;35(11):108–117 OPEN

Forty subjects (aged 18–28 years) underwent a combination of Mulligan techniques and traditional treatment (experimental group, n=20) or traditional treatment only (control group, n=20). They were evaluated before the treatment and after 4 weeks, using digital X-ray. The Mulligan intervention was a sustained natural apophyseal glide mobilisation given in 3 sets of 10 repetitions to the affected area of thoracic spine, at three sessions a week, for 4 weeks. The traditional treatment was postural correction exercises. There was a significant decrease of thoracic Cobb angle post-treatment compared to pre-treatment for both groups, with a significantly greater decrease in the Mulligan group.

Co-Kinetic comment If you are already a mobilisation with movement (MWM) aficionado this is a nice piece of evidence for you. Both the MWM and the exercise protocol are well described. The Cobb angle gives an objective measure for spinal disorders such as scoliosis and kyphosis. It is named after John Robert Cobb an American orthopaedic surgeon who in the 1930s worked in New York at what was then called the “Hospital for the Ruptured and Crippled”. You will be glad to know it is now named the “Hospital for Special Surgery”.

Co-Kinetic Journal 2021;89(July):4-11

RESEARCH INTO PRACTICE

MANUAL THERAPY COMBINED WITH THERAPEUTIC EXERCISE VS THERAPEUTIC EXERCISE ALONE FOR SHOULDER IMPINGEMENT SYNDROME: A SYSTEMATIC REVIEW AND META-ANALYSIS. Sharma S, Hussain ME, Sharma S. Journal of Clinical & Diagnostic Research 2021;15(4):10–17 A search of the PubMed and PEDro databases was performed from inception till the last week of August 2020. The selected studies were assessed on methodological quality rating using the PEDro scale and the modified Downs and Black scale for experimental and quasiexperimental studies, respectively. The extracted outcomes were pain levels, strength, range of motion, and shoulder pain and disability index score. The meta-analysis was done on continuous data and the

The usual databases were searched which resulted in 18 studies concerning ruptures of the plantar fascia. There were no RCTs. A total of 155 patients (157 feet) were included in the review. Twelve patients had a spontaneous rupture, 138 patients had a diagnosis of plantar fasciitis, and 130 patients were treated with local injections of corticosteroid before the rupture. Only two cases of bilateral rupture were reported. In all, 15 studies reported conservative treatment, with a total of 154 patients (156 feet) included. Operative treatment was reported in three studies, with three patients (3 feet) treated. Local injections of steroids increase the risk of rupture. Patients who had received steroid injections were at an approximately This narrative review investigates injury types and risk factors associated with crutch use in order to guide healthcare providers on injury prevention strategies. The MEDLINE, Embase, CINAHL databases and the Cochrane Library were systematically reviewed for publications between 1950 and 2018 on neurological, musculoskeletal or vascular complications associated with crutch use. Sixty studies were eligible. Articles were reviewed for level of evidence, crutch type, participant characteristics, and injury characteristics. There were 42 axillary crutch studies, 12 forearm crutch studies, and 6 studies that did not specify crutch type. These studies

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data were summarised qualitatively and quantitatively. This produced 7 trials (n=437) after evaluation. The majority of the studies (6/7) had low risk of bias. The results indicate that evidence exists for improvement in pain level and muscle strength with manual therapy combined with therapeutic exercise and with the latter alone, respectively. The qualitative evidence suggests that glenohumeral mobilisation and exercises are associated with best outcomes for shoulder impingement syndrome.

Co-Kinetic comment The sheer volume of studies uncovered in systematic reviews like this is staggering. The initial search came up with 3109 studies. Screening by title and abstract whittled this down to 70 which were studied in full. This left 12 studies that met the inclusion criteria for systematic review with 7 of those considered for meta-analysis. That is a lot of work to examine a clinical sign – which impingement is – rather than the underlying cause of the impingement.

RUPTURES OF THE PLANTAR FASCIA: A SYSTEMATIC REVIEW OF THE LITERATURE. Mosca M, Fuiano M, Massimi S et al. Foot & Ankle Specialist 2020;1938640020974889 33-fold greater risk of rupture compared with those who had not received steroid injections. The study did not find correlations with comorbidities such as diabetes, hypertension, thyroid disease, arthritis, and high BMI nor between a high activity level in daily life. Almost all of the spontaneous ruptures in patients without a history of fasciitis or local injections occurred during sporting activity. In most studies, after the first period of immobilisation, early physiotherapy and stretching of the plantar fascia were prescribed leading to good outcomes in

most cases. In professional athletes the time for return to play ranged from 21 days to 5 months postinjury.

Co-Kinetic comment Cases of plantar fascia rupture are rare, especially in asymptomatic patients. In fact, the first reported case in the literature was only in 1978, although there must have been previous cases. By far the biggest risk factor is having a steroid injection so perhaps think twice before going down that route.

INJURIES ASSOCIATED WITH CRUTCH USE: A NARRATIVE REVIEW. Manocha RHK, MacGillivray MK, Eshraghi M et al. PM&R 2020;doi:10.1002/pmrj.12514 [Epub ahead of print] incorporated 622 individuals, and most were case series or case reports (n=54). Axillary crutch use was most commonly associated with axillobrachial arterial complications caused by pressure from the axillary bar (n=34). Forearm crutch use was most commonly associated with compressive neuropathies due to pressure from the forearm cuff (n=6). Improper crutch fitting and/or use were identified as contributing factors to injury in 22 cases. Duration of crutch use and medical comorbidities also influenced the types of injuries seen.

Co-Kinetic comment Crutch-use injury is rare but everyone prescribing crutches should be aware that there are potentially serious complications associated with their use. It would be interesting for someone to do a survey on how much, if any, gait training is given to patients given crutches by A&E departments.

A SYSTEMATIC REVIEW AND META-ANALYSIS OF COMMON THERAPEUTIC EXERCISES THAT GENERATE HIGHEST MUSCLE ACTIVITY IN THE GLUTEUS MEDIUS AND GLUTEUS MINIMUS SEGMENTS. Moore D, Semciw AI, Pizzari T. International Journal of Sports Physical Therapy 2020;15(6):856–881 OPEN

The purpose of this systematic review was to evaluate whether common therapeutic exercises generate at least high ( >40% maximum voluntary isometric contraction) electromyographic activity in the gluteus medius (GMed; anterior, middle and posterior) and gluteus minimus (GMin) (anterior and posterior) segments. A search of the medical databases turned up 56 papers. The results showed that for the GMed, different variations of the hip hitch/pelvic drop exercise generated at least high

activity in all segments. The dip test and isometric standing hip abduction are other options to target the anterior GMed segment, whereas isometric standing hip abduction can be used for the posterior GMed segment. For the middle GMed segment, the single-leg bridge; side-lying hip abduction with hip internal rotation; lateral step-up; standing hip abduction on stance or swing leg with added resistance; and resisted side-step were the best options for generating at least high activity. Standing isometric hip abduction and different variations of the hip hitch/pelvic

drop exercise generated at least high activity in all GMin segments, whereas side-lying hip abduction, the dip test, single-leg bridge and single-leg squat can also be used for targeting the posterior GMin segment.

Co-Kinetic comment There will not be many physical therapists or strength and conditioning coaches have not prescribed one or more of these exercises and even fewer that did not know what they were targeting. Now you have some science to prove it!

RHABDOMYOLYSIS AFTER THE USE OF PERCUSSION MASSAGE GUN: A CASE REPORT. Chen J, Zhang F, Chen H et al. Physical Therapy 2021;101(1):1–5 A 25-year-old Chinese women with mild iron deficiency anaemia presented with a history of fatigue and pain in her thigh muscles and tea coloured urine. Two and three days previously, she had cycled in a gym intermittently at an intensity of 6–7mph for approximately 30min each day. Immediately after cycling, she received percussive massage over both thighs for nearly 10min through a commercial percussion gun for the purpose of massage and relaxing tired muscles. The massage was delivered by her coach (who

This is an in-depth review of all aspects of patellofemoral pain (PFP), which is among the most common injuries in recreational runners. It starts with a discussion on why the area hurts and considers the amount of force going

took no medical history) and without supervision by qualified healthcare professionals. She developed pain in both thighs that evening, and urine discoloration was noticed 2 days later. She reported a previous tendency to bruise, even with minor trauma, but otherwise she had been generally healthy, with no family history of relevant disease or psychosocial concerns. She did not report any prodromal or aggravating events. Muscle tenderness and multiple hematomas were found on her thighs, and her urinalysis indicated

haemoglobinuria suggestive of destruction of or lysis of red blood cells. Her serum creatine kinase was reported as “undetectably high”, a hallmark of serious muscle damage leading OPEN to a diagnosis of severe rhabdomyolysis.

Co-Kinetic comment. The take home message here is simple. Don’t follow trends and play with dangerous toys unless you know what you are doing. Better still, hire a properly trained massage therapist for your recovery massage.

A CONTEMPORARY APPROACH TO PATELLOFEMORAL PAIN IN RUNNERS. Esculier JF, Maggs K, Maggs E et al. Journal of Athletic Training 2020;55(12):1206–1214 through the knee. A full marathon with a median time of 4h 20min applies a cumulative load of 80 000-times body weight, so educating patients on the balance between load and capacity is important. Current evidence does not identify alignment, muscle weakness, and patellar maltracking or a combination of these as causes of PFP. Rather than solely investigating biomechanics, the authors suggest a holistic approach to address the causes of PFP. Both external loads, such as changes in training parameters and biomechanics,

and internal loads, such as sleep OPEN and psychological stress, should be considered. As for the management of runners with PFP, recent research suggested that various interventions can be considered to help symptoms, even if these interventions target biomechanical factors that may not have caused the injury in the first place.

Co-Kinetic comment This is one article from a special edition of the Journal of Athletic Training 2020;5(12) (https://bit.ly/34VSOwU). If you are involved with runners in any sport it is worth getting hold of a copy. Co-Kinetic Journal 2021;89(July):4-11

RESEARCH INTO PRACTICE

THE EFFECTIVENESS OF ROUTINE PHYSIOTHERAPY WITH AND WITHOUT NEUROMOBILIZATION ON PAIN AND FUNCTIONAL DISABILITY IN PATIENTS WITH SHOULDER IMPINGEMENT SYNDROME; A RANDOMIZED CONTROL CLINICAL TRIAL. Akhtar M, Karimi H, Gilani SA et al. BMC Musculoskeletal Disorders 2020;21(1):770 A total of 80 patients with shoulder impingement syndrome were randomly assigned into care and experimental groups (40 in each group). Both received the physiotherapy intervention, whereas neuromobilisation (NM) was applied additionally to the experimental group. Patients were treated three times a week on alternative days. The routine physiotherapy consisted of pulsed short wave diathermy with frequency 27.12MHz; ultrasonic therapy with frequency 1.0MHz and intensity 1.45W/cm2; and transcutaneous electrical nerve stimulator 2–200Hz with output current <20mA width 200μs along with continuous mode. Exercises consisted of shoulder strengthening and stretching exercises that were performed for 5s with 10 repetitions for both experimental and care groups. For the NM, initially, the patient performed neural sliders and gradually progressed to neural tensioners. Neural sliders consisted of cervical lateral flexion movement, toward the involved side, simultaneously with elbow flexion and extension movements. While moving the head into cervical lateral flexion the elbow was extended. When the elbow began to flex, the cervical spine was returned to neutral position. The tension position was not held for a length of

time, but was released by extending the elbow and returning the cervical spine to neutral once the patient had reached slight pain or discomfort at any point. NM technique was performed for 5s with 10 repetitions to control the pain. At 11 weeks, the experimental group had a lower mean pain score and functional disability score compared to the care group.

OPEN

Co-Kinetic comment The shoulder impingement syndrome in this paper consists of rotator cuff tendonitis and bursitis of the shoulder. It is not femoral acetabular impingement for which it is doubtful if this routine would make a difference. Measurements were taken at 5 and 11 weeks but it is not clear if the treatment continued until the 11-week mark. If you want to repeat this one the physiotherapy routines are well described. The photos of the sliders are not as clear but if you are familiar with upper limb tension tests you will get the gist.

VETERANS WITH POST-TRAUMATIC STRESS DISORDER ARE LESS STRESSED FOLLOWING MASSAGE THERAPY. Field T, Sauvageau N, Gonzalez G et al. Current Research in Complementary & Alternative Medicine 2020;4(1):141 Forty veterans were recruited and were randomly assigned to a massage therapy or a waitlist control group. Thirty-minute massages were provided weekly for a 4-week period by a massage therapist. Moderate pressure massages were done with the participant in a side-lying position on a massage table. The massage included circular rocking, stroking and kneading the head, neck, shoulders and back. Immediately following the massages on the first and last days of the study the massaged versus the waitlist control veterans were more accurate on math computations, had lower stress levels and lower heart rate. At the end of the study, the massage group had lower PTSD scores, fewer sleep disturbances and expressed less intent of selfharm. In a follow-up 1 month later, the massage group was no longer showing the improvement noted at the end of Co-Kinetic.com

the study, although they continued to express less intent of self-harm.

Co-Kinetic comment This is another production from the massage research assembly line that is the Touch Research Institute. If you are wondering what PTSD has to do with sports medicine the answer is that it can occur after any situation in which victims perceive that their life or safety is threatened. Symptoms include, sleep disturbances, depression and suicidal thoughts. In sport, athletes often place themselves in dangerous situations and are also exposed to the same lifestyle dangers as the general population. If this interests you, start with Shearer D et al. Posttraumatic stress disorder: a case study of an elite rifle shooter. Journal of Clinical

Sport Psychology 2011;5(2):134–147 (https://spxj.nl/3x3iUtY). One debatable point in this study is the waitlist control group which means that the subjects are put on a waiting list to receive the treatment after the active group does. It is a bit of an ethical stretch of a no treatment group.

OPEN

A cross-sectional survey of medical personnel working within professional male cricket within the United Kingdom was conducted from April to June 2020. All 20 pro teams were invited to participate and 15 did so. Most respondents were the clubs’ head physiotherapist (n=8, 53%). Responses were also received from clubs’ strength and conditioning coach (3, 20%), head of medicine or physiotherapist (2, 13%). The survey was based on the authors’ similar work in football where they found that the uptake of the 10-week Nordic hamstring programme (NHP) is as low as 11% and 17% in professional soccer. The survey captured: (i) current team practices of hamstring injury prevention strategies; (ii) adoption and implementation of the NHP; and (iii) reasons for NHP inclusion or exclusion. The majority of clubs (n=12 [80%]) who responded to the survey reported having a current formal hamstring injury prevention programme. All teams who adopted a formal preventive programme included both the NH

THE UPTAKE OF THE NORDIC HAMSTRING EXERCISE PROGRAMME AS AN INJURY PREVENTION STRATEGY IN PROFESSIONAL CRICKET IN THE UNITED KINGDOM AND BARRIERS TO IMPLEMENTATION. Chesterton P, Tears C. Physical Therapy in Sport 2021;50:1–6 exercise and additional eccentric exercise(s) into their regime. Two clubs included high-speed running as part of the prevention programme. Nine clubs felt that the NH exercise is/would be effective at reducing hamstring injuries at their club and 11 respondents also partially agreed the NH exercise could substantially reduce injuries across cricket. Ten (67%) of the respondents would not change anything about the 10-week programme. Of the five who would alter components of the programme the most common change was its duration. Two respondents suggested that some aspects of the NHP are adopted within preseason and then micro-dosed for specific individuals throughout the season. Some of the barriers for nonimplementation included the NHP not being positively perceived by

TREATMENTS FOR ACUTE PAIN: A SYSTEMATIC REVIEW. Chou R, Wagner J, Ahmed AY et al. Agency for Healthcare Research and Quality 2020;20(21)-EHC006 A search of the electronic health databases for RCTs looking at eight acute pain conditions [low back pain, neck pain, other musculoskeletal pain, neuropathic pain, postoperative pain following discharge, dental pain (surgical or nonsurgical), pain due to kidney stones, and pain due to sickle cell disease] found 183 studies. Opioid therapy was probably less effective than nonsteroidal anti-inflammatory drugs (NSAIDs) for surgical dental pain and kidney stones, and might be similarly effective as NSAIDs for low back pain. Opioids and NSAIDs were more effective than acetaminophen for surgical dental pain, but opioids were less effective than acetaminophen for kidney stone pain. For postoperative pain, opioids were associated with increased likelihood of repeat or rescue analgesic use, but effects on pain intensity were inconsistent. Being prescribed an opioid for acute low back pain or postoperative pain was associated with increased likelihood of use of opioids at long-term follow-up versus not being prescribed, based on observational studies. Other findings included the following: l An opioid might be effective for acute neuropathic pain. l Heat therapy was probably effective for acute low back pain. l Spinal manipulation might be effective for acute back pain with radiculopathy. 10

players (40%) and coaches (33%). Respondents felt that the NHP is part of but not the only solution to hamstring incidence and a combination of conditioning work is used in addition to the Nordic hamstring exercise. One club commented they used a variety of loading strategies at various hamstring muscle lengths. This was felt more applicable to the exposures experienced in sports performance and superior to a single intervention or exercise. Two respondents commented that hamstring strains had not historically been significant at their club and therefore current injury preventive strategies were considered effective.

Co-Kinetic comment It would be nice to have a follow-up study noting the hamstring injuries in each club.

OPEN

l Acupressure might be effective for acute musculoskeletal pain. l Massage might be effective for some types of postoperative pain. l A cervical collar or exercise might be effective for acute neck pain with radiculopathy. Most studies had methodological limitations. Effect sizes were primarily small to moderate for pain, the most commonly evaluated outcome. Opioids were associated with increased risk of short-term adverse events versus NSAIDs or acetaminophen, including any adverse event, nausea, dizziness and somnolence. Serious adverse events were uncommon for all interventions, but studies were not designed to assess risk of overdose, opioid use disorder, or long-term harms. Evidence on how benefits or harms varied in subgroups was lacking.

Co-Kinetic comment The title of this study seemed really promising but there are too many “probable”s and “might”s. You have to wonder why we still read about methodological flaws given the amount of guidance available to researchers on the web. On the plus side, there is evidence, however limited, that heat therapy, spinal manipulation, massage, acupuncture, acupressure, a cervical collar, and exercise were effective for specific acute pain conditions. Co-Kinetic Journal 2021;89(July):4-11

RESEARCH INTO PRACTICE

THE EFFECT OF SPORTS MASSAGE TOWARDS CORTISOL AND PRE-COMPETITION ANXIETY AMONG MALAYSIAN ELITE TENNIS ATHLETE. Pa WAMW, Salamuddin N, Zin NM et al. Journal of Contemporary Issues in OPEN Business and Government 2021;27(2):1518–1528 Fourteen elite tennis players were randomly divided into treatment and control groups. They were all members of the Malaysian national squads and shared the same coach. The Sports Massage therapy followed a protocol in The Complete Guide to Sports Massage by Tim Paine (Bloomsbury Sport 2015; https://amzn.to/3cnxHI2). It included effleurage, petrissage, friction and tapotement. Each subject received 9×27min sessions over a 3-week period. Each repetition of the technique lasted 8.4s. The control group just received conventional training provided by the coach, but this is not further described. Cortisol was measured from a saliva sample and anxiety via a competitive state anxiety inventory, pre- and post-intervention. The results showed that there was a significant difference in the cognitive anxiety, somatic anxiety, and self-confidence in favour of the massage group but no significant difference on cortisol.

Co-Kinetic comment What a strange journal title for this to appear in. The driver of the study was that the Malaysian tennis players were not very successful at the 2017 South East Asian Games whereas their teammates in other sports were winning medals by the sack load. Their Tennis Federation was under pressure and looking for an edge. It had been 16 years since one of their players had won gold and they were theorising that anxiety was getting to the players. The study ends with the hope that one day Malaysia will have a star tennis athlete who is ranked in the top 10 in the world. Good for them.

The results of this study came from a search of PubMed, ScienceDirect, Web of Science and Scopus from inception to March 2020. The initial search resulted in 1258 papers which were cut down to 9 studies that met the inclusion criteria of manual therapy on the diaphragm to obtain results in muscle or joint function. Most of the studies were conducted in subjects without a specific pathology, three of them in healthy adults, one of them with sedentary women and one with short hamstring syndrome. One used subjects with chronic nonspecific low back pain, whereas three studies used a sample with respiratory disease. In the four studies that analysed subjects with a specific clinical condition, manual therapy on the diaphragm obtained benefits in the mobility of the diaphragm assessed by ultrasonography, mobility of the

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EFFECT OF MANUAL THERAPY IN HYPERTENSIVE PATIENTS. Mahmoud AM, Elaziz AA, El Nahas NG et al. Egyptian Journal of Physical Therapy 2020;4(1):1–5 OPEN Sixty patients aged 30–60 years, with primary hypertension were randomly divided into two groups (control and an intervention group). Both groups were given standard medication. The intervention group (18 females, 12 males) received what is described as “manual therapy massage” for 3 sessions a week over a 12-week period. The massage protocol is described as being from the neck region to the lower back and sacral region with graduated compression (including a static muscular pressure, applying and then releasing pressure, proceeding to adjacent areas and repeating), and then a programme of muscle stretching to the lumbosacral muscles, hamstrings and calf muscles. The results were that for the intervention group, systolic and diastolic blood pressure decreased more than in the control group.

Co-Kinetic comment A 2015 study reported that 1.13 billion people worldwide suffered from high blood pressure so the news that massage helps is welcome. Sadly, this study doesn’t give much information on the dose in terms of pressure or timings which is a missed opportunity.

EFFECTS OF MANUAL THERAPY ON THE DIAPHRAGM IN THE MUSCULOSKELETAL SYSTEM: A SYSTEMATIC REVIEW. Fernández-López I, Peña-Otero D, de Los Ángeles Atín-Arratibel M et al. Archives of Physical Medicine and Rehabilitation 2021;doi:10.1016/j.apmr.2021.03.031 [Epub ahead of print] thoracic cage and abdominal excursion during the respiratory cycle, increased flexibility of the posterior chain, and improvements in parameters related to the lumbar spine. The five without a specific clinical condition found that positive results were also achieved in the mobility of the diaphragm, thoracic cage and abdominal excursion with improvements in parameters related to posterior chain flexibility and in the lumbar and cervical spine. The interventions classed as manual therapy were muscle stretching used to increase the distance between the origin and insertions of the diaphragmatic muscle to promote greater effectiveness of muscle contraction and myofascial release.

Co-Kinetic comment We don’t think about the diaphragm much but maybe we should given that this paper quotes other studies that have shown that it has the highest contribution of the total work done of all inspiratory muscles (from 60 to 80%. It carries out more than 20 000 movements per day, and in each of them it drags the lungs and abdominal viscera with it. If that were not enough, it is involved in phonation, swallowing, prevention of gastroesophageal reflux, the maintenance of urinary continence during respiration, stabilisation of the spine during postural tasks and pressure differences created by the diaphragm influence lymphatic flow.

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PAIN DOES NOT ALWAYS INDICATE INJURY By Kathryn Thomas BSc MPhil

These days it is understood that for most chronic pain, ongoing nociceptive triggers are rare. Instead, therapists have to treat a much more complex mix of central sensitisation, anxiety and fear of pain. This involves having a thorough knowledge of pain neuroscience as well as biopsychosocially-driven pain management strategies. This article will allow you to start by understanding your patient before educating them to understand their pain and then to deliver a graded cognition-targeted exercise therapy plan to free your patient from their fear and limitations of chronic pain. Read this article online https://bit.ly/3pweyZI 21-07-COKINETIC | PAIN | PSYCHOLOGY FORMATS WEB MOBILE PRINT All references marked with an asterisk are open access and links are provided in the reference list

e currently live in an age of fear. For many of us (luckily) it’s not necessarily to the extent of war, crime, abuse, poverty or safety; but a daily onslaught of fear of illness, disease, acceptance, integration, success or failure. From a health and safety perspective there is a constant assault of reminders (be it from media, parents or community figureheads), such as: Do this, Don’t do that, Eat this, Wear protective gear, Be careful here, Mind your step there, etc. This is generated under the guise of protecting us, keeping us healthy, preventing injury or illness, and living a better life. However, it has also created a society of fear, anxiety and pain catastrophising. Pain catastrophising is when one has a group of negative emotional and cognitive responses to pain, and is thought to be made up of three aspects: helplessness, magnification and rumination (1*). Pain catastrophising has arisen as one of the strongest psychological predictors of poor pain outcomes and has been repeatedly associated with increased sensitivity to pain, increased risk of persistent pain, heightened pain intensity and severity, increased disability, and higher levels of psychological distress and depressive symptoms (2*). A review by Sullivan et al. showed that pain catastrophising accounted for up to 31% of the variance in pain severity (1*). More importantly the connection between pain catastrophising and disability was

PAIN CATASTROPHISING IS A NEGATIVE EMOTIONAL AND COGNITIVE RESPONSE TO PAIN THAT CONSISTS OF THREE ASPECTS: HELPLESSNESS, MAGNIFICATION AND RUMINATION 14

independent of the severity of pain (1*). At the core is a group of overlapping fear-related ideas, consisting of fear of pain, worry, rumination, pain-related anxiety, anxiety sensitivity, and the concept of catastrophic thinking about pain and its possible consequences (3*). It results in the development of fear-avoidance patterns caused by a distressing fear of pain during an activity (or even before the activity) in anticipation of what is to come or what may happen as a consequence of movement or activity. What we do know is that exercise or general physical activity is a proven treatment for managing chronic pain, including musculoskeletal-related pain (4*,5*). It may be almost impossible to ‘talk’ a patient out of their fear of moving a limb (for example a painful shoulder or flexing their lower back). The main aim of treatment for chronic pain is to increase functioning and enhance goal achievement, for example exposing a patient to movement, tackling avoidance behaviour and patterns, not necessarily reducing their level of fear per se (6*). A recent systematic review (which included seven randomised controlled trials and meta-analysis) of painful exercises versus pain-free exercises for chronic musculoskeletal pain found that protocols allowing painful exercises offered a small, but statistically significant benefit over pain-free exercises in the short term (7*). The improvements in patientreported pain were achieved with a range of contextual factors, such as varying degrees of pain experienced (ranging from pain being allowed to advised, with/without a recommended pain scale) and recovery time (ranging from pain subsiding immediately to Co-Kinetic Journal 2021;89(July):14-21

PHYSICAL THERAPY

within 24 hours). Painful exercises were defined as exercises prescribed with instructions for patients to experience pain or where patients are told that it is acceptable and safe to experience pain (7*). But how do you get a chronic pain patient to that point of trusting and believing you that some pain during activity is OK? The pain is not causing more damage, your nerves are not tearing, the disc has not exploded, your muscle did not rupture. Questions you and your patient may have could include: l What type and intensity of pain is OK with exercise? l How do you judge a little or moderate amount of pain? l How much pain would give the best results? l Is there such a thing as good pain (like during stretching and massage) versus bad pain which is presumably harmful? Research has shown that patients with chronic pain are uncertain and fearful when it comes to exercising and pain (8*,9*). This will be linked to their pain- and fear-avoidance beliefs associated with their painful condition. Their belief will probably be something along the lines of, “If it’s painful it must be making it worse; should I be doing this exercise or activity if it’s going to be damaging?” (8*). Patients tend to associate any pain with harm, more trauma and injury. The need for pain to be alleviated or avoided altogether feeds into this pain- and fear-avoidance behaviour. This may have been relevant in a traditional biomedical pain model, but we now know that chronic pain is far more complex than this, and a paradigm shift towards a biopsychosocial model of pain is particularly relevant in the context of performing painful therapeutic exercises (10*). In the case of acute musculoskeletal pain, the focus of treatment is to reduce or eliminate pain. Thereby reducing the ‘activity’ of the peripheral pain generators or nociceptive triggers. Pain science has shown that in cases of chronic musculoskeletal pain, ongoing peripheral nociceptive triggers are rare. The clinical and physiological Co-Kinetic.com

IN CHRONIC MUSCULOSKELETAL PAIN, THERE IS RARELY ONGOING TRIGGERING OF PERIPHERAL NOCICEPTORS picture of pain is generated by a central sensitisation to pain. Chronic musculoskeletal pain conditions including osteoarthritis, rheumatoid arthritis, whiplash, fibromyalgia, low back pain, neck pain, pelvic pain, shoulder pain and lateral epicondylitis are often characterised by brain plasticity that leads to hyperexcitability of the central nervous system (central sensitisation). The concept of this central sensitisation is more widely accepted and understood (although not entirely) (10*,11). In such cases, musculoskeletal therapists need to think and treat beyond muscles and joints and an image of underlying pathophysiology. Within the context of the management of chronic pain, it is crucial to consider central sensitisation to pain. Modern pain neuroscience calls for treatment strategies aimed at decreasing the sensitivity of the central nervous system (ie. desensitising therapies). However, bridging the gap between clinical guidelines and clinical practice can be tricky and complex with these patients. You, the therapist may need to address: l the individual’s perspective of their condition and pain; l diagnosis; l stage of disorder; l pain features; l psychosocial considerations; l work considerations; l lifestyle considerations; l whole person considerations; and l functional behaviour. The clinician does not need to be an expert in all elements. It is important to have awareness of all elements listed above and how they may impact management and outcomes. A clinician should embrace a team approach to management and refer on to other professionals to help with specific parts of the framework (eg. a psychologist). Exercise therapy is proposed as a desensitising treatment for chronic

pain. Bear in mind that many patients with chronic pain will be resistant to exercising, especially if the exercise is painful. They will often display avoidance and altered movements patterns, and fear and pain memories will all contribute to preventing the patient from performing the exercise or maintaining an ongoing programme. Here we endeavour to describe a step-by-step approach to implementing exercise therapy successfully by addressing the patient’s pain behaviours, pain beliefs and pain memories.

STEP 1: Preparation – the Clinician, ie. YOU

The therapist should have certain prerequisites for providing pain neuroscience education and ‘cognitiontargeted’ exercise therapy (11). 1. Therapists need to have an in-depth understanding of pain mechanisms and the dysfunctional central nociceptive processing in those with chronic musculoskeletal pain. This includes a thorough understanding of the role of fear (of movement) in the development and sustainment of chronic pain. 2. Therapists need to have the skills to explain to their patients the mechanism of central sensitisation as an evidence-based explanation for their chronic musculoskeletal pain. 3. Specific communication skills are required. For instance, a Socraticstyle dialogue (a form of cooperative argumentative dialogue between individuals, based on asking and answering questions to stimulate critical thinking and to draw out ideas and underlying presuppositions) of education is preferred over ‘lecturing’ to the patient. 4. Therapists should be familiar (and preferably experienced) with current evidence-based biopsychosociallydriven pain management strategies including graded activity, graded exposure and acceptance-based interventions (eg. acceptance and 15

commitment therapy). 5. A variety of exercises may be required depending on the individual patient and how they respond. Neuromuscular training may also be an option.

STEP 2: Practical Pain Features

Types of pain include (12): 1. Nociceptive pain. This pain arises from actual or threatened damage of non-neural tissue. This is the type of pain most commonly encountered in clinical practice, especially in an acute injury incidence. An example of nociceptive pain is the response that occurs after hitting your leg on a coffee table. Nociceptive pain also includes inflammatory pain associated with disorders such as rheumatoid arthritis. 2. Neuropathic pain. This pain is caused by an injury or lesion of the somatosensory nervous system. An example of this would be peripheral neuropathy or radiculopathy. 3. Nociplastic pain. This is pain that is caused by altered nociception. There is no clear evidence of actual or threatened tissue injury or damage triggering peripheral nociceptors. There is also no clear evidence of a lesion or disease whereby the somatosensory system would be triggered. Conditions such as fibromyalgia and irritable bowel syndrome fit under this label. 4. Mixed pain. It is common to have a mix of types of pain. Central nervous system changes can happen within hours of acute tissue injury. In mixed pain presentations, the clinician should try to identify the dominant type of pain. A presentation with clear aggravating and easing factors and a stimulus that is equivalent to the response is defined as mechanical pain. In contrast, a presentation where the response is disproportionate to the stimulus and the aggravating and easing factors are unclear is defined as non-mechanical pain. It is difficult to differentiate between central and peripheral sensitisation in clinical practice. Sensitisation is helpful and normal after an acute injury. Following a sprained ankle an area 16

the size of your hand will be broadly sensitised to avoid further injury to the tissues. Over time, as the injury heals, the sensitivity should normalise. However, in a proportion of people the sensitivity does not normalise even after the tissue injury has healed. Sensitisation may occur in the absence of tissue injury. The presence of sensitisation shows us that the system is too efficient and responding more than it should to a normal stimulus or excessively to a painful stimulus. A range of factors from local tissue factors to psychosocial factors may be contributing to increased sensitivity; therefore, each patient will require a different management plan. In the presence of increased sensitivity, it is important for the clinician to step back and consider what other factors might be driving this and how they need to modify their management for that individual.

STEP 3: Subjective Assessment At the start of the assessment it is important to take time to understand the patient’s perspective. A patient may present with a complex pain presentation but their primary concern might reflect only one part of it. If the clinician does not take time to understand the patient’s perspective, they cannot tailor management around the patient’s expectations. Questions that may help you to understand the patient’s perspective include (12): l What do you think is wrong? l What do you think needs to happen? l Do you think you are going to get better?

Explaining that half of people with neck pain have a history of injury but half of people don’t have a clear cause may help a patient to start thinking about other factors that can sensitise the tissues and make the nervous system more responsive to the same level of load. These may include factors such as being unwell, poor sleep and high stress levels.

1. The Short Form Örebro Screening Questionnaire

The Short Form Örebro Screening

Questionnaire (https://bit.ly/3zhgkCo) covers the key psychosocial domains and may provide additional information during the subjective assessment (13). The information gained from the questionnaire can then be used to guide further questioning and the use of more specific questionnaires. If the patient scores high on the Örebro questionnaire, then a management strategy should be developed from the start and not left until the patient does not respond to treatment.

2. Sleep

During the subjective assessment ask the patient about the quality of their sleep (12). If they are waking, try to identify what is waking them and if they can get back to sleep and how long this takes. If they are having difficulty sleeping, establish what impact this is having on them during the day. A variety of interventions may help with sleep including short-term medical interventions and a sleep hygiene assessment. Reduced sleep should be addressed as this may be the factor that is winding up the nervous system.

3. Beliefs

Beliefs drive behaviour and, therefore, faulty beliefs should be addressed by the clinician (12). Clinicians need to be careful when confronting faulty beliefs as this can result in a backfire effect. This is when someone with a false belief is presented with evidence against their belief and it strengthens their faulty belief. It may be more appropriate to provide patients with a plausible alternative hypothesis through behavioural experiments. These enable the patient to experience things in a less threatening and painful manner and may help them move down a different treatment path. The use of reflective questions can help the patient to understand how rest or other treatments such as manipulation have had limited benefit to date and how a different approach may be required.

4. Red Flags

It is important to ‘triage’ and rule out Co-Kinetic Journal 2021;89(July):14-21

PHYSICAL THERAPY

the presence of red flags and specific pathologies before concluding a patient presents with maladaptive behaviour (12). A patient who has a stress fracture or radiculopathy will need different management to a patient who is limping 3 months after a low-grade ankle sprain. Each body part has specific red flag disorders to look out for such as tumour, infections or trauma. The presence of a single red flag should not automatically increase the clinician’s alarm about the presence of red flag conditions. For example, night pain is a red flag but if someone sleeps with their arm above their head this could increase local shoulder symptoms.

STEP 4: Objective Assessment

Assessment in clinical practice should be an educative process. The use of reflective questions such as “What do you think about that?” or “What do you think it means?” can help the patient to start thinking about the situation for themselves. When repeated across multiple tests and related back to their story, the patient may begin to identify other contributing factors. A detailed hands-on assessment can be used to provide the patient with confidence and reassurance. If they present with nerverelated symptoms and have a normal neurological examination the clinician should engage the patient in the physical examination specifically around sensitivity as this will help to improve compliance (12). The patient presentation should influence how the clinician transitions from the subjective to the objective assessment. If a patient has a subjective presentation of neuropathic pain with pins and needles then the objective assessment should start with a neurological examination. However, if a patient’s subjective presentation suggests increased sensitivity and non-mechanical pain then the objective assessment may start with an evaluation of allodynia (pain due to a stimulus that would not normally cause pain) and hyperalgesia (enhanced sensitivity to pain) (12).

1. Hyperalgesia and Allodynia

Traditionally clinicians have used light touch, sharp/blunt and cold testing to identify loss of conduction in the Co-Kinetic.com

IT IS CRUCIAL TO EDUCATE THE CHRONIC PAIN PATIENT ABOUT MODERN PAIN NEUROSCIENCE SO THEY CAN RECONCEPTUALISE PAIN BEFORE MOVING ON TO EXERCISE THERAPY presence of sensory symptoms. However, these tests can also be used to identify heightened sensitivity in areas such as chronic back, neck or shoulder pain (12). When assessing sensitivity, start on the opposite side of the body on an unaffected area and compare to the affected area. During sensory testing a patient may report increased pain or increased feeling of cold compared to the unaffected area. These symptoms may last longer than the unaffected side or refer over a larger area. There is a big range of normative values so look for different responses within the same person. If increased sensitivity is present during objective examination, then the clinician should establish if this is a helpful or unhelpful response. If deemed unhelpful then the clinician needs to determine what is driving this increased sensitivity. Sensitivity may have developed as the result of the initial injury or because of poor sleep or high levels of distress. Patients with increased sensitivity will often not respond well to manual treatments and do not respond well to forcing through pain. This can wind up the system and perpetuate the pain cycle. These patients may require a different approach, which includes exercise and pacing.

2. Movement Impairments

The majority of patients presenting with acute spinal pain will have a movement impairment (12). Management may target the resolution of the movement impairment, which may involve education, reassurance and manual therapy. The same approach for a patient with chronic spinal pain who has global restriction of movement and demonstrates pain behaviours such as breath holding may make them worse. For this patient, explore other cognitive factors that might be amplifying their presentation, such as sleep, mood or work situation.

3. Impairment of Function

Impairment of functional control typically manifests as disorders that have no impairments of movement but where pain is associated with postural control or muscle activity (12). Management should focus on modifying positions to improve symptoms which may be achieved through exercise.

4. Deconditioning

Deconditioning may present in patients who have avoided an activity and so have lost strength and/ or cardiovascular fitness and are therefore not capable of returning to their activity (12). Management involves an appropriate targeted exercise conditioning programme with consideration of whether the reasons behind the deconditioning are helpful or unhelpful.

5. Work Considerations

There is a strong link in the literature between work and wellbeing (12). Work should be viewed as a treatment and not just an outcome. Studies show that the longer people are off work, the less likely they are to return to work (14,15*). The focus should be on getting people back earlier doing adjusted meaningful duties; however, this may not always be appropriate after trauma or surgery. Key questions about work include: l How much do you enjoy your job? l Do you see yourself getting back to that kind of work? l Are any alternative duties supported by your employer? l How confident are you on your capacity to return? l What is your relationship with your employer and other members of staff like?

6. Lifestyle Considerations

The patient may have been a regular 17

exerciser who stopped due to the onset of symptoms. Exercise may have been the way they managed their anxiety which could be winding up the system. The aim should be to get them doing some kind of activity such as walking or cycling that does not aggravate their symptoms. Provide the patient with reassurance that they need to be exercising again and give them the confidence to start doing so (12).

7. Functional Behaviours

This considers the physical manifestations of an individual’s pain experience (12). These behaviours may coexist in some individuals. Using the Musculoskeletal Clinical Translation Framework (https://bit.ly/3hVuFye) mskPain app (https://bit.ly/3bQBBss) can help to identify the relationship of these factors to the patient’s presentation and help the clinician to individualise the management for each patient. These tools have been developed by Tim Mitchell, Darren Beales, Helen Slater and Peter O’Sullivan, the Postgraduate Musculoskeletal Physiotherapy Teaching Team, Curtin University, Perth, Australia. Visit their website for further information: Musculoskeletal Clinical Translation Framework (https://bit.ly/3floQIA).

STEP 5: Preparation – the Patient

Before implementing exercise therapy, a preparatory phase implying deep learning and reconceptualisation of pain is proposed. It can be accomplished by providing pain neuroscience education, which should mostly rely on evidence from modern pain neuroscience rather than from psychology. If not, patients often misunderstand the neuroscience education message and believe that they are being told “the pain is all in your head”, which is a common pitfall of this approach. In addition, the crucial point in all kinds of cognition-targeted therapy is that it starts from the patient’s perspective – including pain cognitions and beliefs and expectations for care (11). There are a number of sites to help provide educational tools in this regard. Pain in Motion (http://www. paininmotion.be/) is but one that offers education for patients and tools for 18

clinicians (https://bit.ly/3iwTIYI) to use in addressing issues of pain memories and fear of movement. It is critical that the patient understands the role of fear (of movement) in the pain neuromatrix. The pain neuromatrix is likely to be overactive in patients with chronic pain syndromes. Increased activity may be present in the insula, anterior cingulate cortex, prefrontal cortex, various brain stem nuclei, dorsolateral frontal cortex and the parietal associated cortex (11). Long-term potentiation of neuronal synapses, as well as decreased gamma-aminobutyric acid-neurotransmission represent two mechanisms contributing to the overactive pain neuromatrix. A key area in the brain involved in the pain matrix is the amygdala. It is often referred to as the fear-memory centre of the brain, and plays a key role in producing negative emotions (around pain) and pain-related memories (11). The brain of patients with chronic musculoskeletal pain has typically acquired a protective pain memory, lasting long after the original nociceptive pathology has subsided. For movements that once provoked pain, this implies protective behaviours (eg. antalgic postures, antalgic movement patterns including altered motor control, or even avoidance of such movements) (11). These habits have now become the new normal ‘learned’ behaviour for the patient. Providing exercise therapy to these patients with chronic pain is crucial to alter their perceptions, experiences and memories of painful movement patterns. Essentially, this is re-training of the amygdala. Kinesiophobia, or fear of movement, is seldom applicable to all kinds of physical activity, but rather applies to certain specific movements (eg. neck extension in patients post-whiplash, overhead smashes in patients with shoulder impingement syndrome, or forward bending in patients with low back pain). Even though these movements provoked pain in the (sub)acute phase, or even initiated the musculoskeletal pain disorder (eg. the pain started following an overhead smash), they are often perfectly safe to perform in a

chronic stage. The problem is that the brain has acquired a long-term pain memory, associating such movements with danger/threat. Even preparing for such ‘dangerous’ movements is enough for the brain to activate its fear-memory centre and, hence, to produce pain (without nociception), and employ an altered (protective) motor control strategy (11). The role of exercise therapy may therefore be to expose the patients body (and mind) in a safe controlled environment – ‘without danger.’ This is explained further below.

STEP 6: Exercise Therapy

Following pain neuroscience education, as soon as the patient with chronic pain understands that all pain is produced in the brain and has adopted less threatening perceptions about pain, one can proceed to the next level: cognition-targeted exercise therapy (11). Exercise therapy can include various types of exercise interventions, for example motor control training, aerobic training or muscle strengthening. In theory it can be applied to a variety of patients with chronic pain syndromes with central sensitisation. ‘Cognition-targeted’ exercise therapy stands for several principles to be applied during therapy for patients with chronic musculoskeletal pain (Table 1) (16*). The goal of cognition-targeted exercise therapy is systematic desensitisation, or graded, repeated exposure to generate a new memory of safety in the brain, replacing or bypassing the old and maladaptive movement-related pain memories. Hence, such an approach directly targets the brain circuitries orchestrated by the amygdala (the memory of fear centre in the brain) (11). A number of recent studies (17*,18,19*,20,21) have shown that the combination of a treatment protocol combining pain neuroscience education and cognition-targeted exercises may be expected to normalise central alterations by addressing central nervous system dysfunctions, psychological factors, as well as peripheral dysfunctions in a broader biopsychosocially-driven framework (17*). Co-Kinetic Journal 2021;89(July):14-21

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Table 1: Principles of cognition-targeted therapy Sourced Nijs J et al. A modern neuroscience approach to chronic spinal pain: combining pain neuroscience education with cognition-targeted motor control training. Physical Therapy 2014;94(5):730–738 (16) Principle

How to address it

1. Make exercises time contingent

i. Do not let pain or symptoms determine the number of repetitions or exercise duration. ii. It will require the reconceptualisation of pain to exercises and in a later stage to daily physical activities, eg. gardening and lifting heavy objects.

2. Goal setting

i. Let the patient define their treatment goals. ii. Use the predefined goals to design the exercise programme. iii. Use the goals for motivating patients. iv. Goals should be SMART – Specific, Measurable, Achievable, Realistic, Time-targeted.

3. Address perceptions about exercise

i. Question (and if required discuss thoroughly) the patient’s perceptions about the exercises (before, during and after exercise). ii. Include discussion of the anticipated consequences of the exercises. iii. Asking questions like: “Is this particular exercise threatening for your back?” “ How confident do you feel being able to successfully do this exercise/movement/activity?” “Do you feel that the exercise is useful for your recovery?” iv. It may reveal irrational fear about performing an exercise, ask yourself and the patient why they feel it is dangerous: “Why do you think this exercise is dangerous for you?” “What do you think will happen when you perform the exercise?” v. By challenging the nature of and reasoning behind a patient’s fears, the therapist may be able to decrease the anticipated danger or threat level for an activity thereby assuring them of their safety and increasing confidence and belief in movement. In some cases a graded exposure to an exercise may be required to build trust. vi. The therapist should be aware of ‘inappropriate safety behaviour’ – co-contraction of stabilisation muscles or segmental stabilisation exercises. Patients may use this to convince themselves of their ability to successfully perform an exercise or physical activity. This kind of behaviour can enhance the biomedical perceptions of the patient and, hence, increases the threat value of performing the exercise/activity. vii. Once an exercise has been performed for the first time, discuss with the patient their experience. Generally, the threat value of the exercise(s) decreases after performance. This is due to the fear and anticipated pain pre-exercise versus the actual experience and pain. Even if the pain increase following exercise is similar to that which was anticipated, the threat value of the exercise may be decreased due to the patient’s enthusiasm and realisation of their ability to perform it. viii. The difference between actual and expected outcomes experienced through exercise is known as associative learning. Exposure of chronic pain patients to exercises or daily activities without danger aims to convince the brain of its ‘error.’ This is a crucial component to cognition-targeted exercise therapy.

4. Motor imagery

i. When progressing to a next level of (more difficult) exercises, a preparatory phase of motor imagery can be useful.

5. Address feared movements

i. Retrain pain memories especially for feared movements. Discuss the fear and challenge the patients negative perception of the consequences. Apply graded exposure if necessary. ii. A final step in exercise therapy would be performing exercises during a physically demanding task or doing activities, and exercising under cognitively and psychosocially stressful conditions.

6. Make use of stress

i. Progress towards exercising under cognitively and psychosocially stressful conditions. ii. This includes performing simple exercises (eg. rotation together with extension of the neck), not only while sitting comfortably on a kitchen chair, but also while walking and during cycling or cleaning. iii. Stress, through the availability of cortisol and adrenaline in the brain, facilitates long-term potentiation of brain synapses especially of excitatory synapses. iv. This is often the case when feared exercises are practised, often after a long time of avoiding these movements/ activities. v. Provoking the ‘painful movement’ will definitely elicit a stress response. vi. However, increasing stress can also increase central sensitisation. It is a balance between enough stress to cause memory consolidation but not enough to increase central sensitisation.

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STEP 7: How Much Pain?

So, you have done all this work about building trust, changing mindsets about pain and tissue threats, endeavouring to reverse sensitisation, fear and pain memories and yet the question still remains: How much pain should a patient experience during therapeutic exercise? For the clinician there is little (and often conflicting) information on what to advise patients. Cross-sectional online questionnaires tell us many clinicians advise patients to avoid pain altogether, whereas others recommend patients can continue if the exercises: 1. only provoke pain below a certain level (2/10 to 4/10 on a VAS); 2. are only ‘moderately’ painful; 3. are associated with pain that remains ‘acceptable to the patient’ (22). What is ‘acceptable’ or ‘moderate’ to one person can be completely different to another and illustrates the lack of sufficient quantifiable clinical data. When a chronic pain patient receives exercise instructions from multiple clinicians with differing guidelines on how much, if any, pain is to be experienced during and after exercise, it is likely to undermine the patient’s trust and belief in therapy and discourage them from adhering to any of the exercises. So, regardless of what is decided as best for your individual patient, ensure there is consistency across the team of clinicians you work with (22*). In the published version of Consensus on Exercise Reporting Template (a guide for researchers conducting RCTs), exercise-related pain only exists as an ‘adverse event’. It defines an adverse event as “an untoward occurrence, which may or may not be causally related to the intervention or other aspects of trial participation” (7*). Classifying pain as an adverse event biases exercise therapy towards being pain free. There is no recommendation or requirement to include different levels of pain during exercise in RCTs. Thus only seven RCTs have investigated painful versus pain-free exercises (7*). As a result, clinicians have very little information with which to answer patients’ questions about exercise-related pain, and it is no surprise that clinicians advise 20

inconsistently. Let’s be honest, you are often forced to use your own clinical judgement.

Conclusion

The experience of and response to pain associated with exercise or movement is vitally important to so many conditions; and may be the critical factor to successful recovery or not. A patient’s pain experience is currently absent from most reporting or assessment guidelines. With more data being published about potential benefits of allowing exercise with pain, the following are questions future researchers will have to address (and are no doubt questions you have in daily practice). l Pain during exercise. Is it allowed and/or recommended; and if so to what level or extent. How is pain defined or described? What about patients with pain at rest – what level of pain are they permitted during exercise? l Pain after exercise. Is pain after exercise acceptable and if so for how long? If the pain has increased is this a flare-up or exacerbation or an acceptable response to loading? Understanding the patient’s pain, pain experience and any psychosocial components to their pain will help provide you with some direction of the management the patient needs beyond standard treatment and what else may need addressing if the patient is not getting better within the expected time frames. Using a framework to guide your assessment will be beneficial. Management itself does not need to be complex. Having the right pain education tools, questions and communication skills, as well as a graded cognition-targeted exercise plan may be the key to freeing patients from the fear and constraints of chronic pain. References

1. Sullivan MJ, Thorn B, Haythornthwaite JA et al. Theoretical perspectives on the relation between catastrophizing and pain. Clinical Journal of Pain 2001;17(1):52–64 Open access https://bit.ly/3ulsypR 2. Burri A, Ogata S, Rice D, Williams F. Pain catastrophizing, neuroticism, fear of pain, and anxiety: Defining the genetic and environmental factors in a sample of female

twins. PLoS One 2018;13(3):e0194562 Open access https://bit.ly/3fRAtGq 3. Fisher E, Heathcote LC, Eccleston C, Simons LE, Palermo TM. Assessment of pain anxiety, pain catastrophizing, and fear of pain in children and adolescents with chronic pain: a systematic review and metaanalysis. Journal of Pediatric Psychology 2018;43(3):314–325 Open access https://bit.ly/3hQaK3D 4. Geneen LJ, Moore RA, Clarke C et al. Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. Cochrane Database of Systematic Reviews 2017;1(1):CD011279 Open access https://bit.ly/3yDDSkp 5. Pedersen BK, Saltin B. Exercise as medicine – evidence for prescribing exercise as therapy in 26 different chronic diseases. Scandinavian Journal of Medicine & Science in Sports 2015;25(Suppl 3):1–72 Open access https://bit.ly/3bQZK1V 6. Meulders A. Fear in the context of pain: Lessons learned from 100 years of fear conditioning research. Behaviour Research and Therapy 2020;131:103635 Open access https://bit.ly/3yyx6g1 7. Smith BE, Hendrick P, Smith TO et al. Should exercises be painful in the management of chronic musculoskeletal pain? A systematic review and metaanalysis. British Journal of Sports Medicine 2017;51:1679–1687 Open access https://bit.ly/2QTDVYz 8. Smith BE, Moffatt F, Hendrick P et al. The experience of living with patellofemoral pain—loss, confusion and fear-avoidance: a UK qualitative study. BMJ Open 2018;8(1):e018624 Open access https://bit.ly/3flRB8b 9. Bunzli S, Smith A, Schütze R, O’Sullivan P. Beliefs underlying pain-related fear and how they evolve: a qualitative investigation in people with chronic back pain and high pain-related fear. BMJ Open 2015;5(10):e008847 Open access https://bit.ly/3uoIOGu 10. Smith BE, Hendrick P, Bateman M et al. Musculoskeletal pain and exercise— challenging existing paradigms and introducing new. British Journal of Sports Medicine 2019;53(14):907–912 Open access https://bit.ly/2QMQ5T1 11. Nijs J, Girbes EL, Lundberg M et al. Exercise therapy for chronic musculoskeletal pain: Innovation by altering pain memories. Manual Therapy 2015;20(1):216–220 12. Mitchell T, Beales D, Slater H, O’Sullivan P. The Musculoskeletal Clinical Translation Framework (MCTF): from knowing to doing. Musculoskeletal Framework Team 2020; eBook Purchase at their website https://bit.ly/3fkGxb3 13. Linton SJ, Nicholas M, MacDonald S. Development of a short form of the Örebro Musculoskeletal Pain Screening Questionnaire. Spine 2011;36(22):1891– 1895 14. Awang H, Shahabudin SM, Mansor N. Return-to-work program for injured workers: Co-Kinetic Journal 2021;89(July):14-21

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factors of successful return to employment. Asia Pacific Journal of Public Health 2016;28(8):694–702 15. Godges JJ, Anger MA, Zimmerman G, Delitto A. Effects of education on return-towork status for people with fear-avoidance beliefs and acute low back pain. Physical Therapy 2008;88(2):231–239 Open access https://bit.ly/3wAp18Q 16. Nijs J, Meeus M, Cagnie B et al. A modern neuroscience approach to chronic spinal pain: combining pain neuroscience education with cognition-targeted motor control training. Physical Therapy 2014;94(5):730–738 Open access https://bit.ly/2REM2ss 17. Malfliet A, Kregel J, Meeus M et al. Applying contemporary neuroscience in exercise interventions for chronic spinal pain: treatment protocol. Brazilian Journal of Physical Therapy 2017;21(5):378–387 Open access https://bit.ly/2TieZuC 18. Nijs J, Leysen L, Vanlauwe J et al. Treatment of central sensitization in patients with chronic pain: time for change? Expert Opinions in Pharmacotherapy 2019;20(16):1961–1970 19. Malfliet A, Kregel J, Coppieters I et al. Effect of pain neuroscience education combined with cognition-targeted motor control training on chronic spinal pain: a randomized clinical trial. JAMA Neurology 2018;75(7):808–817 Open access https://bit.ly/3fiQUwe

20. Louw A, Zimney K, Puentedura EJ et al. The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature. Physiotherapy Theory and Practice 2016;32:332–355 21. Rabiei P, Sheikhi B, Letafatkar A. Comparing pain neuroscience education followed by motor control exercises with group-based exercises for chronic low back

KEY POINTS

l Chronic pain affects up to 30% of the Western population. l Over the past decades, neuroscience has advanced our understanding about pain, including the role of central nervous system sensitisation – more briefly termed central sensitisation. lA stepwise musculoskeletal framework may help you and your patient successfully work through an assessment of their pain, which will lead you in the correct management path. l It is crucial that the patient understands that pain during exercise may not mean further trauma or damage and they fully grasp the concept of central sensitisation. l Clinicians should treat the patient as a biopsychosocial human being suffering from chronic pain, and take central sensitisation into account when educating, designing and delivering the treatment. l Management will require the correct questions, discussions and cognition-targeted exercises for patients to overcome their fear, avoidance and altered movement patterns and change their pain memories. l Pain neuroscience education combined with cognition-targeted motor control training is superior to usual care at reducing pain and improving function and pain cognitions. l Recent studies have shown that pain during therapeutic exercise is superior (in reducing pain and improving function) to pain-free exercise when treating patients with chronic pain.

RELATED CONTENT

lP ain: The Brain’s Interpretation of Danger [Article] https://bit.ly/3fEN7rX lT he brain, movement and pain: part 1 [Article] https://bit.ly/3fzr99G lT he brain, movement and pain: part 2 [Article] https://bit.ly/3vgvntv

DISCUSSIONS

l What is your experience and predicted success rate in changing patients’ mindsets about central sensitisation of pain? l Have you used a ‘cognition-targeted’ exercise programme in the past? l What are you thoughts about allowing patients to exercise with pain and if yes, how much pain would you advise?

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Tweet this: Pain catastrophising is associated with heightened pain intensity and severity https://bit.ly/3pweyZI Tweet this: Exercise or general physical activity is a proven treatment for managing chronic pain https://bit.ly/3pweyZI Tweet this: In chronic musculoskeletal pain, ongoing peripheral nociceptive triggers are rare https://bit.ly/3pweyZI Tweet this: Chronic pain patients need pain neuroscience education before beginning exercise therapy https://bit.ly/3pweyZI Tweet this: The goal of cognition-targeted exercise therapy for chronic pain is systematic desensitisation https://bit.ly/3pweyZI Co-Kinetic.com

pain: a randomized controlled trial. Pain Practice 2021;21(3):333–342 22. Smith BE, Riel H, Vicenzino B, Littlewood C. Elephant in the room: how much pain is ok? If physiotherapy exercise RCTs do not report it, we will never answer the question. British Journal of Sports Medicine 2020;54:821–822.

THE AUTHOR Kathryn Thomas BSc Physio, MPhil Sports Physiotherapy is a physiotherapist with a Masters 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

PAIN IN THE ATHLETE 21-07COKINETIC | PAIN FORMATS WEB MOBILE PRINT All references marked with an asterisk are open access and links are provided in the reference list

hen we discuss pain, especially chronic pain, we tend to develop an image of an older person limping into the clinic who has recently been booked off work because of their pain. Or maybe someone with a persistent shoulder pain who can no longer comb their own hair for fear of raising their arm. It is not often you think of a strong, fit athlete suffering from central sensitisation of pain. However, to be honest, I think most competitive and professional athletes have some degree of chronic or persistent pain somewhere in their body at some time! When an athlete is injured, we often think of an acute traumatic injury, be it a hamstring or ankle strain or an overuse injury related to poor training habits or biomechanical errors. We know musculoskeletal pain is common in athletes, but we must remember it is not always associated with injury (ie. tissue damage) (1*). Damage occurs when load exceeds tissue tolerance, such as a ligament tear or a fracture. However, pain in athletes that occurs in the absence of trauma and tissue damage is still often labelled as an ‘injury’ by clinicians, coaches and athletes themselves (2). This highlights a gap between knowledge (tissue damage is not necessary for pain) and practice (assuming that all pain arises from tissue damage) in our clinical community (1*,3). This applies particularly in the area of acute nontraumatic pain, such as back and joint pain (2). To help bridge this gap, Caneiro et al. (2) have outlined the eight principles discussed below to guide clinicians who manage musculoskeletal pain in sport, trying to reinforce that there is more to pain than simply tissue damage!

Many competitive and professional athletes live with some form of chronic or persistent pain that is not caused by tissue damage. This article will allow you to distinguish between ‘pain’ and ‘injury’ and to treat pain in the athlete in a holistic manner using physical therapy as well as a biopsychosocial approach, a positive unified message across the interdisciplinary team, informed and shared decision-making that empowers the athlete. Read this article online https://bit.ly/2Scomfi By Kathryn Thomas BSc MPhil

1. In the Absence of Trauma, Pain Does Not Necessarily Indicate Tissue Damage

l Do not assume pain indicates tissue damage. l Labels such as ‘sports injury’, ‘overuse injury’ or ‘microtrauma’ convey that pain is caused by tissue damage, resulting in over-protection of the athlete. l Although pain related to repetitive loading may be associated with a stress fracture, pain that presents with no identifiable pathoanatomical basis should not be labelled or treated as tissue damage (3). l In the absence of trauma and relevant pathology, the use of labels such as sports-related ‘knee pain’ rather than ‘knee injury’, enables clinicians to practice in line with guidelines, while exploring and targeting modifiable factors relevant to the athlete’s pain experience (2).

2. No Imaging

in athletes who have no pain (ie. disc bulges, degeneration and labral tears, thickening of tendons) (3,4). l Imaging an athlete with no red flags or indicators of specific pathology increases the risk of clinicians mislabelling them as having ‘pathology’, and attributing such findings as the cause of pain. Inaccurate and threatening health information can adversely impact the athlete and lead to invasive interventions. Many athletes have ‘positive’ imaging findings and are completely asymptomatic (5,6,7*). l When imaging is not indicated, clinicians must reassure patients and provide an evidence-informed alternative explanation for their symptoms (2).

3. Explore Biopsychosocial Factors that May Contribute to Pain

IN THE ABSENCE OF TRAUMA/RELEVANT PATHOLOGY, USE THE TERM ‘PAIN’ RATHER THAN ‘INJURY’

Although we may put some athletes into ‘godly’ realms, don’t forget an athlete is also human. They have stress, anxiety, home, family and work commitments which could all be a part of their current complaint. l Musculoskeletal pain is modulated by the interplay of different biopsychosocial factors (8*), such as training load, conditioning, levels of fatigue, sleep quality, stress, mental health, and abdominal obesity (3,9,10). l Patient-centred communication

Co-Kinetic Journal 2021;89(July):22-24

l DO NOT refer the patient for imaging unless it will directly influence care, or when there is suspicion of serious or specific pathology. l Many imaging findings are present

PHYSICAL THERAPY

DO NOT ASSUME THAT PAIN INDICATES TISSUE DAMAGE and psychosocial screening tools form an integral part of the assessment of athletes with acute non-traumatic musculoskeletal pain (11). This enables clinicians to explore how different biopsychosocial factors interact to influence the athlete’s pain experience (Table 1).

4. Positive Messages

Deliver positive messages about pain during examination and treatment. l Positive language validates the athlete’s pain experience while reducing the perception of threat and fear (12*). l Pain during examination and treatment should be framed as tissue sensitivity rather than tissue damage (12*). l Reinforce that the body is strong, trustworthy and adaptable (2). l Behavioural experiments can be used to reinforce positive messages that the athlete is safe when engaging in feared, avoided or pain provocative movements and activities (12*). l Engage athletes in graded loading and time-contingent rather than pain-contingent participation. This promotes a message of body confidence and reinforces that movement and loading are protective (9).

5. Improve Tissue Tolerance to Load and Sports Exposure l Rehabilitation programmes must involve graduated exposure to movement and loading (sports specific), and also meet strength and conditioning needs for the athlete to remain active and/or return to sport (2). l Mental and physical resilience should be built into their rehabilitation. This may include helping individuals sleep better, be more resilient to stress and maintain a healthy body weight (2).

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6. Use Passive Treatments Only as an Adjunct to Active Management

l Although passive treatments may provide short-term pain relief, in isolation they may undermine the athlete’s self-efficacy and create dependency (2).

7. Use Shared Decision-Making to Build Self-Efficacy l Educating and engaging the athlete in a process of informed and shared decision-making will help build the athlete’s self-efficacy (2). l This empowers athletes to take charge of their health, make evidence-informed treatment choices and effectively advocate for themselves when communicating with stakeholders including, clinicians, coaches, media, sponsors and family (2).

8. Use an Interdisciplinary Approach to Deliver a Unified Message l Adopt a uniform narrative about non-traumatic pain across medical and coaching staff to ensure the athlete has consistent health messages regarding treatment and sports participation (2,9). l This is particularly important when athletes have comorbidities such as diabetes, Crohn’s disease and mental health disorders (2).

Figure 1: Infographic of the key points to remember when treating athletes in pain. Available at Caneiro JP, Alaiti RK, Fukusawa L et al. There is more to pain than tissue damage: eight principles to guide care of acute non-traumatic pain in sport. British Journal of Sports Medicine 2021;55:75–77 (2).

In order to implement these principles a cultural change may be required within sports and sports medicine. Clinicians, athletes, coaches and the general sporting community may present enormous barriers as pain beliefs are reinforced from a young age, past experience, access to early imaging, treatment expectations and the provision of quick fixes, along

Table 1: Examples of athlete-centred communication to explore biopsychosocial factors (11,12*) Factor to explore

Questions to ask the patient

Pain onset

“Tell me how this pain started.” “What was the context around the time of pain onset?”

Sleep quality

“Have you been sleeping well regularly?”

Stress levels

“How would you rate your levels of stress lately?”

Pain beliefs

“What do you think this pain means?”

Pain emotions

“How does this pain make you feel?”

Causal beliefs

“What do you understand is the cause of your pain?”

Understanding of imaging

“What is you understanding of your scan results?”

Avoidance beliefs

“Why do you think you shouldn’t bend/lift/run/play?”

with conflicting messages regarding training and return to sport for athletes in pain. Even with ‘buy-in’ from clinicians, coaches and athletes, this new paradigm of pain beyond the domain of tissue damage will surely provide some challenges during implementation. See the paper by Caneiro JP et al. for the handy quick reference infographic (Fig. 1) that summarises the key points to remember when treating athletes in pain (2). References

1. Hainline B, Derman W, Vernec A et al. International Olympic Committee consensus statement on pain management in elite athletes. British Journal of Sports Medicine 2017;51:1245–1258 Open access https://bit.ly/3upalrH 2. Caneiro JP, Alaiti RK, Fukusawa L et al. There is more to pain than tissue damage: eight principles to guide care of acute nontraumatic pain in sport. British Journal of Sports Medicine 2021;55:75–77 3. Hainline B, Turner JA, Caneiro JP et al. Pain in elite athletes – neurophysiological, biomechanical and psychosocial considerations: a narrative review. British Journal of Sports Medicine 2017;51:1259–1264 4. Zadro JR, Harris IA, Abdelshaheed C et al. Choosing wisely after a sport and exercise-related injury. Best Practice and Research Clinical Rheumatology 2019;33(1):16–32 5. Mascarenhas VV, Rego P, Dantas P et al. Imaging prevalence of femoroacetabular impingement in symptomatic patients, athletes, and asymptomatic individuals: a

systematic review. European Journal of Radiology 2016;85(1):73–95 6. Mosler AB, Agricola R, Weir A et al. Which factors differentiate athletes with hip/groin pain from those without? A systematic review with meta-analysis. British Journal of Sports Medicine 2015;49(12):810 Open access https://bit.ly/3fIb1ml 7. Bezuglov E, Khaitin V, Lazarev A et al. Asymptomatic foot and ankle abnormalities in elite professional soccer players. Orthopaedic Journal of Sports Medicine 2021:9(1):2325967120979994 Open access https://bit.ly/2Sp0ynP 8. Brodal P. A neurobiologist’s attempt to understand persistent pain. Scandinavian Journal of Pain 2017;15:140–147 Open access https://bit.ly/3ukn9zk 9. Gabbett TJ. Debunking the myths about training load, injury and performance: empirical evidence, hot topics and recommendations for practitioners. British Journal of Sports Medicine 2020;54:58–66 10. Cahalan R, O’Sullivan P, Purtill H et al. Inability to perform because of pain/injury in elite adult Irish dance: a prospective investigation of contributing factors. Scandinavian Journal of Medicine & Science in Sports 2016;26:694–702 11. Lin I, Wiles L, Waller R et al. Patientcentred care: the cornerstone for highvalue musculoskeletal pain management. British Journal of Sports Medicine 2020;54(21):1240–1242 12. Smith BE, Hendrick P, Bateman M et al. Musculoskeletal pain and exercise– challenging existing paradigms and introducing new. British Journal of Sports Medicine 2019;53(14):907–912 Open access https://bit.ly/2QMQ5T1.

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DISCUSSIONS

l Think about the language that you usually use when treating athletes with pain – is there anything you need to change or tweak? l It is hard for the general population to understand that apparent ‘pathology’ seen by imaging is not necessarily the cause of their pain. How do you reassure your patient that, in the absence of red flags, imaging is not needed? l How do you incorporate a biopsychosocial approach into your practice and is there anything you could do to improve it? If you don’t, how would you start?

KEY POINTS

l I n the absence of trauma, pain does not necessarily indicate tissue damage. l I maging is not needed unless it will directly influence care or if there are red flags for a serious or specific pathology. lB iopsychosocial factors that may contribute to pain need to be explored. lD eliver positive messages about pain during examination and treatment. l I mprove tissue tolerance to load and sports exposure. lP assive treatments should only be used as an adjunct to active management. lU se shared decision-making to build the athlete’s capacity for self-efficacy. lE nsure that a unified and consistent message is delivered to the athlete from all members of their multidisciplinary care team.

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 Co-Kinetic Journal 2021;89(July):22-24

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WORKING WITH THE LONG COVID CLIENT: A MASSAGE THERAPIST’S PERSPECTIVE

ovid-19 is the now-familiar name for the disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus that led to a global pandemic starting in 2020. As with most viral infections many people caught the disease and recovered well. However, what has become apparent are the long-term effects that the virus can have. More so than any disease studied in recent years, a significant number of people who are infected with Covid-19 can still experience symptoms more than 12 weeks after infection. This is termed long Covid (1*). What we are learning is that the presenting symptoms can be wide and varied (Box 1) in both the acute and long Covid stages. Fatigue (94%) and dyspnoea (89.5%) are the most commonly experienced (2*), but patients usually experience a ‘cluster of symptoms which can fluctuate and change over time and can affect any system in the body’ (1*).

What Is Happening to the Body?

Initially SARS-CoV-2 was treated as a respiratory virus but the medical world soon realised that this did not do justice to the damage it causes as it quickly spreads within the body through the vascular system. Once in the lungs, SARS-CoV-2 triggers an immune response. In some people this has led to the detection of significantly high numbers of inflammatory cells, in quantities expressed as a ‘cytokine storm’ (4*,5*). The influx of the immune cells in the presence of the virus causes damage to some of the delicate lung tissues and allows the SARS-CoV-2 virus to escape into surrounding tissues, usually through blood vessels into the rest of the body. Using our blood vessels as its own transport system, SARS-CoV-2 has an effective way of latching onto a variety of cell membranes via ACE2 (angiotensinconverting enzyme 2), found in blood Co-Kinetic.com

As of April 2021, it is estimated that there are 1.1 million people in the UK living with long Covid, according to the Office of National Statistics: a condition that did not exist one year ago (https://bit.ly/3p2r8Qf). Yet, since March 2020 many massage therapists have been unable to work hands-on in clinic and so as a profession we have little or no clinical experience of treating people with long Covid. With many massage therapists being independent self-employed practitioners, how can we best inform ourselves for treating this new cohort of clients? We need to have some clear ideas to develop our clinical reasoning behind our treatments based on the experience of those within the medical profession. Even then, we need to realise that our understanding of long Covid is developing and, as yet, there is not a clear definitive strategy to ‘fix’ long Covid symptoms. Read this article online https://bit.ly/3x6FhyC vessels and many organs in the body (6*), as well as via NRP-1 (neuropilin-1) receptors, which are present in the olfactory bulb and in nerve cells (7*) including the brain stem. The brain stem controls many involuntary mechanisms in the body, such as breathing, blood pressure, heart rate, vomiting, respiratory rate and coughing (8*). Once it is attached to a receptor, SARS-CoV-2 uses various

BY SUSAN HARRISON BTEC L6, SMA 21-07-COKINETIC | COVID-19 FORMATS WEB MOBILE PRINT All references marked with an asterisk are open access and links are provided in the reference list

Box 1: Long Covid clients can experience more than one of any of the following symptoms Sourced Goërtz et al. ERJ Open Research 2020;6(4):00542-2020 (2); Al-Jahdhami et al. Oman Medical Journal 2021;36(1):e220 (3) l Breathlessness/dyspnoea, chest pain l Ongoing cough, change in voice, ‘lung burn’ l Fatigue and/or post-exertional fatigue l Poor sleep or sleep that isn’t refreshing l Brain fog, cognitive impairment, ‘fuzziness’, memory loss l Headaches l Orthostatic hypotension, dizziness, light-headedness l Muscle and joint pain l Skin rashes: urticaria, ‘Covid-toe’, skin mottling l Heart issues such as racing heart rate, myocarditis, arrhythmia l Anosmia (loss of smell), parosmia (distorted taste/smell) and ageusia (loss of taste) l Blood coagulopathy, microembolisms, stroke l Gastrointestinal issues, abdominal pain, nausea

Covid-19 infection

Virus triggers an immune response. In some instances there appears to be an overreaction leading to a cytokine storm

SARS-CoV-2

Olfactory entry

Lungs

Damage to the olfactory bulb indicates virus also utilises NRP-1 receptors

Organ damage

Damage to the lung’s alveolar tissue allows the virus to circulate via the blood stream using ACE 2 receptors which are on many cells throughout the body including blood vessels

NRP-1 receptors

ACE 2 receptors Damage to central nervous system

Close to the central nervous system this provides another entry point for the virus, possibly explaining how SARSCoV-2 detected in the brain

A simplified diagram to explain how SARS-CoV-2 can impact multiple systems in the body. Both ACE 2 and NRP-1 are widespread in the body and assist with multiple processes. Figure 1: How SARS-CoV-2 can impact multiple systems in the body

cellular proteins to cleave its spike and allow genetic material to infiltrate the cell. As with many bacteria and pathogens in the body, once detected, the body’s self defence mechanism kicks in with an immune system response. A variety of proinflammatory processes occur that can trigger a ‘cytokine storm’, which can cause organ failure (9*). This overreaction increases oxidative stress on

Biological eg. aching joints

Psychological eg. anxiety

Social eg. isolation Figure 2: Biopsychosocial model

the body (and can overwhelm the ability of the body to convert reactive oxygen using various biological systems), possibly fuelling further cellular destruction and inflammation (10*). A simplified diagram of these processes is shown in Figure 1.

So How Does All of This Information Help Us to Treat Long Covid Clients? Biopsychosocial Approach

The Jing method adopts a biopsychosocial approach to treating clients (Fig. 2) (11). This means trying to collate information about the biological symptoms a client is experiencing as well as any psychological and social factors that might be contributing to a person’s experience of good health. We know that if someone has chronic joint pain (biological symptom), it might affect their ability to go out as they are worried about the painful consequences (increasing social isolation) and they then become

more anxious about their condition (psychological factors). These can feed off each other and exacerbate symptoms. Salduker et al. point out that patients’ experiences of pain are profoundly influenced by their emotional and psychological wellbeing, social circumstances, cultural and spiritual beliefs (12*). Pain is isolating, emotionally exhausting and adversely impacts on social relationships, daily functions, sleep and self-worth. Then we have to factor in the effect of 2020–21 and lockdown on people’s subjective experience of Covid-19.

Informing Our Clinical Reasoning for Treatment

In informing our clinical thinking, we need to: l interpret the lessons learnt from medical and allied health professionals with respect to their knowledge on long Covid gained during a period when many massage therapists were unable to practice; l evaluate information learnt from Co-Kinetic Journal 2021;89(July):25-32

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other related pathologies where we have clinical experience, in particular those associated with post-viral syndromes and myalgic encephalomyelitis (ME) / chronic fatigue syndrome (CFS) and any crossover to long Covid; l cautiously apply our skills using an informed approach to develop a holistic treatment of long Covid knowing that there is not a ‘one size fits all’ approach because of the variability in symptoms not just between clients but also experienced by individual clients; and l accept that we are on a learning curve about treating long Covid and be aware of the need to refer to other professionals to work collaboratively to optimise outcomes for the client. Let’s review some of the implications from long Covid that we might need to consider during the planning of an advanced clinical massage programme. With long Covid, the damage is done. It is possible that the individual has medical evidence, such as scans, lung X-radiographs, blood test results, etc, that show actual tissue damage. Some of these test results for organ damage might be less clear if SARSCoV-2 has affected the brainstem or central nervous system. This might be because there is a neural component to the dysfunction. Equally we might be seeing clients who have not even had a positive test result for Covid-19, yet have the symptoms of long Covid. We need to consider the impact of any medication a person is having to take to combat the symptoms caused by the effect of Covid-19 infection. Eccles and Davies state that a person might actually be suffering from multiple syndromes at the same time: post-intensive care syndrome, postviral fatigue syndrome and/or long Covid syndrome (13*). We know that many people who are experiencing long Covid were not hospitalised and we need to factor in their thought processes: we can imagine a scenario where someone is thinking, “I wasn’t so badly affected Co-Kinetic.com

that I needed to be hospitalised but I just can’t understand why I … feel so tired … struggle with breathlessness … now have diabetes”. These are normal psychological processes in response to adversity (12*). Simplistically, we also know how one symptom can have an effect on another and when there are multiple issues to address where do we start?

What Can We Do When Treating Long Covid?

From a business perspective, we need to perform appropriate risk assessments about clinical practice and work within our code of conduct as identified by our professional associations. In our work with long Covid clients, the first step will be to take a really detailed consultation and be clear about a client’s goals of treatment, which will include asking the following questions. l Did they have any underlying ailments before Covid-19 infection? l What symptoms have they experienced since? l Have they seen any medical professionals for treatment? l Are they on any medication? l What were their activity levels like before Covid-19? l What are their activity levels like now? Consider using email or online client booking software to gain answers to these questions as part of your consultation form process in advance of an appointment. This will help clients who are struggling with fatigue and brain fog by allowing them the opportunity to answer questions in their own time. Getting this information in advance of the clinic appointment will help you to identify areas that need further assessment or medical clearance before treating. Depending on a person’s long Covid symptoms once you have the consultation form details, a video call to perform some initial assessment may be helpful. Once at clinic, most of the preparatory work for treatment will have been undertaken and a shorter appointment time might be

IT IS ESTIMATED OVER 1 MILLION PEOPLE IN THE UK ARE LIVING WITH LONG COVID appropriate for the client. However, from a business perspective, the client may benefit from a shorter treatment time but the overall work from a therapist’s perspective is probably in excess of a clinical hour’s work. You might, therefore want to review how you are charging for your appointments: do you need to consider splitting your costs to separate out consultation and treatment costs? During the consultation, Fairweather and Mari suggest that when treating a client with chronic pain identifying which one of their multiple issues they would like addressed during the treatment not only helps empower the client in the treatment process but makes them feel listened to, builds a therapeutic alliance and taps into the psychological aspect of treating a client yielding better results (11). The following are some questions that could be used during the consultation process that will really help benchmark the client’s current status and give you something concrete to measure changes against so that you can gain some ideas of the efficacy of treatment. l You have multiple areas that are causing you some difficulties, which one is the most problematic one for you that you would like us to work on and improve? l On a scale of 1 (low) to 10 (high) where would you say your pain levels are now? l Are there any particular movements that are challenging for you right now? Werner provides an overview of complications of Covid-19 on various body systems and the implications to treatment for massage therapists. This article merits reading in its own right for many therapists returning to work with Covid-19 clients and so a link is provided here: https://bit.ly/3pzd6FN (14*). Once a thorough assessment and consultation has been performed, what would be a cause for concern as treatments progress is the development of new symptoms such as: breathlessness, loss of sensation 27

or power, headache, confusion, heart palpitations and chest pain. These would necessitate immediate investigation and referral to a GP or A&E (Video 1). From a massage perspective any new skin rashes or blisters could be indicative of clotting issues and medical clearance before treatment is advised. Breathwork It is known that people who have been

Video 1: Post-acute Covid-19 advice and rehabilitation: long Covid recovery guidance (Courtesy of YouTube user The Physio Channel) https://www.youtube.com/watch?v=zUFS_SAkovc

Video 2: Professor Lynne Turner-Stokes in RSM COVID-19 Series | Episode 32: Rehabilitation after the viral infection (Courtesy of YouTube user The Royal Society of London Medicine ) https://www.youtube.com/ watch?v=KW1Gdw9D_Pk

Video 3: TEDxAdelaide: Lorimer Moseley – Why things hurt (Courtesy of YouTube user TEDx Talks) https://www.youtube.com/ watch?v=gwd-wLdIHjs 28

ventilated can have some cognitive impairment but some problems with memory loss are also being experienced by people who had Covid within the community. This might be related to low levels of oxygen (hypoxia) experienced by people who were not hospitalised but managed their symptoms at home [Video 2 (15*)]. See Further Resources 1 and 2 for more information on the effects of Covid-related hypoxia (https://bit.ly/2R2Zaag) and postCovid rehabilitation management (https://bit.ly/3p1zGqm). For symptoms such as anxiety, brain fog or fatigue some gentle breathing exercises may be hugely beneficial. Research on patients diagnosed with postural orthostatic tachycardia syndrome has also shown the benefits of breathing exercises on managing their symptoms (16*). Covid-19 may cause dysfunctional breathing patterns so getting clients to engage with diaphragmatic breathing and optimising that may help with reducing some of these other symptoms also (17*). The importance of optimal breathing during activities has been advocated for years. For long Covid clients, exercise where the effort to perform a task requires breath holding needs to be avoided. This will minimise risk of increasing fatigue and also possible stroke (18*). Crucially though, with chronic pain conditions such as ME/CFS – and let’s put long Covid in this category as well since it has many overlaps with a variety of post-viral syndromes – a key phrase used by Fairweather and Mari is ‘less is more’ (11). For these clients, do not overdo it. Their autonomic nervous system is easily overloaded and there is a balance to maintain between treating and overtreating these clients: our enthusiasm to help may inadvertently create a temporary worsening of symptoms. So, spend time on techniques such as breathing, after all, if you can’t breathe how can you expect to do anything else! Heat/Cold Therapies The use of heat needs to be assessed carefully. If a client has any pins and needles or loss of sensation arising

from neuropathy since Covid-19, careful evaluation of risk versus benefit needs to be made before using hot/ cold therapies. Many therapists use heat during treatment. Hot stones, heated underblankets and wheat-bags can dilate blood vessels and combined with the focus of the treatment lead to a reduction in blood pressure. Therefore, caution should be used when treating clients who experience dizziness, lightheadedness and/or postural hypotension dysfunction (orthostatic intolerance). Getting long Covid clients with orthostatic intolerance to squeeze and relax their hands and legs before sitting up may help stimulate the circulatory system to prepare for an adjustment in position. Once seated, a glass of water may also help to minimise any postural orthostatic intolerance thereby reducing any symptoms before the client leaves the clinic. Adjustment of Manual Pressure During Treatment Massage has been shown to be effective in reducing stress and anxiety in many studies (19,20*,21,22*). Adapting pressure to the individual needs of the client will also have to be taken into consideration to maximise the benefits for the autonomic nervous system. Diego et al. found that moderate pressure exerted a better effect on reducing stress measurements than light pressure (19). This study potentially has relevance in the treatment of long Covid clients with heart-related issues as it demonstrated relaxation of the heart muscle using EEG assessment. So, depth of pressure and rhythm of each stroke could be factors to review with each client. Research on chronic pain has shown that in many instances the stimulation of neural pathways is hypersensitive to stimulation, whether a threat or not (Video 3). Activation of certain neural connections can lead to a disproportionate response from the brain, increasing pain. We sometimes see this when treating clients with fibromyalgia when even gentle work can have a profound effect. So, evaluating your client’s response to Co-Kinetic Journal 2021;89(July):25-32

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hands-on work will be an ongoing part of consecutive treatments. For many, not only might this be the first time they have received a massage it could also be the first time for many months that they have had listening touch applied to their body. This in itself could lead to significant emotional release and we need to realise that this could also be overwhelming to them.

LONG COVID IS WHEN SIGNS AND SYMPTOMS THAT DEVELOP DURING OR FOLLOWING AN INFECTION CONSISTENT WITH COVID-19, CONTINUE FOR MORE THAN 12 WEEKS AND ARE NOT EXPLAINED BY AN ALTERNATIVE DIAGNOSIS (1)

Coagulopathy and the Skin As many manual therapists work directly on the skin, a contraindication to treatment would be the presence of any skin reactions such as urticaria, lace type patterning of the skin, blisters, Covid toe, etc. Some of these could be an ongoing histamine response in the body as a result of the excitatory immune response or as a reaction to some of the medication taken to combat Covid-19 (23*). The first priority would be to assess if any presentation of skin symptoms are a local or global contraindication to treatment. If the client has not had these evaluated medically then err on the side of caution and refer back for medical review before commencing treatment. There is a risk that some skin issues are indicators of increased blood coagulopathy and in severe cases in acute Covid-19 infection, these can appear within 5 days before death (24*). Secondly, if the rash has been present for a long time, has the client been able to undertake any cardiovascular activities without adverse effects (chest pain, leg pains, swelling, etc)? These could indicate ongoing clotting problems that need to be medically assessed (25*). A client that presents with a history of clots arising from their Covid experience might still be on anticoagulants, usually for at least 3 months. Again, medical clearance is advised before treatment. Next, we might need to review the medium we use in treatment: wax, oil, water-based lubricant or no lubricant. A client whom we saw pre-Covid might experience some increased sensitivity to certain products post-Covid. This might not be just to the skin but possibly could include altered sense of

Stretching and Strengthening Exercises For many long Covid clients, one of their chief goals is to restore their energy levels so that they do not experience the fluctuations in fatigue that are so common. Post-exertional fatigue is sometimes accompanied by a drop in blood pressure (orthostatic hypotension) and/or tachycardia as well as feelings of lightheadedness, breathlessness, etc. This is in response to physical over-activity and is different to fatigue, which almost inhibits any type of exertion happening. Patients might also experience post-exertional malaise (PEM), which is when the onset of symptoms occurs usually 24 hours or more after the activity and can last for days, weeks or months (26*), and is disproportionate to the activity. This can be frustrating for the individual concerned but given that fatigue is such a prevalent after-effect of Covid-19, it needs to be addressed in the development of treatment protocols for long Covid clients. For clients with orthostatic intolerance, consider strength training exercises that can be undertaken while horizontal to start with before getting them into upright positions (27*). Studies on the effects of cardiopulmonary exercise testing on patients with ME/CFS (28*,29*) have found consistently lower performance in this cohort of patients than in control groups. Turner-Stokes states that an exercise programme for long Covid patients should not be undertaken without adequate supervision until their pulmonary and cardiovascular status is known [Video 2 (15*)]. Liaising with clients about what their current activity levels are and how that

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smell, such as parosmia, which could affect their treatment experience.

impacts upon them afterwards will be necessary to devise appropriate exercises for them. If this is not within your scope of practice or if your client is experiencing new breathing or heart-related dysfunctional symptoms then a referral back to their GP is advised to ensure there is no new underlying issues arising from long Covid. NICE guidelines reflect what has been learnt from working with ME/CFS patients and the approach of graded exercise is abandoned in favour of adopting a more person-centred approach to improving physical, mental, cognitive and emotional wellbeing (30*,31*). VanNess suggests that for moderately affected ME/CFS patients, a guideline used to monitor heart rate, activity and fatigue levels is to evaluate resting heart rate (let’s assume it is 85 beats per minute), and do not exceed 15 beats above normal resting heart rate initially (so 100 beats per minute) when undergoing activities (32*). This could be equivalent to just standing to make a cup of tea. An alarm can be set as a trigger for the client to rest and lower their heart rate. This simple approach has been used successfully to prevent PEM (32*). It might be a useful guideline to start using with long Covid clients for managing their own fatigue levels and it gives them a baseline from which to start their own rehabilitation successes. Suggestions for Self-Care Advice The Jing method of treatment acknowledges that the client plays an important role in their own recovery. This is clearly advocated for in teaching clients some appropriate selfcare (11). So, what guidelines could be safe suggestions for long Covid clients? Shepherd suggests that individuals with long Covid use strategies 29

BE AWARE OF ANY SKIN ISSUES THAT MIGHT INDICATE INCREASED BLOOD COAGULOPATHY AND REFER THE PATIENT IF NECESSARY adopted from his work with ME/CFS (33*): l Plan your activities not just for the day but the week ahead. l Prioritise what needs to be done. l Delegate any tasks to friends and family to help manage your tasks. l Explaining to family and friends why you need some support for a while will hopefully lessen the strain on yourself. Keeping an activity log can be a useful strategy to see if there are any triggers that lead to delayed fatigue in clients. When an individual is able to have a regular routine that they can maintain, at that point consider adding a new activity/task and monitor it. Recording their activities could have a positive psychological effect as it can show improvements that might not otherwise be measured. In addition, combining this with journaling could enhance the benefits. Francis and Pennebaker’s study on journaling showed that not only did this process help with the processing of events but it led to decreased blood pressure and reduced work absenteeism (34). Similar benefits in wellbeing have been seen among nurses (35*). Although no studies were found relating to Covid-19, it is an easy suggestion as a self-care tool that might be helpful to some clients.

For individuals who are suffering from brain fog, cognitive impairment, fatigue, etc, don’t underestimate the effort required to use smartphones, tablets and computers. Prioritise which tasks, including electronic ones, are needed. Cognitive learning can be aided by suggesting tasks such as colouring in, puzzle books, jigsaws, board games, etc (36*). A self-care suggestion for long Covid clients with breathing difficulties, brain fog or anxiety could be to join a choir as a study undertaken by the English National Opera (37*) showed that singing led to benefits in breathing and wellbeing. Not only will this help with breathwork but also provides an opportunity for social interaction. Referral to a dietician or nutritionist might be advisable. Clients with a loss, or distorted, sense of smell and/ or taste can experience decreased appetite and weight loss. Maes and Twisk identified a number of nutrients deficits in their study on ME/CFS patients, such as zinc, coenzyme Q10 and omega 3 (38*). These are some nutrients that contribute to many anti-inflammatory processes so addressing any nutritional imbalances could be beneficial for the long Covid client. Some foods also trigger histamine responses in the body thereby

Figure 3: Outline of olfactory training Sourced Whitcroft KL, Hummel T. Olfactory dysfunction in Covid-19: diagnosis and management. JAMA 2020;323(24):2512–2514 (39) Olfactory training Olfactory training for people experiencing anosmia after Covid is not routinely given. Use essential oil on a scent stick: sniff for 20s a day, twice a day, for at least 3 months.

Rose Lemon Clove Eucalyptus

Using images of rose, lemon, cloves and eucalyptus may help with anosmia but may not be helpful for people with parosmia

increasing inflammation. However, just advising a client to try a low histamine diet is insufficient as these diets are nutritionally lacking. Currently, advice on diet for long Covid is very personcentred and there is no specific Covidrelated advice. Whitcroft and Hummel suggest olfactory training as a potential way of relearning a sense of smell (Fig. 3) (39*). This process commonly uses rose, lemon, cloves and eucalyptus oil on scent sticks. These are oils that are commonly found and could be suggested as some self-care for clients. It might also be a strategy to help individuals with parosmia (a distorted sense of smell) along with some visualisation techniques, although there is no research available as yet to indicate if this could be effective. Finally, there are many long Covid self-help groups online. These can be a great support network to people enabling them to feel they are not alone experiencing these symptoms. It also allows people to discuss their symptoms in a non-medicalised well with people who have similar experiences.

What Happens Next?

Our understanding of long Covid is still in its infancy. There are some correlations with other pathologies and viruses but being clear about similarities and differences that give Covid-19 its unique set of characteristics is still a learning curve that we are on. Many therapists will have a huge variety of self-care techniques that can be delivered online or in clinic. With each client we will be selecting the tools to meet the needs of that individual. We should remember that as science strives to devise the best treatment programmes to help long Covid, we know that there is never a ‘one size fits all’ approach. This will also apply to us in clinic. Just as the medical world is adopting a multidisciplinary approach to treating long Covid, this is something we too should embrace. Know our individual strengths and find others with relevant skills to help support our clients. Covid-19 may herald new insights Co-Kinetic Journal 2021;89(July):25-32

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for many post-viral syndromes and ME/ CFS as the science tries to understand the impact of SARS-CoV-2. In the meantime, we embark on our own professional journey into treating this new pathology.

Further Resources

1. Østergaard L. SARS CoV-2 related microvascular damage and symptoms during and after Covid-19: Consequences of capillary transittime changes, tissue hypoxia and inflammation. Physiological Reports 2021;9(3):e14726 Open access https://bit.ly/2R2Zaag 2. Greenhalgh T, Knight M, A’Court C et al. Management of post-acute Covid-19 in primary care. BMJ 2020;370:m3026 Open access https://bit.ly/3p1zGqm. References

1. Covid-19 guideline scope: management of the long-term effects of Covid-19. National Institute for Health and Care Excellence (NICE) [NG188] 2020 Open access https://bit.ly/2SeWQxq 2. Goërtz YMJ, Van Herck M, Delbressine JM et al. Persistent symptoms 3 months after a SARS-CoV-2 infection: the postCovid-19 syndrome? ERJ Open Research 2020;6(4):00542-2020 Open access https://bit.ly/3ipr5wC 3. Al-Jahdhami I, Al-Naamani K, Al-Mawali A. The post-acute Covid-19 syndrome (long Covid). Oman Medical Journal 2021;36(1):e220 Open access https://bit.ly/34TKcH71 4. Zhang Y, Geng X, Tan Y et al. New understanding of the damage of SARSCoV-2 infection outside the respiratory system. Biomedicine and Pharmacotherapy 2020;127:110195 Open access https://bit.ly/3pvptmm 5. Que Y, Hu C, Wan K et al. Cytokine release syndrome in Covid-19: a major mechanism of morbidity and mortality. International Reviews of Immunology 2021:1–14 Open access https://bit.ly/3uXy8it 6. Tang T, Bidon M, Jaimes JA et al. Coronavirus membrane fusion mechanism offers a potential target for antiviral development. Antiviral Research 2020;178:104792 Open access https://bit.ly/3uZSk3s 7. Kyrou I, Randeva HS, Spandidos DA, Karteris E. Not only ACE2 – the quest for additional host cell mediators of SARSCoV-2 infection: Neuropilin-1 (NRP1) as a novel SARS-CoV-2 host cell entry mediator implicated in Covid-19. Signal Transduction and Targeted Therapy 2021;6(1):21 Open access https://go.nature.com/3v3CHI2 8. Yong SJ. Persistent brainstem dysfunction in long-Covid: a hypothesis. ACS Chemical Co-Kinetic.com

Neuroscience 2021;12(4):573–580 Open access https://bit.ly/3pzfI6z 9. Yang M, Lai CL. SARS-CoV-2 infection: can ferroptosis be a potential treatment target for multiple organ involvement? Cell Death Discovery 2020;6:130 Open access https://bit.ly/2S9Do5u 10. Wood E, Hall KH, Tate W. Role of mitochondria, oxidative stress and the response to antioxidants in myalgic encephalomyelitis/chronic fatigue syndrome: A possible approach to SARS-CoV-2 ‘long-haulers’? Chronic Diseases and Translational Medicine 2021;7(1):14–26 Open access https://bit.ly/3imVP19 11. Fairweather R, Mari M. Massage fusion: the Jing method for the treatment of chronic pain. Handspring Publishing 2015. ISBN 978-1-909141-23-0 Buy from Amazon (Print £32.50 Kindle £28.00) https://amzn.to/3fZ7Hoo 12. Salduker S, Allers E, Bechan S et al. Practical approach to a patient with chronic pain of uncertain etiology in primary care. Journal of Pain Research 2019;12:2651– 2662 Open access https://bit.ly/3ipG4q0 13. Eccles JA, Davies KA. The challenges of chronic pain and fatigue. Clinical Medicine 2021;21(1):19–27 Open access https://bit.ly/3z8mJj3 14. Werner R. Covid-19-related complications: implications for the massage therapist. Massage & Bodywork Digital 2020;September/October:44–53 Open access https://bit.ly/3pzd6FN 15. RSM COVID-19 Series | Episode 32: Rehabilitation after the viral infection. The Royal Society of Medicine [webinar chaired by Roger Kirby, President of The Royal Society of Medicine. YouTube 2020 Open access https://bit.ly/3g1nDGG 16. Reilly CC, Floyd SV, Lee K et al. Breathlessness and dysfunctional breathing in patients with postural orthostatic tachycardia syndrome (POTS): The impact of a physiotherapy intervention. Autonomic Neuroscience 2020;223:102601 Open access https://bit.ly/3510WvO 17. Siddiq MAB, Rathore FA, Clegg D, Rasker JJ. Pulmonary rehabilitation in Covid-19 patients: a scoping review of current practice and its application during the pandemic. Turkish Journal of Physical Medicine and Rehabilitation 2020;66(4):480–494 Open access https://bit.ly/3gAOrN9 18. Reinhard M, Schwarzer G, Briel M et al. Cerebrovascular reactivity predicts stroke in high-grade carotid artery disease. Neurology 2014;83(16):1424–1431 Open access https://bit.ly/3w5llfs 19. Diego MA, Field T, Sanders C, Hernandez-Reif M. Massage therapy of moderate and light pressure and vibrator effects on EEG and heart rate. International Journal of Neuroscience 2004;114(1):31– 44 20. Moraska A, Pollini RA, Boulanger K et al. Physiological adjustments to stress measures following massage therapy: a

review of the literature. Evidence-Based Complementary and Alternative Medicine 2010;7(4):409–418 Open access https:// bit.ly/3gh1FOT 21. Kütmeç Yilmaz C, Duru Aşiret G, Çetinkaya F. The effect of back massage on physiological parameters, dyspnoea, and anxiety in patients with chronic obstructive pulmonary disease in the intensive care unit: a randomised clinical trial. Intensive and Critical Care Nursing 2021;63:102962 22. Rapaport MH, Schettler PJ, Larson ER et al. Six versus twelve weeks of Swedish massage therapy for generalized anxiety disorder: preliminary findings. Complementary Therapies in Medicine 2021;56:102593 Open access https://bit. ly/2S7RdRT 23. Shams S, Rathore SS, Anvekar P et al. Maculopapular skin eruptions associated with Covid-19: a systematic review. Dermatologic Therapy 2021;34(2):e14788 Open access https://bit.ly/3przmBy 24. Droesch C, Do MH, DeSancho M et al. Livedoid and purpuric skin eruptions associated with coagulopathy in severe Covid-19. JAMA Dermatology 2020;156(9):1–3 Open access https://bit.ly/3g0w5pH 25. Werner R. Covid-19-related coagulopathy: blood clotting – through thick and thin. Massage & Bodywork Digital 2020;July/August:32–34 Open access https://bit.ly/3x2tktv 26. Wormgoor MEA, Rodenburg SC. The evidence base for physiotherapy in myalgic encephalomyelitis/chronic fatigue syndrome when considering post-exertional malaise: a systematic review and narrative synthesis. Journal of Translational Medicine 2021;19(1):1 Open access https://bit.ly/3gf9x3h 27. Fu Q, Levine BD. Exercise and nonpharmacological treatment of POTS. Autonomic Neuroscience 2018;215:20–27 Open access https://bit.ly/3iuChYR 28. Davenport TE, Lehnen M, Stevens SR et al. Chronotropic intolerance: an overlooked determinant of symptoms and activity limitation in myalgic encephalomyelitis/ chronic fatigue syndrome? Frontiers in Pediatrics 2019;7:82 Open access https:// bit.ly/3pyaLLw 29. van Campen C, Rowe P, Visser F. Validity of 2-Day cardiopulmonary exercise testing in male patients with myalgic encephalomyelitis/chronic fatigue syndrome. Advances in Physical Education 2020;10:68–80 Open access https://bit.ly/2RvdkBd 30. Torjesen I. NICE cautions against using graded exercise therapy for patients ecovering from Covid-19. BMJ 2020;370:m2933 Open access https://bit.ly/3gkLbFD 31. Myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome: diagnosis and management. In development [GID-NG10091]. NICE 2020 Open access https://bit.ly/2SfQ2zL 32. ME/CFS Clinician Coalition USA. 31

lC hronic Fatigue Patient Resources https://bit.ly/3gTLuIE

Neuroscience 2021;15:634158 Open access https://bit.ly/3xhJO1l 37. English National Opera’s singing programme for people recovering from Covid-19 rolls out nationally. Imperial College Healthcare NHS Trust [website]. News 2021, 28 Jan Open access https://bit.ly/3pybFaS 38. Maes M, Twisk FN. Why myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) may kill you: disorders in the inflammatory and oxidative and nitrosative stress (IO&NS) pathways may explain cardiovascular disorders in ME/ CFS. Neuro Endocrinology Letters 2009;30(6):677–693 Open access https:// bit.ly/3cpaNA1 39. Whitcroft KL, Hummel T. Olfactory dysfunction in Covid-19: diagnosis and management. JAMA 2020;323(24):2512– 2514 Open access https://bit.ly/3ilcK4d.

lC ovid-19 Patient Rehabilitation and Recovery Resources https://bit.ly/2CYgDJP

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Diagnosing and treating ME/CFS. Bateman Horne Center 2020. Open access https://bit.ly/3zbsP2c and https://bit.ly/3zbUu2Y 33. Shepherd C. Post Covid-19 fatigue, post/long Covid-19 syndromes and postCovid ME/CFS. The ME Association 2020 Open access https://bit.ly/3fZUrjl 34. Francis ME, Pennebaker JW. Putting stress into words: the impact of writing on physiological, absentee, and self-

reported emotional well-being measures. American Journal of Health Promotion 1992;6(4):280–287 35. Dimitroff LJ. Journaling: a valuable tool for registered nurses. American Nurse Today 2018;13(11):27–28 Open access https://bit.ly/2RwzLGd 36. Umejima K, Ibaraki T, Yamazaki T, Sakai KL. Paper notebooks vs. mobile devices: brain activation differences during memory retrieval. Frontiers in Behavioral

RELATED CONTENT

lR ehabilitation Following Covid-19 Part 1: Theoretical Considerations [Article] https://bit.ly/379wArx lR ehabilitation Following Covid-19 Part 2: Practical Applications [Article] https://bit.ly/2YcNjWT

KEY POINTS

l L ong Covid is the term used to describe individuals who have had Covid-19 and are still experiencing symptoms more than 12 weeks later. l Consider ways that clinic appointments can be adapted to help benefit long Covid clients. l Long Covid clients that experience new symptoms of breathlessness, loss of sensation or power, headache, confusion, heart palpitations or chest pain should be referred to a GP or A&E. l Be aware of the cautions regarding new symptoms but also understand that for existing chronic symptoms adopting a biopsychosocial approach to treatment and working within the client’s tolerances will be beneficial. l From your client consultation, understanding which long Covid symptoms are most problematic for the client will help give a framework to your treatment plan. l Be prepared for the emotional relief that listening touch could give to your clients but understand that for some clients, the protection offered by the ‘Stay at Home’ approach could increase anxiety. l Giving some self-care suggestions to clients to help them manage their symptoms can be empowering. l One of the most powerful tools available to us as massage therapists will be to help clients with breathing techniques. Breathwork can help calm the autonomic nervous system, reduce anxiety, improve memory, help reduce symptoms of postural orthostatic tachycardia syndrome. l Informing clients about pacing of activities is a strategy that may help clients manage their energy levels.

DISCUSSIONS

l The medical field has worked collaboratively to try to understand and treat Covid-19. How can we support long Covid clients and work with other professionals within medical and complementary fields to continue this holistic approach? l What skills/techniques/resources do you have in your toolbox to devise a bespoke treatment for long Covid clients? l What information could you prepare to provide your long Covid client with some self-care strategies?

Here are some suggestions

Tweet this: 1. A significant number of people still experience symptoms more than 12 weeks after Covid infection https://bit.ly/3x6FhyC 2. Long Covid patients often experience a cluster of symptoms usually including fatigue and dyspnoea https://bit.ly/3x6FhyC 3. Gentle breathing exercises may benefit long Covid symptoms such as anxiety, brain fog and fatigue https://bit.ly/3x6FhyC 4. Adapt manual therapy pressure to each client to maximise benefit to the autonomic nervous system https://bit.ly/3x6FhyC 5. Be aware of skin issues in long Covid patients indicating increased blood coagulopathy and refer on https://bit.ly/3x6FhyC THE AUTHOR Susan Harrison BTEC L6, SMA qualified as a massage therapist in 2008 and completed her BTEC L6 Advanced Clinical Massage at Jing Advanced Massage Training, Brighton, in 2012. Since then, she has worked in private clinics in Woking and at various multinational companies. In 2017 she started teaching at Jing and is now the programme co-ordinator for the BTEC L6. Deeply passionate about helping treat chronic pain, Susan has completed many courses in manual therapy, including ScarWork, Myofascial Release and Active Isolated Stretching and Strengthening; and a variety of rehabilitation courses including Anatomy in Motion, as well as Jing’s Exercise Rehabilitation course. In 2020 she joined the Sports Massage Association (SMA). Email: Susan@powertouchtherapy.co.uk Facebook: https://www.facebook.com/ PowerTouchTherapy Twitter: https://twitter.com/Powertouch_UK Co-Kinetic Journal 2021;89(July):25-32

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ONCOLOGY MASSAGE: THE LYMPHATIC SYSTEM Given that the statistics suggest that one in two of us will get cancer at some point in our lives, we will undoubtedly see patients who have been or are being treated for cancer. Massage therapy is beneficial in many ways, but the ill-informed therapist can also easily make their patients’ lives worse by triggering lymphoedema. This article gives you a brief overview of the lymphatic system, a thorough look at how it can be affected by cancer treatment and the adaptations that you need to make to your practice so that you can safely treat patients who have or at risk of developing lymphoedema. This article has been extracted from the authors’ book Oncology Massage: An integrative approach to cancer care, which is a must-read for anyone involved with people with or who have had cancer treatment. Read this article online https://bit.ly/3wtIV5C

21-07-COKINETIC | MASSAGE THERAPY FORMATS WEB MOBILE PRINT All references marked with an asterisk are open access and links are provided in the reference list

By Janet Penny RMT and Rebecca L. Sturgeon LMT, CMLDT

s noted in previous chapters of our book Oncology Massage: An integrative approach to cancer care, the effects of cancer treatment can continue for a long time (long-term effects) or can appear months or years after treatment has been completed (late effects). A massage therapist’s awareness of the changes in the body, even years after treatment, is essential to safe and effective practice. Often, cancer surgeries will involve the removal and biopsy of nearby lymph nodes. This creates an elevated risk for the patient to develop lymphoedema, a chronic condition that requires labour-intensive maintenance care. About 10 million people in the USA have lymphoedema, and it is estimated that 7 million of those individuals developed lymphoedema as a result of cancer treatment (1*). About 30–50% of people who have lymph nodes removed will develop lymphoedema. Some experts suggest that up to 30% of breast cancer survivors will develop lymphoedema. A 2011 study estimated that healthcare costs for cancer survivors who have lymphoedema can be up to US$10,000 per year more than for cancer survivors who do not have lymphoedema. Lymphoedema is also a primary quality of life indicator, which means that living with lymphoedema can negatively affect every aspect of a person’s life. The management of lymphoedema is time- and costintensive.

CANCER SURGERY THAT REMOVES LYMPH NODES (OR OTHER CANCER TREATMENTS THAT CAN RESULT IN LYMPH NODE DAMAGE) CREATES AN INCREASED RISK OF THE DEVELOPMENT OF LYMPHOEDEMA Co-Kinetic.com

People whose treatment has affected their lymphatic system will require massage adaptation for the rest of their lives, as massage therapy applied without proper education or adaptation could trigger lymphoedema. There are specific massage adaptations for lymphoedema, or lymphoedema risk. These adaptations are largely the same for all individuals who are at risk for lymphoedema. The oncology physician’s focus is treating cancer and concomitant issues, and so for a variety of reasons, comprehensive lymphoedema education may not be provided to patients. Massage therapists trained in oncology massage are well positioned to fill this gap (later in this article, Elizabeth K’s story will show how lack of knowledge about the condition can have significant consequences). It is our responsibility as oncology massage therapists to understand the causes and triggers of lymphoedema and to be able to communicate that information clearly to our clients. For this reason, the lymphatic system is covered in greater detail here.

Structure and Function of the Lymphatic System

The lymphatic system is vital to the health of the body. It is involved in multiple body functions, such as digestion, cellular transport and immune system function (2*). The lymphatic system consists of lymphatic vessels, nodes and lymphatic organs (Fig. 1), and functions to: l remove excess fluid from interstitial spaces; l absorb fatty acids and transport fat and chyle to the circulatory system; and 33

Tonsils

Liver

Thymus

l produce and transport immune cells (2*).

Spleen

Lymph Fluid

Lymph capillaries are intertwined with blood capillaries. The lymph capillaries drain excess fluid, proteins, fats, and larger molecules from the interstitium.

Figure 1: The lymphatic system consists of vessels, nodes, and lymphatic organs Lymph capillary

Tissue cells

Venule

Tissue/interstitial Arteriole space Lymphatic Flow of tissue ﬂuid vessel

Figure 2: Lymphatic and blood capillaries in the interstitium

The sections of lymph vessels can be likened to a string of pearls, and they are called lymphangions. As one lymphangion contracts, the Lymph valve opens, propelling lymphatic fluid to the next section of the vessel. Valve closed

Fluid entering lymphatic capillary

Valve open Overlapping endothelial cells Fluid entering lymphatic capillary

Figure 3: Lymph vessels consist of sections with one-way valves between each section

Lymphatic fluid, or lymph, is a whitish fluid which is drawn from the interstitial spaces and circulates in the lymphatic system (3). Lymph is different from the components of blood in that it is protein-rich, and as such, it is prone to infection if left stagnant. Lymphatic fluid moves through the lymphatic system in one direction, unlike the circulatory system which moves fluid through a closed circle. From the interstitial spaces, the lymphatic vessels pick up excess fluid and large molecules, and move the fluid through the vessels to a major lymph node cluster, then to the main drains of the lymphatic system which are located in the neck. From there, lymph flows into the circulatory system where waste material is filtered through the kidneys and excreted in urine. The circulatory system has a central pump, the heart, to move blood through the system. In the lymphatic system, there is no central pump. Fluid moves through the system primarily by means of skeletal muscular contraction or other forces which change the pressure gradient in the interstitial space, thus allowing the lymphatic vessels to open and fill with fluid. In deeper vessels, the lymphatic system also has intrinsic pumps, or smooth muscle, to move lymph through the body (2*).

Lymphatic Vessels

Lymphatic vessels roughly follow the structure of the blood vessels (Figs 2&3). They travel throughout the body and end in the interstitial spaces, or capillary beds. The smallest lymphatic capillaries rest in the capillary beds along with the blood capillaries. A large portion of the lymphatic system is located in the intestines. Here, the lymphatic vessels pick up intestinal fats and move it through the system, which gives lymphatic fluid its white colour. The most superficial lymphatic capillaries have overlapping cells connected to surrounding tissue by anchoring filaments. When the skin or surrounding tissue is stretched or displaced, the filaments pull on the

overlapping cells, creating an opening into the lymphatic capillary: fluid from the interstitial spaces is then drawn into the vessels. Lymphatic capillaries then flow into larger collecting vessels and finally into the lymphatic trunks located deep in the abdomen. These larger vessels have valves to prevent backflow of fluid. The vessels also have a small layer of smooth muscle to propel lymphatic fluid, although most fluid movement comes from skeletal muscle contraction. The larger lymphatic trunks move lymph into the right and left thoracic ducts, located in the supraclavicular fossa. There, lymphatic fluid is emptied into the subclavian vein and enters the circulatory system.

Lymph Nodes

Hundreds of lymph nodes are scattered throughout the body, with estimates ranging between 500 to 1000 from person to person. A large percentage of these lymph nodes are located in the abdomen. Outside the abdomen, lymph nodes are gathered into major clusters in the neck, axillae, and inguinal area. Lymph nodes are the main filtering station for lymphatic fluid as it moves through the body (3). Lymphatic fluid contains large molecules such as proteins and other waste products. As the lymph moves through node clusters, these molecules are filtered into smaller molecules that will eventually filter through the circulatory system (Fig. 4). The lymph nodes are also a way station for suspect cells. It is theorised that unusual or foreign cells are examined inside the lymph nodes, and if they are found to be dangerous or foreign to the body, the lymph nodes then recruit immune cells to destroy the invader cells (4). Swollen or painful lymph nodes are often the first sign of a virus or other infection. Many cancer surgeries involve removal and biopsy of lymph nodes because it is believed that cancer cells can use the lymphatic system to travel to distant sites in the body (metastasise). As the cancer cells enter the lymphatic system, some are trapped in lymph nodes and are discovered when the nodes are examined by a pathologist (Things to Think About 1). Co-Kinetic Journal 2021;89(July):33-43

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Dendritic cells

THINGS TO THINK ABOUT 1: The often-overlooked effects of manual lymph drainage (MLD)

Germinal center

by Julie Ackerman, LMT, CLT When we think of using MLD in an oncology massage setting, it is usually in terms of treating lymphoedema. While this is a wonderful use of this method, it leaves out what I consider the two most profound effects: relaxation and pain reduction. Last week I walked into my treatment room to greet my client Beth, an avid cyclist. She expressed a great deal of fear about her upcoming scans, fearful that her cancer had spread. Beth said that she was feeling anxious and was unable to sleep, and that her neck and shoulders were really achy. Our previous massage therapy sessions had always specifically addressed her issues of pain in her neck and shoulders. But today I thought a session of MLD would be beneficial. I remembered the words of my teacher Prof. Hildegard Wittlinger (founder of the Dr Vodder School International) that we should not forget that although MLD is wonderful for treating lymphoedema, the most important effects are relaxation and pain relief, and its ability to calm the nervous system. I suggested that we change the session from our usual massage techniques to MLD in order to help her relax, as well as decrease some of the pain in her neck and shoulders. Beth agreed, although with a bit of scepticism after I explained what the process, pressure and pace of MLD was. Beth is representative of many of my clients. She was initially annoyed when I explained what a safe and effective oncology massage session would be, in terms of the pressure and pace of the session. She had wanted the type of really deep pressure massages she had enjoyed before her cancer diagnosis. But at the end of each massage session she had with me she expressed, with a bit of surprise in her voice, that she loved the gentle touch and the relaxing rhythm. For this treatment, my intention for using MLD was to support Beth using light pressure – the weight of a nickel [5g]. The slow, constant rhythm of the technique which helps produce the relaxation response, supports a decrease in anxiety and provides an analgesic effect which aids in decreasing the tonicity in the muscles. Within a few minutes, Beth’s breathing slowed and became steady, her face relaxed and she dozed off and on throughout the session. After the session, she commented that “I have never felt so relaxed. I can’t believe that I even fell asleep and the achiness in my shoulders feels much better.” Two of the main benefits according to the Dr Vodder method of MLD are: lR elaxation (the sympatholytic response): The slow, gentle (the weight of a nickel), repetitive and rhythmic hand movements sedate the sympathetic nervous system and engage the parasympathetic nervous system. It serves to take us out of the ‘flight or fight’ reaction and allows us to experience deep relaxation. It is literally a sympathetic antagonist. lP ain reduction (the analgesic effect): The refined hand movements of MLD’s ‘stretch, twist, release’ affect the nociceptors (pain receptors) and mechanoreceptors (touch receptors) in the skin, and produce an inhibitory effort. The repetitive and rhythmical movements can decrease pain by interrupting transmission of pain signals to the brain. We can’t forget that people going through treatment for cancer are still humans with a history of emotional and physical issues that may have little to do with their cancer diagnosis. As in Beth’s case, she was dealing with her sudden anxiety but still had the chronic pain in her neck and shoulders. We need to treat the whole person and MLD can do just that.

Co-Kinetic.com

B cells

Dendritic cells

T cells

Macrophages Plasma cells Medulla

Cortex Outer Inner

Dendritic cells Some T cells B cells

Subcapsular sinus Dendritic cells

Lymphatic nodule Macrophages

The lymph node contains dendritic cells, as well as immune cells (T-cells, B-cells, macrophages.) The node can identify and destroy bacteria, foreign particles, and mutated or cancerous cells. Figure 4: Lymph capillaries leading into a lymph node (Creative Commons. Attribution-Share Alike 4.0 International license.)

Axillary

Cervical

Inguinal

Figure 5: The body is divided into quadrants: each section drains to the corresponding major lymph node cluster

Lymphatic Quadrants

In an unaffected, fully functioning lymphatic system, lymphatic fluid flows in one direction from the interstitial spaces through the body in a predictable pattern following specific anatomical pathways. The body has certain landmarks, called watersheds, where lymphatic flow changes course as it heads towards one of the main clusters of lymph nodes, eventually draining to the right or left thoracic ducts located in the supraclavicular fossa in the neck. [There are also many lymph nodes and larger vessels deep in the abdomen, but for the purposes of adapting oncology massage, a more involved understanding of the superficial lymphatic vessels is more important. Therapists who are interested in more detail about the lymphatic system are encouraged to pursue advanced training in manual lymph drainage (MLD) or the equivalent.] In the body, the lymphatic system is divided into quadrants (Fig. 5). Each quadrant directs fluid into one of the major lymph node clusters: the right or left cervical, the right or left axillary, or the right or left inguinal clusters. From there, lymphatic fluid moves into the supraclavicular fossa and the right or left lymphatic duct (Things to Think About 2) (3). 35

Box 1: In a fully functioning lymphatic system, lymphatic fluid drains as follows:

THINGS TO THINK ABOUT 2: Right and left ducts

l right head and neck → right cervical cluster l left head and neck → left cervical cluster l right upper quadrant → right axillary cluster l left upper quadrant → left axillary cluster l right lower quadrant → right inguinal cluster l left lower quadrant → left inguinal cluster.

The areas that drain into the right thoracic duct are: l right upper limb l right thorax l right side of the head and neck. The areas that drain into the left thoracic duct are: l left upper limb l left thorax l left side of the head and neck l both lower limbs.

The bold lines indicate the watershed lines on the body where lymphatic flow changes direction. The arrows show the direction of lymphatic flow. Note how fluid moves towards one of the major lymph node clusters (cervical, axillary, or inguinal). Figure 6: Lymph drains from different parts of the body in specific directions

Stage 1

Stage 2

Stage 3

Stage 4

Figure 7: Different stages of left upper quadrant lymphoedema (DocHealer. Creative Commons. Attribution-Share Alike 4.0 International license.)

Exercise

Phase 1 Reductive/ decongestive

Phase 2 Mainenance

Skin care and wound care

Manual lymph drainage

Compression bandages

Manual lymph drainage

Exercise

Compression garments

Figure 8: Complete decongestive therapy (CDT) for lymphoedema

For the majority of oncology patients whose lymphatic systems are affected by treatment, one of the body quadrants is compromised. For that reason, we will focus our discussion and adaptations to the body. The same principles can be applied to the head, neck, and face as well. The watershed lines in the body are (3): l the clavicle in front and spine of the scapulae in back (divides head/ neck from other body quadrants); l the centre line of the body in front and the vertebral column in back (divides left and right); and l the natural waistline all the way around the body (divides the upper and lower quadrants of the body). In a fully functioning lymphatic system, lymphatic fluid drains as described in Box 1 and shown in Figure 6. When a lymph node in one of the CDT for lymphoedema consist of two phases: decongestion and maintenance. Although the components of the therapy are the same in both phases, the decongestion phase is more aggressive and time-consuming. Patients may return to their therapist for daily bandaging, along with skin care, exercise, and MLD. In the maintenance phase, daily bandaging is replaced with wearing compression garments.

major clusters is removed or damaged by radiation, that entire body quadrant becomes compromised. Anyone with a compromised lymphatic quadrant is at risk for lymphoedema, for the rest of their life. Chemotherapy may also compromise the lymphatic system. Certain chemotherapies can affect lymphatic vessels, reducing their ability to transport fluid. As chemotherapy is a systemic treatment, we cannot identify an affected quadrant from chemotherapy alone. It is when chemotherapy is delivered in addition to surgical lymph node removal or radiation that the massage therapist must use lymphoedema precautions. When any of these standard biomedical treatments are used in combination (eg. surgery followed by radiation, or chemotherapy followed by radiation) the risk for developing lymphoedema increases exponentially.

Lymphoedema Causes and Triggers

Lymphoedema develops when lymphatic fluid becomes trapped in the interstitial spaces and produces swelling. The causes of lymphoedema are primary, secondary, or often some combination of the two. l Primary: caused by a congenital defect in the lymphatic system. This may be apparent at birth or early in life, or may be at a level that does not produce noticeable swelling unless some secondary cause is also present. l Secondary: caused when the lymphatic system is compromised through outside interference, most commonly lymph node damage or removal.

Most standard biomedical cancer treatments involve some increase in the risk for developing lymphoedema. Surgery for cancer treatment is the most common risk factor for developing secondary lymphoedema. Many cancer surgeries involve the removal of one or more lymph nodes, which are then tested for the presence of cancer cells. Radiation Co-Kinetic Journal 2021;89(July):33-43

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THINGS TO THINK ABOUT 3: Risk of lymphoedema The most important thing for massage therapists to remember is that removing or damaging even one lymph node in a major cluster increases the risk of developing lymphoedema. Therefore, massage therapists must adapt their techniques for every patient who has compromised lymph nodes, for every massage, every time.

therapy also increases risk. When a lymph node is in the field of radiation, it becomes damaged and unable to function properly, much the same as if it were removed outright. Some chemotherapies are also linked to increased lymphoedema risk. When multiple therapies are combined, the lymphoedema risk can be exponentially higher. Some chronic conditions, such as diabetes and hypertension, also add to lymphoedema risk (Things to Think About 3).

Triggers

Lymphoedema does not always develop immediately after a cause. It can develop years, or even decades after the cause. The damage to the lymphatic system, through removal of lymph nodes, for example, is the cause. Triggers, on the other hand, are behaviours or environmental factors which increase demand on the lymphatic system in such a way that lymphoedema can result. Any action, condition, or effect that increases the fluid demand on the body could trigger lymphoedema. Some of the potential triggers for lymphoedema include: l excessive heat; l sedentary lifestyle; l wounds in the affected limb/ quadrant; l insect bites in the affected limb/ quadrant; l any injury or trauma to the affected area; and l infection in the affected area. Lymphoedema develops when the fluid demand on the body exceeds the system’s carrying capacity Co-Kinetic.com

(Fig. 7). When lymph nodes are compromised, the carrying capacity is reduced. As yet, we cannot test exactly how much a system is compromised, or for the exact risk of developing lymphoedema, which is why massage therapists must adapt for every person, every massage, every time.

Biomedical Lymphoedema

Currently, there are very few biomedical treatments for lymphoedema. At the time of writing, in the USA, there are limited imaging or testing modalities for measuring the capacity of an individual’s lymphatic system, so it is difficult to predict who is most at risk for lymphoedema. Therefore, anyone who has had even one lymph node removed or compromised is considered at increased risk (Patient Story 1).

PATIENT STORY 1: A personal experience of managing lymphoedema by E. Mertz I developed lymphoedema in my arm after breast cancer surgery. Managing lymphoedema in my arm has turned out to be much harder than I expected. Even when I do the exercises or self- massage fairly regularly and wear the garment constantly, I experience set-backs that don’t go away easily. I’ve found getting professional lymph drainage massage invaluable for staying on top of things – especially when I’m losing ground. It’s not just the physical help, which is very important, but it’s also the coaching to help keep me on track, and to lift my spirits. Sometimes it seems like you can work and work at keeping on top of lymphoedema, and then one small slip creates a huge set-back. I wear a night garment (like a long oven mitt!) and one night I just fell asleep without it, resting my head on the affected arm. In the morning, all the progress I’d achieved over two weeks was gone. It can be really discouraging, but I’ve found over time with patience and help, you can work back from set-backs. I made a huge mistake of leaving my overnight garment behind when I had to fly somewhere for work – five days without it, and long flights, left me with new pain and swelling all over the arm. Again it was a slow, patient path to work back from that, with help from my lymphoedema massage therapist. One thing that’s been fun is using compression garments that have tattoo- like patterns on them. I’m older, and have no tattoos, so I started out very cautiously. But now I use garments with flower patterns, lattice patterns, very colourful and noticeable. It makes it a little easier to wear them all the time. And other survivors will often come up to me to ask where I got them, or to cheer me on. I love the connection and support we give each other – even just for a minute or two. One time a woman ran up to me at an airport, touched my arm, and exclaimed, “Been there, done that, love your sleeve!” and kept on running for her flight. We both laughed as she moved on. Another time a worried husband came up to me in a grocery line and asked where I got the garment. He said his wife wouldn’t wear hers and kept getting worse, and that he hoped maybe a patterned garment might change her mind. The doctor told me to avoid nicks and cuts on my affected hand. Good luck with that! All it takes is a hangnail or a chapped finger – I can’t imagine how people avoid those. The good news for me so far is that if I carry a little tube of antibiotic ointment and some Band-Aids with me, I can just keep putting them on until the cut is healed. Another piece of impossible advice is to never put weight on the arm. I have grandkids I take care of. You can’t tell a toddler not to ever lean on your arm. I of course try to keep them leaning on the healthy arm, but I also try to schedule a lymph drainage the day after I babysit (and I do my self- massage right away afterwards). It’s for sure an up-and-down process, but I think it’s manageable if you take the long view and get help when you need it.

Compression garments are a key part of the ongoing management of lymphoedema. Several companies manufacture medical-grade, fashionforward compression garments, such as this sleeve, shown on display at the Second Skin: The Science of Stretch exhibition at the Chemical Heritage Foundation. (Science History Institute)

Certain conditions correlate with an increased risk of developing lymphoedema, including excess weight or obesity, older age, and rheumatoid or psoriatic arthritis. In summary, lymphoedema is: l a lifelong condition; l has very limited pharmaceutical or surgical treatments; l requires regular, sometimes daily and time-consuming, maintenance care; and l a primary indicator for quality of life.

Lymphoedema Description and Treatment

The signs and symptoms of lymphoedema include: l a feeling of ‘fullness’, most commonly in a limb, but could be anywhere in the affected quadrant; l swelling or increase in the volume (ie. size) of a limb; l redness, itching, or discomfort in the affected quadrant; and l fibrosis, or hardening of the tissue, most often in the affected limb (1*). Lymphoedema can range from a relatively minor swelling to a major swelling with complications of cellulitis, skin breakdown, and loss of mobility. Currently, lymphoedema is managed as a chronic illness. The most effective treatment for lymphoedema is complete decongestive therapy (CDT). CDT is a time- and labour-intensive process involving compression bandaging, skin care and exercises, and MLD or the equivalent (Figs. 8&9) (Things to Think About 4). THINGS TO THINK ABOUT 4: Stages of lymphoedema (1) l Stage 0: s ubclinical, no swelling or other signs/ symptoms. l Stage 1: a ccumulation of fluid which can be resolved by elevating the affected limb; possibly some pitting oedema. l Stage 2: e arly – some pitting oedema; swelling does not resolve with elevation. Late – some tissue fibrosis develops. l Stage 3: n o pitting in swollen areas; skin changes with warty overgrowths.

Therapists who wish to learn more about CDT and MLD can refer to the list of additional resources at the end of the chapter in the authors’ book. For the purposes of this article, our focus is on adapting a standard Western massage for those at risk of lymphoedema or who have been diagnosed with lymphoedema. If you wish to pursue a practice focusing on oncology massage, advanced training in MLD or the equivalent is highly recommended.

Lymphoedema Treatment Team

The overall treatment of lymphoedema involves a team approach. The patient who is managing lymphoedema may be in regular contact with the following healthcare professionals: l Physician: will diagnose lymphoedema and may make referrals to a lymphoedema therapist or CDT. l Lymphoedema therapist: is trained in CDT and is able to perform all aspects of this treatment, including educating the patient about athome care. l Counsellor: lymphoedema can impact all aspects of a patient’s life, including their mental health. Some counsellors are specifically trained to work with patients who are navigating chronic health conditions. l MLD: for some people whose lymphoedema is mild, or in the early stages, regular visits to a therapist who is trained in MLD may be all the care they need. The MLD therapist can be a massage therapist, physical therapist, occupational therapist, or other healthcare professional. Frequent communication among all the professionals involved in lymphoedema care results in the best outcome. If a massage therapist practices oncology massage but does not have any lymphatic drainage training, they should connect with a

therapist specialising in MLD or CDT in their area for referrals.

Surgical Treatments

In some parts of the world, lymphoedema is treated with surgery. Although these surgeries are not common in North America, it is good to be aware that this treatment exists. A very small number of North American lymphoedema patients are seeking out these surgeries, and there are a few surgeons in the USA who perform them. For now, the massage adaptations outlined later in this chapter remain the same, even for patients who have received lymphoedema surgery. Lymphatic surgeries can involve the transfer of lymph nodes from an unaffected area of the body to the affected area. In the case of these surgeries, a conservative approach would be to treat both areas as if they are at risk for lymphoedema. A specialised form of liposuction can also help some patients better manage their lymphoedema. This surgery, like the others, does not completely eliminate lymphoedema, but it can reduce the swelling to more manageable levels (Patient Story 2). As massage therapists work with clients who may be managing lymphoedema, awareness of these surgeries and related massage adaptations becomes important. Chapter 6 “Surgery” of the authors’ book provides more general information about adapting massage for clients who have had surgery.

Massage Therapy Adaptations

This section outlines massage therapy adaptations for clients with lymphoedema risk, and with active or a history of lymphoedema. These adaptations have been developed with careful consideration of the anatomy and physiology of the lymphatic system, coupled with the clinical

PEOPLE WHO HAVE OR WHO ARE AT RISK OF LYMPHOEDEMA REQUIRE MASSAGE ADAPTATION FOR THE REST OF THEIR LIVES Co-Kinetic Journal 2021;89(July):33-43

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experience of oncology massage therapists and lymphoedema therapists. It cannot be emphasised enough:

These adaptations are considered necessary for the rest of the patient’s life, even if they exhibit no signs or symptoms of lymphoedema. Regardless of how long ago their treatment ended or how healthy the client appears to be overall, it is still necessary to make these adaptations. We simply do not know what might be the trigger for a client to develop lymphoedema: these adaptations are designed to keep the client safe (Things to Think About 5). THINGS TO THINK ABOUT 5: Massage adaptations for lymphoedema risk In the affected quadrant: l Pressure: no more than a 2 on the Walton pressure scale. l Site: the entire affected quadrant, including the entire limb. l Positioning: make sure the entire limb is equally supported on the table, eg. don’t allow the affected arm to hang off the table. l Direction: on the trunk, direct strokes away from the affected lymph node cluster. On limbs, work from proximal to distal sections; direct strokes from medial to lateral with a slight upward (towards the heart) direction (see Figs 10&11).

One Question

First, the massage therapist must conduct a thorough and effective intake interview that includes identifying the affected body quadrant. It is good practice to ask new clients if they have had lymph nodes removed, irradiated, or tested. Remember that many patients may not know that when a lymph node is tested or biopsied, it is removed from the body. Lymph nodes, once removed or damaged, are gone Co-Kinetic.com

WHEN A LYMPH NODE IN ONE OF THE MAJOR CLUSTERS IS REMOVED OR DAMAGED BY RADIATION, THAT ENTIRE BODY QUADRANT BECOMES COMPROMISED

Figure 9: Compression bandaging is part CDT for lymphoedema

PATIENT STORY 2: Surgery for lymphoedema and the importance of education Elizabeth K’s story Elizabeth developed lymphoedema in both legs, more significantly in her right leg, secondary to treatment for endometrial cancer. She had a radical hysterectomy, during which 17 lymph nodes were removed from her inguinal area and from the omentum. About a year and a half after the surgery, she began to notice that her ankles and feet would get “a little puffy” sometimes. At the time, she was having some work done to treat spider veins in her legs, when the doctor noted the fluid in her leg and sent her to have it checked out. The cancer clinic diagnosed stage 1 lymphoedema. Elizabeth bought over-the-counter compression tights to manage the swelling. A few years later, Elizabeth took a long flight from Canada to Australia, a flight she takes on a regular basis to visit her daughter. When she arrived, it was very hot in Australia. The day after her arrival, Elizabeth’s legs started to swell. As she states, “My leg became enormous.” She immediately found a lymphoedema clinic and physiotherapist in Australia and began treatment for what was now stage 3 lymphoedema. The lymphoedema affects every part of Elizabeth’s life. She continues lymphoedema treatment back home in Canada, with MLD massages, compression garments and a compression pump for her legs. Her right leg swells much more than her left; so much so that she needs to buy a shoe one full size larger for the right foot. The swelling has also affected her gait, causing her hips to be out of alignment and her balance to suffer. “I tend to trip,” Elizabeth says, “I fall over.” In Australia, Elizabeth has found more opportunities to treat lymphoedema, including a surgical option. A specialised form of liposuction could reduce the fat volume in her leg. Early stages of lymphoedema are composed primarily of fluid, but as the lymphoedema progresses, significant amounts of adipose tissue can develop as the result of lymph fluid accumulating over an extended period of time. In stage 3 lymphoedema, the swelling is often very firm because it is composed of more adipose tissue. Liposuction is not always a cure for lymphoedema, but it does reduce limb volume and could make lymphoedema treatment (compression, MLD, etc.) more effective. While in Australia, Elizabeth went to a physician who used indocyanine green dye to map her lymphatic system. In this procedure, the dye is placed into the lymphatic system and traced to discover where there may be blockages. This procedure showed she could be a candidate for liposuction. When she is next in Australia, she will receive an MRI to find out if there is fat to be removed. If so, she will have liposuction. The procedure may sound simple at first, but it involves an extended hospital stay afterwards to monitor for infection and to make sure Elizabeth is able to put on the required wraps and compression bandages on her own. Elizabeth feels that there were “huge gaps in the information [she was] given” after her hysterectomy. She did not seek out treatment for her early stage lymphoedema because she did not know much about it. From her own experience, she knows that lymphoedema can go from an early stage to stage 3 very quickly. She urges people now, “If [you] have stage 1 lymphoedema, treat it.” Elizabeth also urges massage therapists and other professionals who work with cancer patients to become educated about lymphoedema so that they can pass this information along to patients, and so that they can help patients who are seeking treatment. “Clients will be desperately looking for someone or something to help them,” she says.

LYMPHOEDEMA IS A CHRONIC CONDITION THAT REQUIRES LABOUR-INTENSIVE MAINTENANCE CARE

(a)

(b)

forever. They do not regenerate. In the case of a chair massage session, or other situations where a longer intake conversation is not possible, this one question allows a therapist enough information to work in a way that does not add to lymphoedema risk (Things to Think About 6). THINGS TO THINK ABOUT 6: Clinical considerations If you only ask one question, ask: “Have you ever had lymph nodes removed, irradiated, or tested?” Be sure to include wording about nodes in the field of radiation. And note that some clients may not know that if a lymph node is biopsied or tested, that means it has been removed.

Directional Strokes On the trunk, front and back, massage strokes should be directed away from the left axillary lymph node cluster. Figure 10: In these illustrations the left upper quadrant is affected: strokes to use on the trunk

(a)

(b)

Use the quadrant and direction map in Figure 6 to confirm which quadrant is at risk for lymphoedema. For example, if a client had lymph nodes removed from the right axilla, the entire right upper quadrant is affected. This includes the entire right arm, as well as the right side of the trunk. Note that when a major lymph node cluster is compromised, massage adaptations are necessary in that entire body quadrant, forever. Damaged lymphatic vessels can regenerate – slowly. Damaged lymph nodes do not regenerate (Things to Think About 7). THINGS TO THINK ABOUT 7: Language

Note that strokes on the limb move up and towards the lateral seam of the arm. A long finishing stroke over the shoulder towards the cervical (unaffected) lymph node cluster is also indicated. Figure 11: In these illustrations the left upper quadrant is affected: strokes to use on the arm

We recommend you refer to the ‘affected’ or ‘treated’ area when you are talking about the area that is at risk for lymphoedema. Keeping your language neutral is another way of respecting and accepting your client as they are, right in this moment.

When a Patient Is at Risk for Lymphoedema, in the Affected Quadrant(s): l use a 1–2 pressure on the Walton pressure scale in the affected area;

l direct all strokes away from the affected lymph node cluster; and l on the limbs, work in proximal to distal sections, and direct strokes laterally. When a Patient Has Active or a History of Lymphoedema: l use only holds at a pressure of 1–2 on the Walton pressure scale in the affected quadrant; l move holds in the same directions as strokes; and l refer to MLD or CDT therapist for more focused care. Visualise the affected lymph node cluster as a cup which is already full of fluid. The image of moving away from the full cup is useful for remembering which direction to stroke for massage. On the trunk of the body, direct any effleurage or other strokes away from the compromised lymph node cluster. For example, for a patient who has lymph nodes removed from the right axilla, strokes on the right side of the chest would move away from the armpit towards the centre line of the body. On the back, move strokes down the back and towards the inguinal area, or towards the centre of the body. On the arms (or other limbs) it is helpful to picture a gutter or drain along the lateral edge of the limb. This would be a straight line down from the middle deltoid on the arm, or from the greater trochanter on the leg. Short strokes should be directed from the more medial aspect of the limb to, but not across, this lateral line. The strokes should have a slight upward direction as well (Fig. 10). Work proximal to distal on the limbs. For example, on the arm, work first the section from elbow to shoulder, then from wrist to elbow. Strokes on the hands should also move towards the shoulder.

Other Adaptations

The affected quadrant, as shown in Figure 11, includes a portion of the trunk and the entire limb. In addition to making the adaptations described above, the massage therapist must not do anything that would increase fluid demand on the patient’s body and potentially trigger lymphoedema. For example, avoid applications of heat Co-Kinetic Journal 2021;89(July):33-43

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or cold therapy, allowing the affected limb to hang off the table or otherwise constricting the limb, and using deep massage strokes. Maintaining a 1–2 on the Walton pressure scale is the most important adaptation for a patient who has or is at risk for lymphoedema.

Integrative Approaches to Lymphoedema and the Lymphatic System TCM/Acupuncture

In TCM, lymphoedema is seen as a disorder of the spleen and kidneys, or an accumulation of excess damp. Lymphoedema has a ‘yin’ consistency, meaning it moves sluggishly or involves blockages. More specifically, lymphoedema is considered a phlegm–damp accumulation, or ‘tanyin’. The phlegm part of the diagnosis comes from the composition of lymphatic fluid, which contains lipids, proteins, and other molecules, giving it a milky-white appearance. TCM uses a variety of modalities in the treatment of diseases, and lymphoedema is no different. The treatments may consist of herbal medicine, acupuncture, or, in some cases, Tuina massage. Herbal treatments for lymphoedema may address the underlying cause or may focus on a complication of lymphoedema, such as cellulitis. General herbal treatments for lymphoedema focus on phlegm–damp accumulation. For upper extremity lymphoedema, herbs for the treatment of pain or ‘lumps’ in the arms may also be used. There have been a few small studies of herbal treatments for cellulitis, one of the most common complications of lymphoedema. The most common herbal remedies include mulberry leaves, among other herbs. At the time of writing, there are also some clinical trials testing herbal extracts for the treatment of cellulitis: these are potential alternatives to systemic antibiotics, which is the common biomedical treatment for cellulitis. People who are at risk for lymphoedema are advised to not have injections of any kind in the affected limb. The reason being that any kind of needle stick can produce Co-Kinetic.com

an inflammatory response, thus increasing the fluid demand on the area. Although the needles used in acupuncture are quite delicate and they are inserted superficially, many acupuncturists will not use needles in the affected quadrant. A 2013 pilot study suggested some benefit to acupuncture for the treatment of lymphoedema in a small number of breast cancer patients. The protocol in the study targeted points related to pain, weakness, motor impairment, and dampness. The authors of the study emphasised that needles were only used on the unaffected side of the body (most acupuncture meridians are bilateral) and that the treatments were administered by highly trained professionals (5*). The results were not conclusive, however, and further research is required before a definitive recommendation can be made.

Naturopathy

In general, naturopaths seek to use non-invasive treatments to facilitate the body’s own natural healing capacity. Naturopathic approaches to lymphoedema risk or management may include aspects of TCM, Ayurveda, nutrition, and many other systems. Naturopaths acknowledge that some people may be more prone to lymphatic congestion than others. Often, a naturopath will work in conjunction with a lymphoedema therapist, or CDT practitioner to manage lymphoedema. Naturopathic recommendations for lymphoedema management are largely the same as those recommended in evidence-based biomedical approaches. An emphasis on CDT and exercise (the current gold standard in biomedical treatment for lymphoedema) along with supportive herbs and nutrition is common. For individuals who are at risk for developing lymphoedema, a naturopath may recommend herbal teas such as dandelion or calendula along with a nutritional approach based on reaching and/or maintaining a healthy weight. In addition, a patient may receive counselling around sleep hygiene and exercise. Other options

a naturopath may recommend are low-level laser therapy and aqua therapy. These have limited evidence of efficacy. Naturopathy approaches the individual as a ‘biospiritualpsychosocial’ system. This means that the function of the physical body is not separate from emotional, social, and spiritual well-being. A naturopathic physician will consider aspects of the person’s life beyond the direct management or prevention of lymphoedema and may recommend larger lifestyle interventions. Naturopathic physicians will often work in concert with lymphoedema therapists. Their work focuses on nutritional support and patient empowerment. There is minimal evidence to support a solely nutrition-based approach to lymphoedema management, although some naturopathic physicians may want to check levels of B vitamins, as deficiencies are associated with increased capillary permeability.

In Conclusion

Lymphoedema caused by cancer treatment has a massive impact on quality of life. Simple, gentle and non-invasive massage therapy is one of the few forms of treatment open to sufferers of this condition. It is the responsibility of the therapist to deliver the treatment safely and from a position of knowledge to have the best impact on the patient.

IN THE BODY, THE LYMPHATIC SYSTEM IS DIVIDED INTO QUADRANTS AND EACH QUADRANT DIRECTS FLUID INTO ONE OF THE MAJOR LYMPH NODE CLUSTERS 41

References

1. Lymphedema FAQs [website]. Lymphatic Education & Research Network (LE&RN) 2018 Open access https://bit.ly/3zdY4JW 2. Zawieja DC. Contractile physiology of lymphatics. Lymphatic Research and Biology 2009;7(2):87–96 Open access https://bit.ly/3gff3Di 3. Földi M, Strössenreuther R. Foundations of manual lymph drainage, 3rd edn. Mosby 2005. ISBN 978-0323030649. Buy from Amazon (Print £24.99 Kindle £12.34) https://amzn.to/3x5j5on

4. Hantusch B. Morphological and functional characteristics of blood and lymphatic vessels. In: Geiger M (ed.) Fundamentals of vascular biology. Springer 2019. ISBN 978-3030122690. Buy from Amazon (Print £64.54 Kindle £61.31) https://amzn.to/3g2FlJM 5. Cassileth BR, Van Zee KJ, Yeung KS et al. Acupuncture in the treatment of upperlimb lymphedema: results of a pilot study. Cancer 2013;119(13):2455–2461 Open access https://bit.ly/3pvY0B3.

Oncology Massage: An integrative approach to cancer care Janet Penny and Rebecca L. Sturgeon Handspring Publishing 2021; ISBN 978-1-912085-75-0 Buy it from Handspring https://www.handspringpublishing.com/product/oncology-massage/ In Oncology Massage: An integrative approach to cancer care the authors have created a textbook which will provide both experienced and inexperienced therapists with a resource to expand their knowledge and understanding of working with people with cancer. Cancer occurrence and survivorship are now so common that every massage therapist will at some time work with clients who have been through cancer treatment. The short and long-term effects of biomedical cancer treatment require massage therapy adaptations to pressure, site, position and duration to provide safe and effective treatments. Informed massage therapists can support the body to promote overall wellness as well as identify the underlying secondary effects of cancer treatment that contribute to physical dysfunction. Oncology Massage: An integrative approach to cancer care provides massage therapists with essential information for: l t reatment planning based on the physiology of cancer and cancer treatments l c ritical, thoughtful treatment decision making l c onsideration of the psychosocial effects of cancer le nhancing therapist self-awareness and building a therapeutic relationship. The information is presented in a clear and simple format with plentiful use of illustrations and information boxes which allows it to be used both as a learning tool for those new to the field of oncology massage and as a resource for quick referral when working with new patients. The techniques of massage therapy change very little; it is the knowledge and understanding of their use that distinguishes a massage therapist. Oncology Massage is unusual in that it includes contributions not only from a range of experienced practitioners but also from people with cancer who have received massage during and after cancer treatment. This feedback from clients provides an invaluable addition to the understanding of how massage can be used as a safe and effective part of cancer care.

CONTENTS Chapter 1: T reatment considerations, and oncology massage through the life cycle Chapter 2: Integrative cancer care Chapter 3: Cancer and metastasis Chapter 4: Research Chapter 5: I ntroduction to oncology massage treatments Chapter 6: Surgery Chapter 7: Chemotherapy Chapter 8: Radiation therapy

Chapter 9: Chapter 10: Chapter 11: Chapter 12: Chapter 13:

Immunotherapy Hormone therapies The lymphatic system Intake Therapeutic relationship/The impact of massage on the massage therapist Chapter 14: Cancer and emotional health Chapter 15: Massage at the end of life Chapter 16: Oncology massage around the world

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KEY POINTS

lT he lymphatic system is a one-way system consisting of vessels, nodes and lymphatic organs. lM ajor lymph node clusters are in the neck, axillae and inguinal area. lT he direction of lymphatic flow in the body is divided along anatomical watersheds, which divide the body into quadrants. lD amage or removal of even one lymph node means the affected quadrant is compromised. lM assage adaptations to the affected quadrant are necessary forever. lM aintaining a pressure of 2 or less on the Walton pressure scale in the affected quadrant is the most important adaptation. l L ymphoedema, once triggered, is a lifelong chronic condition requiring time-consuming maintenance and care. l L ymphoedema can have primary or secondary causes. lC ancer treatment is one of the most common secondary causes of lymphoedema, where lymph nodes are often removed during cancer surgery or can be affected by radiation treatment and chemotherapy. lT herapists wishing to do more work with clients at risk for lymphoedema are encouraged to seek training in manual lymphatic drainage (MLD) or the equivalent.

RELATED CONTENT

lC ancer, Exercise and Massage [Article] https://bit.ly/2ONYEve

DISCUSSIONS

l Think about your first meeting with a patient who has been treated for cancer and plan what information you need to elicit from them and the language that you would use. l Become familiar with the different quadrants of the body and the lymph drainage patterns. Seek out in-person guidance from a teacher or experienced practitioner before practising this on a patient. l If a patient came to see you after treatment for cancer but showed no sign of lymphoedema, would you be prepared to educate them about the condition? How would you broach the subject and what would you discuss with them? l What are the signs that indicate that the patient needs to be referred on for more specialist treatment?

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Tweet this: Cancer treatment creates a lifelong elevated risk of lymphoedema development https://bit.ly/3wtIV5C Tweet this: People with or at risk of lymphoedema require massage adaptation for the rest of their lives https://bit.ly/3wtIV5C Tweet this: As oncology massage therapists we must educate patients about causes and triggers of lymphoedema https://bit.ly/3wtIV5C Tweet this: Using a 1–2 on the Walton pressure scale is crucial for a patient with or is at risk of lymphoedema https://bit.ly/3wtIV5C Co-Kinetic.com

LYMPHOEDEMA CAN DEVELOP YEARS OR DECADES AFTER THE CANCER TREATMENT BY TRIGGERS SUCH AS BEHAVIOURS OR ENVIRONMENTAL FACTORS WHICH INCREASE DEMAND ON THE LYMPHATIC SYSTEM IN SUCH A WAY THAT LYMPHOEDEMA CAN RESULT THE AUTHORS Janet Penny RMT has extensive experience working with people living with cancer in both her private practice and at an integrative cancer centre. Janet has developed a treatment approach that addresses the multi-faceted needs of oncology massage clients. Her approach focuses on pre- and post-surgical treatments, scar tissue, radiation fibrosis, neuropathy and pain within the complex context of the client’s emotions that pervade and influence the body. Janet is forever amazed at the resiliency of the human body and all it goes through. Email: info@focusmassagetherapy.ca LinkedIn: https://www.linkedin.com/in/ janet-penny-7598201b/ Rebecca L. Sturgeon LMT, CMLDT started her career as a massage therapist in 2008 and began working with oncology patients in 2010. She has worked in clinical and community environments providing massage and manual lymphatic drainage. She has been a massage therapy educator for the majority of her career and currently teaches oncology massage continuing education as part of the faculty for Healwell, an Americanbased organisation which works towards the meaningful integration of massage therapy into healthcare through multiple educational offerings and interdisciplinary collaboration in a clinical setting. Email: rebecca@healwell.org 43

Which Marketing Metrics Matter 21-07-COKINETIC FORMATS WEB MOBILE

s many of you will already know, one of my key missions through Co-Kinetic is to help you to navigate your way through the maze that appears to be marketing, and to help you to drill down to the small number of marketing activities that can actually move the needle for your business ie. the ones that generate customers and therefore revenue. I say ‘the maze that appears to be marketing’ because marketing is actually nothing like as hard as most people think it is, as long as you focus (and stay focused) on the right things and this was THE major objective of the marketing compendium I wrote earlier this year entitled The Co-Kinetic Compendium of Marketing and Clinic Growth for Physical Therapists and Manual Therapists. After receiving some truly inspirational feedback about the compendium, I decided to make this 60-page resource fully openaccess. You can access it here (http://co-kinetic.com/compendium). It’s basically a marketing handbook packed full of articles, images, infographics, cheat sheets and lots of marketing ideas and inspiration, delivered in a structured way, so you know where each activity should fit within your business. What I didn’t discuss in that compendium is which metrics you need to be using in order to inform your marketing decisions, because remember, ‘you can’t manage what you can’t measure’. No, I’m not going to discuss cashflows or profit margins, this is specifically about what numbers you need to know in order to both plan and measure your marketing, so that you’re getting the results you need, in the 44

(And Which Don’t)

All too often we get caught up measuring the wrong things when it comes to our marketing and as the saying goes, ‘garbage in, garbage out’. In other words, if you put in the wrong data, you’ll get the wrong answers. This article looks at eight marketing metrics that matter and explains why they matter when it comes to helping you achieve the right business goals from your marketing. It also exposes the vanity metrics that don’t matter, which are often the ones we spend too much time on. You’ll be glad to hear that all eight metrics are relatively easy to track as well, so gathering them doesn’t need to consume great amounts of time either. Read this article online https://bit.ly/3zVdt27 By Tor Davies, physiotherapist-turned Co-Kinetic founder most cost-effective way possible. And by the way, that’s an iterative (ongoing) process because it involves constant testing, measuring, adapting, retesting, remeasuring etc. So before we look at what you DO need to be tracking, let’s look at what you DON’T need to waste time tracking.

Vanquish the Vanity Metrics

What’s a vanity metric? In short, indicators that don’t serve an actionable purpose. In other words, they don’t directly drive a business goal. There’s a great article at this link (https://bit.ly/3gncccx) by Michael O’Neill which describes vanity metrics as follows:

“These metrics are often reported as ROI [return on investment], but are rarely useful: l page views l social media likes l website bounce rate l social media followers l site visitors l organic traffic growth l keyword rankings.”

Vanity metrics can measure nontransactional activity, but they do not correlate in any way to revenue. They can be useful to measure brand awareness but, as I repeatedly say, every single person reading this article has many more important marketing activities to be prioritising and investing in, before you start throwing money down the brand awareness drain. That might sound harsh, but it’s true.

The Marketing Metrics that DO Matter

These are the metrics you need to know in order to be able to answer the all-important question: If I spend £100 [for example], how much can I expect to get back? These metrics include: 1. average search position for buyer-intent keywords 2. email leads collected 3. lead magnet downloads 4. marketing-qualified leads 5. sales-qualified leads

6. conversion rate 7. customer acquisition cost 8. customer lifetime value So let’s look at each of these in turn.

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1. Average Search Position for Buyer-Intent Keywords

Buyer-intent keywords are search queries which demonstrate that someone is actively looking to make a purchase, in other words, they’re primed and ready to buy from you. It’s well worth employing some specialist search engine optimisation (SEO) input to help you define these search queries/keywords, and help you optimise your SEO with that in mind, and show you how to track your average search position for those keywords.

2. Email Leads Collected

As you probably already know, I deem growing and nurturing your email list one of the single most important marketing activities you can do, so collecting new email leads is one metric that can definitely can correlate with revenue. Once collected, these leads then need to be entered into an email nurture process where you send regular value-added resources, such as links to the patient information leaflets that Co-Kinetic provides in all our subscriptions. Having an active and engaged email list means you can get people to take action when you want them to, whether it’s to take you up on special offers or attend new events that you launch.

3. Lead Magnet Downloads

Giving people resources to download (ie. lead magnets; whether that’s patient leaflets, ebooks or anything else downloadable) is one of the best ways to collect marketing-qualified leads. Remember, you should only give access to these resources in return for, at the very least, an email address: in other words they should fill out an email lead collection form in order to obtain the download. Not only do you collect an email address that you can then nurture through your email nurture programme towards other marketing or sales-led activities, but it also helps inform you about people’s interests meaning you can more accurately target them Co-Kinetic.com

in future with information that you already know is likely to be relevant to them. For example, if someone downloads a lead magnet on running injuries, there’s a very good chance that they might be interested in a running injury prevention presentation you might offer in the future, which leads us neatly into the next metric: marketing-qualified leads.

4. Marketing-Qualified Leads

A marketing-qualified lead (MQL) is someone who has demonstrated some interest in your services, based on marketing activities that you’ve put out there. This could mean lead magnets they’ve downloaded, website pages they’ve visited, social media posts they’ve engaged with, etc. Essentially they are demonstrating an early interest in the services you offer. The goal here is to turn a MQL into a sales-qualified lead. One of the best examples of a MQL is someone who has downloaded a lead magnet from you.

5. Sales-Qualified Leads

A sales-qualified lead (SQL) is someone who may have demonstrated more investment or effort in you, or engaged at a deeper level with your marketing activities. This indicates that they are a viable prospect with needs that match the service you can offer. Take the example of a running injury presentation; if they’re ready and willing to attend an educational event then there’s a good chance that you have expertise and input that they need. Offer them a compelling reason to take the next step into becoming a paying customer, and there’s a good chance they’ll take it. As another example, they may have signed up to your email list, or regularly comment on or share your social media posts. These are all indications that they’re ready for the next step, so why not offer them a one-off free taster appointment, or some sort of discount offer to move them into the paying category.

with this sequence of metrics, is a marketing and sales funnel where you lead someone along a customer journey from becoming a lead, to taking a deeper, more involved interest in what you have to offer and finally making a purchase from you. In the purest sense, your conversion rate is the number of leads who become paying clients divided by the number of leads entering the top of your funnel (this could be email sign ups). So say you get 100 new email leads a month, 50 of them sign up to a lead magnet which turns them into an MQL, 25 of them take actions that move them from a MQL into a SQL (like attending some sort of conversion event that you have run), and 10 of those convert into paying customers. That would be 10 paying customers out of 100 leads: 10/100=0.1. Multiplying this answer by 100 gives you a percentage, ie. a 10% conversion rate (which is a pretty good conversion rate). Equally you will also have conversion rates at each level as prospective customers move down the funnel, but the most important one (for these purposes) is the conversion rate between the start of the funnel/ customer journey and the end sale. That means you know how many people you need to put into the top of the funnel (X) in order to get Y conversions. Once you know that you can focus on improving the conversion rate at each layer.

7. Customer Acquisition Cost

Now we get down to one of the most important metrics: customer acquisition cost (CAC). This does exactly what it says on the tin, it’s how much it costs you to acquire a new customer. At the very simplest level it can be calculated by dividing all the costs spent on acquiring more customers (ie. marketing

6. Conversion Rate

In essence what we’re describing 45

and sales expenses) by the number of customers acquired in the period that money was spent. For example, if you spent £500 on marketing in a quarter and acquired 10 new customers in that same period, their CAC is £50. To give you the most accurate number, you should also include the cost of any time spent by employees in that same process; arguably that should also include your time because if you weren’t spending that time on those activities, you could be earning money seeing patients. Whenever you run a campaign, you should try and keep as accurate a record as possible of these costs. However, remember that as a result of a campaign, you might still acquire a new customer several months or maybe even years later, and this will fall outside the measuring period, so it will never be 100% accurate. It does nevertheless give you a fairly accurate answer to the question: If I spend X in the next 3 months, what am I most likely to make in return from that investment (ie. Y) in the next 4–6 months? However, it’s only one part of the answer, because there’s one more metric that’s equally, if not more, important: customer lifetime value. This is a metric that’s frequently ignored, because it requires a more detailed knowledge of your customer purchase history.

8. Customer Lifetime Value

Now, I’ve written about customer lifetime value (also known as CLV or CLTV) on a couple of occasions and I often include it in my webinars because knowing it helps to inform many business decisions, including what you can afford or might be willing to invest in acquiring a new customer. Customer lifetime value is the metric that indicates the total income you might reasonably expect from a single customer throughout the lifetime of that relationship. Let’s take physical therapists (in the UK at least): most of whom I’ve worked with will bank on an average of a patient attending 4–5 appointments per episode/issue. (And let me just say here that there’s a very valid 46

argument that 4–5 sessions probably won’t give you enough time to truly resolve an issue, prevent it reoccurring in the future, and get the real ‘success’ outcome that the patient wants deep down, but that’s an argument for another time.) For example, say you charge £50 a session, each patient should be worth at least £200–250 per issue or episode they present with. Now, assuming you’ve treated them well and they walk away happy, how many different issues or episodes might you see the average client for? Maybe 2–3 different issues potentially during the course of their lifetime? (NB. If you’re a massage therapist you may have a more ongoing programme, so your rates could potentially be even better.) That means that each client could potentially be worth at least £500– 750+ and that’s without taking into account people they recommend you to. If you’ve lived in the same area for a long time, and you’re better at your customer re-booking/retention than most, this figure could be considerably much higher, possibly 2 or 3 times higher. So suddenly the £50 it costs you to acquire a new patient, actually means £500–750+ value, even if it isn’t in immediate sales. But you can see how quickly that exponentially affects your numbers if you’re consistent with your marketing and regularly bringing in new clients. It is the difference between taking on a new therapist, moving into a bigger clinic or if you want to stay as a one-wo/man band it could give you the necessary demand you need to increase your rates – all of which should contribute to a substantially increased quality of work life and subsequently personal life.

Further Resources

lT he Co-Kinetic Compendium of Marketing and Clinic Growth for Physical Therapists and Manual Therapists; pages 4–13 describes a proven marketing and sales funnel you can replicate. l Strategies for Converting Prospects into Paying Clients https://bit.ly/371lbLi

What’s Next?

Instead of penny-pinching your marketing efforts or being worried to invest in it, take the following 4 steps: 1. Put a marketing (and sales) funnel in place that is proven to work. Read my Compendium for a detailed model you can follow (http://co-kinetic.com/compendium)]. 2. Set a process in place to measure the key metrics outlined in this article, in as much detail as you’re able to (but don’t overdo it or make it so complicated you give up, especially to start with). 3. Keep a spreadsheet of what you’re spending on each marketing campaign (later if you want to, you can break it down by level), including wherever possible any staff time involved (including your time). 4. Crunch whatever data you can to come up with as accurate an estimate as possible of customer lifetime value (it doesn’t have to be perfect) – and put measuring tools in place to track how this number changes in future. And then you’ll be able to confidently answer the question: If I invest £X in my marketing over the next 3 months, that will result in £Y income over the next 6-8 weeks, and £Z income over the course of those new customers’ lifetimes.

RELATED CONTENT

lC o-Kinetic Compendium of Marketing and Clinic Growth for Physical Therapists and Manual Therapists http://co-kinetic.com/compendium

THE AUTHOR Tor Davies began her professional life training as a physiotherapist at Addenbrookes Hospital, Cambridge, UK. She went on to complete a BSc in Sport & Exercise Science at the University of Birmingham while also achieving a WTA international tennis ranking. After graduation she worked in marketing with a London agency and then moved into medical journalism where her passion for publishing was born. At 27 she established sportEX medicine, a quarterly journal for physical and manual therapists. With a passion for technology as well as publishing, Tor’s leadership grew sportEX into the Co-Kinetic journal and website which included a more collaborative, royalty-based form of publishing as well as a wider content remit. Tor’s focus is on providing resources to help therapists develop their professional authority and brand, and grow their own businesses while working more efficiently and effectively, a topic that she speaks regularly on at global conferences. Join us on Facebook: www.facebook.com/CoKinetic/ Connect with Tor: www.facebook.com/cokinetic.tor Co-Kinetic Journal 2021;89(July):44-46

ENTREPRENEUR THERAPIST

estimonials take the spotlight away from you the ‘seller’, and shine it on the client. Once a potential new patient hears from someone they can actually relate to – someone who isn’t being paid to say great things – it deepens their trust and increases the chances of them buying into you. Anyone who has listened to just about any of the marketing presentations I’ve given, will know that I consider reviews and testimonials to be a marketing super-power. Add growing your review and testimonials count to email list building and email list nurturing, and you have the three most powerful and influential marketing activities available to any business, of any size, in any industry, anywhere in the world. But why are reviews and testimonials so powerful?

The Influences of Reviews and Testimonials 1. Testimonials Build Trust

Testimonials, case studies, reviews and star ratings are all designed to build trust and confidence by communicating a real customer’s experience. This also gives prospective customers a more personal insight into you and your business, so they can decide whether it’s a good fit for them (social networks can also help here). l9 2% of customers read online reviews before buying (Big Commerce). l7 2% of consumers say positive testimonials and reviews increase their trust in a business (Big Commerce). l7 0% of people trust reviews and recommendations from Co-Kinetic.com

of r e Pow ws e i v e R The

21-07-COKINETIC FORMATS WEB MOBILE PRINT

By Tor Davies, physiotherapist-turned Co-Kinetic founder strangers (Nielsen). l8 8% of consumers trust online testimonials and reviews as much as recommendations from friends or family (Big Commerce). l7 2% of consumers will take action only after reading a positive review (Search Engine Watch). But numbers do matter. Ten or more reviews can increase search traffic (Big Commerce) and 40+ reviews are needed before consumers will consider a star-rating accurate (Opt-In Monster).

2. Testimonials Drive Revenue

Testimonials are perfect for resolving customers’ objections, which reduces buying resistance and increases confidence in you and your service. This, in turn, increases the likelihood of them becoming a customer. lU sing customer testimonials regularly can generate approximately 62% more revenue (Strategic Factory). lC ustomer testimonials placed alongside more expensive items increased conversion rates by 380% (Power Reviews). lO n average, testimonials on sales pages increase conversions by 34% (Impact). lC ustomers who interact with reviews are 58% more likely to buy (Big Commerce).

3. Testimonials Improve Website Traffic and Search Engine Optimisation

Search engine developers like Google, want their customers to find the best

results for their queries and the best possible businesses that most accurately answer that query, which is why reviews and testimonials play a role in which businesses come up for which search queries. Testimonials also create fresh, ever-changing and relevant content that proves to search engines that customers are interacting with your brand, and reviews are naturally filled with long-tail keywords that customers are actually searching for. Here are some testimonial statistics that demonstrate clearly how using reviews and testimonials can improve search engine optimisation (SEO) and help you to win more search traffic. lW ebsites using testimonials saw a 45% increase in traffic compared to those who didn’t (Yotpo). l L isting 10 or more reviews increased traffic by 15 to 20% on Google Business listings (Big Commerce). l I mproving star ratings from 3 to 5 stars can increase clicks on Google up to 25% (Bright Local). lB usinesses with 5 stars earned 69% of total clicks amongst top Google listings (Bright Local). lR eviews account for nearly 10%, or 1 in 10 of total search engine ranking factors (Search Engine Watch). The customer review software platform Yotpo performed their own research to see how testimonials could impact SEO rankings. They tested 30,000 ecommerce businesses of all sizes and industries to “see how SEO traffic 47

4. Testimonials Impact Google Local Pack Results

A Local Pack is a collection of the top 3 or 4 most relevant results for your local search. It’s like SEO but with the added element of geographical location. For example, if you search for things like: “physiotherapist near me” or “osteopath in Wimbledon”, Google understands that you’re looking for a

5k Google Organic Page Views Per Month

increased when the only common denominator was adding reviews to their site.” Over the course of nine months, they found that, on average, a site using customer reviews increases site traffic about 45%. That’s how powerful customer reviews can be. If you’re interested you can find the full article in the resources below. It’s worth a read. It also discusses in more detail that you won’t be penalised (and your SEO won’t suffer) for bad reviews because Google knows no one is perfect and even the best sites can get bad reviews and ultimately it points to a more authentic overall rating.

7.5k 7k 6.5k 6k 5.5k 5k

Month 1

Month 2

Month 3

Month 4

local business and it’s going to provide a Local Pack selection at the top position in search results. Based on your geo-location, Google will deliver the most relevant answer to your query, in your local area. You get paid ad results first, then the Local 3 pack (or in this case 4 pack) above other organic results (see image below). The strength of your reviews will to a large extent decide who goes where.

1. Create a Google My Business Listing … NOW!

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Month 6

Month 7

Month 8

Month 9

How Reviews Boost SEO: The change in time in organic page visits for 30,000 businesses that began using reviews

Practical Ways to Grow Your Review Count

Local pack

Month 5

Data courtesy of Yotpo’s global user database of over 150,000 online businesses, 2016

The number one priority over all things is set yourself up a Google My Business account which you can do at this link https://bit.ly/3gTCbsm. Google is the king, queen and jack of search, so do whatever you can to be seen by it! You need to have a Google My Business account in order to collect the Google Reviews that will help you increase your search visibility as we’ve discussed above. There are other benefits too, including appearing in a big area at the top of the Google search engine results page (SERP) if someone searches for something that is close to or matches your business name. You’ll see that Google also picks up other reviews, so my Facebook reviews have also been found. And you can add opening times and key contact details. You can hit the Directions button to open Google Maps, which is incredibly important to you as a local business (not so much to me as I don’t

have an actual physical destination for my office) and the phone number is hyperlinked making it easy to call you with one click. As I frequently say in my webinars, don’t look a gift horse in the mouth, let Google help you!

2. Follow the Advice Below

Getting Great Reviews lP ut in place ideally an automated process to request testimonials and where possible exclude people who have already provided you with one so they’re not hassled. If you can’t automate it, send a manual email if you feel you’ve had a particularly good session with someone and tag them so you don’t ask them again once they’ve given you a review. It’s always best to strike while the iron is hot when asking for reviews. Failing that, send out an email every month to that month’s clients and again try to tag them so you don’t keep sending them the same email. lM ake it easy for more customers to submit a testimonial – give them a direct link to your Google Review area in your Google My Business account (here’s a help post telling you how https://bit.ly/3gZi5Mh) lH elp people write quality reviews by adding some suggestions in your email request, for example ask your customers to share specific details that demonstrate the ways you helped them or what changed in their lives as a result of their sessions with you. We have produced an editable leaflet template that you can you can send to clients and include your own review links.

ENTREPRENEUR THERAPIST opportunity to turn a disillusioned customer into a future fan, but it won’t impact your Google Listing. If anything it will make it more authentic. lF or Co-Kinetic we use review management software called EmbedSocial, which helps us to collate reviews across different platforms into one place that can then be published in one widget onto our respective website pages (you can see it in action on our pricing page; https://bit.ly/35R7spI). It comes highly recommended and gets great reviews!

References and Further Reading

lW here possible make your customers look good: back links help everyone so include mentions of their businesses, their skills, or things that are important to them wherever you can in your responses. lU se a mix of content types – prioritise Google and Facebook reviews, but videos can be very effective when shared on your social networks – as videos connect on an even greater emotional level. lS creenshots of tweets and social media posts add visual interest (just make sure to blur out personal identifiers) and a collection of company logos adds to the perfect blend.

Editable Canva Templates

lY our Thoughts Matter: Client Review Request Leaflet lY our Thoughts Matter: Client Review Request Postcard l5 Ways to Support Your Local Business Poster l5 Ways to Support Your Local Business Postcard

Co-Kinetic.com

Getting the Technical Stuff Right lM ake sure the majority of your testimonials and reviews are optimised for search, ie. they’re in html text form and can be found by search engines. Text in most images won’t be found by search engines, so while screenshots can add visual impact don’t overuse them. Same goes for logos. lU se testimonials across your site, but particularly where you want to drive conversions – including the homepage (this also adds engagement). l I f your clients run a business, or have a logo, ask if you can display these too. lU se the highest-quality photos and video you can manage… l… and if you have a handful of clients you know well or who are your best advocates, why not ask them to do a video testimonial and organise a day at your clinic. You can always thank them with perhaps a voucher or coupon for a free session/s or bonus treatments. lQ uantity and authenticity really do matter in your reviews. Anyone can type out a model (ie. ‘fake’) quote, but if you have 30+ authentic quality reviews on Google or Facebook, these will blast a so-called ‘model’ review out of the water. lD on’t worry about the occasional bad review, they happen and Google knows it and allows for it, so it won’t impact your SEO. It is a good idea to address it promptly in person (in private), and offer a solution because it gives you an

l3 0 Testimonial Statistics You Should Know in 2021 https://bit.ly/2U0TGOk l How to Use Customer Testimonials to Generate 62% More Revenue From Every Customer, Every Visit https://bit.ly/3h5khBI l New Data Reveals The Real SEO Benefits of Reviews https://bit.ly/2UvdQ3j l How to Rank #0 in Google with Local Packs – The Ultimate Local SEO Guide https://bit.ly/3dcnHl3

KEY POINTS

l Reviews directly influence purchasing decisions. l Reviews increase search traffic (SEO). l Reviews increase local SEO. l Reviews increase click through rate on paid search by 10%. l Reviews make your home page more engaging. l Reviews build trust (and increase purchasing likelihood). lA ll you need to do is ask! 7 out of 10 consumers will leave a review if asked. THE AUTHOR Tor Davies began her professional life training as a physiotherapist at Addenbrookes Hospital, Cambridge, UK. She went on to complete a BSc in Sport & Exercise Science at the University of Birmingham while also achieving a WTA international tennis ranking. After graduation she worked in marketing with a London agency and then moved into medical journalism where her passion for publishing was born. At 27 she established sportEX medicine, a quarterly journal for physical and manual therapists. With a passion for technology as well as publishing, Tor’s leadership grew sportEX into the Co-Kinetic journal and website which included a more collaborative, royalty-based form of publishing as well as a wider content remit. Tor’s focus is on providing resources to help therapists develop their professional authority and brand, and grow their own businesses while working more efficiently and effectively, a topic that she speaks regularly on at global conferences. Join us on Facebook: www.facebook.com/CoKinetic/ Connect with Tor: www.facebook.com/cokinetic.tor 49

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Content and Technology

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The Co-Kinetic Compendium of Marketing and Clinic Growth for Physical and Manual Therapists

Business Growth Campaigns – NEW for 2021 Introductory Offer/Taster Appointment Clinic Growth Campaign

All the content you need to run an Introductory Offer/Taster Session business growth campaign to jumpstart the conversion of prospects into paying clients, and generate revenue. It includes a range of editable content, such as a pre-written web sign-up page, ready-to-post social media, and printable artwork including posters and leaflets that you can use to promote your campaign. If you wish to charge for your introductory session, you can also set your web page up to take payments. Ideal times to use a campaign like this are when people take ‘first step’ actions such as: l s igning up to your email newsletter; l f ollowing one of your social media pages; l s igning up to a lead magnet; lm aking an enquiry off your website (that’s maybe a little tenuous and doesn’t look like a willingness to commit to a fully paid appointment at that point); and lm eeting you (or your team) at local events.

All you need to do is include the link to your web sign-up page in any material you distribute. You can watch a video demonstration of this campaign at the following link https://bit.ly/3gmoJ0l. It’s a great way to jump-start the process of turning a prospect into a paying client at an early opportunity. Who Can Access this Content? lF ull Site subscribers – included in your subscription lA nyone else – this content is purchasable individually for £90+vat at the following link https://bit.ly/3gmoJ0l

Open Clinic Event Clinic Growth Campaign

This campaign includes all the content and technology you need to run an

doing the right marketing at the right time. It’s our way of ensuring you’re getting the best value – and the most customers – from your Co-Kinetic resources as you look to build your business. Who Can Access this Content? As of June, it is fully open-access. Visit co-kinetic.com/compendium.

Open Clinic event to generate new clients and bookings. It includes a ready-to-use, editable web sign-up page allowing you to take sign-ups to your event, along with some predesigned artwork including social media, a ticket/coupon and printable promotional material including a poster and postcard (which can be mailed) to existing and past clients. All the content can be edited to add your specific event details. If you wish to charge for your event, you can also set up the web page up to take payments. In short, we’ve done almost everything for you, all you need to do is decide what your event will be, pick a time/ date to run it and then use the various pieces of artwork provided, to promote it. This is a great way to introduce new equipment, new therapists, new clinic areas or facilities and to reduce barriers to booking paid appointments in the future. It could be combined with offering free sessions to increase attendance. The goal of the event is to offer exclusive packages or incentives to book paid appointments. You can watch a video demonstration of this campaign at https://bit.ly/3sCenvP Who Can Access this Content? lF ull Site subscribers – included in your subscription lA nyone else – this content is purchasable individually for £90+vat at the following link https://bit.ly/3sCenvP. Co-Kinetic Journal 2021;89(July):50-51

CO-KINETIC NEWS

Social Media

Who Can Access this Content? The social media campaign (for those holding a Social Media subscription) was just released before Euro 2021. There is also a pre-existing full content marketing campaign already available to Full Site subscribers which

Forty unique pieces of social media including 17 infographic images, 7 videos (incl. an explainer animation), 6 lead magnets/handouts, an email lead collection/sign-up form and a lead magnet delivery page.

Webinars

Updated Webinar: Discover the 20% of Marketing Activities That Will Give You 80% of Your Marketing Results

The first version of this webinar was watched by more than 1000 therapists worldwide, a whopping 80% of whom watched the webinar from start to finish! If your worries about marketing include not knowing what you should be focusing on, being worried about not having enough time (or worse, wasting time doing the wrong things), thinking you don’t have good enough IT skills, or not wanting to come across as a second-hand car salesman, then this webinar will be a huge help in giving you direction, focus and confidence. I will show you how to create a regular (but controllable) flow of patients (the controllable part is important) when you need them, and how to smooth out the peaks and troughs that the usual ‘feast and famine’ nature of appointments can

create. Probably the best thing is that I will show you how to do it all without being or feeling in the least bit salesy. It doesn’t matter if you’re a one wo/man business, or a multi-therapist practice, it doesn’t matter if you have no marketing knowledge or consider yourself pretty advanced, and it doesn’t matter if you’re starving for clients, or just need a couple of extra ones here and there, this webinar will help you. The principles I guide you through are actually applicable regardless of the business you’re in or where you live in the world; I just happen to have written this with my physiotherapist hat on, so it’s particularly pertinent if you work as an allied health professional. This webinar is jam-packed with value so if you haven’t had a chance to watch it yet, you can catch it for a couple more weeks (I’m scheduled to stop running it in mid-July but I may extend this). It’s free to register. You can sign up here http://co-kinetic.com/8020.

New Help Content

At the time of writing this update, I’ve completed 9 out of the 21 help posts that go with the article we published in the April issue entitled “20 Things You Probably Didn’t Know Your Co-Kinetic Subscriptions Could Do For You”. You can find links to each help post at the following link https://bit.ly/3gQz4Bl They cover: 1. Offer a free or paid taster/introductory appointment 2. Run an Open Clinic event 3. Take sign-ups to just about anything! 4. Deliver a free content download 5. Give access to a private/premium web page 6. Run a prize draw/competition/raffle 7. Offer a downloadable discount coupon 8. Offer a free telephone/video consultation 9. Take sign-ups for your email newsletter Co-Kinetic.com

includes all the above, plus a prewritten blog post, nurture email, PowerPoint presentation, and education-based conversion event campaign. There is also a soccer version of the same campaign (where all references to football have been changed to soccer).

Coming Up This Month

Post-Viral Fatigue/Long Covid Campaign

l 10× Patient Information Leaflets l 30+ Social Media Posts, incl. animated explainer video l Content Marketing Campaign, incl. blog post, PowerPoint presentation, nurture email, educationbased conversion event Fatigue Post-Viral Managing ROME: and Chronic POST-VIRAL FATIGUE SYND ing Syndrome Understand g ndrome Fatigue Sy anagin

ene for Sleep Hygi Fatigue Post-Viral Syndrome

and M Stress

a used to treat commonly but can be You depression beneficial. nxiety and physical sleep) is very mental and into your than actual useful for other rest periods . cure for post-viral should introduce should ideally health problems here is no known (PVFS) or chronic These daily routine. at a time Health fatigue syndrome (CFS), although to 30 minutes Your Mental . be used be limited ilated, dark 5. Manage of relaxation groups can fatigue syndrome symptoms. to and support is quiet, well-vent temperature. and be a period n can help help to ease easy for Counselling ble reduce mental health. n. 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If you Most people should of activity and techniques being suggeste We also know is importan it If you are employe whetherItyou l Avoid day is not feel quite before 3pm. demand most any pain, leading are also good on for sleep. you healthy sleep when they or in many people. also improve aggravate 30 minutes the condition you about off PVFS/CFS. However, of you in preparati of which activities stop activities before tend to do with a friend more than causes health. It can to manage take time able to advise ly in the day s ents. mental of life mind and body worry. aim to to music, talk andcan And, if youdirectly back tomany people it is one caffeine and excessive yourselve learning ways as and quality improvem also listen put enough work. should such to off s You make have some to tend are sleeping and overall to gothat for sleeping hours take time readyseems so that you of good Regular exercise makes them You may also l Avoid stimulant bedtime. When it productivity can help people nals is needed for of the to reduce your you may be much on a muscles are some essentials feel the impact to go for a walk. of factors that work doing may need makes g; by doing some work, when difficult to cut Doing too number t point needa to is key. tension in the Below nicotine close illnesses and A team of professiosupport and counsellin will be too under stress be that you moderation the impact , as does The most importan ely. If you energy in reserve. help to reduce e to physical gradually. It is with different advice, work. It may hygiene. make you feel comes to alcohol, hours immediat n to help There is evidence sleepmethods feeling of wellbeing usual to get to sleep treatment, hours or evenvulnerabl should also following things: than you can possible good day may is well-know and give a stretching, more difficult. is down by several change your importantly r when trying nal health more slightly different an occupatio es your usual close to recovery While alcohol the day, yoga, about sleep take time to to remembe which causes that team very l taking on have close friends. ise faster, too much second later. It can exercises important in massage. Sometimmay become lesstry too hard. Worrying to be stress, are tired during family and likelylong-term duties. If you can comprom you fall asleep pacing is very they arethat in the some breathing your stress not to a certain than just being awake. do; term. include your for cortisol, work, sleep long at of time people; and handling nt the activities but of disrupt in beyond work uction taking a link ‘no’ to tiring putting to departme overprod stress rises much more bedtime can your condition may explain n or simply body begins what you have l never saying you also regarding times to have managing effective when t that you have function. This and meditatio night as the recover and satisfied with PVFS/CFS time off. some involved with immune during these that may half of the very importan if you take TREATING and stress for help your body l never being try to treatments nism); and l Diet. It is ‘sleep point. It is useful back to work alcohol. PVFS/CFS dealing with feet up will of BED your the You should number of E going (perfectio for a night. diet. between are process methods each nced BEFOR achieved confusing There S. a well-bala to which you some specific become difficult the day and may be less a regular routine enough. d for PVFS/CF may have and drinks Relapses people. and mind may also have l Establish how stress be considere l not relaxing sleeping through Setbacks or avoid any foods stress. They regular meals ‘cue’ your body lly and clock’ than Table shows Thewhen 7. Manage BED , emotiona of your illness. Thisofhelps to Eating small, to have setbacks the s a night owl. ONCE IN are sensitive. to do because signs foods is often natural away from on you physically becoming a while. Your Symptom It can be common worse foran effect These few hours your mind exposure to aware of the to sleep. some starchy in 1. Manage Other Effects spotting drinking for the last you may have pooryou behave. Becoming become l Try to turn that contain and drops on way that example, l Ensure adequate and any worries important for symptoms or What and stressland your your is Eating Avoiding spikes triggers – forin the with Medicati particularly Behaviour to manage days’ activities, to stimulate start. your energy future. This beneficial. increased tension light. This is in is a useful venture outside bed is likely can be used can have various stress. will do in the Emotional before our will help manage settled. early stage things earlier Medication for example tion who may not or People Notice or what you of these things. blood sugar them at an tension in so you individuals try to do these Physical Poor concentra with sunlight during sleep, infection where possible, time to think you feel more and food that Changes body, not aware of symptoms may discuss Exposure to or events not the best medication track is oneSteering clear of levels and make We are often a setback. frequently. at night, helps Your doctor ‘Short fuse’ Changes anti-nausea pleasant places to a relaxation sleep. Memory problems the evening. up painkillers, may help during well as darkness aware. Think about s, right before (GET) Tense to conjure bodies. Listening to become morebe ke cycle. the day, as strategies which relaxation technique meals, imagination g Always rushing racing cancan disruptive Exercise Therapy antidepressants. a healthy sleep–wa Heartthe Difficulty making fatty or fried or use your right include 3. Graded way of beginnin physical exercise to maintain that you ed Frustrated environment or rich foods, These may and finding Heavy use of regular, relax means Loss of humour that the sleep decisions relaxing images. are unable to sleep out of thecitrus fruits, and carbonat S. With Sweating GET is the Learning to with your family, and rest, if possible. Quality of Make sure and break and pillows l PVFS/CF Your you talking dishes, some Afraid from that for tension spicy activity 2. Manage Your mattress tension, relaxation activity, indigestion l If you find Impatience to aid recovery reduce muscle you to faster is pleasant. stress and Breathing can trigger balance between necessary for perform your to a low level ble. The bedroom drinks with of fatigue, close to Irritable/angry Life and Function that you will be given while in bed, can be as it may be regular exposure adapt and gradually this occurs vicious cycle activities should be comforta stomach when living 15 and 19°C Don’t listen is likely to become Queasy to However, people. When as good relaxation some of your – between begins to be worsened l Sleep. It painful heartburn stop cool to Any changes can to routine body thoughts be Tiredness change even lead the our have or which sleep. can should you sleep. Bright your too sleep. easy for reduce us feel is tolerance of restTrembling Sudden mood it l’s bedtime, itTV individua – for optimal advice about restful as good to sleep, GET UP after this can make increase the amount example, having and TV HTSincrease an unwell PVFS/CFS. sleep. Fear/dread from watching (60 and 67°F) and pattern (for THOUG get the negative and activity. actually sad. is different how mobile phones that disrupts to and Forgetful out thatmore your sleep sleep) maywe think affectscarrying Relaxation Dry throat l If you cannot , angry and during a setback. television outside tative usually it is quite easy light from lamps, it difficult to fall asleep, lie there tossing What This and act too much, watch frustrated should thought or Argumen where be don’t even can you more (CBT) or Read l own a book, worse. should make we feel therapy a setback stop negative Following 20 minutes, these things rallittle, anxious watching or reading aims to(CBT) tiring in their , the bedroom screens can Muscle tension ral Therapy that make adjust them your of some of sex. It tiredness (fatigue) becoming your which ognitive behaviou that help bedroom and may be e Behaviou CBT lights off or to return to makecan management Being aware help down things turning and you needwith sleep and perhaps canbreaking wake your 4. Cognitiv blackout remain tense in the daytime, therapy thatby so turn those are positive are a s be able gradually cycles therapy this will only by is a talking associated Consider using practising relaxation includes sleeping level. be useful. There Any changes the symptom the clock – physical reactions changing calm space. adrenalin warm, where by bad, CBT is a talking problems right. When your problems when possible. plugs, ‘white youractivity stress and for be a quiet All of these previous you feel with increased re quiet and shouldand ideally be avoided. be done you manage your to physically shades, ear should strategies for movies or most By making and behave. body more It’s scared. go and do you manage to find somewhe fans and curtains, eye for normal survival response watch scary ble position modern way you think your sleep pattern should anxious or Get up and ble, CBT can think and behave. , humidifiers, a comforta l Try not to allow However, in upon as a basis to content, these of stress. changing the and anxiety. more managea the way you relaxing to situations. you can find not be relied stress distressing noise’ machines can make the bedroom d. ly used to treat thought LEVEL problems . dangerous boring and and should (rather that create shows with that n only your negative tic 2020 THE RIGHT not be interrupte you can also It’s most common something may your adrenalin and stimulate times to rest butgradually again. Have change of the things informatio such other devices WHAT IS case. ©Co-Kine STRESS it. If increase ME?you will beginnin relaxation help you gof depression, way you feel. Setting aside society, a lot situations, guidance and in to feel sleepy good as hand. each individual physical l Rest. overall ING as general anxiety and being asked improve the your body and TIONISE FOR Atisthe the to ess. Comedies are life-threatening what . In to theREDUC where or videos on more relaxing. OF EXERC is intended it difficult medical advice patterns and benefits other mental do about GH RELAXA problems that are not tofind gradually to is which can wakefuln if you known in this article get to a point boring books ‘just relax’ family for specialist It to sleep THROU or many many continue you adapts be useful for some released you you has contained post-viral you frustrating with to help be n If body substitute as worries be told a working. ns will and fit. those such notneed exercise or as everThe rise and CBT can informatio financial ent in which it isyou may also as The PERCEPTIONS egular fitter, endorphi on your own become less getfeel stressful medical care ages and te or Has someone chronic of awill health problems (PVFS) and of alllevels your bedroom l The environm a bit ofyou to relax. IOURS you can achieve this less, you concentraTo CHANGING middle constant. Doing take of peoplestress help of a planning individual do. in thedo to BEHAVdo while we these Try and ensure healthsituations will remain is likely to help affects without the yourself, when you’re youitnormally and afters.a to fitness fatigue syndrome (CFS). night and aim important. for planning your thanand high,condition What we is a skill thought Over a medical e you quite alarm each yousame, bit more and tackle problems NS upon as a basis remain differing effects of this. each morning EMOTIOfeel at the doing just a how we think s and discourag l Set your situation, and not be relied fatigue syndrome to say!” ISTS regularly to feel the e to same time be you feel your symptom of getting fitter after therapist. involves looking r and only and should 2020 easy for What we L THERAP may begin can become get up at the exacerbate Treatment information tic we stress can contribut “Well, that’s aspect AND MANUAthem, affects how ALthoughts guidance and Negative too much will case. ©Co-Kine your:of time period starting , feelings, behavioud. most difficult unwell.function BY: act benefit as general and cognitive FOR PHYSICwe pay attention to It can long a very low again. The in each individual PRODUCED think and way thoughts is intended exhaustedl concentration) system from trying us feel s are interlinke this slowly. to terms with RESOUR CES medical advice in this article the more cular es and can making (memory and automatic: l cardiovas may be coming about increasing The information containedas a substitute for specialist physical sensation up by themselv that our TIME-SAVING that PVFS/ PVFS/CFS effective heart being patient seem to pop r is care or NOT imply l fitness levels (lungs and be the most exercise and to remembe This DOES the more they ’ as for many individual medical regularly, will amount of The first thing real, just that, that the negative thoughts extra, done l balance ISTS l muscle strength to get rid of. CFS is not ‘automatic L THERAP be difficult A small amount s, there is evidence manage it identifying l sleep fitter. AND MANUA l flexibility exercising and not facts. 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Negative physical activity quality of l Injuries l “I am useless; find it of whether deal with overwhelinto (PVFS) or t pattern of improve your Regardless a primary illness, always interlinke CBT aims to help you – many people exercise: working hard, a consisten making you g to prevent your them down fatigue syndrome are the first step cycle. s feeling. After else that is of post-viral and attemptin thoughts is way to prepare(CFS), there way by breaking in a vicious l Heavines feel heavy. and, exercise. all ages. are a good If you feel anything during exercise be sure Noticing these fatigue syndrome a more positive are likely to . These chronic are really true a stretching AND beneficial across r. rtable them down. problems in to plan your muscles whether they PY (GET) comes in varying 3. Gentle stretches You may wish you add Here to remembe feel uncomfo helpful to jot these negative ISE THERA further. stiffness. This is to think about balanced alternative. to do before activity. some things for step talking smaller parts. how to change Muscle EXERC concerns D l therapist next you other muscles The shows to discuss physical GRADE with a more Unlike some and some more from CBT therapy e with your WHAT IS NSE is degrees. to come up way you feel. rather than L programm thought patterns L RESPO IT HELP ME? to aid recovery if not, to try is normal and enjoy or problems, improve the of negative 1. NORMA that you HOW WILL regular physical exercise fatigue syndrome HING IS HELPFU patterns to o Mild stiffness positive changes and ISE with your current for practical ways to any activity. your show keep your EXERC questions an initial activity 4. STRETC are some examples alternatives. use of with CBT deals or chronic looks addition to will help to yourself the GET is the activity. Plan DURING associated be in to adapt and treatments, helpful good warm-up your past. It and level syndrome (PVFS) signs and feelingsright thought, ask 4. Realistic This should Regular stretching s and joints flexible and balanced or a more body begins last long. A issues from in your life. The following your body slightly you think of post-viral fatigue low level activity, the have a negative at the should not focusing on on a daily basis. reduce this. is necessary understanding When you to challenge They may help muscles, ligament you move freely, without wn will help regular state of mind you are working out that activity. much with to your lactic (CFS). With and is lets and warm-do everyday activity you that Table overleaf. improve your ability to carry changes the build-up you osocial which ability, a overlaps very in and your normal, S by positive current supple, shown you know when caused the biopsych ming problems to make real at a level it. if you CBT for PVFS/CF gradually increase your level of tightness. 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CBT can also symptoms muscles. minutes wouldyourbodies , and affecting Any activity of the to start tend only to You will feel walking, can to increase to my kids”. to. from 5 to 10 positive and is essential our temperature. and the potential if they want regular stretching interconnected will feel more or intense stiffness happen, it 100% increase;l Increased work harder on ‘bad’ capacity has balance between S harm to these thoughts o Moderate your muscles enormous that this doesn’t your muscles have a good manage (even not indicate supple and with PVFS/CF warmer as Most people worse. To ensure level that you can easily muscles does become Many people uncomfortable, heat. . When we comfortable. a low but, as it is they feel when give off more activities at in colour. This your body negative thoughts much better gradually. turning red to adjust your report how close to build up . parts need and vessels Body may l stretching days), you the blood they do regular e. happens because to allow more blood to programm will make ISTS widen L THERAP tiredness. Exercise to the skin ISTS which helps keep you I Stretch? tiredness MANUA Natural do Should l to natural AND them, if day and AL i. When only you L THERAP through BY: PHYSIC flow energy each this improvements you feel a normal PRODUCED CES and FOR AL AND MANUA enjoy. You will see start by improve sleep: BY: many signs cool. activities you FOR PHYSIC way of helping ng as RESOUR You might than PRODUCED and will help to e TIME-SAVING RESOUR CES . This is another stretch regularly. feel more intense S. but work up as the It is worth recognisi your own experienc day, ure: may VING a Sweating l once from tiredness TIME-SA body temperat time. to y with PVFS/CF ise with post-viral stretching just characteristics down. help you next to control your y. It is useful yourself at Comprom ost people usual in somebod as this can (PVFS) chronic es it cools you too much of stretching frequentl of setbacks list those warning sweat evaporat legs may feel Are you asking step back and fatigue syndrome (CFS) will following times: overleaf to to Exercise Your arms or be afraid to stretch at the a Reactions Use the space before and present? Don’t fatigue syndrome l ‘Jelly feeling’. like jelly. When you stop ons during have noticed during 3. Rare Adverse or flare-ups; times your expectati signs that you what you become aware of these signs gradually a little shaky setbacks or reconsider ones as you If you get any of activity and er to recognise a period of experience feeling should add any new s worsen for d-bust patterns e team will help exercising this setback. Rememb your when symptom . to maintain an To reduce boom-an of them. your healthcar go away. be difficult are achieving Completing with energy levels, times. time. It can to help you activity patterns. your energy stabilise your during these a do, t skills to learn d your current termed you post-viral be setbacks, levels of activity Signs importan of being activity understan s is may it most feel like what Warning you to the day. will provoke symptom the type of ne of the Socialise easy to and best of planning, ISTS levels during will record reduceinyour Different things for varying lengths of response involving cytokine storm). tired it is However, if L THERAP Even with the activity diary being or chronic fatigue syndrome recovery in your energy establish a last If you’re very your er that(PVFS) surge’ (or ways experience fluctuations to avoid a setback. it as a way necessary and Rememb and they may ‘cytokine AL AND MANUA graded exercise have different your any people may syndrome so what impossible BY: levels and any the changes you use fatiguecan FOR PHYSIC person will isolating yourself. will include be helpful, PRODUCED ) fatigue; without making one, could you to make ent, whicha time. Each FS VING RESOUR CES You may be can sustain, you do have This will help PFVS/C with someone chronic (long-term necessarily the signs? What touch (CFS) with a setback. approach is is activity managem of a ring, or inviting level that you TIME-SA you ignore of dealing DIAGNOSINGthe main this is not symptoms will know this aware of those be all of us balance y? to learn? Did baseline activity giving someone of worse. You control will however, to become which is about therapy (GET). that can help mental done differentl especially for you significantly control. The encouraged Although one ent is a way prolonged and syndrome (CFS), could you have resting. It is symptoms feel more in of omyelitis provoke a setback friend round? is severe and chronic fatigue things and ent has stopped Activity managem with a you start to things that PFVS/CFS is also a range are much lower ‘bad’ as myalgic encephal fatigue between doing helping when a plan for coping blame as if your improvem ‘good’ and fatigue, there energy stores also known might feel MANAGEMENT our daily activity PVFS/CFS as your t. and to develop between and physical Do not give to manage degree of post-viral SETBACK good but you fluctuations s that can include: it happens. Pamper yourself and even more importan if you have (ME). Some below). think of it t part of learning useful is still have small setback when other symptom tough,, pace is a fairly common level diagram do happen: An importan balance becomes you might to manage or relaxing If the going es pain (PVF) or debility of viral infection. S is learning Baseline activity and, therefore yourself. Setbacks solved. If a massage that l Headach and/or joint after any type your PVFS/CF days (See the This means to be for it. Decide ad muscular yourself a break. Level occurrence this is short then go PY therapy best you can. Widespre Activity the as a problem cases, as l helps, of quickly most or bath OF THERAas a kind ofthe Three stages Baseline setbacks ly, in ce more to normal shower K? Fortunate Good yourself STAGES improve able to recover l Sleep disturban include a steady return you through Good will indulge KES A SETBAC you will be occurs. control and the way you work with and there is Day ing sleep may how you Good lived aim tonext confident in a few weeks. time a setback g you to gain We ation Day WHAT PROVO clear-cut Good l Unrefresh post-infection reminders a period of Day and feel more Good always have in the early 6 Good e below, supportin compens symptoms Here are some health over Day things restless programm hypersomnia Setbacks don’t and flu-like Day number of handle a setback. that may help. ed sleep and of life. Day When fatigue there are a of time once your quality stage, fragment causes but more severe s longer period e to one: 5 of useful strategies of later on. In Thinking persist for a think influence and accpetance of normal legs syndrome which can contribut may be the result is over, a diagnosis the way we ndingit is might may be a reversal at night g it. This Remember of a setback the acute infection a l Understa cases, there l Overdoin and bust’ 4 syndrome (PFVS) In the midst or simply as on the ‘boom Relaxation (ie. being awake ce of proper, too much, how we feel. and dwell post-viral fatigue te, which has many l Reducing the importan sleep rhythm of taking on for too long. day. into bad habits thisng regular try outrelaxation symptoms Remember appropria and one activity during the Try to use your easy to slip there is of be moreBad l Introduci 3 relaxation. reducing but sleeping result of doing tion and if you fail to With PFVS, Try to be aware recuperating g sleep and Badsimilarities to CFS. be triggered negatives. s with concentra technique. that what is ion l Improvin Day Bad Setbacks can thinking. l Difficultie to indicate if you fail to Stabilisatof Cognitive Day Bad favourite relaxation properly, or different ways Day (‘brain fog’). will apply to Bad 2 research evidence normal immune system working memory activities strategies pace yourself Day Bad in short-term these Day (GET) d some Not all and prioritise. involving has not Gradual increase initially a perfectly l develope Day e in exercise dysfunction plan, prepare in your life most may have tion and attention the acute infection It is also Planned Rest ion of/increas 1 feelings out about the Time lly managing period of stress you and you those response to l Introduct is over. memory, concentraprocessing, and wordyou found l Stress. A thoughts and timeBe aware of the infection l ideas for successfu It’s What have at difficult on there after setback. planned, a is It additiona CFS, setback. Looking a abated informati lof with of rest? of others span, may provoke spot the signs the length as happens be effective use g demands upset you and or reducing possible that, worry, don’t l Managin that energy enjoyable. finding ability don’t things that – feeling unduly stressed. do with the way le to say limited and to level in g becoming impossib tional malaise TOLERANCE ted when you The Increasin you will be able is a problem especially ress summary that you are l Post-exer place at a cellular or disappoin INCREASING the plan/prog your baseline, ent may be ill after activities. be helpful to n takes activity, exercise, concerned normal for dria. established feeling increases in fatigued and activity. It can productio Stress managem Yes, itlisWellness ly when you s (a general Once you have increases in Activity sustainable steps. It called mitochon times. forfrustrating smallstructures fatigue have a setback. very Plans l S but a bout to stop complete r what malaise symptom or unease) are introduce gradual increases as a series of helpful at these with persisting school of PVFS/CF It’s tempting increase working situation illness an and/or illness. Following to a these rt, is remembe The been condition of appears – work step visualise – don’t mental is discomfo l Periods prone you may have on nded that each pass Each coronavirus infection than are fatigued your baseline willsetbacks physical and/or – later may become 10–20%. for you when is recomme to still work know itwith following2–3 ted and adjust l Coping . Just activities amplified by of illness, you gs you wish approximately for improving more complica illnesses. slowly you have learnt, er to restart goals/thin I feel OK a delayed impact in activity of nce l itFuture sustained hard and you should to be rather viral Maintena exertion with or even later. needs to be setback. Rememb pacing yourself. learnt from with other is taken. accordingly. increase then the next day, gradually by and having to your previous a further stepwhat happens more serious as fatigue Many the same day, provokes and exercise recover back weeks before be only asonal factors. as people start of activity that to be be able to to increase n It could also very for everyone turning out The amount l Low mood/se an interactio It is usually best are very tion can be important of activity. Prioritise a time; forof energy are will be different that there is level of symptoms circumstances into the most activities at and lack This process symptom exacerba and their people find one or two people’s life time by a istic long-term long-Covid. I feel Put your energy and keep some frame of mind levels, andfor planning reading I do a lot very character life first. Try at varied minimal termed between their glands The Boom example, extend anxious upon as a basis minute tous infection, areas of your and tender not be relied . feeling and add onecoronavir on for what about energy levels. l Sore throats to everyone only and should 2020 diverse. problems, few minutes and Bust activityprecise explanati remains information factors apply and balance not doing ©Co-Kinetic Trying to increase The guidance and Not all these l Dizziness ction/viral fatigue ously a daily walk. as general individual case. feel Activity Cycle much is intended causes post-infe of the reasons why advice in each of your life simultane needles STABILISATIONto do a lot when they faint in this article in every area like pins and specialist medical . But one s tend contained unwell n for feel people energy, g. uncertain sensation they of substitute Most The informatio l Odd care or as a fatigue, loss activity when could be challengin small increases can lead s people have and generally individual medical below. 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It example, Different people develop serious others. For more than us infection, in people who symptoms ISTS from coronavir L THERAP e immune complications due to an overactiv AL AND MANUA BY: this may be FOR PHYSIC PRODUCED RESOUR CES TIME-SAVING

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FATIGUE SYND

Pacing Yourself

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Activity Level

Football Social Media and Lead Collection Campaign

Co-Kinetic Journal – July

l Physical and Manual Therapy Journal Watch l Pain Does Not Always Indicate Injury l Pain in the Athlete l Working with the Long Covid Client: A Massage Therapist’s Perspective l Oncology Massage: The Lymphatic System l Which Marketing Metrics Matter (And Which Don’t) l Timeless Testimonials: The Power of Reviews 1999

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