Co-Kinetic Journal Issue 90 - October 2021

1999

2021

ISSUE 90 OCTOBER 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.

Register Now!

https://spxj.nl/2PAsnVq

what’s inside PRACTICAL

50-52 45-49

ENTREPRENEUR THERAPIST

FULL SITE SUBSCRIPTION

SECTION 1

Planning Your Event

The goal here is to run an educational event targeting post-viral fatigue or long-Covid sufferers (and ideally also their support networks) with the goal of bringing new prospective clients into your business.

Here are some questions to ask yourself before you start, to help guide and inform your event. Do you (or team members/associates) have specific skills/qualifications/facilities or services that would lend themselves to supporting this target audience?

Are you interested/passionate enough about the topic or about supporting this target audience?

You don’t have to answer Yes to the last couple of questions, but the more passionate, engaged and committed you are about the topic of the campaign and/or the audience you’re pitching too and planning to support, the more effective your campaign is likely to be.

TASK 1: Decide on the desired outcome of your event

Option 1: To encourage attendees to book a free discovery session (phone/ web/face-to-face) with the goal of using that session to bring them in as a new client.

OR Option 2: Offer a paid upgrade service. If it’s an upgrade service you need to decide: What service will you offer?

How much will it cost?

Will it be a one-off purchase or can you turn it into a multipurchase event, such as a fixed

C

Graded Exercise Treating Therapy Post-Viral/Chronic for Fatigue Syndrome

Cognitive Therapy Behavioural and Its in Treating Role Post-Viral/ Chronic Fatigue

ognitive behavioural is a talking therapy therapy (CBT) you changing manage your that can help THOUGHTS problems the way What It’s most you think by we commonly and behave. how we THINK affects anxiety feel and used to thoughts and act treat to become be useful depression, but can for other this can more negative also health make problems mental and and angry and us feel more physical fatigue such as frustrated, sad. syndrome post-viral fatigue CBT aims syndrome (PVFS) and chronic to stop cycles (CFS).

Treatment by breaking negative thought way thoughts, involves make you down things looking feel bad, at the feelings, that physical By making CHANGING anxious behaviour sensations your problems or scared.

EMOTIONS This DOES manageable, and PERCEPTIONS are What more NOT imply interlinked. we FEEL CFS is your negative CBT can help affects that PVFS/ not how we you change thought physical real, just that, think BEHAVIOURS improve and act patterns as for many conditions, the way and way we What you feel. help you we DO think about there is evidence CBT can affects get to can achieve makes how we a point that the think a difference. illness and where this on and feel how we tackle your own you problems manage and it HOW without therapist.

CBT WORKS the help Humans of a Negative automatic: are very thoughts how we the more complex the can feel and be difficult more they beings. seem to we pay attention become we feel what we So to get thoughts and what pop up do; equally how we think rid of. to them, are not by always The first will affect what is a good facts. So interlinked.we think. Our thing to themselves and thoughts, we do influences identifying place to in a vicious remember can Negative start. feelings ‘automatic is that problems cycle. CBT aims thoughts and and actionshow our negative Here are feelings in a more to are thoughts’ some examples: smaller can trap positive help you deal l “I woke parts. you with overwhelming way by breaking CBT therapy l “There’s feeling exhausted, them down patterns no point shows I l “I’ll you how into to in trying, must be getting never get ost people to change treatments, improve the worse.” any better.” I’ll only fail.” l “I am these negative CBT deals way you feel. any people useless; syndrome with post-viral focusing Unlike with your on issues some syndrome (PVFS)/chronic fatigue I didn’t achieve syndrome with post-viral current setbacks improve from your characteristicseverything fatigue (PVFS) fatigue problems, other talking (CFS) Noticing your state fatigue past. It or flare-ups; will experience these thoughts irrespective rather from your I’d planned have difficulties syndrome or chronic of mind looks for of setbacks CBT for symptoms than times helpful of how on a daily own to do.”

PVFS/CFS practical worsen as this when to jot them time. is the first during the complexity with sleep. (CFS) find they habits ways for basis.can be can help experience the night. much sleep overlaps down.Use the step (often Poor sleep l Taking next you had very much activity difficult toto a period ofThe of PVFS/CFS Compromise approach. space – manyyou make these referred to next maintain if not,time. It step iswarning a warm overleaf people to think signs with understanding find it during to to regarding bath difficulties as ‘hygiene’) quiet,It involves identifying massage Are you to list those mayisbe aboutthat you these times. your healthy levelstry will provoke well-ventilated, are some the biopsychosocial can asking maintaining are good and/or having worse. of comebefore have sleep up with and add whether l Avoid too much examples Obtaining present?

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For example,

FATIGUE Advice SYNDROME: on Setting Exercise and Expectations

POST-VIRAL/CHRONIC FATIGUE SYNDROME:

Coping

Sleep with Hygiene Post-Viral/Chronic for Setbacks Fatigue Syndrome M

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PLAYBOOK

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POST-VIRAL/CHRONIC

Understanding and Managing Stress FATIGUE

SYNDROME:

Managing Syndrome Post-Viral Fatigue and Chronic Fatigue Syndrome

S

T

Level

POST-VIRAL FATIGUE CAMPAIGN

Activity

NEWLY RELEASED CONTENT & TECHNOLOGY

Post-Viral Chronic Fatigue Syndrome Fatigue Syndrome and

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This article provides a detailed, step-by-step Playbook explaining how to use the resources included in a Co-Kinetic Content Marketing campaign (provided as part of a Full Site subscription) to plan and implement a highconverting, new-customer-generating conversion event. Read this article and download the associated resources at https://bit.ly/3kdZ9MG

By Tor Davies, physiotherapist-turned Co-Kinetic founder number of sessions or even a recurring membership, or perhaps some sort of ongoing patient support network? This creates greater revenue opportunities and you should ALWAYS look for opportunities to create sources of recurring (subscription) income.

You could even have an offer which combines both options.

Do you have any colleagues/ associates you could collaborate with to add value or uniqueness to your offer? Don’t worry if you don’t, but equally don’t be afraid to think outside the box.

What special incentive will you offer event attendees on the day to encourage them to take up your offer?

Will you provide a post-event offer (after they have left the event)?

Usually this would be slightly less incentivised than the ‘on the day’ offer. It must also be time-specific ie. have a deadline for sign-up to encourage ‘scarcity’. And hold your ground about this deadline, however hard you might find it.

If you start negotiating, you will 21-10undermine yourself both in that COKINETIC moment, but also in the future. | GENERATINGMaybe you could offer a small CLINIC-SALES concession instead so they feel they FORMATS WEB still scored a ‘win’.

MOBILE PRINT One last thing to consider is will you target existing paying customers, or would you prefer to target a completely new set of people?

And if so, can you segment existing customers versus people who have never become paying clients in your email list? If you can’t currently, this is definitely something to prioritise going forward. There’s nothing wrong with inviting existing clients

FULL -SITE SUBSCRIPTION POST VIRAL FATIGUE CAMPAIGN PLAYBOOK

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JOURNAL WATCH

DO YOU (OR TEAM MEMBERS/ASSOCIATES) HAVE SPECIFIC SKILLS/ QUALIFICATIONS/FACILITIES OR SERVICES THAT WOULD LEND THEMSELVES TO SUPPORTING THIS TARGET AUDIENCE?

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29-37 THE ROOTS OF YOGA AND HOW IT PERTAINS TO PAIN

MANUAL THERAPY

21-10-COKINETIC | PAIN | YOGA FORMATS WEB MOBILE PRINT All references marked with an asterisk are open access and links are provided in the reference list

By Niamh Moloney PhD, MManipTh, BPhysio, SMISCP and Marnie Hartman DPT, CSCS, RYT

Yoga: An Introduction

The word yoga can elicit a number of reactions from the general public, including: “I am not flexible enough to do yoga” or “I already have a faith system”. These responses represent a misunderstanding of what yoga is and what the practice involves. Yoga is the study of self and living with awareness.

It encompasses philosophies and tools to facilitate this, to promote self-regulation, and hence to improve wellbeing. The yoga philosophy presented here and throughout the rest of the book Pain Science – Yoga – Life, as we weave the concepts of yoga with pain science, is a product of the combination of our individual yoga teacher training, clinical experience, self-study and contemplations. While reading, we encourage you to keep in mind the primary purpose of this book, which is to use yoga to facilitate a change in one’s relationship with pain. We recognise that yoga as it is presented may feel over-simplified for some or difficult to fully digest for others. It may be helpful to proceed with the mindset of ‘take what you need and leave the rest.’

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TURNING PROSPECTS INTO PAYING CLIENTS: BUILDING AND IMPLEMENTING A 12-MONTH MAKETING AND SALES PLAN

PHYSICAL & MANUAL THERAPY AND HEALTH & WELLBEING INFOGRAPHICS

ROOTS OF YOGA

and How it Pertains to Pain Many people, if not most, think of yoga as being useful for developing flexibility or perhaps for rehab, and know that it has ‘some sort of mindfulness’ aspect. This article sets straight some of the misconceptions about yoga as well as describing the Eight Limbs of yoga, the concepts of which can inform a complete way of ‘being’.

Combined with an emphasis on how these ideas are relevant to pain, this article will enable you to encourage your patients to manage their pain holistically – both physically and emotionally – as well as being of benefit in your own life. This article has been extracted from the authors’ book Pain Science – Yoga – Life. Read this article online https://bit.ly/3yWYcMB Yoga misconceptions: l It is not a religion. l It is not a fixed series of exercises for flexibility or handstands. l It is not a trendy lifestyle of clothing, foods and social media posts.

Yoga does encompass: l A spiritual connection and practice with the many layers of ourselves and the world we live in. l Exercises or postures known as asanas that promote strength, proprioception, flexibility and mindfulness or awareness. l Positive thinking and mindfulness with meditation practices. l Awareness of, and activities to promote understanding of, our own perceptions of body, emotions and the self. l Awareness of, and activities for, breathing known as pranayama. l Awareness of how we nourish ourselves through food, society, nature, thought, etc. l Promotion of rest and relaxation. l Positive social and environmental living, harnessing wisely from these entities, taking no more than we need and learning to give back as well.

At its core, yoga is the study of self and living with awareness. In Sanskrit, yoga’s root language, the word yoga comes from the root word, yuj, meaning to yoke, to unite or bring together. This can be thought of simply as connecting the body, mind and spirit. For our purposes, spirit can be thought of as the way our inner self connects with the outer world. At a more in-depth level, this union is the ability to detach from dualistic thinking. Non-dualism allows the bringing together, yoking, of all things. Comprehension of dualism is challenging; we will look more closely at it in just a moment.

A Look at the Self – One Potential Viewpoint

People spend years attempting to understand and define ‘the self’. To keep it simple and for the purpose of pain, we will consider the self as one entity with two distinct layers. The superficial self is the physical body, including the senses, the brain and the psychological mind. The mind here is all of your thoughts, beliefs and opinions. This is the self that we tend to identify strongly with, the one that we put up against others for comparison. This is the ego-driven

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14-21 22-28

STRETCHING THE TRUTH

THE CORE OF YOUR FOOT PROBLEMS

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

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CLICK ON RESEARCH TITLES TO GO TO ABSTRACT This is about cupping, which according to this paper is really called Hijāma.

This is an Arabic word that means application of cups, and the literal meaning of Hijāma is sucking. There are several types: wet cupping, dry cupping, hydro cupping, and cupping with fire. The paper gives a traditional medicine view of how cupping works. It is either an evacuation or a diversion of morbid matter. It goes on to speculate in modern medicine terms how/why it works citing pain gate theory, stimulation of prostaglandins, endorphins and encephalin production. Another theory is that the trauma of the cupping releases nitric oxide which contributes to vasodilatation, muscle relaxation and anti-inflammatory properties.

The authors follow this up with what is basically a literature review (although they do not say what they searched or the criteria they used). They cite RCTs

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EVIDENCE-BASED THERAPEUTIC BENEFITS OF CUPPING THERAPY (HIJĀMA): A COMPREHENSIVE REVIEW. Kouser HV, Nayab M, Tehseen A et al.

Journal of Drug Delivery and Therapeutics 2021;11(4-S):258–262 on cupping for non-specific low back pain, sciatic pain, neck pain, shoulder pain, knee osteoarthritis rheumatoid arthritis, carpel tunnel syndrome, dysmenorrhea, female infertility, migraine and reduction of blood pressure – all of which showed positive results after the treatment.

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Co-Kinetic comment It’s a tad suspicious that only the positive stuff is reported but if you are into cupping then this paper gives you an evidence base to quote. We offer a much more balanced view so you may also like to check the internet search engine of your choice for examples of the damage cupping can do if it goes wrong. Be warned that some of the photos are not for the faint hearted.

EFFECT OF MUSCLE ENERGY TECHNIQUES ON FUNCTIONAL ABILITIES IN PATIENTS WITH DISCOGENIC UNILATERAL SCIATICA. Yousef KH, Khalefa BM, Badawy MS et al. Turkish Journal of Physiotherapy and Rehabilitation 2021;32(3):8698–8705 This was a randomised controlled trial of 30 patients with a 12-week history of discogenic sciatic pain.

They were divided into two groups and were treated 3 times a week for 6 weeks. Group A received muscle energy technique (MET), with lateral recumbent positioning along with conventional physiotherapy. The MET was directed at lumbar side flexion and rotation. Group B received conventional physiotherapy consisting of infrared radiation on the low back area for 15min, ultrasound waves (Digi sonic device) for 10min on the trigger areas of the low back, myofascial release of the thoracolumbar fascia, stretching of the paraspinal muscles and the hamstrings, mobilisation of the lumbar and thoracic spine from prone lying position and strengthening of abdominal muscles,

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multifidus, and transverse abdominal muscle.

Pre-post treatment data was obtained using a visual analogue pain scale, the Oswestry disability index, modified Rolland and Morris scale, and goniometric straight leg raise. There was statistically significant improvement in all variables measured between both groups, with a greater improvement in the MET group.

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Co-Kinetic comment Not strictly speaking a sport-related paper, but it does show two important results for physical therapy. One is that if you can give your patients a lot of your time and throw the book of treatments at the problem, the patient will feel better. The second is that adding MET to the treatment list gives even better results. Now can we have this repeated with a home exercise programme and a longer term followup, please?

Co-Kinetic Journal 2021;90(October):4-11

RESEARCH INTO PRACTICE

Journal Watch This involved a search of PubMed, MEDLINE and Embase since 1990 following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for studies of all levels of evidence pertaining to injuries sustained by active players in the National Basketball Association (NBA) and the Women’s NBA. The initial search yielded 1253 unique studies, of

SYSTEMATIC REVIEW OF INJURIES IN THE MEN’S AND WOMEN’S NATIONAL BASKETBALL ASSOCIATION. Lian J, Sewani F, Dayan I et al. The American Journal of Sports Medicine 2021;2:03635465211014506 which 49 met final inclusion criteria for this review. Only four studies included athletes in the Women’s NBA. Based on the mean annual incidence, the five most common orthopaedic sports injuries were concussions (9.5–14.9 per year), fractures of the hand (3.5–5.5 per year), lower extremity stress fractures (4.8 per year), meniscal tears (2.3–3.3 per year), and anterior cruciate ligament tears (1.5–2.6 per year). Cartilage defects treated using microfracture, Achilles’ tendon ruptures, and anterior cruciate ligament injuries were three issues that led to significant reductions in

performance measurements after injury. Studies were also found on injuries to the foot and ankle, hip arthroscopy, hip/groin injury, patellar tendon tears, ophthalmologic injuries, oral maxillofacial injuries, shoulder instability injuries, cervical spine injuries, lumbar spine injuries, and venous thromboembolism.

Co-Kinetic comment As the authors point out, research on sports injuries can inform team medical personnel about injury preventive measures and treatment algorithms. According to a cited study in the paper, a player performs an average of >1000 movements during a game, resulting in a change of action every 2 seconds, and >10% of playing time is spent in highintensity activity. Stopping them getting injured is a big ask.

PHYSIOLOGY, FASCIA. George T, De Jesus O. StatPearls [website] 2021, January [updated 2021, 13 March] Everything you need to know about fascia starting with the latest definition from the Fascia Research Conference: fascia is a ‘fibrous collagenous tissue which is part of a body-wide tensional force transmission system’. This new definition encompasses fascia’s dynamic ability to adapt to various changes in stretch and tension produced by the surrounding tissue.

Multiple roles for fascia have been outlined, including forming distinct muscular compartments, providing attachments, improving circulation, and serving a protective function.

It is fascia’s role in myofascial force transmission that will be of most interest to physical therapists. The concept of this is that a muscle not only produces force towards the tendon and joint but also that force is transmitted to the connective tissue within and outside the Co-Kinetic.com

muscle and thus due to the intimate relationship between muscle and fascia, the fascia plays a role in force transmission. When a muscle produces force, the force is transmitted towards the joint’s direction and towards the muscle’s surface. A study is quoted that suggests that the myofascial connections can play a role in up to 30% of force transmission. At the macroscopic level, force is transmitted from the muscle to the surrounding connective tissue. At the microscopic level, cellular changes occur involving

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the various cells making up the fascia. Fibroblasts, one of the principal cells within the fascia, respond to the increased force by increasing cellular signalling and gene expression.

These changes lead to increased cell proliferation and connective tissue remodelling.

Co-Kinetic comment This is one of the latest articles in the StatPearls series. If you have not yet come across StatPearls, it is a library of medical information which boasts of being the largest library of medical education in the world with more than 7600 medical authors and editors who have published more than 8500 peer-reviewed PubMed indexed articles covering every specialty in healthcare. Go to https://bit.ly/2UXKTO6 and pick a subject.

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THE EFFECT OF SPORT MASSAGE ON LACTIC ACID RECOVERY. Brilian M, Ugelta S, Pitriani P. Gladi 2021;12(02):138–142 OPEN

This was a study involving four national wrestlers in West Java. The procedure was that they underwent a 6min simulated wrestling programme followed by a blood lactate test using an Accutrend Monitor. They then received a 20min sports massage, and their lactate levels were measured again and the results showed that the lactate levels were reduced.

Co-Kinetic comment Good result for massage BUT it is a controversial finding.

Many previous studies have shown little effect. In this case, sadly, there is no control group, and it is possible that the participants could have drained their own lactate 20min after the exercise. There is also no description of what the massage protocol was. The last word on lactate clearance should go to Morsaka who stated, ‘from a simple practical standpoint, lactate clearance after massage does not warrant investigation’ [See Moraska A. Massage and lactate clearance. Medicine and Science in Sports and Exercise 2011;43(4):738 (https://spxj.nl/2WWPNvf)].

Sixty healthy participants (24 male, 36 female; age, 27.1±8.8 years; weight, 75.2±17.9kg, height, 172.8±9.7cm) presenting with upper trapezius pain and a trigger point were recruited and randomised into either a therapeutic massage (TM) or positional release therapy (PRT) group. Upper trapezius trigger points were found via palpation. Pain level was evaluated using a visual analogue scale, and pain pressure threshold was assessed using a pressure algometer. Muscle thickness was measured by B-mode ultrasound, and muscle stiffness was measured by shear-wave elastography. Participants were measured at baseline, posttreatment and again 48h later.

TM treatment started with effleurage (1–1.5min) and proceeded to petrissage (2.5–3min) again followed by effleurage (1min) over the marked area of the trigger point, but also in some surrounding areas. The pressure applied by the researcher progressed throughout the massage into the petrissage phase as tolerated by the participant and pressure was then reduced during the final effleurage phase. The PRT group received three successive treatments or releases in 6

EFFECTIVENESS OF IASTM (INSTRUMENT-ASSISTED SOFT TISSUE MOBILIZATION) IN THE TREATMENT OF CHRONIC CALF PAIN: A CASE STUDY. Ranji K, Hosur A. Journal of Medical Science and Clinical Research 2021;9(7):40–42

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This is a case study involving chronic calf pain in a 27-year-old female dancer who presented with complaints of vague calf pain in the right lower limb for 2 to 3 years. There was no history of trauma or injury. The onset of pain was gradual, and it was a dull ache. The pain was aggravated after prolonged walking and when she went for dance performances. Gradually her daily activities started to become affected as the pain started increasing in severity. She had multiple soft tissue nodular restrictions on palpation, light weakness of right plantar flexors and tightness of right gastrocnemius/soleus. All other causes of calf pain (such as venous thrombosis, skeletal abnormalities, limb length discrepancy, etc) were ruled out.

During each treatment session, the interventions were: a warm-up of spot marching for 5min; IASTM, 6–8 min of IASTM on the right calf using edge 2 of the edge tool (brushing strokes were performed); stretching exercises for gastrocnemius and soleus; eccentric calf exercises, single-leg calf lowers with the right leg, two sets of 15 repetitions each, once daily; and ice pack application for 10min to control inflammation. The patient showed significant improvement after 10 sessions.

Co-Kinetic comment On paper, this shows the effectiveness of IASTM. However, given that there were multiple other treatments, it is difficult to isolate IASTM as the sole reason for improvement. The goods news, though, was that the combined treatments worked.

If all else fails do a bit of everything.

POSITIONAL RELEASE THERAPY AND THERAPEUTIC MASSAGE REDUCE MUSCLE TRIGGER AND TENDER POINTS. Bethers AH, Swanson DC, Sponbeck JK et al. Journal of Bodywork and Movement Therapies 2021;doi:https://doi.org/10.1016/j.jbmt.2021.07.005 the marked area. The therapist located the marked trigger point and, while maintaining contact, a light pressure with the clinician’s fingertip was applied creating slight dimpling of the skin and blanching of the clinician’s fingernail bed. Following palpation, the researcher moved the participant’s shoulder into passive abduction and scapular upward rotation and retraction until a position of comfort was achieved with no pain reported by the participant, as directed

by Speicher in his book Clinical Guide to Positional Release Therapy [Speicher TE. Clinical guide to positional release therapy. Human Kinetics 2016. ISBN-13 978-1450496247 (https://amzn.to/3yta74G)].

The participant was instructed to remain completely relaxed during the 90s treatment. After the recommended 90s had passed, the limb was returned to the starting position. This was repeated immediately two more times in tender points immediately adjacent to the first one, as recommended by Speicher.

The results showed that both treatments were effective in treating pain and muscle stiffness. Although no statistical group differences existed, treatment using PRT showed decreased pain averages and decreased pressure sensitivity at both post-treatment and 48h later. Neither treatment was able to maintain the reduced muscle stiffness at the 48h measure in males.

Co-Kinetic comment This is much better massage research than the Andreossi et al. paper we have commented on (p.7: ‘Effect of massage and pseudo massage on acute performance and self-perceived recovery: a study placebo-controlled’). It tells us the relevant experience of the therapist; it gives an indication of how they regulated the depth of treatment and there is enough information for you to follow the protocols. There is detail about the measurement tools and pictures of the scans. Good work.

Co-Kinetic Journal 2021;90(October):4-11

RESEARCH INTO PRACTICE

LONG-TERM CLINICAL RESULTS OF AUTOLOGOUS PLATELET RICH PLASMA (PRP) IN RECALCITRANT PLANTAR FASCIITIS. Choudhary R, Agrawal AC, Garg AK et al. IP International Journal of Orthopaedic Rheumatology 2021:7(1):12–16 This research aimed to assess the clinical effectiveness of autologous PRP injection in cases of recalcitrant plantar fasciitis (RPF) over a long period. A total of 60 patients (23 male, 37 female) with RPF met the inclusion criteria of a 3-month period of conservative treatment yet had no pain relief from it. They were injected with approximately 3ml of PRP mixed with 0.5ml lignocaine into the maximum tender point of the heel. Of the cohort, 28% described themselves as moderately active, and 40% as having heavy or longstanding activity lifestyles. Data was collected at 1 month, 3 months, 6 months, 1 year and 2 years after injection.

The results showed that mean pain scores (visual analogue scale) went from 7.92±1.2 at pre-injection and reduced progressively post-injection to 5.61±1.56 at 1 month, 3.1±0.83 at 3 months, and 2.4±0.68 at 6 months, and remained at a low level (2.5±0.92 at 1 year and 2.7±0.56 at 2 years). The mean ankle-hindfoot score (American

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Orthopaedics Foot and Ankle Society) went from 56.92±13.24 to 66.41±10.26 at 1 month, 78.31±12.64 at 3 months and 90.54±10.71 at 6 months, and remained good at 89.24±8.92 at 1 year and 87.54±10.56 at 2 years.

Co-Kinetic comment One in ten people will experience heel pain at some point in their lives and plantar fasciitis affects 15% of all patients complaining of plantar heel pain, in both nonathletic and athletic populations. So, there is a lot of it about. The references for those bold facts are in the paper and it’s open access if you want it. The injections appear to work in both the short and long term. However, it would have been nice to know if those participants who described themselves as active had to curtail their activities because of the heel pain and when (or if) during the recovery process they returned to full pre-condition activity levels.

EFFECT OF MASSAGE AND PSEUDO MASSAGE ON ACUTE PERFORMANCE AND SELF-PERCEIVED RECOVERY: A STUDY PLACEBO-CONTROLLED. Andreossi AA, Marchetti PH, Lass AD et al. Journal of Physical Education 2021;32(1):e-3274 OPEN

Fifteen participants were randomly subjected to three experimental conditions. They were required to perform three unipodal vertical jumps followed by the intervention and then do three more jumps. For the massage condition, a lotion was applied in the calf area of the dominant leg, in which the therapist worked through several techniques, such as deep sliding, deep friction, vertical friction and kneading at the triceps surae level. For the placebo condition, the same lotion was applied, although the massage offered no pressure in the targeted muscle area. In the control condition, subjects

remained at rest for the same length of time. The order of the intervention was random and there was an interval of 1 week between them.

Pre- and post-intervention jump height was measured along with a total quality recovery (TQR) questionnaire, which consists of a combination of a numerical scale and phrases that represent various levels of recovery.

Results showed no statistical differences on jump height between pre- and post-intervention nor between experimental conditions. There were also no statistical differences in the TQR results between experimental conditions.

Co-Kinetic comment This paper is included here in case any of our readers are thinking about conducting research involving massage. It is an example of almost everything that is wrong with massage research. The massage was done by a ‘professional therapist’ but there is no mention of the qualifications. It states that said therapist ‘was required to keep a constant rhythm and force’ but does not state how this was achieved. The massage techniques are only described as ‘deep slides, deep friction, vertical friction, kneading’. Frictions create an inflammatory response so there is no way they should be used as part of a recovery routine. How was the depth of the stroke calculated? The treatment only lasts 2min which is little time to get an effect in the tissues (even if you are using the right strokes). It is little wonder that the massage had little effect.

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EFFECTIVENESS OF LOCAL EXERCISE OPEN THERAPY VERSUS SPINAL MANUAL THERAPY IN PATIENTS WITH PATELLOFEMORAL PAIN SYNDROME: MEDIUM TERM FOLLOW-UP RESULTS OF A RANDOMIZED CONTROLLED TRIAL. Scafoglieri A, Van den Broeck J, Willems S et al. BMC musculoskeletal disorders 2021;22(1):446 Forty-three patients with patellofemoral pain syndrome were randomly assigned to a local exercise or spinal manual therapy group. The local exercise group received 6 sessions (1 session per week) of supervised training of the knee and hip muscles with mobilisation of the patellofemoral joint.

The spinal manual therapy group received 6 interventions (1 intervention per week) of high velocity low thrust manipulations at the thoracolumbar region, sacroiliac joint, and/or hip. All patients were also asked to do home exercises. Maximum, minimum and current pain were measured using the visual analogue scale. Function was assessed with the anterior knee pain scale and maximum voluntary peak force was recorded using a Biodex System 3 dynamometer. Patients were assessed before intervention, after 6 weeks of intervention and after 6 weeks of follow-up.

Pain and functionality improved more following spinal manipulative therapy than local exercise therapy.

Co-Kinetic comment Evidence (if you need it) that as the great James Cyriax said, ‘all pain has a source’. You just have to find it and often it’s nowhere near where the patient says it is.

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EFFECTS OF MULLIGAN MOBILIZATION WITH MOVEMENT IN SUBACUTE LATERAL ANKLE SPRAINS: A PRAGMATIC RANDOMIZED TRIAL. Nguyen AP, Pitance L, Mahaudens P, et al.

Journal of Manual & Manipulative Therapy 2021;doi:10.1080/10669817.2021.1889165 Fifty-one participants with subacute lateral ankle sprains (grade 1–2, 2–10 weeks post-injury with a 20% dorsiflexion deficit as measured by a weight-bearing knee to wall lunge) were randomised to either an intervention group, who received a mobilisation with movement (MWM) treatment, or a sham group. The MWM group received inferior tibiofibular, talocrural, or cubometatarsal MWM. The treatment or sham was administered upon 3 sessions, each 4 days apart. Sadly the sham treatment is not described.

Changes from baseline were measured and compared between the sessions for dorsiflexion ROM, pain, stiffness

Sixty-six patients of both genders, aged 20–50 years old and diagnosed with lateral epicondylitis were randomised into two groups. Pre-, mid and at 8 weeks post-treatments they completed a patient-rated tennis elbow evaluation questionnaire for functional outcomes and their grip strength was measured using a handheld dynamometer.

The results showed that Cyriax manual therapy and Mulligan technique

TONGUE STRETCHING TECHNIQUE AND CLINICAL PROPOSAL. Buscemi A, Coco M, Rapisarda A et al. Journal of Complementary and Integrative Medicine OPEN 2021;doi:10.1515/jcim2020-0101

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perception, and the Y balance test.

In total, 43 (80%) of the participants were considered responders to MWM. A statistical and clinically meaningful improvement in dorsiflexion ROM was revealed in the MWM group, whereas no improvement following the first session occurred in the sham group.

Pain and stiffness significantly improved, yet below the clinically meaningful level. The MWM group demonstrated a significant improvement after 3 sessions for the Y balance test. Conclusion: More than 80% of participants with subacute lateral ankle sprains responded well to the MWM approach. Three sessions of pragmatically determined

MWM provided a significant and clinically meaningful benefit in dorsiflexion ROM and Y balance test performance compared to a sham treatment.

Co-Kinetic comment It is nice to have a paper that is saying ‘pick your patients’. Not everyone will respond to every treatment. There is no ‘one size fits all’. If you do not have institutional access to this paper it will cost you £44 or £87 if you want the whole issue. This price is about par for the course. Does anyone pay these crazy one-off fees?

EFFECTS OF CYRIAX MANUAL THERAPY VERSUS MULLIGAN TECHNIQUE ON PAIN AND GRIP STRENGTH IN PATIENTS WITH LATERAL EPICONDYLITIS. Rajput N, Atta S. Rawal Medical Journal 2021;46(3):733–735 were both equally effective in improving pain, whereas Cyriax manual therapy improved grip strength better than Mulligan technique.

Co-Kinetic comment You will have noticed something important missing from our summary of

The aim of this study is to describe and provide a tongue muscle normalisation technique that helps the manual therapist in the treatment of problems related to it. It opens with the statistic that tongue dysfunctions are quite frequent (10–15%) in the population and cites another paper that links tongue position with postural stability and balance in addition to the more obvious issues with swallowing and breathing, so it is relevant to the fitness, injury, and health industries. It is a review of studies found in PubMed and Google Scholar over the last 10 years.

This search revealed 16 papers for further consideration.

It describes in detail (and with pictures) the manual technique to ‘normalise’ the tongue muscle. The goal of the technique is to reset the deep

this paper. There is no description of the actual treatments other than ‘Cyriax’ and ‘Mulligan’. That is because there is none in the paper itself. The two gurus do not even have their work cited in the reference list. Very strange and a great pity because it seems to endorse the use of these popular manual therapies.

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tongue receptors by stretching the tongue muscle. Given that it involves griping the hyoid bone and thyroid cartilage it may be better for readers to go to the paper itself rather than reading a summary. It is an open access paper.

Co-Kinetic comment This is something different. A quick Google search reveals that tongue issues can lead to TMJ disorder and obstructive sleep apnoea. You may want to read ‘The anatomical relationships of the tongue with the body system’ by Bordoni B et al. (Cureus 2018;10(12):e3695; https://bit.ly/3BqEkDe). It is also an open access paper. There is also research on the incidence of sleep disorders caused by sleep apnoea in the National Football League (American football) and university rugby players because they usually have a higher BMI and larger neck circumference than athletes from other sports. So if your players are sufferers, it may be worth giving the technique a try.

Co-Kinetic Journal 2021;90(October):4-11

RESEARCH INTO PRACTICE

EFFECTS OF DRY NEEDLING ON BIOMECHANICAL PROPERTIES OF THE MYOFASCIAL TRIGGER POINTS MEASURED BY MYOTONOMETRY: A RANDOMIZED CONTROLLED TRIAL. Jiménez-Sánchez C, Gómez-Soriano J, Bravo-Esteban E et al. Journal of Manipulative and Physiological Therapeutics 2021;doi:10.1016/j.jmpt.2021.06.002 Fifty asymptomatic volunteers were randomly assigned to an intervention group (n=26) or control group (n=24).

One session of dry needling (DN) was performed in every group as follows: 10 needle insertions into the latent myofascial trigger points (MTrP) of the soleus muscle or the taut band (TB) adjacent to the MTrP. Myotonometric measurements (frequency,

decrement and stiffness) were performed at baseline (pre-intervention) and after the intervention (post-intervention) in both locations. The results showed that stiffness outcome significantly decreased with a large effect size after DN in the MTrP when measured in the MTrP location but not when measured in the TB location.

EFFECT OF MASSAGE THERAPY ON PAIN AND QUALITY OF LIFE IN DOGS: A CROSS SECTIONAL STUDY. Riley LM, Satchell L, Stilwell LM et al. Veterinary Record 2021;doi:https://doi.org/10.1002/vetr.586 Clinical canine massage therapy is achieved by the application of a range of manual techniques (eg. effleurage, compression, friction, percussion and stroking) to a dog’s fascia and muscle by skilled practitioners following veterinary consent or referral to address musculoskeletal injury, disorder and/or disease.

In 2018, case notes from a convenience sample of 527 dogs were shared, with permission from owners, by a self-selected sample of 65 practitioners. Changes in number and severity of issues for five pain indicators (gait, posture, daily activity, behaviour, performance) and quality of life score (reported by owner and practitioners) were investigated.

After massage treatments there were significant reductions in reported pain severity scores for all pain indicators over successive treatments, with each treatment causing further significant reduction in pain severity. Numbers of pain indicators recorded over successive treatment sessions remained constant, in keeping with a cohort presenting with degenerative disease and chronic pain. Post-treatment, a dog was significantly more likely to have a ‘positive’ quality of life.

Co-Kinetic comment Before everyone starts complaining that this has nothing to do with sport – you are quite right, it doesn’t. It has to do with business. In the UK vets are reporting being overwhelmed with work following so many people buying pets during lockdown. People spend a lot of money on their dogs. For trained massage therapists there is money to be made. There are courses in canine massage which teach techniques you already know such as myofascial release, sports, Swedish and deep tissue massage. And there is a Canine Massage Guild to provide regulation. Check your insurance covers you for bites though. Dogs can’t complain that you are going too deep, they express their disquiet in other ways.

Co-Kinetic.com

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Co-Kinetic comment Myotonometry is a technique that provides objective assessment of muscle spasticity by quantifying tissue displacement with respect to perpendicular compression force using a handheld digital palpation device. This study indicates that to be effective the needles need to be in the right place, which is into the trigger point and not nearby.

MANUAL THERAPY: ALWAYS A PASSIVE TREATMENT? Rhon DI, Deyle GD. Journal of Orthopaedic & Sports Physical Therapy 2021;doi:10.2519/jospt.2021.10330 This essay is based on the principle that the use of any manual therapy is controversial and is at the centre of intense debate between its adherents and opponents that claim it is a passive therapy and as such is of low value, provides low quality care and should not be recommended for musculoskeletal disorders.

The authors define manual therapy ‘as a synergistic application of movementoriented strategies including exercise and manually applied joint and soft tissue mobilisations and manipulations, guided by a clinical reasoning framework that informs dosing and progression of all components’. They argue that high-quality manual therapy interventions must have the active participation of the patient to reinforce, use and perpetuate any changes in symptoms or movement that came about from the hands-on treatment. They quote the International Federation of Orthopaedic Manipulative Physical Therapy definition as ‘a specialised area of physiotherapy/physical therapy for the management of neuromusculoskeletal conditions, based on clinical reasoning, using highly specific treatment approaches including manual techniques and therapeutic exercises’. They go on to state that the problem with manual therapy research is that far too often the hands-on element and follow-up exercise are separated and thus the hands-on treatment alone rarely solves a clinical problem. The result of this is that clinical commissioning groups take it as gospel and issue edicts against manual therapy.

The authors give the example of the American College of Rheumatology who published updated clinical practice guidelines for managing knee osteoarthritis in 2019, and recommended against the use of manual therapy.

The conclusion of the essay is that clinicians should look beyond a research paper’s title or headline conclusions and look at the methodology and apply the above definitions. Then, if the interventions don’t include the complete package of the hands-on element and follow-up exercise it is not manual therapy, and you can’t use such research to state that manual therapy is of no clinical value.

Co-Kinetic comment Talk about preaching to the converted. Few, if any, therapeutic interventions work on their own: they should be part of a package of treatment techniques where the last element should be a functional exercise so that the patient uses gains in ROM or reduction in pain levels to do the things they couldn’t do.

Research that breaks down the components of a treatment plan to an individual technique and concludes that it doesn’t work is not worth the paper it is written on. It is like taking a single word and complaining that it does not convey the meaning of a full sentence.

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4BR: EDUCATIONAL TRAINING PROGRAMME FOR THE PREVENTION OF SPORTS INJURIES IN YOUNG ATHLETES. Palmi J, Alcubierre N, Gil Moreno de Mora G et al. International Journal of Environmental Research and Public Health 2021;18(10):5487 The aim of this study is to present a proposal for the prevention of training overloads by reducing the risk of intrinsic injuries in young athletes through the 4BR programme. The 4BR programme contains three sub-programmes: 1. Technician advice. This is about raising awareness and involving the coaching staff in the need to know the risk factors of both internal (personality, anxiety, daily stressors, injury history) and external factors that predispose to injury.

2. Athlete vulnerability detection, and the implementation of recovery habits. This includes assessment systems that are applied to athletes to assess their risk of injuries due to internal predisposition (neuroticism, impulsivity, coping, competitiveness, motivation

oriented to success, distress tendency, history of stressors, injury history, burnout, and other states). Athletes should be provided with feedback on the results so that they are aware of their vulnerability to injury.

3. Implementation of recovery habits. The intervention programme content includes the improvement of sports recovery behaviours and the adjustment of habits education. There are four elements to this: Nutrition and Hydration; Relaxation–Stretching and Rest; Social Life, which includes taking care of the psychosocial component of a young athlete’s environment; and Personal Moments, which is basically a time for reflection on when the athlete feels most at ease, together

STRATEGIES TO FACILITATE MORE PLEASANT EXERCISE EXPERIENCES. Jones L, Zenko Z. In Zenko Z, Jones L (eds).

Essentials of exercise and sport psychology: an open access textbook (Ch11, pp242–270). Society for Transparency, Openness, and Replication in OPEN Kinesiology 2021. ISBN-13:978-0-578-93236-1 This is a chapter from an open access textbook provided by STORK (see the explanation in the item ‘A critical evaluation of percussion massage gun devices as a rehabilitation tool focusing on lower limb mobility: a literature review’, also on this page). It has content from more than 70 experts in the subject. Its aim is to provide a free, open and accessible textbook. It is primarily directed at undergraduate students, but it is also appropriate for graduate students. The topics covered are broad, ranging from an ‘Introduction to Exercise Psychology’ (Chapter 1), to an ‘Introduction to Sport Psychology’ (Chapter 19), to ‘Working in Sport, Exercise, and Performance Psychology’ (Chapter 33). Chapters also contain learning exercises to prompt students and instructors to engage with the material on a deeper level.

Co-Kinetic comment This was mainly written during the lockdown era and so by textbook standards it is hot off the press. It has 33 chapters on separate but related subjects covering nearly 800 pages which is far too many to summarise here. Go and take a look, its free!

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OPEN

with time management analysis as this can be a source of stress. There is no ‘one size fits all’ plan to achieve all this, but the authors envisage several 20min education sessions fitted in around training sessions, sports season, educational activities (lessons, exam periods, etc), and personal commitments (activities with family, friends, etc).

Co-Kinetic comment Having an education plan for injury prevention and recovery that puts an emphasis on the athletes themselves (which this does) is a great idea. If you are working in youth sport you need to read this paper (and drop a copy on your coach’s desk). The authors conclude that there is a need to conduct further research to find empirical evidence of the positive effects of applying the 4BR programme to different sports.

Over to you.

A CRITICAL EVALUATION OF PERCUSSION MASSAGE GUN DEVICES AS A REHABILITATION TOOL FOCUSING ON LOWER LIMB MOBILITY: A LITERATURE REVIEW. Martin J. OPEN SportRxiv 2021;doi:10.31236/osf.io/j9ya8 This literature review aimed to explore the current literature regarding the effect of muscle gun devices on ROM, muscle activation, force output and the possibility of reducing perceived muscle soreness. Four databases were searched along with two academic search engines. A total of 39 studies were found that satisfied the inclusion criteria of studies that had a pre-post design focusing on the use of percussion massage devices.

It was found that handheld percussive massage devices are the most effective method of increasing lower limb ROM compared to foam rolling and other self-myofascial protocols. The use of handheld percussive massage devices directly after exercise reduces delayed onset muscle soreness. However, there was no reported significant increase in muscle activation or force output following the usage of a handheld percussive massage device.

Co-Kinetic comment This comes from ‘SportRxiv’, an online repository for Sport, Exercise, Performance and Health. It is managed by the Society for Transparency, Openness, and Replication in Kinesiology (STORK) whose aim is to provide a platform for kinesiologists, movement scientists, sport and exercise scientists, physical activity, and health scientists to come together to improve methods and practices within our respective disciplines. Anyone with an interest in improving kinesiology research, regardless of experience, is welcome to join. Go to https://storkinesiology.org/. As to this study, power tools will never be a substitute for trained and experienced hands that can ‘read’ tissue and detect problems.

Co-Kinetic Journal 2021;90(October):4-11

RESEARCH INTO PRACTICE

In a repeated measures design, 20 male rugby players (age, 20.7±1.5 years) from the University Malaya Rugby team who had no history of quadriceps injuries in the past 6 months were divided into two groups. Both underwent a DOMS protocol (10 sets of 10 repetitions of barbell back squats with 60% of 1RM) followed immediately afterwards by a session of foam rolling (FR), or no FR (what the control did is not described).

Participants used a foam roller that had a 15cm diameter and 30cm length. They were instructed to begin with the foam roller at the most distal portion

EFFECT OF FOAM ROLLING ON DELAYED ONSET MUSCLE SORENESS (DOMS) WITH PAIN SCORES AND POWER PERFORMANCE IN VARSITY RUGBY PLAYERS. Mustafa MS, Hafiz E, Hooi LB et al. A 2021;1(2):84–88 of the muscle and to always place as much body mass as tolerable on the foam roller and to roll their body mass back and forth along with the roller as smoothly as possible at a cadence of 50 beats per minute. This was done for 4 sets of 45s and followed by a 15s rest. The protocol was applied to the quadriceps, adductors, hamstrings, iliotibial band and gluteals giving a total FR time, including rest, of 20min.

FR was performed directly after the DOMS protocol and at 24h, 48h and 72h afterwards. Data was recorded at

baseline and the same time points.

The results showed reduced pain scores (numerical analogue score) and increased power (standing vertical jump) at various time points after exercise compared with the control.

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Co-Kinetic comment This is a similar result to previous studies. Using the body weight of the rugby players as tolerated is going to result in a lot of force going into tissue but it seems to have the desired effect. Massage researchers wondering about the depth of treatment to apply please note.

CHRONIC SEQUELAE AFTER MUSCLE STRAIN INJURIES: INFLUENCE OF HEAVY RESISTANCE TRAINING ON FUNCTIONAL AND STRUCTURAL CHARACTERISTICS IN A RANDOMIZED CONTROLLED TRIAL. Bayer ML, Hoegberget-Kalisz M, Svensson RB et al. The American Journal of Sports Medicine 2021;49(10):2783–2794 The rationale for this study is that muscle strain injury leads to a high risk of recurrent injury in sports and can cause long-term symptoms such as weakness and pain and the authors wanted to determine if there is a way to minimise this damage. A total of 30 participants with long-term weakness and pain (for example) after a strain injury of the thigh or calf muscles were randomised to eccentric heavy resistance training (HRT) of the injured region or control exercises of the back and abdominal muscles (CORE).

The HRT programme focused on eccentric contractions with a gradual increase in resistance and decrease in volume. The CORE training involved strengthening the back and abdominal muscles, omitting any exercises of the thigh or calf muscles.

Co-Kinetic.com

Isokinetic (hamstring) or isometric (calf) muscle strength was determined, muscle cross-sectional area measured, and pain and function evaluated. Scar tissue ultrastructure was determined from biopsy specimens taken from the injured area before and after the training intervention, and an MRI of the injured thigh or calf was performed before and after intervention (where the second scan was obtained at least 48h after the final training bout). The result was that HRT over 3 months improved pain and function, normalised muscle strength deficits, and increased muscle cross-sectional area in the previously injured region. No systematic effect of training was found upon pathologic infiltration of fat and blood vessels into the previously injured area. Control exercises had no effect on strength, cross-sectional area, or scar tissue but

a positive effect on patient-related outcome measures, such as pain and functional scores.

Conclusion: Short-term strength training can improve sequelae symptoms and optimise muscle function even many years after a strain injury. However, it does not seem to influence the overall structural abnormalities of the area with scar tissue.

Co-Kinetic comment Muscle function being affected many years after an injury suggests that the post-injury rehab left something to be desired. Athletes need to understand that the healing process continues for many months after they return to play, and they need to follow a specific exercise programme to stress the injured tissue on top of any other training they do.

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TIME-SAVING RESOURCES FOR PHYSICAL AND MANUAL THERAPISTS

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Applied Sciences

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Journal of Manual & Manipulative Therapy (Journal of Manual & Manipulative Therapy)

EFFICACY OF MOBILIZATION WITH MOVEMENT (MWM) FOR SHOULDER CONDITIONS: A SYSTEMATIC REVIEW AND META-ANALYSIS

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Medicina (MDPI)

THE EFFICACY OF MANUAL THERAPY IN PATIENTS WITH KNEE OSTEOARTHRITIS: A SYSTEMATIC REVIEW

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Journal of Physiotherapy (Australian Physiotherapy Association)

PHYSIOTHERAPISTS AND PATIENTS REPORT POSITIVE EXPERIENCES OVERALL WITH TELEHEALTH DURING THE COVID-19 PANDEMIC: A MIXED-METHODS STUDY

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Journal of Orthopaedic & Sports Physical Therapy

MANUAL THERAPY: ALWAYS A PASSIVE TREATMENT?

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Journal of Physiotherapy (Australian Physiotherapy Association)

PATIENT EDUCATION IMPROVES PAIN AND FUNCTION IN PEOPLE WITH KNEE OSTEOARTHRITIS WITH BETTER EFFECTS WHEN COMBINED WITH EXERCISE THERAPY: A SYSTEMATIC REVIEW

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DUTCH MULTIDISCIPLINARY GUIDELINE ON ACHILLES TENDINOPATHY

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British Journal of Sports Medicine

The PDF version of this infographic includes hyperlinks to the individual pieces of research.

Click here to access https://spxj.nl/3n6MLjt

EFFECTIVENESS OF EXERCISE AND MANUAL THERAPY AS TREATMENT FOR PATIENTS WITH MIGRAINE, TENSIONTYPE HEADACHE OR CERVICOGENIC HEADACHE: AN UMBRELLA AND MAPPING REVIEW WITH META-META-ANALYSIS

Produced by:

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MASSAGE THERAPY AS A COMPLEMENTARY AND ALTERNATIVE APPROACH FOR PEOPLE WITH MULTIPLE SCLEROSIS: A SYSTEMATIC REVIEW

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THE 10 MOST DISCUSSED PIECES OF RESEARCH IN PHYSICAL & MANUAL THERAPY (JUL - SEPT 2021)

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NO TIME TO LIFT? DESIGNING TIMEEFFICIENT TRAINING PROGRAMS FOR STRENGTH AND HYPERTROPHY: A NARRATIVE REVIEW

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THE 10 MOST DISCUSSED PIECES OF RESEARCH IN HEALTH & WELLBEING (JUL - SEPT 2021) Produced by:

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The PDF version of this infographic includes hyperlinks to the individual pieces of research.

Click here to access https://spxj.nl/3gS5Th6

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ALL COFFEE TYPES DECREASE THE RISK OF ADVERSE CLINICAL OUTCOMES IN CHRONIC LIVER DISEASE: A UK BIOBANK STUDY

BMC Public Health

CONFRONTING OUR NEXT NATIONAL HEALTH DISASTER – LONG-HAUL COVID New England Journal of Medicine

PLANT-BASED DIETS, PESCATARIAN DIETS AND COVID-19 SEVERITY: A POPULATION-BASED CASE-CONTROL STUDY IN SIX COUNTRIES BMJ Nutrition, Prevention & Health

SLEEP AND PHYSICAL ACTIVITY IN RELATION TO ALL-CAUSE, CARDIOVASCULAR DISEASE AND CANCER MORTALITY RISK British Journal of Sports Medicine

GUT-MICROBIOTA-TARGETED DIETS MODULATE HUMAN IMMUNE STATUS Cell

AN EVIDENCE-BASED ASSESSMENT OF THE IMPACT OF THE OLYMPIC GAMES ON POPULATION LEVELS OF PHYSICAL ACTIVITY The Lancet

EFFECTS OF NINTENDO RING FIT ADVENTURE EXERGAME ON PAIN AND PSYCHOLOGICAL FACTORS IN PATIENTS WITH CHRONIC LOW BACK PAIN Games for Health Journal

PREVALENCE AND EARLY-LIFE DETERMINANTS OF MID-LIFE MULTIMORBIDITY: EVIDENCE FROM THE 1970 BRITISH BIRTH COHORT BMC Public Health

PARTICIPATION OF PEOPLE LIVING WITH DISABILITIES IN PHYSICAL ACTIVITY: A GLOBAL PERSPECTIVE The Lancet

PLANT-CENTERED DIET AND RISK OF INCIDENT CARDIOVASCULAR DISEASE DURING YOUNG TO MIDDLE ADULTHOOD Journal of the American Heart Association Cardiovascular and Cerebrovascular Disease

Stretching the Truth 21-10-COKINETIC | S-C | FORMATS WEB MOBILE PRINT

By Kathryn Thomas BSc MPhil All references marked with an asterisk are open access and links are provided in the reference list

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Stretching is good for us, right? Well, yes and no! It turns out that you have to do the right kind of stretching for the right duration at the right time according to what activity you are about to do. This article makes sense of the confusing mass of literature about stretching and will allow you to give individually tailored, sport-specific advice to your clients about how to get the benefits of stretching while avoiding the potential decrease in power output. This is not only crucial for the professional athlete where marginal gains can make all the difference, but is also useful for amateurs looking for improvements too. Read this article online https://spxj.nl/3zCnHnK

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commonly held belief, by both professionals and the public, is that static stretching (StS) plays an important role in injury prevention and improving athletic performance (1). It is common practice therefore for athletes of all levels, both recreational and professional, to include StS in their routine. This may be during a ‘warmup’ before a game or run, at the end of a run or activity, or as part of a strength training or rehabilitation programme.

The physical practice of StS involves lengthening a muscle to a point where gentle tension is felt and that position is held, typically, for a minimum of 20–30 seconds (s; or longer) per stretch (2). Current research evidence, however, reports that this belief is, in fact, incorrect (3,4*).

Historically, until the 1990s, it was believed that StS promoted flexibility and improved athletic performance (5). This was mainly based on the thought that greater range of motion (ROM) reduced resistance to movement and improved movement economy (5). Passive and active stretching techniques have been shown to increase both chronic and acute ROM. In the past, StS was also promoted for longer durations – holding an individual stretch repeatedly for more than 30s to allow for viscoelastic (muscle) ‘creep’ (6). However, since the early 2000s, research had started discussing the potential harmful effects of StS on strength and power-related activities (5,7). Acute ROM improvements can

be countered by decreases in muscle performance, primarily after prolonged StS and proprioceptive neuromuscular facilitation (PNF) techniques when not incorporated into a full warmup procedure (8*). As a result, it has been widely recommended to avoid performing prolonged StS before strength and power-related tasks, with dynamic stretching (DS) exercises being favoured instead (5). DS (and even to an extent ballistic) stretching techniques typically induce either an increase or no change in muscular force and power (8*).

Subsequent to this, new evidence challenged the view that StS was taboo and should not be conducted before activity or performance. Findings by Behm et al. and Kay et al. showed that short-duration acute StS (≤60s) had trivial (almost negligible) negative effects on strength and power as opposed to prolonged StS (>60 seconds) (9*,10*). In addition to this, recent findings demonstrated that when short-duration StS was included in a full warm-up routine, it did not impair subsequent strength and power performances (11*,12). For clarity, the stretch times discussed in research are total time per muscle group – so a total of less than 60s of stretching does not seem to be detrimental, but greater than 60s does. Thus, 3×30-second stretches of the quadriceps equates to 90s, potentially inducing deficits in muscle strength and power according to the research (9*,10*).

It seems that the contradictory

and constantly changing reports with regard to the benefits or detriment of StS may cause confusion, particularly with coaches, practitioners and in the messages being disseminated to the public. This article aims to inform the reader to better understand when, why and for how long to use StS in the athletic and general population.

Stretching Controversies and Clarity

Following the evidence for stretchinduced performance decrements, there has been a paradigm shift on optimal stretching routines within a warm-up (13*). Impaired power and force performance subsequent to StS lead many people to incorporate DS into their routines. Owing to the closer similarity to movements that occur during subsequent exercises, DS would be expected to be superior to StS (13*). However, the evidence is not unanimous. Studies implementing DS have reported both facilitation of power, sprint and jump performance as well as no adverse effect [see Samson et al. and references therein (13*)]. Much of the research would suggest that combining StS and DS during warm-up may attenuate the harmful effects of StS alone (8*).

Granted, there are discrepancies as to whether DS improves or has no effect on performance (13*); however, currently there are no studies to report dynamic stretch-induced impairments to subsequent performance.

After reading the information

Co-Kinetic Journal 2021;90(October):14-21

PHYSICAL THERAPY

SINCE THE EARLY 2000s, RESEARCH HAS STARTED DISCUSSING THE POTENTIAL HARMFUL EFFECTS OF STATIC STRETCHING ON STRENGTH AND POWER-RELATED ACTIVITIES

above, you may ask yourself why then even consider including StS in a warm-up if DS does the job? There are a number of sports where improved static flexibility, essentially joint ROM, could enhance performance.

Gymnastics, a soccer or ice hockey goalie, synchronised swimming, martial arts, wrestling, ballet and figure skating are just a few examples where pronounced static ROM is a necessity.

DS has shown to increase static flexibility, but not to the same extent as StS. Hence, it may be important to include StS in certain sport-specific situations or with certain individuals.

Timing when to do the StS must also be considered so as not to negatively impact training or performance.

StS performed before strength and power activities has been shown to have negative effects. But what about endurance events such as running? Running is one of the most popular activities worldwide and is the base of many people’s physical activity routines. So should they be stretching before running? Performing StS before distance running (a mile or more) has shown to reduce running performance (14*). A possible biomechanical explanation for this was a more pronounced ground contact time. StS before running resulted in a higher ground contact time caused by a “decrease in the efficiency to transfer previously stored energy” (essentially an adverse effect on the stretch-shortening cycle) and therefore a decrease in running performance (14*). StS exercises performed before running showed a decrease in jump height and isometric strength, but no difference in running economy (RE) (which includes oxygen uptake, minute ventilation, energy expenditure, respiratory exchange ratio) or heart rate response (15). Similar studies have shown StS has no effect on RE Co-Kinetic.com

Figure 1: Myth: static stretching reduces injury risk in runners Alexander JLN, Barton CJ, Willy RW. Infographic running myth: static stretching reduces injury risk in runners. British Journal of Sports Medicine 2020;54(17):1058–1059 (17)

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STATIC STRETCHING IN A WARM-UP CAN BE USEFUL FOR SPORTS WHERE PRONOUNCED JOINT ROM IS REQUIRED but did affect jump performance (13*). Yamaguchi et al. applied a DS intervention on running performance in male middle- or long-distance runners (16). The study included five exercises performed 10 times, as fast as possible, and showed no changes in RE. However, the time to exhaustion and running distance were prolonged in the DS group compared to those in the non-stretching control.

Figure 1 shows a handy downloadable infographic by Alexander et al. that nicely summarises the myths around StS, what the evidence does show and what runners could do instead of StS (17).

Therefore, if the goal is to increase running performance, DS should be considered but not StS alone (14*). Behm et al. found that even though rigorous StS is likely to have no beneficial effect on running performance, a 54% reduction in acute muscle injuries was reported with stretching (9*). Therefore, StS, especially if applied for short durations and in combination with additional warm-up exercises (discussed below), still has overall positive effects for an athlete (9*,18*).

Stretching Public Opinion

The benefits of stretching have traditionally been well documented and as such is a very popular exercise modality. It is used for general health, recreation and performance.

Stretching may be implemented into exercise programmes for therapeutic reasons (prehabilitation or rehabilitation), in different diseases such as rheumatoid arthritis, or to correct muscle imbalance. Thousands of research papers have been published to determine the acute or chronic effects of stretching, to find the optimal techniques, duration and intensity. Briefly, stretching exercises are used as pre- and/or post-activity to increase joint ROM, health, muscle performance, to promote recovery, or 16

to reduce activity-related injury risks (8*,19*,20*).

Quite often sport or physical activities are not guided or supervised by a professional, and therefore identifying an individual’s stretching practices is of paramount importance to give adequate practical guidelines for performance as well as for health benefits.

A recent survey investigated the stretching habits of over 3000 active individuals who were involved in regular physical activity, across a range of sports, and at varying levels of competition (20*).

Briefly, the results of that study showed the following outcomes.

1. General Habits and Reasons l Individuals mostly indicated it was a necessity to stretch because of muscle pain (59.6%), muscle stiffness (59.0%), or simply for wellness (60.0%). l Stretching was a necessity after training or competition (77.9%) or after a series of training or competition (32.6%). l People who did not conduct stretching indicated it was because of a lack of motivation (26%), time (22%), knowledge (why and how to do, 20% and 13.7%, respectively), lack of supervision (10.3%), or poor efficiency (6.4%). l Those performing stretching mostly reported it was for recovery, to gain flexibility, for injury prevention and performance. l Stretching was mostly performed after training. l National/international level

individuals mostly practised stretching on a daily basis.

2. Education and Supervision l Most respondents had not received education, but obtained information (~60%) while reading books (45.0%), discussing with others (47.0%), or from the internet (34.5%). l Two-thirds of the individuals were not supervised while stretching. l Stretching was mostly supervised by coaches (95.3%), health professionals (34.5%) and other athletes (24.7%) – this pertained to national and international level athletes.

3. Stretching Type l Both men and women, as well as recreational up to international level athletes reported the most common type of stretching was static, followed by passive, then active and dynamic.

When considering the opinions of the general public it is easy to see that there are some misapprehensions regarding stretching. It was felt that stretching was necessary to improve flexibility and wellness. Yes, stretching can improve the joint ROM but this must not be confused with a person’s sense of muscle stiffness and using stretching to relieve this, which potentially may have negative effects on their exercise performance (discussed in further detail below). Stretching has been used in office-based settings and other studies to relieve tension and promote wellness and quality of life.

Certainly, stretching is only one part of an exercise programme that should

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include other components such as strength or cardiovascular activity.

As a result of the perceived negative effects of stretching, a recent paper suggested that flexibility should be ‘retired’ from fitness programmes, partly to save time and to emphasise the other components that could have more robust benefits for health and performance (21).

Nearly 75% of individuals performed stretching after activity and reported using it for recovery and to reduce pain or muscle soreness. There may be some evidence of positive effects of stretching on pain sensitivity and pain inhibitory systems (22).

There is, however, no clear evidence to demonstrate the positive effects of stretching on recovery. Some studies have shown small to moderate effects on perceived muscle soreness (delayed onset muscle soreness or DOMS) following eccentric exercises (23); however, in contrast, numerous studies have shown stretching to be ineffective in decreasing muscle pain and cramping. Stretching performed at intervals, for example between sets, could potentially have detrimental effects because of the negative effects on the neuromuscular system in generating torque (20*).

Indeed, although injury prevention was often cited (in nearly 50% of responders) to justify the use of stretching during pre-activity warm-up routines, the effects were generally unclear and with only limited beneficial results. This agrees with the current literature where a direct link between flexibility and injury prevention is unclear (9*,24*,25*).

Individuals believe they can improve performance and ROM as well as prevent injury by stretching during the warm-up (before training or competition). The question of the effectiveness of stretching for performance is currently widely documented. As stated earlier, research has shown that StS before activity may have a detrimental effect on reduced muscle strength and power (5,7). It is now generally agreed that short-duration stretching exercises could be performed within a comprehensive warm-up procedure (5,9*,10*,12,19*) and that DS (slow Co-Kinetic.com

conducted dynamic stretch) is also recommended (7).

A recent survey of 138 coaches involved in 21 different sporting disciplines had different views on stretching (26*). Some reported not doing any stretching with their athletes based on time restrictions and “leaving conditioning up to the athlete”. The majority of coaches (86%) used StS over DS in their warm-up and cooldown routines. During these, the static stretches were held on average for 20s. Coaches reported using stretching to reduce injury risk, increase flexibility, and (specifically for DS) to improve performance. The study found that there may be gaps between the evidence of stretching and its practice, and that coaches may not have the means to interpret the evidence and convert that into practice, so future focus on how this can be achieved is crucial (26*).

Elite competitive individuals appeared better supervised and conducted slightly more adequate and evidence-based stretching sessions than the recreational athlete (20*). This is not surprising given that athletes at that level work closely with coaches and physical therapists. In general, however, education, instruction and supervision should be developed to favour appropriate stretching intensity, technique and positioning. Indeed, from the current survey, supervision appeared poorly provided, as did the understanding of when or why we stretch (20*), with the majority of people believing in essentially only one type of stretch – static. Surely it is our responsibility to educate them about the current science, ensuring best practice of timing and duration to maximise benefits.

Stretching Type

1. Static Stretching – Passive and Active

StS consists of lengthening the muscle towards the end of ROM until experiencing near or maximal point of discomfort and then holding this position for an extended period of time (15–90s)

with no additional forces applied (8*,9*,10*). Passive StS is defined as “elastic structures being stretched by an external force with no rate change for a period of time” (8*). Active StS is similar except the individual exerts their own force, either through contraction of an antagonist muscle, or use of their arms to pull their limbs or use body mass to help elongate musculotendinous tissues (8*). This technique has been incorporated as one of the most popular warm-up routines and/or can be performed individually to improve joint flexibility.

2. Dynamic Stretching

This form of stretching involves performing larger movements over a full or nearly full ROM. These movements should be performed under controlled conditions: moderate to relatively rapid angular velocities (7,9*,27). There must, however, be an emphasis on controlled motion. As already mentioned, although StS leads to improvements in joint ROM the decrements in muscular performance and muscle force have resulted in many coaches, athletes and medical professionals opting to prescribe active DS rather than StS. Studies have shown that the ROM improvements with DS are similar to that of StS but without the negative effects on muscle performance (7,8*,9*,10*,19*).

This has resulted in DS experiencing a flood of popularity, especially with athletic warm-ups that don’t specifically require high levels of flexibility as their primary training focus.

DS may be considered preferable over StS in preparation for physical activity, as it more closely mimics the exercise movement patterns. DS can elevate core-temperature which may increase nerve conduction velocity,

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FOR RUNNERS, STATIC STRETCHING CAN HELP REDUCE ACUTE MUSCLE INJURIES AND IF IT IS USED FOR SHORT DURATIONS AND IS COMBINED WITH ACTIVE WARM-UP ACTIVITIES, THERE ARE NO DETRIMENTAL EFFECTS ON PERFORMANCE muscle compliance and enzymatic cycling, accelerating energy production. Finally, DS and dynamic activities tend to increase rather than decrease central drive – all beneficial in preparing the body for activity and performance [for further details see Behm et al. and references therein (9*)].

3. Ballistic Stretching

This mode of stretching involves rapid and active movements throughout the entire joint ROM (9*,27). This is typically a highly sport-specific technique used in, for example, gymnastics, ballet, synchronised swimming and figure skating.

Ballistic stretching consists of repetitive, fast movements at end of joint range. This must not be confused with DS (28*). Ballistic stretching has the potential for a greater risk of injury with individuals that are not well versed and practised in this technique or who have low flexibility levels (29*).

4. Proprioceptive Neuromuscular Facilitation

PNF stretching incorporates StS and isometric contractions in an alternating cyclical pattern to increase joint ROM. Despite its efficacy in increasing ROM, PNF stretching is rarely used in athletic pre-activity (30).

This may be because (i) it requires an assistant or partner to stretch; (ii) it can be uncomfortable or painful; and (iii) muscle contractions performed on highly stretched muscle lengths can result in muscle

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damage and speculatively increase injury risk (9*). PNF stretching still, however, remains an effective practice.

Although StS, DS and PNF all significantly increase passive ROM (30), whether one technique is superior to the other in providing greater acute ROM benefits is disputed. It is not possible to rank the different forms of stretching in hierarchy; all are effective when performed at the right time, for the right duration and within the right context relevant to the athlete and their activity.

Stretching Duration

Several original and review articles [see Behm et al. (9*) and references therein] report a dose–response relationship, with more than 60s of StS being more likely to result in performance deficits; however, shorter duration StS has little effect (10*,31). Research by Palmer et al. examined the acute effects of different StS durations (30, 60 and 120s) of the hamstrings on maximal strength and power (32). Their results showed significant declines in muscle power post-StS for 120s but not after 30 and 60s (32). Interestingly research has shown that prolonged (120s) hamstring unilateral StS stretching revealed a significant performance decline in knee extensor strength after StS in both the ipsilateral (∆, −8%) and contralateral (∆, −4.2%) leg (33). The change in strength (∆) is negative for a decrease in strength and positive for an increase. The most recent literature reviews have concluded that more than 60s of StS per muscle group substantially inhibits strength and power measures (∆, −4.6%). Whereas StS totalling 60s or less has proved to be less harmful (∆, −1.1%) (9*,10*). The negative acute effects of StS have to be interpreted from a dose–response perspective, and not a blanket approach to avoid the stretching technique altogether. In

other words, StS conducted over short durations (≤60s per muscle group) can be recommended while long-duration (>60s per muscle group) StS has negative effects on strength and power performances. If followed by an active dynamic warm-up or sufficient rest time before performance/racing/activity then these negative effects (regardless of duration) become negligible (discussed in more detail below).

The likely effect on performance even after longer duration StS is moderate (<5% negative change in performance). However small, in many contexts these performance losses may be very relevant to an athlete, specifically in sports involving speed, power and strength: for example elite sprinting, long and high jumps, throwing (discus, javelin, shot put), etc.

(9*).

The underlying mechanisms responsible for long-duration StSinduced impairments in strength and power activities may not be fully understood. Some research suggests an increased compliance of the musculotendinous unit (MTU) that lowers MTU stiffness combined with lower motor unit activation (19*). Less is known about the potential physiological mechanisms underpinning short-duration StS when performed as a single-mode treatment or when integrated into a full warm-up routine. Studies have shown that the rate of electromyography rise (moderated by factors such as early recruitment of motor units and discharge rates) during short-duration (≤60s) StS were not significantly affected (32). Unchanged or minor reductions in MTU stiffness are associated with short-duration (<60s) StS, which could contribute to the maintenance of muscle capacity to generate torque (32). Research by Kay et al. revealed that short-duration StS reduced muscle but not tendon stiffness; and thus concluded that

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stiffness alterations resulting from short-duration StS could be tissue specific (34*).

There is limited literature investigating the ‘non-local’ effects of prolonged StS. However, research revealed that both the stretched and contralateral (ie. non-stretched) limbs of young adults demonstrate small-magnitude force deficits (35).

However, the frequency of studies with these effects were similar with three measures demonstrating deficits, and four measures showing trivial changes. These results [and others highlighted in Behm et al. (35)] suggest the possible global (non-local) effects of prolonged StS. More research is necessary to investigate the effects of lower intensity stretching, upper versus lower body stretching, different age groups, incorporating full warm-ups, and identify predominant mechanisms among others in this global effect (35).

Stretching Intensity

StS is commonly used as part of a warm-up routine in order to increase ROM and potentially prevent injuries.

A sufficient level of MTU compliance is needed for sports that use a stretchshortening cycle. This is to ensure the MTU works effectively in storing and releasing high amounts of elastic energy. If a MTU has insufficient compliance the demands in energy absorption and release may exceed the capacity of the MTU, which may increase the risk of injuries. In the event of insufficient MTU compliance, the demands in energy absorption and release may rapidly exceed the capacity of the MTU, which may cause a higher risk of injuries (36,37). Past studies [cited within Behm et al. (9*) and Takeuchi et al. (38*)] have reported that StS may decrease MTU stiffness, effectively implying therefore that StS used as part of a warm-up routine decreases MTU stiffness and could lead to the prevention of injuries. Both the duration and intensity of the StS will affect MTU stiffness (39*,40*).

StS at high intensity can be accompanied by moderate-to-severe pain (38*). On an 11-point numerical rating scale (NRS) ranging from 0 (no pain) to 10 (worst imaginable pain), studies indicated that the median Co-Kinetic.com

NRS for pain during StS at high intensity was 8 (40*). However, NRS immediately after stretching and 24h after the stretching were both level 0 (40*).

Data has suggested, however, that high-intensity StS for 20s used as part of a warm-up routine does not change MTU stiffness and may therefore not have an effect on injury risk reduction (40*,41*). Kataura et al. showed that long-duration (180s) StS at greater intensity (80, 100 and 120% of maximum tolerable intensity without pain) is more effective for increasing ROM and decreasing passive MTU stiffness (42*). However, two issues exist with this method. Firstly, as has been discussed, long-duration StS of more than 60s results in strength and power deficits which can affect performance. Secondly, many athletes practise within a limited time, it is difficult to perform StS for more than 180s for each muscle. So, if the potential benefits to reduce injury risk come from long-duration and highintensity StS, how can we get the same result of decreasing MTU stiffness in under 60s to avoid the performance deficits?

Peak torque, an indicator of muscle strength, decreased after high-intensity StS for 10s, although there was no further change after more than 15s of high-intensity StS (38*). The decrement in muscle strength following StS is restored within 10min (43*). In addition to this, performing active warm-up and dynamic activities following StS can mitigate the negative effects of high-intensity StS on strength and power (discussed in more detail below) (13*,19*,23). Athletes who elect to stretch statically, need to choose the duration, intensity and timing of StS taking into account their subsequent activities; be it active warm-up or directly into performance. If great muscle strength activity is required immediately after high-intensity StS (without any activities) more than 15s of stretching should be used to maximise decreases in MTU stiffness.

If athletes have more

than 10min before performance or participate in an active warm-up following high-intensity StS, then 10s of high-intensity StS will be effective and minimise stretching pain (38*).

Stretching Combined with Active Warm-Up

Research by Reid et al. investigated the effects of StS durations (30s, 60s, 120s) as part of a full warm-up which included DS and dynamic activities (12). Strength and power measures were significantly affected by prolonged StS (120s) even when incorporated into an active warm-up.

However, despite the StS-induced neuromuscular activation impairments, muscle strength and power seemed not to be simultaneously affected by short-duration StS (30s, 60s) with active warm-up (12). Although 120s StS per muscle increased ROM, even within a comprehensive warm-up routine, it elicited notable performance decrements. However, moderate duration StS with active warm-up seemed to improve ROM while having either negligible or beneficial (but not detrimental) effects on specific aspects of athletic performance (12).

Physiologically it seems therefore that ‘something’ during active warm-up counters the negative effects of the central neuromuscular impairment of StS. During

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IT IS NOW GENERALLY AGREED THAT SHORTDURATION STRETCHING EXERCISES COULD BE PERFORMED WITHIN A COMPREHENSIVE WARM-UP PROCEDURE AND THAT SLOW CONDUCTED DYNAMIC STRETCHING IS ALSO RECOMMENDED a dynamic warm-up muscles are stretched and contracted actively through a variety of activities increasing body and muscle temperature (19*).

It has been shown that increased muscle temperature is accompanied by increased muscle fibre conduction velocity and improved binding of contractile proteins actin and myosin (19*). A large positive association between muscle temperature and power output exists: a 1°C increase in muscle temperature results in a 2–5% improvement in muscle power performance (44*). A raised muscle temperature can also alter forcevelocity, improving performance (19*).

A conclusion made by Behm et al. was that although prolonged (>60s per muscle group) StS and PNF stretching performed in isolation typically induce performance impairments, there is little evidence that these deficits linger when the stretching is combined with a full active warm-up (8*,9*).

Post-stretching dynamic activities might be a possible approach to decrease the likelihood of a drop in performance following StS exercise. Studies that include post-StS dynamic activity do not report significant impairments (11*,12,13*). Samson et al. compared the effects of specific active warmups with StS or DS on ‘springiness’ exercises (for example jump height or 20m sprint time) (13*). The stretching was performed for 3×30s for each muscle, resulting in a total stretching time of 90s. When a sport-specific warm-up was included following StS and DS, the 20m sprint time showed an improvement compared to the StS and DS groups without an active warm-up component. Additionally, 20

subjects that performed either a 5s StS, a 30s StS, or a five-repetition DS for each muscle [including both a low-intensity (pre-stretching) and a high-intensity (post-stretching) warmup] showed no deficit in ‘springiness’ tasks (11*).

What is more, Reid et al. showed that StS (30 or 60s) when combined with a post-stretching comprehensive warm-up increased vertical jump performance and did not change force production (12). In contrast, subjects that performed StS for 120s (with the same comprehensive warm-up) showed no change in vertical jump performance. Combining these results shows that active warm-up performed after StS and DS of up to 90s increased ‘springiness’ performance, whereas a longer stretching period (120s) produced either a negative effect or has no effect (12). Several authors [cited in Behm et al. (9*)] have suggested including post-stretching dynamic activities in the warm-up regimes of athletes, counteracting any detrimental effects on performance by StS alone.

Conclusion

Flexibility has often been considered a major component in physical fitness. Flexibility has little predictive efficacy with health and performance outcomes (for example mortality, falls and occupational performance) in apparently healthy individuals, particularly when viewed in light of the other major components of fitness (such as body composition, cardiovascular endurance, muscle endurance, muscle strength) (21). If flexibility requires improvement, it does not demand a prescription for stretching in most people. Flexibility can be maintained or improved by exercise modalities that cause more robust health benefits than stretching

alone, for example resistance training (21). The general population are often looking to simplify their fitness routines, to save time and resources.

One author’s opinion is that deemphasising stretching (on the back of its current ‘bad rap’) in exercise prescription will ensure it does not negatively impact other exercise or take away time that could be allocated to training activities that have more robust health and performance benefits (21).

Yes, the literature on StS has been subject to controversial debate over the past decades. Figure 1 ‘Timeline of the controversial mindset about the acute effects of static stretching (StS) on strength and power performances’ from Chaabene et al. provides a good summary of the previous and current available evidence and practical recommendations on StS (https://bit.ly/3sgwc51) (19*). There is strong evidence now suggesting that StS causes only trivial negative effects on subsequent strength and power performances if the accumulated duration per muscle group does not exceed 60s. Consequently, we as practitioners should update these previous beliefs on the harmful effects of StS and rather apply greater specificity in stretching instruction to achieve optimal outcomes.

In the research laboratory setting, where post-stretching testing is performed almost immediately (on average 3–5min), StS-, DS- and PNFinduced performance changes were typically small to moderate: –3.7, +1.3 and –4.4%, respectively (9*). An initial assumption, based on the overall negative results that StS and PNF have on performance, is not to prescribe them and rather to advise the use of DS to increase ROM. However, the reality is that stretching-to-performance durations are often more than 10min in many circumstances (for example sports competitions). In studies that conducted tests more than 10min after stretching, performance changes were typically statistically trivial or negligible unless extreme stretch protocols were used (9*,43*).

StS impairments were more substantial with more than 60s (–4.6%) versus 60s or less (–1.1%) of stretching

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duration per muscle group. It should be considered that for certain athletes and sporting disciplines requiring greater ROM increases, longer duration StS and PNF may be performed well before (for example >10min) the task/ performance to allow the negative effects to resolve. However, DS may be performed closer to the performance.

Considering the application of stretching in sports practice, further conditions have to be considered to give recommendations. First of all, post-stretching dynamic activities or active warm-up must be implemented to decrease the likelihood of performance deficits (9*,14*). Secondly, targeted stretching of only the muscle groups for which greater compliance is beneficial for the athletes activity should be applied (14*).

The few studies that included post-stretching (StS up to 90s) dynamic activity did not show substantial negative effects on performance (12,13*). All forms of muscle stretching have been shown to provide significant

KEY POINTS

acute ROM benefit. StS and PNF show no overall effect on all-cause injury or overuse injuries, but there may be a benefit in reducing acute muscle injuries with running, sprinting, or other repetitive contractions (9*). There is conflicting evidence as to whether stretching in any form before exercise can reduce exercise-induced muscle soreness (DOMS) (9*).

Stretching in some form appears to be of greater benefit than cost (in terms of performance, ROM and injury risk); however, the type of stretching chosen, and the make-up of the stretch routine (duration, intensity, inclusion of active dynamic warm-up and timing to event/performance) needs to be carefully considered. In high-performance sports, minimal performance differences can have a major impact on athletes’ success in competition. Rather than prescribing a generic stretching routine, the context of the individual’s needs and their sporting activity must to be considered to ensure peak benefit.

l The literature on static stretching (StS) has been subject to controversial debate over the past decades. l Evidence suggested that prolonged duration StS caused decrements in performance of power and strength activities. l StS impairments on performance were more substantial when performed for ≥60s total per muscle group. l Research now shows that StS performed for <60s total per muscle group resulted in trivial, almost negligible effects on muscle performance. l Post-stretching (short or long-duration StS) dynamic activities in an athlete’s warm-up regime counteract any detrimental effects on performance created by stretching alone. l Any negative performance changes elicited by short or long-duration StS are typically statistically trivial or negligible after 10min of elapsed time to performance (unless extreme stretch protocols are used). l StS used as part of a warm-up routine decreases musculotendinous unit (MTU) stiffness and could lead to the prevention of injuries. l Instead of long-duration (180s) StS, greater intensity StS (pain rating scale of 8–9) for shorter duration (10s per stretch) may elicit a decrease in (MTU) stiffness without detrimental performance effects. l Dynamic stretching (DS) increases range of motion (ROM) and does not elicit negative performance effects like StS and proprioceptive neuromuscular facilitation (PNF) stretching. l StS and PNF are most effective in increasing ROM and should be considered on an individual athlete and sport-specific basis. l Performing short-duration StS combined with an active warm-up and allowing time between stretching and performance negates any negative performance effects of stretching alone

Co-Kinetic.com

References Owing to space limitations in the print version, the references that accompany this article are available at the following link at the following link https://spxj.nl/3zCnHnK

RELATED CONTENT

l Fascial Stretch Therapy™ for the Lower Body [Article] https://bit.ly/2GTUPB3 l Yoga and Biomechanics: A New View of Stretching Part 1 [Article] https://bit.ly/3qEnUS8 l Yoga and Biomechanics: A New View of Stretching Part 2 [Article] https://bit.ly/3bDHpWu

DISCUSSIONS

l What is your current stretching prescription, especially in athletes? l Would you consider prescribing higher intensity stretching over a shorter period to achieve the same results in decreasing MTU stiffness thereby increasing ROM and reducing injury risk? l How do you plan to move forward incorporating StS, PNF and DS in individuals with different sporting demands?

Kathryn Thomas BSc Physio, MPhil Sports Physiotherapy is a physiotherapist with a Master’s degree in Sports Physiotherapy from the Institute of Sports Science and University of Cape Town, South Africa. She graduated both her honours and Master’s degrees Cum Laude, and with Deans awards. After graduating in 2000 Kathryn worked in sports practices focusing on musculoskeletal injuries and rehabilitation. She was contracted to work with the Dolphins Cricket team (county/provincial team) and The Sharks rugby teams (Super rugby).

Kathryn has also worked and supervised physios at the annual Comrades Marathon and Amashova cycle races for many years. She has worked with elite athletes from different sporting disciplines such as hockey, athletics, swimming and tennis. She was a competitive athlete holding national and provincial colours for swimming, biathlon, athletics, and surf lifesaving, and has a passion for sports and exercise physiology. She has presented research at the annual American College of Sports Medicine congress in Baltimore, and at South African Sports Medicine Association in 2000 and 2011.

She is Co-Kinetic’s technical editor and has taken on responsibility for writing our new clinical review updates for practitioners.

Email: kittyjoythomas@gmail.com

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Stretching the Truth References

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Medicine 2018;39(4):243–254 28. Lima CD, Brown LE, Wong MA et al. Acute effects of static vs ballistic stretching on strength and muscular fatigue between ballet dancers and resistancetrained women. Journal of Strength and Conditioning Research 2016;30(11):3220– 3227 Open access https://bit.ly/3jLZIvD 29. Wyon M, Felton L, Galloway S. A comparison of two stretching modalities on lower-limb range of motion measurements in recreational dancers. Journal of Strength and Conditioning Research 2009;23(7):2144–2148 Open access https://bit.ly/3lWv857 30. Sharman MJ, Cresswell AG, Riek S. Proprioceptive neuromuscular facilitation stretching: mechanisms and clinical implications. Sports Medicine 2006;36:929–939 31. Behm DG, Chaouachi A. A review of the acute effects of static and dynamic stretching on performance. European Journal of Applied Physiology 2011;111(11):2633–2651 32. Palmer TB, Pineda JG, Cruz MR et al.

Duration-dependent effects of passive static stretching on musculotendinous stiffness and maximal and rapid torque and surface electromyography characteristics of the hamstrings. Journal of Strength and Conditioning Research 2019;33(3):717–726 33. Caldwell SL, Bilodeau RLS, Cox MJ et al.

Unilateral hamstrings static stretching can impair the affected and contralateral knee extension force but improve unilateral drop jump height. European Journal of Applied Physiology 2019;119(9):1943–1949 34. Kay AD, Husbands-Beasley J, Blazevich AJ. Effects of contract–relax, static stretching, and isometric contractions on muscle–tendon mechanics. Medicine and Science in Sports and Exercise 2015;47(10):2181–2190 Open access https://bit.ly/3iCLMVs 35. Behm DG, Alizadeh S, Drury B et al. Non-local acute stretching effects on strength performance in healthy young adults. European Journal of Applied Physiology 2021;121(6):1517–1529 36. Brazier J, Maloney S, Bishop C et al.

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Lower extremity stiffness: considerations for testing, performance enhancement, and injury risk. Journal of Strength and Conditioning Research 2019;33(4):1156– 1166 37. Lorimer AV, Hume PA. Stiffness as a risk factor for Achilles tendon injury in running athletes. Sports Medicine 2016;46(12):1921–1938 38. Takeuchi K, Nakamura M. The optimal duration of high-intensity static stretching in hamstrings. PLoS One 2020;15(10):e0240181 Open access https://bit.ly/3xEBLLK 39. Nakamura M, Tome I, Nishishita S et al. Static stretching duration needed to decrease passive stiffness of hamstring muscle-tendon unit. Journal of Physical Fitness and Sports Medicine 2019;8(3):113–116 Open access https://bit.ly/3CHIIz7 40. Takeuchi K, Nakamura M. Influence of high intensity 20-second static stretching on the flexibility and strength of hamstrings.

Journal of Sports Science & Medicine 2020;19(2):429–435 Open access https://bit.ly/3sd6tdJ 41. Sato S, Kiyono R, Takahashi N et al. The acute and prolonged effects of 20-s static stretching on muscle strength and shear elastic modulus. PLoS One 2020;15(2):e0228583 Open access https://bit.ly/3s9kTvr 42. Kataura S, Suzuki S, Matsuo S et al.

Acute effects of the different intensity of static stretching on flexibility and isometric muscle force. Journal of Strength and Conditioning Research 2017;31(12):3403– 3410 Open access https://bit.ly/3ACYhGB 43. Mizuno T, Matsumoto M, Umemura Y. Stretching-induced deficit of maximal isometric torque is restored within 10 minutes. Journal of Strength and Conditioning Research 2014;28(1):147– 153 Open access https://bit.ly/3m5lBZo 44. Racinais S, Oksa J. Temperature and neuromuscular function. Scandinavian Journal of Medicine & Science in Sports 2010;20(Suppl 3):1–18 Open access https://bit.ly/3AzNgpy.

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THE CORE OF YOUR FOOT PROBLEMS

By Kathryn Thomas BSc MPhil

21-10-COKINETIC | ANKLE-FOOT | LOWER LIMB FORMATS WEB MOBILE PRINT All references marked with an asterisk are open access and links are provided in the reference list

T

he human foot is a complex system with multiple degrees of freedom that play an essential role in its many diverse functions. It is our only point of contact with the ‘earth’. During standing, it is our base of support. While walking or running, the foot needs to be stable during foot-strike and push-off. However, during the mid-stance phase, the foot is required to be dynamically adapting and reducing loads. It possesses spring-like qualities required for storing and releasing elastic energy. This is achieved through the deformation of the arch, which in turn is controlled by the intrinsic and extrinsic foot muscles.

There is evidence that the foot arch architecture and musculature has changed with evolution in response to the increased demands of load carriage and running; wearing shoes; and changes in terrain from sandy soils, rocks, and grass to pounding concrete pavements.

So, What’s the Problem?

Dynamic foot control arises from the interaction between active and passive structures and should be of primary interest in rehabilitation (or prehabilitation) of lower limb injuries.

The stability of the arch, proposed to be the central ‘core’ of the foot, is requisite for normal foot function (1*).

The concept of core stability in the lumbopelvic–hip region is well known, understood and clinically practised.

So why not extend that concept to the arch of the foot? Both local stabilisers and global movers of the foot control the arch, similar to the lumbopelvic 22

We all know that the foot is an amazing piece of anatomy and we probably all feel a bit chuffed once we’ve memorised the names of all the bones, know how they are held together, and understand the windlass mechanism and plantar fasciitis. But, other than their existence, what do we know about the intrinsic foot muscles (IFMs)? Well, it turns out that they are pretty crucial for proper functioning of the foot, and that strengthening them can help with many problems relating not only to the foot, but also the ankle and even the knee. This article allows you to understand the concept of the ‘foot core’, how to assess the IFMs and how to strengthen them. Read this article online https://spxj.nl/3kLmWSV core. The local stabilisers include the four layers of intrinsic foot muscles (IFMs). These muscles originate and insert on the foot, have generally small moment arms, small cross-sectional areas and serve primarily to stabilise the arches (1*); see Further Resource 1 for more detail about the anatomy of the IFMs. The muscles that originate in the lower leg, cross the ankle and insert on the foot are the global movers; and traditionally have larger cross-sectional areas, larger moment arms, are prime movers of the foot, and also provide some stability to the arch and ankle (1*).

The IFMs form part of the active and neural subsystems that make up the foot core. These muscles eccentrically lengthen during the stance phase of running and then shorten at the propulsion phase, as they recoil with the arch. They play a key role in supporting the medial longitudinal arch (MLA) of the foot, providing flexibility, stability and shock absorption. Studies have shown that the IFMs provide an active contribution in late stance phase, in order to provide sufficient stiffness in the joints to facilitate propulsive forces for push-off (2*). It may seem obvious therefore to strengthen foot muscles, specifically the IFMs, to maintain and improve optimal capacity to generate and absorb these forces.

The arch of the foot deforms with

each step and the intrinsic muscles are integral in controlling the extent and speed of these changes. Should the IFMs faulter in their function, an unstable or misaligned foundation results. Abnormal foot movement can form which over time could cause pain and injury. It seems that the value of the arch musculature in the prevalence of foot injuries is not fully appreciated. Little mention of specific foot strengthening (as a component of an intervention) is seen in clinical trials and guidelines for plantar fasciitis, as is the case with posterior tibial tendon dysfunction, medial tibial stress syndrome, plantar heel pain and chronic lower leg pain. Quite often exercise therapy is focused from the top down – for example strengthening the hips, glutes, quads, hamstring and calf. If we are to adopt the concept of the foot acting as the core to the lower limb then exercise therapy needs to be considered from the bottom up!

There are some studies that support multiple exercises to achieve greater strength in the foot, such as the ‘short foot exercise’ (SFE), doming, toes curl, towing exercises or the more dynamic hopping exercises, or even barefoot running.

The real impact of these exercises on foot muscle strength and, more importantly, on improving foot core stability remains unclear. Despite Co-Kinetic Journal 2021;90(October):22-28

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a recognised need, data related to the assessment and efficacy of these exercises is scarce. There is emerging evidence of intervention studies focusing on improving IFM function. Two studies showed that following a programme focusing on training the intrinsic muscles of the foot resulted in improvement of dynamic stability during single limb reaching tasks (3,4). It was concluded from these studies that increasing toe flexor strength and executing the prescribed SFE improved the ability of the MLA to provide dynamical stability. However, it is unclear whether these improvements in function during relatively low-intensity static activities would translate to more dynamic high-intensity activities. Nigg et al. in 2009 (5) and 2017 (6*) showed that the smaller, intrinsic muscles are proficient in detecting inversion/eversion and/ or abduction/adduction movement in the foot. It was suggested that stronger small muscles may act to minimise lower limb injuries (5,6*). Thus, it may be possible that by increasing the activity and strength of the IFMs and extrinsic foot muscles, arch function can be optimised. In turn, this may decrease the transfer of load and rotational forces to the knee and ankle, possibly decreasing ACL injury or ankle sprain risk during dynamic activities (7). Similarly, the SFE has been shown to be more effective than standard proprioceptive sensory exercises for treating patients with ankle sprains, with SFE generating significantly greater improvements in balance index, vibration sensory threshold, joint position sense and ankle stability (8*).

A preliminary randomised controlled trial showed that 4 weeks of IFM strengthening resulted in improved motor performance and decreased perceived difficulty when performing the exercises (9).

A randomised clinical trial is underway that may prove interesting for patients with knee osteoarthritis (KOA) (10*). Previous research [discussed by Dantas et al. (10*)] has reported that: l KOA patients have: l weak foot–ankle muscles; l foot muscle strength deficits directly related to increased knee Co-Kinetic.com

Neural Subsystem

Musculotendinous receptors (local and global ligamentous receptors, including plantar fascia) Plantar cutaneous receptors

Neural Passive

Active

Foot Core System Passive Subsystem

Bones of the arches (foot half dome) Plantar fascia Ligaments

Active Subsystem

Intrinsic foot muscles (local stabilisers) Extrinsic foot muscles (global movers)

Figure 1: The foot core system. The neural, active and passive subsystems interact to produce the foot core system which provides stability and flexibility to cope with changing foot demands. McKeon et al. The foot core system: a new paradigm for understanding intrinsic foot muscle function. British Journal of Sports Medicine 2015;49:290 (1*)

pain and stiffness, decreased physical function and more severe KOA; and l reduced plantar grip strength, a deficit that may impact on kinetic chain during gait; and l studies have shown that 8–12 weeks of physical therapy targeting the trunk, hip and knee muscles may be effective in reducing pain and improving function and strength, but does not reduce the knee joint loads during gait or stair climbing.

However, studies have shown that minimally flexible shoes (essentially shoes with a more rigid base of support) reduced knee joint loads during gait and stair descent (11). Also, it has been seen that the use of minimalist shoes (6 hours daily, 5 days a week, for 6 months) resulted in reduced pain and analgesic intake, and improved self-reported functionality (12*,13). These results raise the question: can an increase

in the neuromuscular reflexes of IFM minimise impact and knee overload?

The new study, which is underway, will focus on the fact that a decrease in knee joint loads is essential to prevent the aggravation of KOA, and therefore propose a foot–ankle strengthening programme to affect the symptoms and outcomes of KOA (10*).

It seems that there is a shift in thinking or focus about the importance of the IFMs. Training the IFMs may offer benefit to the foot core system by increasing its functional ability to control movement and load during the changing demands of dynamic foot control. Moving from targeted isolation of these muscles in a strength training programme to their global integration in movement patterns (like heel raises, hopping, running, jumping) may offer an excellent strategy for reducing the effects of lower extremity overuse injuries related to poor foot control (14).

AT DIFFERENT STAGES OF THE GAIT CYCLE, THE FOOT NEEDS TO BE EITHER STRONG AND STABLE OR DYNAMICALLY ADAPTING 23

THE CONCEPT OF CORE STABILITY IN THE LUMBOPELVIC–HIP REGION IS WELL KNOWN AND HAS NOW BEEN APPLIED TO THE FOOT Understanding the Foot Core System

Panjabi originally proposed the theoretical model of the lumbopelvic– hip core stability, which is based on the functional interdependence of the passive, active and neural subsystems controlling spinal mobility and stability (15). Hodges further described the lumbopelvic core stability approach as having ‘control’ and ‘capacity’ components (16). The control components aim to restore coordination of the muscles acting as the core. The role of the capacity components, however, is to provide sufficient muscle strength and endurance to prevent the spine from being mechanically unstable under differing loads. At the end of the day the control and capacity components must complement each other to provide a stable lumbopelvic core. Jam was the first to apply these concepts to the foot core system (17*), as shown in Figure 1 (1*).

McKeon and co-authors describe in detail the different subsystems of the foot and how they together can form a

‘foot core’ that ideally would provide optimal stability, mobility and function for the rest of the lower limb (1*). The movement and stability of the arch (specifically the MLA) is controlled by intrinsic (local stabilisers) and extrinsic (global movers) muscles. As mentioned earlier, the IFMs are largely ignored or forgotten by clinicians and researchers. The muscles are seldom specifically addressed in rehabilitation programmes. Interventions for footrelated problems or lower limb injuries are more often directed at externally supporting the foot rather than training these ‘core stabiliser’ muscles to function as they were intended.

Table 1 describes the functional qualities of the IFMs (1*).

Assessment of the Foot Core

Clinical assessment of the IFMs in musculoskeletal injury has received little attention. A recent systematic review concluded “[t]here is no gold standard to measure intrinsic muscle strength in the foot” (18*). Assessment techniques have been categorised into ‘direct’ and ‘indirect’ evaluations

Table 1: Functional Qualities of the Intrinsic Foot Muscles (IFMs) Adapted from McKeon et al. The foot core system: a new paradigm for understanding intrinsic foot muscle function.

British Journal of Sports Medicine 2015;49:290 (1*) Functional quality

Description

Supportive of the foot arches

l Diminished function of the IFMs leads to detrimental alterations in foot posture l Training the IFMs enhances foot posture

Activity dependent

l IFMs are more active in dynamic activities, such as walking compared to standing

Load dependent

l As postural demands increase (moving from double to single limb stance) so the activity of the IFMs increases

Synergistic

l During the propulsive phase of gait, the IFMs work together as a unit to provide dynamic arch support

Modulating

l The IFMs support the foot in its role as a platform for standing and as a lever for propelling the body during dynamic activities

24

of intrinsic muscle function (18*).

Direct evaluations are methods that focus on assessing toe flexion strength. Indirect evaluations include imaging techniques (including MRI and Ultrasound) and EMG (surface and fine wire) to estimate function of the IFMs; however, these are not practical on a daily basis in a clinical setting (18*).

Testing toe flexion strength is fundamentally limited by the inability to separate the contributions of the intrinsic and extrinsic toe flexor muscles (1*). Common methods for assessing this are manual muscle testing, toe grip dynamometry and pedobarography. In addition to these, two special tests include ‘the paper grip’ and ‘intrinsic positive tests’ (18*).

The limitation of all of these tests is the assumed primary role of the intrinsic muscles being toe flexion, while ignoring their more proximal functions of supporting the arches of the feet. There are additional tests that can be performed. Although they do not specifically assess the IFMs, they can be useful in identifying the strength or stiffness of the foot arch expressed by its deformation when moving between weight-bearing and non-weight-bearing postures. These tests include the arch rigidity index, the medial arch height, navicular drop (ND) and the foot mobility measurement (FMM) (2*).

Below are the most common and practical methods (based on equipment within a standard clinic setting) for assessing the IFMs and the foot core.

1. Medial Arch Height

This can be measured during gait and/or standing phase, and requires the use of the Oxford Foot Model, a 3D multi-segment foot model with a good to excellent repeatability.

Although accurate, this may not be a viable option within many clinics.

There is, however, also a simpler version of assessing medial arch height, which is described next.

A functional assessment of a patient’s ability to maintain a neutral foot posture and MLA height during single limb stance has been proposed as a test to assess IFM integrity (17*).

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The following instructions guide you through how to perform the IFM test: i. The clinician sets the patient’s test foot in subtalar neutral with the calcaneus and all the metatarsal heads on the ground, and instructs the patient to fully extend the toes. ii. The patient then lowers their toes to the ground and is asked to maintain the foot position in single limb stance for 30 seconds. iii. The clinician observes for gross changes in navicular height and overactivity of the extrinsic muscles.

4. Foot Mobility Measurement (FMM)

Evidence suggests that the IFM test can detect improvements in foot core function, but more research is needed.

Training the Foot Core

2. Arch Rigidity Index

The arch rigidity index (ARI) provides an indication of the structural mobility of the MLA, and is determined by dividing the standing arch height index by the sitting arch height index. An ARI of 1 indicates low arch mobility (stiff MLA), whereas higher numbers correlate with higher arch mobility (more flexible MLA). This is explained and illustrated in more detail by Tourillon et al. (2*)

3. Navicular Drop (ND)

The most popular evaluation of longitudinal arch stability found in the literature is the sit-to-stand double-leg or single-leg ND test (2*).

The patient should sit with their feet (barefoot) resting on the floor such that their hips, knees and ankles are all flexed to 90°. Palpate the inferior border of the prominent tuberosity of the navicular bone and mark with a pen. Using a steel ruler (resolution: 0.5mm), measure the distance from your pen mark to the ground. Instruct the patient to then stand up onto a 10cm box, with their full weight through the foot being assessed.

The other foot rests, for balance, lightly on the box. Repeat the measurement from your pen mark to the box. The ND is the difference between the two measurements (sitting vs standing). Ideally this should be repeated three times and an average value recorded (2*).

Video 1 illustrates how to perform the ND test.

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The FMM is a measure of both vertical and medial to lateral mobility of the midfoot. The FMM differs from the ND test, which only assesses vertical mobility, and the FMM may be a relevant test in the assessment of foot mobility differences between nonweight-bearing and weight-bearing positions (2*). A detailed description of how to perform the test can be found at Tourillon et al. (2*) and McPoil et al.

(19*).

The same training principles used for any other muscle group can be applied to the strengthening of the foot muscles. IFM strengthening can be performed in isometric, concentric, eccentric or plyometric modes (2*).

Exercises traditionally prescribed for IFM training primarily involved toe flexion such as towel curls and marble pick-ups. Although these exercises may activate some of the intrinsic muscles, they also involve substantial recruitment of the extrinsic toe flexor muscles (1*).

1. Short Foot Exercise (SFE)

The SFE is a recently described method of isolating the IFMs. By pulling the first metatarsophalangeal joint towards the calcaneus, essentially shortening the foot and elevating the MLA, the IFMs are being isolated. This action is also termed ‘foot doming’ (1*,2*). As with lumbopelvic–hip core control, the Hodges’ concept of establishing control of intrinsic foot muscle function first, before increasing capacity should be followed (1*,16) .

The SFE can often be difficult for both the therapist to teach and the patient to learn, so Tourillon et al. (2*) have described three gradual training steps: i. Passive mode. Initially the patient should simply sit while their foot is moved by the therapist in and out of the short foot positions. This allows the patient time to feel and observe the required movement. ii. Active-assisted mode. Here, the patient can actively start to attempt the movement and muscle contractions while still being guided

Video 1: The navicular drop test for foot overpronation (Courtesy of YouTube user Physiotutors) https://youtu.be/BejuNMmD7-Y

Video 2: Foot – short foot intrinsic muscle strengthening Courtesy of YouTube user Physical Therapy First https://youtube.com/watch?v=QnnsoOIAFm0 and physically assisted by the therapist. iii. Active mode. The patient performs the exercise without assistance (Video 2).

The SFE is illustrated at McKeon et al.

(1*), Tourillon et al. (2*), and Fourchet et al. (20*). Ideally the SFE should be progressed from sitting to bipedal, to unipedal positions, followed by functional activities such as squats and single-leg hops (1*). As with rehabilitation principles for other body parts, an area should not be worked in isolation, and functional movement patterns should be integrated to ensure a successful outcome. It has been suggested that upper body active and resisted activities be combined with SFE to create crossbody movement patterns (ie. trunk and pelvis rotation and its effect on foot posture) and facilitate muscular chain action (2*).

There is an increasing body of evidence to suggest that SFE training 25

THE SHORT FOOT EXERCISE HAS BEEN SHOWN TO BE MORE EFFECTIVE THAN STANDARD PROPRIOCEPTIVE SENSORY EXERCISES FOR TREATING PATIENTS WITH ANKLE SPRAINS of the foot core can improve foot function. For example, according to the literature (8*,21,22*,23*,24): l 4 weeks of SFE training can: l reduce arch collapse (as assessed

by ND and arch height index) and improve balance ability; l improve dynamic balance compared to those who performed 4 weeks of towel curl exercises; l significantly increase great toe flexion strength and the crosssectional area of the abductor

Video 3: Foot intrinsic muscles activation (Courtesy of YouTube user REACH Rehab + Chiropractic Performance Center) https://youtube.com/watch?v=Jyha3RA2UAg

Video 4: Foot & ankle exercise: towel toe curls (Courtesy of YouTube user stoneclinicPT) https://youtube.com/watch?v=dVDMUuWtX00 26

hallucis muscle after 4 weeks of SFE and foot orthotic intervention, compared to foot orthotic intervention alone; and l improve self-reported function in chronic ankle instability patients. l 6 weeks of SFE training: l provided a reduction in ND, foot pronation, foot pain, and disability and increment in plantar force of medial midfoot in pes planus. l the SFE: l can be used to decrease ND – particularly in individuals with a flexible flatfoot; l is more effective than standard proprioceptive sensory exercise for treating ankle sprain patients; and l creates a more active foundational posture for functional movements and dynamic activities.

Traditionally a top-down approach, targeting the muscles of the lumbopelvic–hip complex, is commonly used in addressing a number of lower limb injuries. The functional effectiveness of the SFE suggests a ground-up approach may be a feasible option. Incorporating the SFE into performance and rehabilitation training may optimise lower extremity joint alignment and kinematics for more efficient muscle activity by way of the ground-up approach (24).

2. Toe Yoga or Toe Posture Exercises

five while maintaining the hallux in contact with the ground (2*).

3. Towel Curl

Although we have stressed that toe flexion exercises recruit more of the extrinsic foot musculature (such as the flexor digitorum longus) rather than focusing on the IFMs, Hashimoto et al. developed an IFM strength training programme that minimised involvement of the extrinsic muscles by bringing the ankle into plantar flexion (2*,25*). The steps for performing the towel curl are listed below and shown in Video 4. l Have the patient spread a towel out on the floor. l The patient can be in either a sitting or standing position and should have their feet resting flat on top of the towel. l Then have the patient pull the towel towards themselves by grabbing it with their toes and slowly flexing (curling) their toes, and then relaxing. l This exercise can be progressed by adding a weight to the edge of the towel.

4. Dynamic and Plyometric Foot Strengthening

‘Toe yoga’ or ‘toe posture exercises’ have been shown to activate the IFMs in an isometric contraction (19*). Some examples of toe posture exercises are described below and shown in Video 3. l Toe-spread-out exercise is carried out by a sequential extension of all toes, followed by hallux abduction, hallux flexion, and fifth toe flexion (2*). l The ‘first-toe extension’ or ‘hallux-extension’ exercise is performed by extending the first metatarsophalangeal joint while maintaining the lesser toes (second to fifth) in contact with the floor (2*). l The ‘lesser-toe-extension’ exercise consists in extension of toes two to

As we know, isometric exercises are not reflective of how foot muscles work during locomotion. Performing low load tasks, like the SFE, would seem insufficient to take on the magnitude of load at the midfoot during running or even walking. The foot muscles would be ill equipped to generate sufficient force with SFE exercises alone. A progression from isometric (core) to plyometric exercises in order to get closer to the specific function of running, jumping or sporting activities is suggested. More progressive functional exercises incorporating SFE are illustrated in Tourillon et al. (2*).

Minimalist or Barefoot Running

The literature on the effects of running on foot muscular adaptations is relatively scarce and somewhat contradictory. It seems that you are either for or against barefoot/ minimalist running. Granted, there is no conclusive data to suggest a causal link between footwear use and

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injury risk; however, it is believed by some that the inclusion of barefoot or minimalist training in a runner’s programme would be beneficial towards injury prevention. Arguably this is due to the following: 1. An increase in sensory input to the sole of the foot improves postural stability and therefore, fine control of movement (26*).

Stability progressively increased with decreasing amount of footwear support.

2. IFM size and strength improve with barefoot or minimalist activities leading to a restoration of the foot arch (2*,27*).

3. Individuals with extended lower limbs on ground contact (commonly demonstrated when wearing shoes) have an increased reliance on passive tissues for shock absorption. These individuals tend to under use the posterior muscles of the lower limb, and are associated with both traumatic and chronic overuse injuries (26*). Many habitually barefoot or minimalist shoe runners do not use these mechanics. Runners who transition to barefoot running cease to use these mechanics (26*).

Greater hip, knee and ankle flexion are required to reduce the load traditionally absorbed by passive tissues (shoes) during dynamic movement. Greater eccentric muscle work, by the posterior chain muscles, is thus required. Options to achieve this may be via neuromuscular training programmes, gait retraining or barefoot running. Evidence suggests that barefoot running (or walking to start) has a positive impact on mechanics associated with injury (26*).

The transition towards barefoot activities in daily life, especially barefoot running, needs to be managed carefully in adults who have spent most of their lives shod. Slowly increasing time spent barefoot and on variable surfaces (starting with more forgiving carpeting, sand, or grass) may provide a suitable introduction to barefoot training. In this way, adults may be able to restore innate impact moderating mechanisms without muscle–tendon strain.

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Conclusion

In order to best transfer lower limb forces during propulsion, the foot core system must act as a strong and rigid lever. On the contrary, it must cope with significant amounts of constraint at the absorption phase, in the sense of impact reduction. Deficits in active foot stabilisation during running or walking, may lead to increased tissue stresses resulting in overuse injuries linked to the lack of control of the arch of the foot.

‘Prehistorically’ our feet were designed with the strength for unsupported endurance walking and running. Unfortunately, adding permanent support to the foot (a.k.a shoes), as opposed to strengthening the foot core, is the current standard of care.

Barefoot activities or minimalist shoes can be considered in safe environments as part of a training programme as it could assist in improving foot function.

The foot core should be approached in a similar way to the lumbopelvic–hip core system, which needs to be strong, but in the right way. That means the IFMs of the foot need to provide stability not only through strength but endurance too.

The global, extrinsic muscles are there to support the foot and generate gross movement. A foot strengthening programme that includes the SFE should be considered when treating a foot injury or possibly any other lower limb injury. According to the guidelines, managing a foot injury should still include the use of orthoses and other supportive devices (braces or taping), albeit temporarily where possible.

Greater focus needs to be placed on static and dynamic foot core function in prehabilitation and/or rehabilitation programmes.

In summary, this article aimed at increasing the awareness of the importance of the foot core, making up the arch, and contributing to overall foot function. It is apparent that a stronger foot is a healthier foot.

Further Resources

1. Speller J. Muscles of the Foot [website]. TeachMe Anatomy 2021 https://bit.ly/3gtSdZy References

1. McKeon PO, Hertel J, Bramble D et al. The foot core system: a new paradigm for understanding intrinsic foot muscle function. British Journal of Sports Medicine 2015;49:290 Open access https://bit.ly/3sJwTUK 2. Tourillon R, Gojanovic B, Fourchet F. How to evaluate and improve foot strength in athletes: an update. Frontiers in Sports and Active Living 2019;1:46 Open access https://bit.ly/3ygvOov 3. Mickle KJ, Caputi P, Potter JM et al. Efficacy of a progressive resistance exercise program to increase toe flexor strength in older people. Clinical Biomechanics 2016;40:14–19 4. Mulligan EP, Cook PG. Effect of plantar intrinsic muscle training on medial longitudinal arch morphology and dynamic function. Manual Therapy 2013;18(5):425–430 5. Nigg B. Biomechanical considerations on barefoot movement and barefoot shoe concepts. Footwear Science 2009;1(2):73–79 6. Nigg BM, Baltich J, Federolf P et al. Functional relevance of the small muscles crossing the ankle joint – the bottom-up approach. Current Issues in Sport Science 2017;2:doi:10.15203/CISS_2017.003 Open access https://bit.ly/2WpE9ZZ 7. van der Merwe C, Shultz SP, Colborne GR et al. Foot muscle strengthening and lower limb injury prevention. Research Quarterly for Exercise and Sport 2021;92(3):380–387 8. Lee E, Cho J, Lee S. Short-foot exercise promotes quantitative somatosensory function in ankle instability: a randomized controlled trial.

Medical Science Monitor 2019;25:618–626 Open access https://bit.ly/3sKBVQN 9. Fraser JJ, Hertel J. Effects of a 4-week intrinsic foot muscle exercise program on motor function: a preliminary randomized control trial. Journal of Sport Rehabilitation 2019;28(4): 339–349 10. Dantas G, Sacco ICN, dos Santos AF et al. Effects of a foot-ankle strengthening programme on clinical aspects and gait biomechanics in people with knee osteoarthritis: protocol for a randomised controlled trial.

BMJ Open 2020;10:e039279 Open access https://bit.ly/3zlm79M 11. Trombini-Souza F, Kimura A, Ribeiro AP et al. Inexpensive footwear decreases joint loading in elderly women with knee osteoarthritis. Gait & Posture 2011;34:126–130 12. Sacco ICN, Trombini-Souza F, Butugan MK et al. Joint loading decreased by inexpensive and minimalist footwear in elderly women with knee osteoarthritis during stair descent. Arthritis Care & Research 2012;64:368–374 Open access https://bit.ly/3zgH9WQ 13. Trombini-Souza F, Matias AB, Yokota M et al. Long-term use of minimal footwear on pain, self-reported function, analgesic intake, and joint loading in elderly women with knee osteoarthritis: a randomized controlled trial. Clinical Biomechanics 2015;30:1194–1201 14. Fourchet F, McKeon. Foot core strengthening: an update about the intrinsic foot muscles recruitment. British Journal of Sports Medicine 2015;49(Suppl 1):A6. Presented at the 6th International Ankle Symposium 2015, Dublin, Republic of Ireland 15. Panjabi MM. The stabilizing system of the spine. Part I. Function, dysfunction, adaptation, and enhancement. Journal of Spinal Disorders 1992;5(4):383–389; discussion 397 16. Hodges PW. Core stability exercise in chronic low back pain.

Orthopedic Clinics of North America 2003;34(2):245–254 17. Jam B. Evaluation and retraining of the intrinsic foot muscles for pain syndromes related to abnormal control of pronation. Advanced Physical Therapy Education Institute Clinical Library 2004, 21 July Open access https://bit.ly/3ynajTa 18. Soysa A, Hiller C, Refshauge K et al. Importance and challenges of measuring intrinsic foot muscle strength. Journal of Foot and Ankle Research 2012;5(1):29 Open access https://bit.ly/3mumWJx 19. McPoil TG, Vicenzino B, Cornwall MW et al. Reliability and normative values for the foot mobility magnitude: a composite measure of vertical and medial-lateral mobility of the midfoot. Journal of Foot and Ankle Research 2009;2:6 Open access https://bit.ly/3DesUEp 27

20. Fourchet F, Gojanovic B. Foot core strengthening: relevance in injury prevention and rehabilitation for runners. Swiss Sports & Exercise Medicine 2016;64(1):26–30 Open access https://bit.ly/3zjY8aG 21. Unver B, Erdem EU, Akbas E. Effects of short-foot exercises on foot posture, pain, disability, and plantar pressure in pes planus.

Journal of Sport Rehabilitation 2019;29(4):436–440 22. Haun C, Brown CN, Hannigan K et al. The effects of the short foot exercise on navicular drop: a critically appraised topic.

Journal of Sport Rehabilitation 2021;30(1):152–157 Open access https://bit.ly/2UKqcVI 23. Pabón-Carrasco M, Castro-Méndez A, Vilar-Palomo S, JiménezCebrián AM et al. Randomized clinical trial: the effect of exercise of the intrinsic muscle on foot pronation. International Journal of Environmental Research and Public Health 2020;17(13):4882 Open access https://bit.ly/3gyXwqB 24. Arant A, Johnson D. The effect of the short foot exercise on proximal lower extremity and trunk muscle recruitment during the drop jump. Azusa Pacific University, ProQuest Dissertations Publishing 2020;28093974 25. Gooding TM, Feger MA, Hart JM et al. Intrinsic foot muscle activation during specific exercises: a T2 time magnetic resonance imaging study. Journal of Athletic Training 2016;51(8):644–650 Open access https://bit.ly/3zkULAk 26. Hashimoto T, Sakuraba K. Strength training for the intrinsic flexor muscles of the foot: effects on muscle strength, the foot arch, and dynamic parameters before and after the training. Journal of Physical Therapy Science 2014;26(3):373–376 Open access https://bit.ly/3mw7kW1 27. Francis P, Schofield G. From barefoot hunter gathering to shod pavement pounding. Where to from here? A narrative review.

BMJ Open Sport & Exercise Medicine 2020;6(1): e000577 Open access https://bit.ly/38jeKDz 28. Holowka NB, Wallace IJ, Lieberman DE. Foot strength and stiffness are related to footwear use in a comparison of minimally- vs. conventionally-shod populations. Sci Rep 2018;8(1):3679 Open access https://go.nature.com/3yljrrc.

KEY POINTS

RELATED CONTENT

lH eel Pain: The 10 Minute Assessment [Article] https://bit.ly/38bfAlM l Plantar Fasciitis: A Pain in the Heel [Article] https://bit.ly/3sMVKa5 lP atient Information Leaflet: Chronic Plantar Heel Pain [Printable Leaflet] https://bit.ly/389LwqQ lP atient Information Leaflet: Burning Feet and Cycling [Printable leaflet] https://bit.ly/3sNDiOQ l Syndesmosis Injury Part 1: Diagnosis and Evaluation [Article] https://spxj.nl/2ZhRByL l Syndesmosis Injury Part 2: Treatment and Rehabilitation [Article] https://bit.ly/3coR6aH

DISCUSSIONS

l What is the best test (if you have one) in your clinical practice to assess foot core function? l Have you used or considered the use of a ‘ground-up’ approach to managing lower limb injuries? And if so, what was your choice of exercises and the outcome? l What are your beliefs and attitude towards barefoot and/or minimalist footwear in rehabilitation?

lT he foot core system (not unlike the lumbopelvic core) is composed of interacting subsystems that provide relevant sensory input and functional stability for accommodating the changing demands during both static and dynamic activities. lP lantar cutaneous input from the foot can influence whole-body postural stability and kinematics during movement. lT he intrinsic foot muscles (IFMs) play a critical role in the foot core system as local stabilisers and direct sensors of foot deformation. lA ssessment of the foot core system can provide clinical insight into the ability of the foot to cope with changing functional demands, although no gold standard test exists (…yet). lT argeting the intrinsic muscles via the short foot exercise (SFE), is the start of foot core training, slowly building on control and then capacity. lT he SFE creates a more active foundational posture for functional movements and dynamic activities. lT he functional effectiveness of the SFE suggests that a ground-up approach in managing lower limb injuries is possible. lS FE should be incorporated into dynamic and plyometric activities to optimise lower limb performance and rehabilitation training. lB arefoot activities or minimalist shoes can be considered in safe environments as part of a training programme as it could assist in improving foot function. l A shift in thinking or focus about the importance of the IFMs or the foot core is needed to ensure optimal outcomes for our patients with lower limb injuries or pain.

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Kathryn Thomas BSc Physio, MPhil Sports Physiotherapy is a physiotherapist with a Master’s degree in Sports Physiotherapy from the Institute of Sports Science and University of Cape Town, South Africa. She graduated both her honours and Master’s degrees Cum Laude, and with Deans awards. After graduating in 2000 Kathryn worked in sports practices focusing on musculoskeletal injuries and rehabilitation. She was contracted to work with the Dolphins Cricket team (county/provincial team) and The Sharks rugby teams (Super rugby).

Kathryn has also worked and supervised physios at the annual Comrades Marathon and Amashova cycle races for many years. She has worked with elite athletes from different sporting disciplines such as hockey, athletics, swimming and tennis. She was a competitive athlete holding national and provincial colours for swimming, biathlon, athletics, and surf lifesaving, and has a passion for sports and exercise physiology. She has presented research at the annual American College of Sports Medicine congress in Baltimore, and at South African Sports Medicine Association in 2000 and 2011.

She is Co-Kinetic’s technical editor and has taken on responsibility for writing our new clinical review updates for practitioners.

Email: kittyjoythomas@gmail.com

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21-10-COKINETIC | PAIN | YOGA FORMATS WEB MOBILE PRINT All references marked with an asterisk are open access and links are provided in the reference list

By Niamh Moloney PhD, MManipTh, BPhysio, SMISCP and Marnie Hartman DPT, CSCS, RYT

Yoga: An Introduction

The word yoga can elicit a number of reactions from the general public, including: “I am not flexible enough to do yoga” or “I already have a faith system”. These responses represent a misunderstanding of what yoga is and what the practice involves. Yoga is the study of self and living with awareness.

It encompasses philosophies and tools to facilitate this, to promote self-regulation, and hence to improve wellbeing. The yoga philosophy presented here and throughout the rest of the book Pain Science – Yoga – Life, as we weave the concepts of yoga with pain science, is a product of the combination of our individual yoga teacher training, clinical experience, self-study and contemplations. While reading, we encourage you to keep in mind the primary purpose of this book, which is to use yoga to facilitate a change in one’s relationship with pain. We recognise that yoga as it is presented may feel over-simplified for some or difficult to fully digest for others. It may be helpful to proceed with the mindset of ‘take what you need and leave the rest.’

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ROOTS OF YOGA

and How it Pertains to Pain Many people, if not most, think of yoga as being useful for developing flexibility or perhaps for rehab, and know that it has ‘some sort of mindfulness’ aspect. This article sets straight some of the misconceptions about yoga as well as describing the Eight Limbs of yoga, the concepts of which can inform a complete way of ‘being’.

Combined with an emphasis on how these ideas are relevant to pain, this article will enable you to encourage your patients to manage their pain holistically – both physically and emotionally – as well as being of benefit in your own life. This article has been extracted from the authors’ book Pain Science – Yoga – Life. Read this article online https://bit.ly/3yWYcMB Yoga misconceptions: l It is not a religion. l It is not a fixed series of exercises for flexibility or handstands. l It is not a trendy lifestyle of clothing, foods and social media posts.

Yoga does encompass: l A spiritual connection and practice with the many layers of ourselves and the world we live in. l Exercises or postures known as asanas that promote strength, proprioception, flexibility and mindfulness or awareness. l Positive thinking and mindfulness with meditation practices. l Awareness of, and activities to promote understanding of, our own perceptions of body, emotions and the self. l Awareness of, and activities for, breathing known as pranayama. l Awareness of how we nourish ourselves through food, society, nature, thought, etc. l Promotion of rest and relaxation. l Positive social and environmental living, harnessing wisely from these entities, taking no more than we need and learning to give back as well.

At its core, yoga is the study of self and living with awareness. In Sanskrit, yoga’s root language, the word yoga comes from the root word, yuj, meaning to yoke, to unite or bring together. This can be thought of simply as connecting the body, mind and spirit. For our purposes, spirit can be thought of as the way our inner self connects with the outer world. At a more in-depth level, this union is the ability to detach from dualistic thinking. Non-dualism allows the bringing together, yoking, of all things. Comprehension of dualism is challenging; we will look more closely at it in just a moment.

A Look at the Self – One Potential Viewpoint

People spend years attempting to understand and define ‘the self’. To keep it simple and for the purpose of pain, we will consider the self as one entity with two distinct layers. The superficial self is the physical body, including the senses, the brain and the psychological mind. The mind here is all of your thoughts, beliefs and opinions. This is the self that we tend to identify strongly with, the one that we put up against others for comparison. This is the ego-driven 29

AT ITS CORE, YOGA IS THE STUDY OF SELF AND LIVING WITH AWARENESS Figure 1: Depiction of the concepts of dualism Moloney and Hartman.

Pain Science – Yoga – Life.

Handspring 2020

As humans are part of the natural world we are all simply molecules in different forms. One human to another is no different than these two water molecules: here one molecule is in wave form while the other is part of the spray, different but the same.

self. The second or deeper layer of self can be thought of as the true self.

The true self is not driven by ego or comparison. It is the consistent centre of you, the one that doesn’t change based on the outer environment.

When yoga is thought of as the study of self, it is this deeper layer of self that one is seeking to connect with and understand. With practice we can learn to live our lives more connected to and rooted in this deeper, more consistent self. It is from here that we can process the vicissitudes of life with greater equanimity.

An Introduction to Dualism

Dualism is a philosophical concept that is centuries old. Simply stated, it is the idea that for most experiences or entities a division into categories can occur (1*). We, as humans, tend to view the world through the lens of expectations, judgments and comparisons. For example, good versus evil, you versus me, mind versus body. Dualism is a recognition of differences. It is rooted in comparison and often in the idea of better or worse, good or bad, success or failure, power or submission. If we live primarily from the superficial layer of self it is difficult not to live with a dualistic outlook. This comparative 30

outlook can be prevalent in pain states and may be a root of unnecessary suffering. Pain is perceived as a negative experience or negative state, a state to be rid of. A non-dualistic outlook on pain would suggest that pain is not good or bad, it just is: a normal sensory or emotional experience and a part of all human life.

Non-dualism is the recognition that all living things are made equal and are precious: everything made from nature (humans, animals, plants, etc.) is made of particles and elements, and is connected as one aspect of a bigger whole. It is the recognition that life’s experiences will be varied, including pleasure and pain, neither being more or less important than the other. This view can be incredibly challenging to grasp because it is not exactly tangible.

However, once accepted, even on a conceptual level, it can be healing for many human struggles and promote a place of loving kindness for ourselves and others. Think of this: a water molecule at the top of a wave looks at its neighbour and says: “Why would you think you are less worthy than the entire ocean? You are in fact the same, just in a different form” (Fig. 1). Can you see that we humans are all the same, just in different forms?

The connectivity and likeness don’t stop at humans. When we find this ability to recognise connection rather than separateness, we can begin to step away from unhealthy attachments to our own sufferings, comparisons and perceived short-comings. This perception or ‘awakened/enlightened’ mindset is not easy and will only come with observation and practice.

When we think about persistent pain, we often think of it as a negative, as a disability. These thoughts come from comparison: “I used to be able to…”, “Because of my pain I can no longer…”, but what if we choose to see pain and its effects as one part of a whole? Take Russell, for example.

He is an Alaskan smoke-jumper: he hurls himself out of helicopters to fight forest fires and ensure the safety of humans and wildlife. At age 34 he began to struggle with recurrent back pain. To him, this pain could easily have become a disability, and a threat to his sense of self-worth: “If I can’t

jump with the crew, what good am I?” If he attached his sense of self to this vocation, he would undoubtedly suffer with catastrophic thinking patterns which would most likely drive his pain and sensitivity further (see Chapter 4 of the book for more details on this process). However, by recognising that smoke-jumping is something he does and not who he is, he was able to see this scenario as an opportunity to simply continue to learn and grow and add to his life skill set. Now 37, Russell has returned to university to pursue a career in teaching literature. He gets to be a smoke-jumper with back pain and a literature student, and still he is Russell – a human, a part of nature, not better, not worse. Because he has learned to relate to the world from his true self, he can smoothly transition into this additional role without comparing it or getting lost in dualistic thinking and suffering.

The Eight Limbs of Yoga

Historically, yoga was taught only verbally and by direct instruction from sage to student. This was said to keep the knowledge pure and prevent excessive intellectual contemplation.

Sometime around 400CE, Sage Patanjali wrote the Yoga Sutras, which have become known as the first comprehensive system of yoga, also known as the Eight-Fold Path or Eight Limbs (2,3). The Eight Limbs are: 1. Yamas, 2. Niyamas, 3. Asana, 4.

Pranayama, 5. Pratyahara, 6. Dharana, 7. Dhyana, 8. Samadhi, and help to establish a formula for practice. Each limb could be considered a window for observation with curiosity of the various features of ourselves.

Each serves as a means to learn who we are and how we tend to connect with what surrounds us.

There are many other tools in yoga traditions. If you already have a yoga foundation or practice that delves into other traditions, please don’t think you need to abandon that in any way. If we blend traditional

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practices with pain science, we may see yoga as a toolbox for selfregulation and self-care (Fig. 2): first becoming aware of the integration of inputs and outputs associated with pain, and then starting to regulate these processes. With consistent practice the ability to use tools such as self-regulation becomes more natural and efficient (4*).

1. Yamas

The first limb represents self-restraint, moral discipline or vows, and incorporates five subsets: l ahimsa: non-violence; l satya: truthfulness; l asteya: non-stealing; l brahmacharya: positive use of energy (prana); and l aparigraha: non-greed, nonattachment, non-grasping.

It is easy to see how these can be practised as outward expressions and vows of moral actions towards others. However, in yoga these are also emphasised as behaviours towards ourselves. To practise non-violence (ahimsa) with others we must first find self-compassion and loving kindness inwardly. Harbouring feelings of guilt and shame are two of the most violent acts we endure. We must also hold ourselves accountable for our own truths (satya). If I have feelings of anger or jealousy, I can choose not to act out these feelings but I have to admit to myself that they are there. Denying or ignoring such emotional states is an act of lying to the self.

In the context of asteya and aparigraha, it is said if we take more than we need we are indeed stealing and acting out of greed, be it with food, material objects or emotional/ intellectual justifications. These practices suggest that being mindful of our true needs ensures we don’t take more than we need and we balance the act of taking with the act of giving back. Activities we participate in can either feed our Co-Kinetic.com

energy or deplete it (brahmacharya).

The five positive aspects listed above are all a means of nurturing and boosting ourselves physically, emotionally and psychologically. In yoga, giving back to the self may be referred to as increasing one’s prana or lifeforce.

Yamas and Pain

Ahimsa: Non-violence Many of us have a metaphorical tendency to beat ourselves up, especially when we are in pain. This can be a result of negative thought patterns, for example: “I am broken/I can’t/my bad back…” This can also manifest in the actions we take, participating in too much or too little activity. Even though violence can be a bit of an extreme word, these negative thoughts and actions towards our physical body can be an act of harm for ourselves. If we learn to shift to a more compassionate thought process and learn a balance of physical participation, we may feel a shift in pain.

Satya: Truthfulness It is quite common to hear things like: “Everything hurts, I can’t do anything, my pain is horrible, my shoulder is ripped to shreds, it’s all because of the stupid driver who hit me”. All of these things might feel real. But are they actually true? See Chapter 3 of the book to specifically understand the practice of ‘real but not true’.

While learning to be fully honest with ourselves can be difficult and uncomfortable, truthful examination allows us to see the entire scenario for what it really is. This practice may give insight into the areas we have the ability to control and shift us towards the direction we need for healing and recovery. A patient recently stated he had had 18 years of back pain. He said he can no longer do his work as a composer: “I just can’t work at all”, he firmly stated. However, with further questioning he revealed he spends

four hours per day for at least five days per week in his studio, composing – working. He hadn’t been fully truthful to himself; this simple misrepresentation of the truth might lead to a belief, an input, that adds to his pain experience.

Asteya: Non-stealing If we think of non-stealing, for pain this might be over-using medical or healthcare provision or asking more from our friends and family than we are giving back to them. Stealing sounds intentional and malicious but it may be an unintentional lack of awareness and realisation. Are we taking more than we are giving? Expecting someone else to heal us or fix something? Are we contributing equally to our healthcare, doing as much as we can to improve the situation? There are times in life when we need others to take care of us, but even during these times it is important to take only what is actually needed and to continue to offer what we can to give back to those around us, as well as ourselves.

Brahmacharya: Positive Use of Energy (Prana) This means keeping our thoughts and actions around pain in a positive perspective. This could be as simple as focusing on what we can still do instead of what we can’t. Let us look again at the composer. How much time in the studio does he spend ruminating about what he can no longer do, and how his studio time is much less than he would like it to be? This is not a productive use of his time or physical tolerance. He may actually be more productive if he can shift into the optimistic and grateful outlook – he then has four hours to accomplish his desired tasks. This is written as if it is a simple shift to put in place. Of course, it is more complex. Emotional lability about what has been lost will happen and is important to process. But grieving the loss during times of attempting productivity becomes unproductive for both emotional processing and, in this case, composing.

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Aparigraha: Non-greed, Non-attachment, Non-grasping, Non-possessiveness In yoga this goes beyond the idea of wanting money, power or food. This limb also reflects the side of human nature that can lean towards grasping and clinging. In a persistent pain scenario, aparigraha may be practised through the ability to maintain realistic expectations. If walking for

10 minutes is difficult, then having a goal of returning to mountaineering in the next month may be greedy, or grasping at a past demonstration of physical ability. A goal to improve walking tolerance to allow a 30-minute stroll in the woods may be more realistic and obtainable. This isn’t to say mountaineering will never be possible, but learning to accept smaller yet meaningful achievements might actually aid a fuller recovery. This may also mean accepting the scenario at hand, feeling the discomfort or pain, learning how to cope with it and regulate it without trying to escape it or simply get rid of it.

2. Niyamas

This second limb encompasses selfobservances or self-study, and also has five subsets: l saucha: cleanliness; l santosha: contentment; l tapas: discipline, self-will; l svadhyaya: self-reflection and spiritual studies; and l isvarapranidaha: surrender to a system of faith or higher power.

Figure 2: Pain and yoga mandala Moloney and Hartman.

Pain Science – Yoga – Life. Handspring 2020

This mandala depicts aspects of the human experience of pain covered in Pain Science – Yoga – Life. The petals represent ‘inputs’ to the pain experience. The next layer demonstrates systems that are influenced by these ‘inputs’. Listed here are: the somatosensory nervous system (listed as nervous system), the autonomic nervous system, the endocrine (hormonal) system and the immune system. The inner circles represent how this information is processed and integrated to culminate in our awareness, our perception, and our sense of an experience. This processing, integration and creation of awareness primarily happens within the central nervous system. The mandala as a whole represents the circular nature of the pain experience; each aspect can interact with others. At the heart is you: you are you, with and without pain. The Eight Limbs of yoga surround the lotus to offer a depiction of how yoga philosophy and practices may aid in changing inputs and outputs that feed the pain experience. Yoga may also deepen the relationship you have with your inner self and potentially soften the impacts of pain.

Note: Other inputs, dimensions and body systems than those noted here can contribute to pain.

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In this limb, the greatest aim is to create a flexible mind, releasing the tendency towards rigid thoughts and beliefs. Again, these can be looked at as outward acts with an inner shift of perspectives.

Saucha: Cleanliness This includes cleansing the mind and emotions of attachment. For the purpose of pain, this might be thought of as a means of cleaning out unhelpful and automatic reactions of our minds or movement patterns.

Have you ever noticed how sights and sounds can cause our posture to shift?

For instance, every Wednesday in the summer, a giant cruise ship full of curious passengers arrives in my small community in Alaska. On Wednesday mornings, pedalling around the corner to my office, my eyes land on the large structure docked in my view. Automatically, I can feel my body ‘armour’. My chest will puff a little, my shoulders rise up towards my ears. I begin to avoid eye contact with tourists and edge towards being unapproachable. I know the day will

be filled with interruptions, and slowed internet and cellular services. Because of past experiences, my physical posture is affected, based on the visual cue of a cruise ship. Practising saucha might mean letting go of my patterned reactions and allowing the day to unfold however it may.

Santosha: True Contentment This is an intention to accept and understand that all is impermanent and nothing in the outer world will supply us with joy or acceptance; we have to find these for ourselves from within.

Tapas: Discipline, Self-will Tapas does not mean Spanish appetisers, rather it is said to be the internal fire that drives us or motivates us. It is said that within our tapas is where we find the strength to change our behaviours, emotions and perspectives and to endure when things become uncomfortable. Tapas is also how we promote the output of energy or physical strength and endurance. This could be seen as the driving force behind self-regulation.

Svadhyaya: Self-reflection This acts as a catalyst for change.

Making space for awareness is the first step towards a shift in regulation and responses. It is encouraged to be practised as an observation of patterns with kindness and compassion. What would change if we began to treat our own mind and emotions like a small child? We each have the ability to make a friend or a slave out of ourselves. Positive encouragement towards desired changes rather than self-resistance can create a greater balance towards healing for the whole system.

Isvarapranidaha This is the recognition or belief in a higher being or power; it can be inclusive of all faith systems.

Niyamas and Pain

Saucha: Cleanliness With respect to pain, this practice could be thought of as a means to starting and ending each day ‘fresh and clean’. Pain, especially as it persists, is unpredictable and Co-Kinetic Journal 2021;90(October):29-36

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often unreliable. This in itself can be very frustrating. Waking each day and expecting it to go in the same way as the last may not be helpful, even if yesterday was a ‘good day’.

Each evening we can recognise the difficulties and the celebrations of the day, then set both aside equally so the next day can start anew without a comparison or expectation of what will be or what has come before.

Santosha: Contentment I asked my patient with an 18-year history of back pain whether he was OK. He answered that he wasn’t. I reflected back to him: “Are you currently in an active state of dying?” “No.’’ “Do you have shelter and food?” “Yes.” “Do you have a wife who loves and supports you?” “Yes.” “Are you OK?” “Yes.” It can be an important realisation that contentment is a state of mind that is truly a choice. Even when things are not exactly as we want them to be, we can still choose to acknowledge we are, indeed, OK – content. If we consider that pain is a means of protection, driven in part by our emotions, beliefs, and examination of threat, what might happen to the intensity of protection if we simply shift a belief from “I am not OK” to “I am OK”?

Tapas: Discipline, Self-will To take on an active state of recovery from one of persistent pain we must first find the will to persevere. It can be stunning how some people continue to seek answers to their personal painful experience. On one level we might call it over-utilisation or ‘doctor shopping’ but on another they are persevering.

While suffering, they are also continuing to search for someone who might have another perspective that provides a tangible way forwards. When pain has been associated with an activity for a period of time, movement adaptations and reactions to pain may begin to become part of our normal way of being. Think about an injury that has led to a pattern of limping. Sometimes the limp is outside the awareness of the person and becomes difficult to change, even if the injury has healed.

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Another way to look at this is that it takes self-will, or tapas, to change ingrained training or patterns of thinking and even moving; these occur in our biological systems as a response to life and to pain. There are a number of biological processes involved in the multidimensional (initial and lasting) experience of pain. As you read on, you will see some of these in detail.

You will also be exposed to evidence that shows us that it is possible to change these responses. It is our tapas, the internal fire, that will allow us to be uncomfortable and be OK, to fall and stand back up, to face the hard facts of what we learn as we study ourselves and our experiences of pain or otherwise.

Svadhyaya: Self-reflection and Spiritual Studies This practice of self-reflection could be the anchor pin for incorporating yoga into pain care. It is here that we get to ask ourselves the potentially challenging questions. For example: How do I respond to threats? Are they true or perceived? What are my mental and emotional reactions to being physically uncomfortable? Are my pain triggers purely physical or are there social and emotional triggers too? When I’m in pain, do my internal reactions act as a helpful way to engage and protect myself or do these reactions create a barrier, preventing me from true connection to others?

Isvarapranidaha: Surrender to a System of Faith or Higher Power Yoga does not dictate the exact nature of this faith system, but rather encourages recognition that we as humans are not in full control of our lives; surrendering to something bigger than ourselves can be helpful in all aspects of human suffering. The ‘who’ we surrender to is an individual choice.

As care providers, we can simply support and recognise the benefit of a faith system that others may have and that this may aid their pain care.

3. Asana

Meaning a position that is comfortable and steady, asanas are the physical postures of yoga. Originally, these postures were intended to be

performed before meditation to prepare the body to be comfortable for extended periods in a state of physical stillness and relaxation.

Traditionally, meditation would be performed in a cross-legged seated position, and relaxation would take place in savasana (flat on the back, arms open to the side and palms facing upward). In Sanskrit, sava means corpse and asana means pose: therefore, savasana is corpse pose.

When read in Sanskrit, posture names will finish with -asana at the end, and the prefix tends to describe the position. For example, badaconasana is bound angle pose.

In the context of yoga and pain care, we consider any exercise or body position as an asana if it is entered into with the right state of mind and connectivity to the breath. In yoga, through mindfulness and breath awareness, we attempt to view our body as a tool to find connection and awareness, be it the simple connection of the mind, body and breath, or the grander connection of all things. When we look at asanas as a therapeutic tool, the positions or movements might be an avenue to connect with our fears, conditioned reactions and movement patterns. The gained observations can begin to challenge, change and allow us to recognise helpful and unhelpful reactions and patterns: physical, psychological and emotional. Through observation and awareness, we use asanas to help us move beyond our areas of resistance and struggle.

4. Pranayama

Prana means life force and ayama means extension. Pranayama, simply stated, is a breath practice. It is used as a tool to promote connection between the body, mind and spirit. Focus on the breath can act as a vehicle for mindfulness. Pranayama can be a practice in itself or in combination with meditation or asana. Breathing or respiration is a physiological function that occurs automatically (under the control of the autonomic nervous system) but can also be consciously regulated (5*).

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and physically painful scenarios can stimulate physiological responses that lead to a rapid heart rate and rapid, shallow breathing (5*,6). We may not be able to immediately or directly change the physical sensations involved nor directly slow our heart rate. We can, however, ease our breath and this, in turn, can alter the physiological responses and potentially soften the painful experience (6).

A very simple example is someone who fears going to the doctor to get an injection. If this person practises slowing and deepening their breath, they may immediately feel comforted, and better able to endure the needleprick. Our breath can be powerful in times of stress and pain; it can add to the negative or help us to shift back to a more balanced place. Pranayama practices are outlined in the book in Appendix 1: Meditation and Pranayama.

5. Pratyahara

This limb refers to dissociation of consciousness from the outside environment. Pratya means to withdraw or draw in, and ahara is taking in, referring to the things our senses continuously perceive, eg. sight, sound, touch. It is in this limb that yoga realises that all senses rely on the presence of the conscious mind. Our sense organs are responsible for picking up on elements but do not actually create the sensory experience as we know it. For example, our auditory receptors are responsible for receiving vibrations but it is our brain as a whole that makes sound into something that carries meaning for us. This is true even of pain. Through pratyahara we may also be able to identify with a true sense of interoception, the ability to feel and give meaning to what is going on inside the body. Yoga does not look at the dissociation of consciousness in this direct biological way, but through the practice of pratyahara we begin to recognise our senses for what they are: the perception of light, vibration, pressure, muscle tension, heart rate variability, etc. Instead of immediately attaching a meaning to them, we can 34

choose to just be aware.

Through meditation or focused attention, we can begin to practise focusing the mind on desired tasks without getting distracted by inputs from the outside world or being overly alert to physical inputs from the body.

This attention can directly help us moderate our responses to physically unpleasant sensations and in turn change our relationship with pain.

This practice allows us the realisation that we can choose our reactions regardless of what is happening in the external environment, and that we have the ability to focus and produce an internal environment that promotes less suffering and more contentment.

6. Dharana

Dha means holding or maintaining, and ana means other or something else. This is the ability to maintain focus, attention or concentration.

Dharana and pratyahara are symbiotic.

To gain full focused attention or concentration, one must withdraw from the senses that distract from the desired focus. Remember sitting for an exam in a room with an airconditioning unit that is repetitively turning on and off? If you allowed your brain to let this sensory input be registered each time the unit switched on, your focus would have shifted far from the exam in front of you. This ability to dampen the senses occurs only with focused concentration – dharana. Pranayama, mudras (symbolic hand gestures) or external objects such as candles can be used to assist in narrowing the focal point.

We offer some elements of dharana in the practice sections later in the book.

These could be introduced simply as choosing a specific object, a gentle movement or a breath to bring your attention to, while simultaneously choosing to let other sensory, potentially even painful, experiences occur without shifting focus. This is not meant to suggest that we ignore or deny that pain may be present. We are instead actively choosing to place our focus on a different element. If you are making a conscious choice of focused concentration, then you are practising dharana.

7. Dhyana

This limb represents meditation, which can be thought of as an exercise of mindfulness. Mindfulness is the ability to be in the present moment in our daily life: not thinking about this ability or congratulating ourselves for it, but actually being in it. This state of presence doesn’t happen easily without practice. So, meditation is a specific time in which we practise. It can be thought of as a silencing of selfresistance, pausing the tendency to ruminate about the past or grasp at the future. It is the practice of intentional focus or concentration, dharana, that allows us to achieve a meditative state and the ability to be mindful in our daily lives.

Have you ever notice how distracted we tend to be in life – how continuous the thought stream is?

And how often it contains some sort of judgment, opinion or comparison?

“I should/I’m not as good/I will never/ Why, why, why…?” This tendency creates a disconnection from ourselves and may facilitate an unhelpful state of vigilance. A constant stream of thoughts is normal for all of us. We can engage in those thoughts and turn them into full-blown stories that feel like realities. We can allow them to distract us and shift our awareness away from the present moment and what is really here. Or, we can choose to let the thoughts be present without giving them attention: this is mindfulness or a meditative state.

Meditation ultimately is time with yourself, to intentionally practise being mindful, with a promise to leave all self-judgments, stories and questions behind. During this time there is a goal to let go of the lens of society and stop the comparative and judgmental natures of our minds. Meditation is not a space of emptiness, void of all thoughts. Naturally and consistently, our thoughts come without choice or permission. No thought stands independent of another thought.

This leaves us without space for true observation. What we add to a thought creates perspective, and perspective may lead to emotions or physical responses. These perspectives and emotions begin to carve our reality – our stories. When you have thoughts

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and intentionally choose not to add or engage in a ‘conversation’ or analysis with the thoughts, you are in a state of meditation.

Meditation tools and techniques are introduced in Chapters 4–9 in the book. When first attempting these practices, it can be helpful to acknowledge that a meditative state or a state of mindfulness does not occur through the act of doing; it is the culmination of what happens as a result of the foundation of focus or intention. Mindfulness is not the act, it is the result; meditation is the practice.

If you are sitting and thinking, “I am meditating, I am meditating, I am meditating” well, you aren’t actually meditating; you are thinking about it. The state of mindfulness happens when you stop actively thinking and are able to be fully present with your chosen focus. Learning to sit without ruminating on our painful experiences (“Why me/Why has this happened?/ If only/What does this mean for my future?”), we may naturally begin to let go of all that content and chatter and then true emotions (eg. grief) around the experience can be felt.

When we have the ability to acknowledge and feel our genuine emotions, we gain the ability to move past them. We may then be able to identify and separate the emotional experience from the physically painful experience. We can then learn to address each for what it is and take actions to move ourselves into a more productive future. Without taking this purposeful pause, it can be difficult to even notice how much this brain chatter has been clouding our ability to recover – physically, emotionally and psychologically. The act of being aware or in a state of mindfulness is not something easily understood from reading alone; it takes experiential practice, and lots of it, to fully grasp.

8. Samadhi

Samadhi represents identification with pure consciousness, and this limb is broadly thought of as reaching a final stage of bliss or enlightenment. Using the other seven limbs to realign the relationships we have with our inner and outer environments, we have the potential of reaching this arena of Co-Kinetic.com

realisation. This is not about floating away on a cloud of joyful bliss. The Sanskrit roots tell us sama means same or equal, and dhi means to see.

Therefore, this state of consciousness is reached when we can see equally the reality in front of us. A reality that releases the conditioning of judgment or patterned habits of comparison, likes and dislikes, good versus bad and the ability to release the need to attach to any specific aspect. This state of being becomes bliss or joy that is present regardless of what else is also here. In regard to pain, it might be the path of life beyond suffering.

Conclusion

Ultimately, yoga is the opportunity to study yourself – the true self.

Yoga offers tools such as the Eight Limbs to facilitate this study and the practice of self-regulation. Through the practice of yoga, we can gain the ability to recognise that we have a body to inhabit and use to physically interact with the external environment. We have a mind that we use to learn, process and retain knowledge and experience. We have emotions that we can acknowledge and feel in order to connect with ourselves and others. But, these are not the limit of who we are. We are not solely our bodies, or our minds or our emotions. The better we know the constant state of self that runs beneath these superficial entities, the more resilient we can be when one or more of these areas begins to feel threatened.

You certainly don’t have to learn or be able to pronounce the names of the Eight Limbs to understand or practise the concepts they hold.

We hope that you can already see the holistic container yoga supplies for pain care and the bridge that it may offer to get back to a full life.

These practices are as important for us as clinicians and teachers as they are for those suffering from pain.

The more willing we are to go deep into cleaning out our own cobwebs of struggle – physical, emotional or psychological – the more available we will be in facilitating the journey of others beyond pain.

References

1. Robinson H. Dualism. Stanford Encyclopedia of Philosophy 2020 Open access https://stanford.io/3tsdKH1 2. Saraswati SS. Asana pranayama mudra bandha. Yoga Publications Trust 2013. ISBN 978-9386383600 Buy from Amazon (Print £9.00 Kindle £6.47) https://amzn.to/3ttCZZS 3. Iyengar BKS. Light on Yoga: The Definitive Guide to Yoga Practice. Thorsons 2015. ISBN 978-0007107001 Buy from Amazon (£14.31) https://amzn.to/2VqMe03 4. Gard T, Noggle JJ, Park CL et al. Potential self-regulatory mechanisms of yoga for psychological health. Frontiers in Human Neuroscience 2014;8:770 Open access https://bit.ly/3jXgdWW 5. Zaccaro A, Piarulli A, Laurino M et al. How breath-control can change your life: a systematic review on psycho-physiological correlates of slow breathing. Frontiers in Human Neuroscience 2018;12:353 Open access https://bit.ly/3yXOY2A 6. Jafari H, Courtois I, Van den Bergh O et al. Pain and respiration: a systematic review. Pain 2017;158(6):995–1006.

KEY POINTS

l Yoga is not a fixed series of exercises for flexibility. l At its fundamental level, yoga is a way of connecting the body, mind and spirit. l Yoga is the study of the ‘true self’ and when we connect with this deeper layer of self we find greater contentment. l The Eight Limbs of yoga are Yamas (abstinences), Niyamas (observances), Asana (yoga postures), Pranayama (breath control), Pratyahara (withdrawal of the senses), Dharana (concentration), Dhyana (meditation), and Samadhi (absorption). l Each of the Eight Limbs can be seen as a window for observation with curiosity of the various features of ourselves. l In addition to practising the concepts of the Eight Limbs towards others, we also need to learn to practise these behaviours towards ourselves. l The complete practice of yoga lets us discover that we are not solely our bodies, or our minds or emotions. l The practice of yoga will allow patients to live with pain, but not to be defined by it.

RELATED CONTENT

l Yoga and Biomechanics: A New View of Stretching Part 1 [Article] https://bit.ly/3qEnUS8 l Yoga and Biomechanics: A New View of Stretching Part 2 [Article] https://bit.ly/3bDHpWu l Yoga as therapy [Article] https://bit.ly/3k1D1oI

DISCUSSIONS

l How aware were you of the various ‘Limbs’ of yoga before reading this article? l Think of a current patient with chronic pain. You will already be helping them physically, now create a plan to use the relevant concepts from the Eight Limbs of yoga to help them psychologically, based on their character and needs. l Are there any aspects of the Eight Limbs of yoga that you would like to learn more about and apply to your own life, and if so which?

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THE AUTHORS Niamh Moloney PhD, MManipTh, BPhysio, SMISCP is a specialist musculoskeletal physiotherapist, yoga teacher and pain researcher. She practises in Guernsey, in the Channel Islands, but also holds an Honorary Fellow position with Macquarie University, Sydney, where she was previously a Senior Lecturer. A passionate advocate of evidence-based practice, she has over 50 peer-reviewed publications from her pain-related research. Her increasing appreciation of how yoga philosophy and practices can help address some of the complex aspects of pain and its care has led her to integrate yoga into her clinical practice and has ultimately inspired the writing of this book. She runs pain education and yoga courses for people with persistent pain, and teaches widely to healthcare professionals.

Email: info@thrive-physio.co.uk Twitter: https://twitter.com/drniamhmoloney?lang=en LinkedIn: https://gg.linkedin.com/in/niamh-moloney778103a Website: https://www.thrive-physio.co.uk/meet-thrive Facebook: https://www.facebook.com/Thrivephysiocouk-1863232780625511/

Marnie Hartman DPT, CSCS, RYT is a doctor of physical therapy, a certified strength and conditioning specialist and registered yoga teacher. Her drive for compassionate, authentic interactions and connection to the good in all humans and the wild led her to a simple life and challenging practice in the bush community of Haines, Alaska. It was here that she first developed an interest in learning how to care for those in persistent pain. She quickly realised the supportive container that yoga held for people engaging in pain care. She has incorporated pain science education and yoga as part of her clinical care and teaching for nearly a decade. Marnie owns and operates a private physical therapy and yoga practice, and has been an instructor for the International Spine and Pain Institute, and an Education Contributor for Yoga Medicine.

Email: bodyiqpt@gmail.com LinkedIn: https://www.linkedin.com/in/marniehartman-80311411/ Website: www.bodyiqpt.com Facebook: https://www.facebook.com/Body-IQ-PhysicalTherapy-and-Yoga-502648043201076

Pain Science – Yoga – Life Niamh Moloney and Marnie Hartman Handspring Publishing 2020; ISBN 978-1-912085-58-3 Buy it from Handspring https://www.handspringpublishing.com/product/pain-science-yoga-life Pain Science – Yoga – Life combines the neuroscience of pain with yoga philosophy and practice for pain care. Rooted in evidence-based practice, this book is a unique blend of the science of pain, the art and science of yoga and its practical application. It aims to bridge the gap that exists between a person in pain and their ability to move beyond suffering and back to life.

Part One sets the foundation for pain science fundamentals, the Eight Limbs of Yoga, as well as mindfulness practices to aid in shifting perspectives and enhance interventions for those struggling with persistent pain.

Part Two delves into key dimensions of pain and its care such as, perception, emotions, physical contributions, exercise, and sleep. Each chapter has three sections: 1. Headspace: presents a review of pain neuroscience and yoga research related to each dimension.

2. Out of the Head and onto the Mat: translates information from ‘Headspace’ into an experiential practice on the yoga mat.

3. Off the Mat and into Life: demonstrates how to extend knowledge and practice into daily living.

Pain Science – Yoga – Life is a valuable resource for healthcare and yoga professionals, and is designed to deepen pain science knowledge and skills in the use of yoga for pain care. The combination of scientific information along with practice sections will enable professionals to directly apply the information in the clinic or studio. This book will also engage anyone who has an interest in deepening their understanding of pain and the use of yoga to gain resilience in the face of pain.

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CONTENTS Introduction Part One Chapter 1: How pain works: Deepening roots of pain science knowledge Chapter 2: Yoga: Roots of yoga and how it pertains to pain Chapter 3: And this too: Shifting perspectives through mindfulness practices Part Two Case Study: Meeting Phillip Chapter 4: Thoughts, beliefs and pain Chapter 5: Emotions and pain Chapter 6: Physical aspects and pain Chapter 7: Perception and pain Chapter 8: Exercise and pain Chapter 9: Sleep and pain Conclusion Appendix 1: Meditation and pranayama Appendix 2: Asana Glossary of scientific terms Glossary of brain areas and spinal cord Glossary of yoga terms

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21-10-COKINETIC | GENERATINGCLINIC-SALES FORMATS WEB MOBILE PRINT

MEDIA CONTENTS

These files can be downloaded from the Media Contents box of the online version of this article. https://bit.ly/3j1SQtH l 12 Month Planner Template [PDF] l One-Month Diary Template [PDF] l Budgeting Template Spreadsheet [Zip file] l Calendar file for import into your own calendar [Zip]

TURNING PROSPECTS INTO PAYING CLIENTS: Building and Implementing a 12-Month Marketing and Sales Plan

By Tor Davies, physiotherapist-turned Co-Kinetic founder

This article explains in detail how you can plan and implement a 12 month marketing and sales plan for your physical or manual therapy business.

We discuss a range of events you can choose from, how to set budgets and financial targets for your events and how to build audiences who are most likely to convert into paying customers. We also outline a timeline of activities for each event and discuss different event types to suit individual personalities. As you’ll see, planning and preparation is key to achieving your financial goals. We include a budgeting spreadsheet, calendar and diary planning templates and even a schedule that you can import directly into your own calendar. Access the article online https://bit.ly/3j1SQtH

Part 1: Building a 12-Month Marketing and Sales Strategy The Conversion Level of a Marketing Funnel

The conversion level in your marketing and sales funnel (the orange layer in

Fig. 1) is all about generating revenue: it’s a necessary element of running any business, despite the fact that most therapists don’t like doing it!

Thankfully, the strategy we advocate is based on generating this new business in a way that consistently adds value to your recipient, while at the same time helping you to

Figure 1: Simple sales funnel with purpose

Co-Kinetic.com

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OUR CONVERSION STRATEGY IS ABOUT GIVING PEOPLE A REASON AND AN OPPORTUNITY, WITH OR WITHOUT AN ADDED INCENTIVE, TO PURCHASE FROM YOU build trust, strengthen relationships and establish credibility.

Ultimately it’s about giving people a reason and an opportunity to purchase from you. This usually involves running a ‘conversion event’ that leads directly – or indirectly but quickly – towards an incentive to buy. You can take one of two routes to doing this.

1. Direct Upsell Conversion Strategy

This could be a ‘strike while the iron is hot’ direct approach, where you actively promote your offer at the time of your event, and perhaps there is a bigger incentive or unique package offer that wouldn’t otherwise be available through everyday channels.

If you use this approach, it’s good to add either a deadline to the offer or a limited number of purchases, to add a sense of scarcity and encourage takeup, but make that deadline or scarcity reason authentic and genuine.

That purchase opportunity can take many different forms, depending on what works best for you. The goal is to play to your strengths, pick things you’re passionate about, and make sure your ‘upsell’ is relevant and compelling (and you may need to test and tweak to see what works best).

In the second section of this article we’ll go into more specific details about the types of events you can run, but for the purposes of an overview, it could be an education-based event or workshop, with the goal of the session being to make the case for why your upsell is relevant and beneficial.

Equally, it could be an open clinic event which you could run once or twice a year. This creates, for example, an opportunity to meet the team, visit your clinic, perhaps try out some free sample appointments and explain what any cool bits of equipment that 38

you have in your clinic can do. It’s a great opportunity to build on your authority and reputation.

As an extra bonus, if you advertise and take sign-ups to these events through the social networks with some paid social media posts, you’ll also be growing your email list in the process.

This is exactly the kind of thing that the Co-Kinetic editable web pages are designed to take care of for you quickly and easily and without any need for IT skills.

The best open clinic events tend to be physical face-to-face events but there’s absolutely nothing to stop you running an event through a video conferencing platform such as Zoom and taking your viewers for a virtual tour around your clinic and to meet your team members online.

You could also run a live Q+A and offer attendees discount vouchers for physical appointments – this has the benefit of generating cash on the day and again you could use your CoKinetic pages to take these payments for you.

Other event ideas might include a special offer such as a discounted or free mini-treatment, eg. a massage, mini-gait analysis, or mini-bike fit.

This is commonly (and often very successfully) implemented using a relatively simple paid advertising campaign on a social network such as Facebook, and it goes like this: l You would advertise an offer, for example to sign up to a free 30-minute massage. l Your applicants would enter their details (including phone number) and you

(or an assistant/colleague) would follow up with a phone call to get the appointment booked in. l When they attend the appointment (about 30–50% usually do if it’s being offered free), you would offer an ‘upsell’, ie. an incentive for them to purchase further treatments from you (such as a discounted next appointment to ease them into becoming a paying customer).

This is a very effective strategy for drumming up new appointments (and cash) quickly, but I’d advise against using it regularly, because there is a risk of it devaluing you and your business.

It’s best used in very targeted ways, for example as an initial offer to people who have just joined your email list.

The beauty of these events is that you can also plan them to coincide with quieter periods in your diary, instead of worrying about not being able to control the flow of people during already busy periods.

2. Indirect Upsell Conversion Strategy

Do you have to include a pitch for a paid purchase at the event itself?

Absolutely not, it’s more a question of how much time you are willing to spare doing ‘non-earning’ activities and, ultimately, what strategy gives you the best return on your time investment.

One of the clients I work with runs free education sessions, like the ones we’ve discussed above, but specifically chooses not to promote anything for purchase at the end. Instead he offers attendees the opportunity to book in for a ‘Discovery Session’ (it could be online, by telephone or face-toface), and makes this the priority of his education event.

Once he and his fellow therapists get someone to commit to and attend a discovery session, they know they can convert 90–95% of attendees into paying customers, so giving this extra free time away is worth it for him. Again it’s something you should test and then track the conversion rates. It’s also even less salesy than the direct upsell approach and would work

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particularly well for people who feel more comfortable working on a one-toone basis.

goals for the year, the idea is to build a schedule of campaigns to meet those revenue goals.

Planning Which Conversion Events to Run and When

Some Thoughts and Suggestions to Get You Started

OK, so let’s get down to the nitty gritty of the types of events you might run and how to schedule them. This section is designed to help you start putting together a 6–12-month plan. We also have some worksheet resources to help (which I’ll tell you about shortly).

The planning element is important because, as you’ll read in Part 2 of this article which focuses on implementation, you need to be building and nurturing your target audiences for your events ideally a few months ahead of time.

Four Categories of Conversion Event

I group the main sales opportunities I have found work best for physical therapy businesses into the following four categories.

1. Business-based events: open clinic events, clinic launch anniversary celebration, introducing new staff, introductory offers, ‘We Miss You’ or referral campaigns, introducing new facilities or equipment.

2. Education presentations/ workshops: educational presentations and/or practical demonstrations on different health/ wellbeing/MSK/sports injury topics.

3. Local/national/international events: run events based around other events like marathons, triathlons, cycling races, Tough Mudders, World Cups, Olympics, etc., or health awareness days or local fetes – really anything goes if it gives you a good reason to create an event from it.

4. Time-based events: think vouchertype opportunities, Mother’s/Father’s Day, Christmas offers, January sales, Valentines, harvest festivals, religious festivals, Pride…

There are lots and lots of reasons here to run special offers or promotions and some might cross into multiple categories, but you get the general idea.

Now, depending on your sales Co-Kinetic.com

Starting with a blank sheet of paper can be tough, so try asking yourself the following questions and jot down any notes or ideas that are sparked in the process – any idea goes but here are some starting points: l What skills sets do you have? Focus on what you’re passionate about clinically, and also if you have team members you can call on to help out? If so, what particular skill sets do they have? Or perhaps you have local colleagues who could come and contribute? l What local events take place in or around your business during the year? l Do you have traditional quiet times where (a) you have more time available to run events and (b) a greater need to fill empty diaries?

Remember, just because the run-up to Christmas may be quiet for YOU workwise, it’s likely to be a busy for prospective clients, so think about ways you can help them ease this busy-ness rather than demand time from them. This is why vouchers work particularly well around this time of year. l Do you have a larger number of clients in a certain demographic group? For example, do you treat lots of runners or skiers or golfers; or do you have a bias in a client demographic group such as women approaching menopause or in a higher age demographic who may be more invested in programmes for keeping active and healthy? Do you have a high number of clients in a particular minority group that you

could run a specific event for? Or a large number of people working in a particular job or industry? l Can you use any of the nurture emails you’ve been (hopefully) sending to distinguish any particular interest areas? This is why I encourage people to use nurture emails to flush out interests that help you to segment your email audience. Do you get particularly good open rates, for example, when you send out emails on chronic pain or back pain or running injuries? l Do you have any significant clinic events coming up? For example, are you planning on taking on a new member of the team? If so, it would make sense to run a introductory event to bring in bookings before or even as the new therapist starts.

Are you planning on investing in any new equipment or building any extensions to the clinic (or moving)?

Have you got an anniversary coming up from when you started your clinic, or some other kind of celebration, such as a big personal anniversary like a birthday or wedding anniversary?

Unique and different (and highly targeted) is good if you have the audience that will fit that offer, as those Sales Marketing & events will ar Calend MONTH also catch people’s eyes and help you ry Monthly Dia stand out from the crowd, but don’t get caught up feeling pressured into doing something completely original every time. Mix it up a bit.

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CONVERSION EVENTS FALL INTO FOUR MAIN CATEGORIES: BUSINESS-BASED, EDUCATIONAL, LOCAL/ NATIONAL/INTERNATIONAL, OR TIMEBASED EVENTS What’s Next?

l Download the 12 Month Planner PDF and the 30 Day Diary PDF. Use the 12 Month Planner to jot down your ideas, resulting from he questions above. We’ve left the months blank so you can start at any time in the year and still have 12 months to plan forward. You can print out the 30-day worksheet as many times as you need so that you can detail specific jobs that need doing by month. l Download the Checklists and Worksheets in the Media Contents box in the online version of this article to help you plan and run these events. l If you’re thinking about running an open clinic event specifically, and I would definitely recommend thinking about it for the future if you’re not doing it already, it’s well worth reading Vicki Marsh’s article series on implementing an Open Clinic event here.

How Can Co-Kinetic Help Me Run Conversion Events?

l We have a growing range of readymade Clinic Growth campaigns which include all the content you need to run the business-based events including customisable artwork like printable promotional posters and ready-to-post social media, along with the editable web sign-up page which you can use to take sign-ups to the event, or even payments for attendance or the upsells if you choose to – see details via the online article. l If you want to run an educationbased event or workshop, we’ve written the PowerPoint presentations for you and built and written the event sign-up pages – see details via the online article. l If you want to run voucher events, 40

we’ve got you covered there too!

See details via the online article. l And if you want to run any other kind of event, we’ve produced a whole range of more generic but themed editable web sign-up pages which you can customise for your own purposes and use to take sign-ups to, or payments for, the event, offer downloads to documents, or redirect people to your website if you want them to book through another channel. The themes are organised into Health and Wellbeing, Sport and Anatomy – just pick the theme that best matches your event and edit the text to describe your event offering. l Lastly, we have pre-written, preapproved artwork for running specifically Facebook ads designed to help you build your email list with very targeted groups of people.

These ads specifically tie into the CoKinetic campaigns so are best used if you have one of the marketing subscriptions to Co-Kinetic (Social Media or Full Site). The ads are included in a Full Site subscription or can be purchased as a bolt-on if you have the Social Media subscription (details in the online article).

Now let’s take a look at actually running these events.

Part 2: Setting Revenue Targets for Your 12-Month Marketing and Sales Plan Building Your Calendar of Events

If you have read and digested Part 1 of this article, then we can move on to the fun bit! l Hopefully by now you’ve already jotted down some notes about the kind of events you might like

to run over the next 12 months – taking into account dates of events (eg. voucher offers, business, geographical and educational events), available skill sets/interests/ passions (yours and those of your colleagues), audience demographics (all is explained in the article at the link above). l In pencil, plot your potential events on our 12 Month Planner, one square per month where there is a specific date window for the event. Then star the ones you want to prioritise – these should be the ones you feel most excited and passionate about. You need to make sure that the events are distributed realistically in relation to your workload. If you have additional events/ideas that aren’t time-specific record those on the right-hand side of the page so you can add them in later (if you want to), as you get quicker at running your events. l We deliberately didn’t write in the months for each of the squares so that you could start your plan in the month you’re in now, and then plan forward for 12 months. There’s a line under each box so you can write in the month it corresponds to. l Take a deep breath, relax and be realistic. Allow yourself much more time to run these events when you start out than you think you’ll need, ie. set a worst-case scenario timeframe. That way you won’t put yourself under unnecessary pressure, fail, get demoralised and give up.

It’s like learning a skill, everything gets easier with practice! I’d almost say set a timeframe expectation and then double it! It’s better to do the leg-work and get well-prepared at the beginning rather than rush and do it badly. The saying “a stitch in time saves nine” is very relevant here. Take assurance from the knowledge that as you get used to the process you’ll be able to turn these events around increasingly quickly, as well as getting better and better results as you learn what works best for you and your specific situation, and it will all come good at the end of 12 months. So go on, spread those events out, particularly the ones due to take place in the

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first part of your 12-month period! l Now look at those events and consider the following. (a) You want to be focusing on building (and nurturing) audiences well before the event is due to run, at least 1–3 months, longer if possible as the more nurtured they are, the better. This audience should consist of people who are most likely to want to attend each event you plan to run. These decisions should in turn inform your email list building and email nurturing activities in the months before the event, and this is why planning is so important. The sooner you can start this process ahead of the date of your event, the better your event uptake, conversion and revenue results. (b) The easiest way of building a targeted audience is most likely to be by running targeted social media ads to attract the audiences who live in your local area (obviously an important factor). But there are other options too, such as collaborating with a noncompeting business which caters and sells to the same audience you want to attract. You could also get involved with local discussion forums but this is likely to be time-consuming and certainly not scalable. The easiest most scalable way to nurture an audience is by email. (c) In order to keep your newly acquired audiences engaged and interested, you need to be sending out regular (preferably weekly) nurture emails containing helpful resources that are as relevant as possible to this audience, and keep doing this all the way up to your event announcement (and beyond), so they are as warm, interested and responsive as possible when you announce your upcoming event. l Map the activities into your calendar.

I’ve provided a printable 30 Day Diary worksheet which you can print for all the months going foward, and enter in the more detailed things you need to be doing.

Co-Kinetic.com

These activities might include running social media ads to build audiences ahead of your event and scheduling in the nurture emails you will send in the run-up to your event being open for signups. I’ve also produced a Google calendar (see Media Contents box for more details).

Email List Building and Nurturing

In case it’s not clear from the points above, there’s a very good reason why I constantly bang on about the importance of building, segmenting and nurturing your email list! l The more targeted the audience you have, and the more engaged they are with you, your business and your emails, the better the sign-up and attendance numbers you’ll get across all your events. l The same goes for the better your audience fits with your planned events, which is why building targeted audiences with your bigger-picture conversion-event plan in mind, ahead of time, is important. l Remember that a big email list isn’t necessarily better – yes you have more people from which to attract sign-ups to your events, but I can’t emphasise enough, it’s more about quality, accurate targeting and segmentation, than it is about quantity. l In other words, as part of your bigger-picture marketing plan (which is based on the events you’ve decided to run), make sure you are actively building segments of people well ahead of time, to maximise the chance of them signing up to attend the events you plan to offer.

I like to use a tree analogy to demonstrate the revenue-generating potential of an email list. An active and engaged email list is bursting with health, life and opportunity (ie. revenue-generating potential) compared to a stunted, dead or dying email list which has little or no potential for generating revenue (Fig. 2).

To take the analogy a step

Figure 2: The tree analogy demonstrating the revenue-generating potential of your email list

further, the different branches of your tree are equivalent to the different audience segments of your email list.

The fuller the tree, the greater your range of opportunities.

Working Out Your Sales Numbers

As a general rule of thumb, the following points indicate how you could expect your numbers to stack up: l Of people who register to attend your event, around 50% are actually likely to attend. l If your event goal is a paid upsell (ie. it requires them to part with money), around 20% of those attending might purchase (that’s the equivalent of 10% of your original registrants if that makes it quicker to calculate). l If your upsell is to another freebie instead of a paid product, ie. a discovery call/appointment, you could expect a conversion rate of around 40–50% (the equivalent of 20–25% of your original registrants).

So, for example, if 60 people sign up to your event, 30 people attend, 6 people purchase a paid upsell OR 12 might convert to a freebie eg. a discovery call.

I will caveat this by saying these numbers could go up or down depending on factors such as: l how well you’ve built your target audience; l how compelling your upsell offer is for that particular audience; l how good their relationship and trust is in you; and l what type of products/services you 41

offer as your paid upsell. The more longevity and/or value the product has the better, for example a recurring revenue commitment such as a 12-month massage membership product, a training programme or package, or even a 5 treatments for the price of 4, the better your revenue generation numbers.

However, if your audience is relatively new to you, it might be better to offer a simple one-off purchase at the event, and then build up to offering a purchase that requires a bigger commitment after they’ve attended their first few appointments. This is where you have to ‘test, test, test’ with different combinations of offers to different groups of people to establish what works best. Don’t overcomplicate it, just try something, then test a different thing and see which one works better. Then stick with the better one and test it against something else, and see which one works better there, and keep on moving forward that way.

The better your relationship with your audience and the more time you’ve invested in building trust and strengthening relationships, the more you’re likely to be able to sell to your customers and the more quickly. The weaker the relationship they have with you and your business, the smaller steps you’re going to need to take before they’ll be prepared to make the bigger purchases.

For this reason it’s worth seeing if you can find a way to ‘lead score’ your prospects based on how many ‘interactions’ they’ve had with you.

This is an excellent segment to be able to identify and target using your email list because you can start to build your events based on the strength of your relationship (indicated by their lead score) with your different segments of customer.

Interactions and Lead Scoring

Here are some ideas of the sorts of things you could use to ‘lead score’ or segment your prospects (and clients) into engagement levels. Ideally, the different engagement levels would have different values, where purchases rank highest and email opens rank lowest (they still count though): l email opens and activity; l attendance of workshops, open clinic events, etc; l purchases – treatments, services, products, vouchers; l customer reviews; and l survey responses.

The Significance of Knowing your Numbers

If your upsell at the event is something small, say a 50% discount on an introductory massage if booked on the night, which might only be worth say £30 per purchase to you, then on the basis of 6 purchases from the scenario we outlined earlier, that would only generate around £180 for a night of work which probably took a couple of hours to set up and then maybe 2–3 hours to deliver. Obviously that in itself doesn’t translate into much in terms of revenue, and in fact it most likely doesn’t even cover the cost of your own time.

Which is why having a progressive sales funnel is important, for example: l If you know that you’re going to convert most if not all of those first appointments into a series of 5 further treatments, even at a low treatment price of say £60 a session (£60 × 5 + the initial £30 = £330 per person) then those 6 people suddenly become worth a total revenue of just under £2000. l Then say you could get 2 of those 6 people to convert into an annual clinic membership which means a commitment to 12 sessions at say a 20% discount, that would be worth another £1150.

That would give you a total return

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BY MONTH 42

of £3000 for your event, and if your treatment fees were higher, or your ongoing purchase offerings had greater longevity, things would be better still.

We wrote up a case study here which shows how the snowball effect of events like these can start to compound your revenue figures.

There’s another component that’s important to take into account here also and that is your ‘customer lifetime value’ (CLV). Many people don’t actually know what their CLV is, but you should know and it’s worth doing what you can to work it out if you don’t.

Basically what it boils down to is on average the number of times a client is likely to come back to you or the average number of treatments they are likely to have over the lifetime of their relationship with your business. Often the first course of treatments is exactly that, just a first course, and they may return to you 2 or 3 times or maybe more in the future, which means that each new customer is likely to be worth much more than just that first set of purchases resulting directly from your event.

By knowing your CLV, you get a better perspective about the biggerpicture impact that events like these will have on your business in the future. If you know that the average CLV (which remember is an average across all your customers) was £800 per customer, then it helps to inform what you can afford to invest in running events like these.

If you know that you can bring in 10 completely new customers for each event you run, and your average CLV is £800, then that single event is actually worth not just £3000 from the event itself, but £8000 in the long-term additional revenue to your business.

So suddenly the prospect of spending a bit of money, like £500 to £1000 to help you bring in those 10 new customers, whether that’s on some admin support to help you run the event or make follow-up phone calls after the event, or invest in social media ads to get you more new signups, or even both, doesn’t seem like such a risk after all.

Hopefully you can start to see that even if you build in only 2–4 of these

Co-Kinetic Journal 2021;90(October):37-44

ENTREPRENEUR THERAPIST

kinds of events a year, over time, with the ongoing repeat lifetime visits of your growing number of clients, this will develop into a strong and reliable source of ongoing revenue for your business.

l Promote sign-up to event - send an email to your email segment [Day 15–30]. l Actual event date (2–4 hours) [Day 30–35]. l Event follow-ups [Day 31+].

Strategies for Cranking Up Your Sales at These Events

If you are able to start building your targeted audience segments ahead of this, then you will have more time to nurture and build trust, and therefore should get better engagement and take-up when you run the event.

You would also be able to turn the event around more quickly because if you’ve already built your audience, you don’t need to spend two weeks at the beginning of the event cycle, doing the email list-building phase.

Believe it or not, there are only four ways to increase your revenue: l increase the number of customers; l increase the average transaction size; l increase the frequency of transactions per customer; and l raise your prices.

So for people who have more aggressive targets, those need to be forefront in your mind when you’re planning your events, and translate into the following actions. l What you sell at the event needs to be bigger. l You could increase your recurring revenue elements, ie. transactions. l You could run more events or a bigger range of events. l Be much more active and invested in building and nurturing your email list so you have a greater number of targeted prospects to run events for.

Setting Time Frames for Your Event

It should be possible to organise and run an event within a 4–6-week window. Below is a simple list of tasks that need to be done along with the amount of time they would take you to do if you were using Co-Kinetic to organise your event and a rough schedule based on a 4–6 week plan. l Event planning (2hrs) [Day 1]. l Email list building – setting up a targeted lead-generating social media ad (1hr) [Day 1/2]. l Send out nurture email 1 (20-30mins) [Day 5–7]. l Send out nurture email 2 (20-30 mins) [Day 10–12]. l Send out nurture email 3 (20-30 mins) [Day 15–21] – you could mention your event in this email if you felt it was appropriate. l Create event sign-up page (20 mins) [Day 15].

Co-Kinetic.com

Setting Revenue Targets for Your Event

l As an individual practitioner, to make it worth your investment in time, you ideally want to be making at least £1500 and ideally closer to £2000 in sales, for the sort of event I’ve outlined above. This includes revenue that comes in after the event, eg. your follow-up appointments – so it is still directly related to the event. l And this income really needs to translate into cash in your bank account within 4–6 weeks of your event. l It’s OK if you don’t make this kind of amount the first time you run an event as the first one will be more of a learning curve, but you certainly want to be aiming to make that by your second or third events. l A good, progressive sales funnel could bring in £3000+ from an event but a lot of this depends on what you’re selling, and particularly the cost of your sessions. Obviously the higher your rates, the better your results. l I’ve put together a simple spreadsheet, which you can download from the Media Contents box on the online version of this article, which you can use to play with the different variables to ensure you make the event work financially for you. l If you have the capacity to run a bigger event such as an open

DOORS E H T N CORES O S

2018 2019 Email sign-ups

463

516

Attendees (for massage appointments)

142

145

l Pre-event new clients sales

£300

£375

l New clients sales

£1026 £927

Immediate sales

l Membership sales × 6 (annual value) £3960 £4320 TOTAL INCREASED REVENUE

£5286 £5622

Figure 3: The ‘scores on the doors’ of Vicki Marsh’s 2019 Open Clinic event

clinic event, where you can involve colleagues, and accommodate a larger number of event attendees, then you can certainly double this revenue as Vicki Marsh documented in her series of articles talking through the planning and implementation of her own Open Clinic event. Here were the ‘scores on the doors’ from her event (Fig. 3). l Vicki’s Open Clinic event was different to the model we’ve discussed above but it gives you a good idea of what’s possible. l Despite what I’ve said above, you can still hit these revenue targets by running small but very targeted events, especially if you have a very targeted and ideally unique ‘upsell’ offer. If you want to go small then you still want to aim for at least £1000 in sales directly relating to your event, which means if you’re going to convert say just 3 people, you need to convert them to something that’s worth around £350 in total value. l The key is finding what works for you. You could run one bigger, more ambitious event, with more people every 2–3 months and aim to make around £3000+ per event, or you could run one small niche event every 1–2 months, with a smaller number of sales, but of a higher value, or even a combination of both. You could factor in 4 small niche events, one bigger clinic event because you’ve got a triathlon event coming through town and then a couple of voucher campaigns. l There’s no one-size fits all. As I’ve 43

said all along, this is for you to experiment with and find the model that fits you, your communication style, your passions and your financial goals. l The only thing I’d say is that despite a bigger event being bigger pressure, it is likely to take less time to organise and implement – relatively speaking – than organising 3 smaller events.

Factoring in Your Personality Type/Communication Style

I’m a... ”Get Me Out There in Front of People” Kind of Person These people love an audience and are generally energised by being in front of people.

If this is you, you’re perfectly formed for giving educational presentations, workshops and demonstrations in front of larger groups of people.

Equally you could do Q+A sessions either online or tag this onto the end of your educational presentations.

“I’m More of a One-to-One” Kind of Person

That’s totally fine, but it’s particularly important for you to test different strategies and find the one where you get the absolute maximum return from your time investment because one-to-one is quite time-heavy and not scalable, so you want to be aiming for converting these one-to-one sessions into paying clients with ideally an 80+% success rate. The kind of things you can do are:

l discovery telephone or video calls or face-to-face appointments; l free/discounted sample appointments; and l demonstrations in front of a handful of people, perhaps small clinic tours or demonstrations of equipment.

What’s Next?

l All the resources mentioned in this article can be accessed at the following link “Strategies for Turning Prospects into Paying Clients: Building a 12-Month Marketing and Sales Plan” (https://bit.ly/3j1SQtH). l The next article on pages 45–49 describes how to implement a specific conversion event campaign.

“Post-Viral Fatigue Campaign Playbook“ (https://bit.ly/3kdZ9MG)

KEY POINTS

1. The conversion level of the marketing and sales funnel is all about generating revenue.

2. The strategy we advocate for generating income is based on a totally ‘unsalesy’ approach that is of value to your prospective clients and helps you to build trust and credibility.

3. Conversion events can consist of many different types of event (education-based, workshop, open clinic) and are linked to no-pressure incentives (upsells) for prospective clients to purchase your services.

4. Direct upsells can involve special offers such as a discounted or free mini-treatment.

5. An example of an indirect upsell is to offer the chance to book a ‘discovery session’. These might take more time but can have higher conversion rates.

6. Base your conversion events around particular skills or interests that you or your colleagues have or other local/national/international events of interest.

7. Avoid running events at times that are particularly busy for your clinic or for your clients.

8. The more you nurture your email list, the more likely you are to have receptive (‘warm’) prospective clients who will sign up for your event.

9. Plan, plan, plan! We provide you with everything you need to plan your year of events and each event.

10. Test, test, test! Start simple and work out what works for you, your clinic and your clients.

11. Evaluate, evaluate, evaluate! We provide you with all the tools to evaluate the revenue that your event can bring or has brought, so you can see that your timeinput is worthwhile.

44

RELATED CONTENT

lR unning an Open Clinic Event from Start to Finish by Vicki Marsh [Article series] https://spxj.nl/3kVBcJb l How to Generate £3000 in Revenue in Just 6 Hours – Blizard Physiotherapy Running MOT [Case Study] https://spxj.nl/2wLbRZW l Post-Viral Fatigue Campaign Playbook https://bit.ly/3kdZ9MG

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;90(October):37-44

ENTREPRENEUR THERAPIST

FULL SITE SUBSCRIPTION

SECTION 1

Planning Your Event

The goal here is to run an educational event targeting post-viral fatigue or long-Covid sufferers (and ideally also their support networks) with the goal of bringing new prospective clients into your business.

Here are some questions to ask yourself before you start, to help guide and inform your event. Do you (or team members/associates) have specific skills/qualifications/facilities or services that would lend themselves to supporting this target audience?

Are you interested/passionate enough about the topic or about supporting this target audience?

You don’t have to answer Yes to the last couple of questions, but the more passionate, engaged and committed you are about the topic of the campaign and/or the audience you’re pitching too and planning to support, the more effective your campaign is likely to be.

TASK 1: Decide on the desired outcome of your event

Option 1: To encourage attendees to book a free discovery session (phone/ web/face-to-face) with the goal of using that session to bring them in as a new client.

OR Option 2: Offer a paid upgrade service. If it’s an upgrade service you need to decide: What service will you offer?

How much will it cost?

Will it be a one-off purchase or can you turn it into a multipurchase event, such as a fixed Co-Kinetic.com

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POST-VIRAL FATIGUE CAMPAIGN

Post-Vir al Chronic Fatigue Synd rom Fatigue Syndrom e and e

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This article provides a detailed, step-by-step Playbook explaining how to use the resources included in a Co-Kinetic Content Marketing campaign (provided as part of a Full Site subscription) to plan and implement a highconverting, new-customer-generating conversion event. Read this article and download the associated resources at https://bit.ly/3kdZ9MG

By Tor Davies, physiotherapist-turned Co-Kinetic founder number of sessions or even a recurring membership, or perhaps some sort of ongoing patient support network? This creates greater revenue opportunities and you should ALWAYS look for opportunities to create sources of recurring (subscription) income.

You could even have an offer which combines both options.

Do you have any colleagues/ associates you could collaborate with to add value or uniqueness to your offer? Don’t worry if you don’t, but equally don’t be afraid to think outside the box.

What special incentive will you offer event attendees on the day to encourage them to take up your offer?

Will you provide a post-event offer (after they have left the event)?

Usually this would be slightly less incentivised than the ‘on the day’ offer. It must also be time-specific ie. have a deadline for sign-up to encourage ‘scarcity’. And hold your ground about this deadline, however hard you might find it.

If you start negotiating, you will undermine yourself both in that moment, but also in the future.

Maybe you could offer a small concession instead so they feel they still scored a ‘win’.

One last thing to consider is will you target existing paying customers, or would you prefer to target a completely new set of people?

And if so, can you segment existing customers versus people who have never become paying clients in your email list? If you can’t currently, this is definitely something to prioritise going forward. There’s nothing wrong with inviting existing clients

21-10COKINETIC | GENERATINGCLINIC-SALES FORMATS WEB MOBILE PRINT

DO YOU (OR TEAM MEMBERS/ASSOCIATES) HAVE SPECIFIC SKILLS/ QUALIFICATIONS/FACILITIES OR SERVICES THAT WOULD LEND THEMSELVES TO SUPPORTING THIS TARGET AUDIENCE? 45

to your events, in fact it has many benefits like building loyalty and trust, as long as your new offering is unique and additional to their reason for attending their existing appointments.

TASK 2: Set dates, times and financial targets for your event (ideally you would allow 4–5 weeks to run a campaign)

it going to be a one-off event or a Is repeat series of events?

Decide on time(s), venue, refreshments, staffing needs and make necessary preparations and bookings.

Download our ready-made profitand-loss spreadsheet template to set your goals for the event. You can download this from the Media Contents box of the online version of this article. It’s important to make sure you do this before you start implementing the event to be sure you are focused on achieving the goals you need in terms of new revenue and/or new customers.

You may need to tweak your offer to give you the best chance of achieving your revenue goals.

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4 5 6

TASK 3: Use the Co-Kinetic resources (available with your Full Site subscription) to prepare your event

1

2

ownload and edit the preD written PowerPoint presentation on Post-Viral Fatigue. You can use this presentation to run the event. There’s no need to spend hours creating your slides, adding images and making it look pretty, it’s all ready and waiting for you.

Tweak the pre-written, pre-built event sign-up page that we

7

Taking Payments Through Co-Kinetic Is Simple and Free

provide. The whole thing is completely editable so make sure you add details like dates, times and venue. You can even set it up to take payments if you’d like to. So no fussing around trying to build sign-up pages, our page can be up and running in less than 5 minutes, and all you have to do is change the text in a simple form and hit Publish.

Edit the pre-written email autoresponder your new event attendees will receive when they sign up. For example, you can add extra details about attending the event such as sharing parking or transport information.

If you want to run your event as an immediately available prerecorded web presentation you can use Co-Kinetic to do that too.

If you plan to take payments through Co-Kinetic then set up your account with Stripe and connect it to Co-Kinetic.

Use one of our appropriately themed customisable web pages to sell your event ‘upsell’.

If you’re running a face-to-face event then you will most likely take orders and payments at your physical event. But if you want to make an offer for people to buy after the event, or you plan to run your event online, we have pre-built, themed pages that you can use to take payments for the upsell offer. Just edit the text to explain your offer, set the price and let our system take the payments for you.

Produce any necessary information leaflets for your attendees to take away which document your post-event offer,

We connect with one of the most widely-trusted payment processing platforms on the web, Stripe (it’s also internationally available). You set up a free account, add your own bank details, and all payments will be processed through your own Stripe account and deposited into your own bank account.

Co-Kinetic doesn’t take any percentages (although Stripe will take a small one which they deduct from the payment before they pay it into your bank). We provide the front-end payment processing and payment management element, taking away any need for any technology skills.

You can take single, one-off payments, a number of payments over a designated period or set up recurring subscription/membership payments all by making a few choices on a simple form.

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if there is one. Include deadlines for redeeming the offer (imposing a time-urgency is important) and if they can sign up online, give them a link to your purchase page when it’s ready.

Section 1 Summary

By the end of this section, you will have decided on your event, what your upsell will be (ie. whether that’s a free ‘discovery’ call or a paid service/ product/membership), who will be involved in your event, and when and where it will take place. You should also have identified staffing needs or collaborators and booked any venues and services you require.

In the next section we’re going to look at getting ‘bums on seats’ (or eyeballs onto your web presentation).

SECTION 2

Building and Nurturing Your Audience to Generate Sign-Ups

Once you’ve decided to run a conversion event (in whatever form that takes), the next goal is to focus on how you’re going to attract sign-ups to your event.

Your Email List

The first, most obvious place is your email list. However, if the only email list you have is existing paying customers, then that needs some major attention.

Going forward from today, you must prioritise the email list-building aspect of your marketing.

If you have people on your email list such as lapsed customers and/ or prospects (ie. people who have never attended paid sessions) then that’s a help. The next question is how engaged are these people with you? In other words, how much effort have you invested in nurturing these people by sending them regular, education-based, value-adding email (ie. not sales emails)? The more effort you’ve invested then the better your open rates and engagement are likely to be. In turn, the better your engagement, the greater the number of people who are likely to sign up to attend your event. Arguably THE most important goal of any good marketing

Co-Kinetic Journal 2021;90(October):45-49

ENTREPRENEUR THERAPIST

strategy is to build a healthily-sized email list of customers and prospects, which you can segment by interest areas and customer-status (ie. active/ lapsed/prospective). You can never have enough engaged email readers or enough data about their interests, priorities and pains.

Building a New Target Audience

It depends on the financial goals of your event (which hopefully you’ve used my provided spreadsheet to calculate), but the chances are that your existing email list won’t be big enough to generate enough sign-ups, or enough prospective new clients to hit your event targets.

Remember you will get ‘drop off’ at every stage of the sign-up process (this is built into the Excel template I’ve provided you with). You will need to attract at least double the number of sign-ups for the number of people you hope will attend, and then only a small percentage of those will buy.

This means that building a new, fresh, target audience of people who are most likely to be interested in your post-viral fatigue event AND who live within a target distance from your clinic or place of work will be necessary.

And if you are looking for a specific demographic you could also use gender and age group to further refine your target audience. The quickest and easiest way of doing this is by using paid ads on one of the social networks.

Running Paid Ads

I will refer to Facebook as this is the network I have training and experience in for paid advertising, but the principles will be similar whichever social network you choose.

There are two strategies you can use here, and I would definitely recommend doing both: You can go straight ahead and 1 promote sign-ups directly to your event itself (but I’d be tempted to leave this until closer to the event, such as 7–14 days before your event runs), otherwise it’s too far ahead of time and people may lose enthusiasm.

2 You promote sign-ups to something related to your event but which are much lower Co-Kinetic.com

commitment. This is where your Co-Kinetic lead magnets and lead collection pages come in useful.

Let’s discuss…

Getting a stranger to sign up to an event you’re running when they’ve never even come across you or your business before is a bit like asking a stranger you’ve literally only just met to go out for a drink. It’s a bit full-on! And asking them to give up a couple of hours of their time is quite a big ask.

That’s not to say it’s not worth doing because you will always get some take-up. There might be people who are particularly worried about, or are suffering from, long-Covid/ post-viral fatigue and are particularly motivated to hear what you’ve got to say. But others may not be at that stage yet.

This is why the ‘softly, softly, catchee monkey’ approach tends to be my preferred strategy. For example, first of all, try running a paid social media ad campaign promoting the existence of a range of resources, in other words exactly the same sort of social media we produce in our social media campaigns. Signing up to this is a simple, low-ask ‘contract’; ie. give me your email address and I’ll give you some really helpful resources is a much easier task. Not only do you gain an email address, but more importantly you establish an interest in the topic in question, and of your planned event. Because it’s a much lower-effort contract (email address for info), you’re likely to collect more email leads, more cheaply than you will sign-ups to the event itself.

My advice is to spend a majority of your money running a paid promotion to collect email addresses of people who are interested in your lead magnets, and then pitch your event to this same group a couple of weeks later (more about that in a mo). Then when you want to top up final event sign-ups, use a relatively last-minute event-specific ad to do that.

You can get crazily targeted, particularly using Facebook. For example, we know from the research that twice as many women as men are affected by chronic fatigue syndrome

YOU WILL NEED TO ATTRACT AT LEAST DOUBLE THE NUMBER OF SIGN-UPS FOR THE NUMBER OF PEOPLE YOU HOPE WILL ATTEND and remember there is an overlapping relationship between long-Covid and ME/CFS. For this reason, prioritising women over men may get you more email addresses for your buck. It also affects two age groups more than others, 10–19 years and 30–39 years, so you could try targeting these groups. Alternatively, if you’d prefer to target a male demographic, why not build your event to explore the issues of post-viral fatigue from a male perspective (and target accordingly).

Whichever demographic you use, this is potentially a long-term relationship which could develop into an ongoing patient support group, which would be ideally delivered through a private member-only Facebook group (and which you could use Co-Kinetic to charge a small recurring membership fee for – more info here).

Take Time to Nurture and Build Trust

So if you follow my guidance above, you might choose to run your email lead collection campaign based on offering the helpful resources for two or three weeks, before you start promoting your event (hence the campaign lead time of 4–6 weeks).

This gives you time to build trust and nurture your relationship with your new email leads, before hitting them with an invite to attend your event.

I recommend doing this through a couple of followup nurture emails, and don’t worry your Co-Kinetic subscription also has you covered here. The timing is only a rough suggestion, you can make it fit with your own timings.

47

DO A ROUGH-ANDREADY PROFIT-AND-LOSS SPREADSHEET TO SET YOUR GOALS FOR THE EVENT 1–7

lanning and Set-Up – see P Section 1 of this article.

dit the Co-Kinetic E autoresponder that new leads signing up to your resources receive.

Activate the Co-Kinetic social media campaign Send the campaign nurture email (email #1) that we provide out to your wider email list Activate your email lead-generating social media ad (run for 5-7 days).

8

ublish the pre-written P Co-Kinetic blog post 11 on your website (or the link to our hosted version) Send nurture email #2 – with a short discussion about your blog post and a link to it. You could also include a link to the campaign newsletter

leaflet with an extract of text from there too.

Send nurture email #3 – choose a couple of the leaflets in the set that accompany the full campaign to highlight more closely. Keep it short but make sure to explain how your reader can benefit from reading the leaflet, what they’ll learn and how it can benefit/add value to their life.

2

3

4 5

48

end Email #6 – Last chance S to sign up full focus on your event, highlighting benefits of attending.

Find a slightly different tack to your previous email just to mix it up a bit (resend to non-openers 1 day later)

25

16

end nurture email #4.

S Again include a couple of additional leaflets in the campaign with a comment on each to add context (and a link where they can download). And introduce details of your event with your event sign-up link.

28–31

Run your event

21

end Email #5 – Give a S more detailed explanation of your event, date/time/venue, what it will deliver and how it will benefit attendees and don’t forget to include a sign-up link (resend to non-openers 1 day later) This would also be a good time to run a social media ad to specifically

25

How to Use the Co-Kinetic Content to Help Generate Sign-Ups to Your Event

1

attract sign-ups to your event (run ad until you have enough attendees).

irstly activate the inbuilt Co-Kinetic social media campaign that accompanies this campaign F and time it to continue for at least 30 days in the run up to your event. This means you’ll have a handful of social media posts already showing on your social media page, before you start running your email lead generating ad, helping to tie everything together.

Use the email lead collection page, and pre-written lead magnets and lead magnet delivery pages in your Facebook ad. If you want to use the native lead-generation ad option within Facebook to collect the email addresses that’s fine, you can still use the lead magnet delivery page URL that we provide as the redirect URL in your ad set-up (more info below) in order to deliver your resources. No need to write your own lead magnet(s), build your own email collection form, or work out how you’re going to deliver the resources – it’s all done for you.

As part of the Co-Kinetic Full Site subscription, I produce a pre-approved lead-generation Facebook ad (copy and text) on each of our content marketing campaigns. I record a video showing you how to build a targeted custom-audience for your ad and I’ve recorded a couple of help videos showing you step-by-step how to set up the ad using either of the strategies that I have outlined above. So you can literally ‘plug and play’ my pre-written ad to do exactly what I’ve described above, targeting exactly the right audience.

Publish the pre-written blog post that we provide within each campaign to publish a new blog post on your website (this is good for SEO too). If you don’t have a blog area, use the link to the version we host for you.

Use the pre-written nurture email included in the campaign as described above and if you use Mailchimp, even quicker still, use the 1-click template we provide to pull a ready-to-send email into your own Mailchimp account.

Section 2 Summary

By the end of this section you will have 1 Activated the social media campaign included in your CoKinetic subscription and been posting it to your social networks.

2 Set up and activated an email lead generating social media ad promoting your helpful post-viral fatigue resources in order to build a targeted audience who have a high chance of attending your event when you announce it (we’ve provided everything you need to do this).

Put in place an email-based 3 nurture process to warm up your entire email list and build trust (this involves using the pre-written nurture email and the blog post provided in your Co-Kinetic subscription).

SECTION 3

Promoting Your Event Organically

The term ‘organically’ just means posting without paying to promote a post. It’s what you do when you create a normal post on your social networks.

Whatever you do, don’t make the mistake of expecting to collect loads of email addresses by putting a few organic posts on your social media page. The social networks don’t work like that and here’s why. That post will also explain why your social media is exceedingly unlikely to go viral either! You will need to build in paid advertising if you want to actively build your email list.

More info here.

Co-Kinetic Journal 2021;90(October):45-49

ENTREPRENEUR THERAPIST

The blog is ideal because while it may include a link to your helpful resources (accessible through the sign-up page), everything else is about offering help, support and education. It’s a great way to spread the word while still adding value to your readers.

You could also print out some of the branded patient advice resources (ie. the lead magnets) and distribute them in the local community.

Remember, all of our resources are written by clinicians and are fully peer-reviewed, so you can trust the information. Perhaps your local GP surgeries would find them helpful to distribute? Maybe sports centres, health clinics and local shops would be receptive to distributing them?

They may not specifically have an event sign-up link on the leaflets, but if someone is interested in the topic, there’s a good chance they will either visit the web page listed (or your social network) to find out more.

RELATED CONTENT

lP ost-Viral Fatigue Content Marketing Campaign https://bit.ly/3vUf598 lR unning an Open Clinic Event [Article series] https://bit.ly/3lnfjCz lT urning Email Leads into Paying Customers: Using the Powerful Hidden Influences of Nurture Emails [Article] http://spxj.nl/2BU2UO3

Co-Kinetic.com

You can also use the Share Link we provide to each resource, to post the resources anywhere on the web. The blog post is more effective because it’s fully editable and you can mention your event, but the leaflets are also valuable reputation-building content.

In Summary

I could write a book about running Conversion Campaigns, but as I produce a journal, an article seemed more appropriate! Let’s finish with a summary list of each feature of the content we provide, and a reminder of what you do with it.

Campaign Content Included in the Full Site Subscription

POST-

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SICA L 2. Stab AND HOW that RCISE le phys AND are impo GET is MAN UAL ical activ THERAP the WIL rtant and provide ity. Stabi post-viral use of regular L IT HELP Y THER APIS the lising ME? physical consistent foundation fatigue TS s for GET. your activity (CFS). syndrome exercise pattern With 3. Gent levels will to aid This mean (PVFS) of physi le stret recovery gradually regular low s work ches. Thes cal activity level activi or chronic fatigu from muscles incre ing out befor e are a ty, the a e syndr for GET work ase your abilit good way e increasing ome programm activity. You y to carry body begin s direc exercise. directed may to prep s to adap tly with out that by your are your any activi e with your physi wish to plan t and activity. want to own goals your level of a stretc ty. cal thera 4. Reali walk your hing and objec current abilit pist to stic activ enjoyable children do befor y, ity. Plan necessary to schoo tives. For exam and is sport, e you add an initial fitness GET will l or get ple, so you activity everyday in your life. This can achie gradually build back to playin if you that activity should you enjoy ve your g an up your it. to challe be or is goal. strength CAN EXE nge your in addition to 5. Base and your norm body slight line activ Any activi RCISE MAK al, ly and ity level can do ty carrie strengthen . Start capacity on d out to E ME WO the activi RSE has the can’t be at least 5 days excess ty at a worse. potential and beyo ? done every out of level 6. Very To ensu to incre nd your day, then 7, even on your you know small re that activities this does ase symptoms current physi the starti bad days. you at a low comfortab increases in n’t happ cal ng level and make days), lengt level that ly doing en, it is and to is too high! If it activity you feel you can your base h of activity. build up for easily mana essential to After a line activi gradually. eg. a 5-mincan be incre while ge (even start ty, the ased slight ute walk time you of on ‘bad’ 10 minu ly. The becomes do this incre tes woul ases are 6 minu d not be increase; very small advisable tes. An incre our bodie : PROD ase from happy as this UCED with incre s tend only 5 is BY: to an to be enorm ases of ous 100% around 20%.

P atient Information Resources (aka lead magnets) R – designed to help you add value to your customers and prospects locally and attract new email leads Social Media Content – this is used to build your reputation, publish an intelligent, engaging social media presence, raise awareness of your lead magnets, and as ads to help build your email list Lead Collection Page – designed to help you collect leads (email addresses of prospective clients, also called ‘prospects’) when used in conjunction with paid advertising Lead Magnet Delivery page – the place people completing your email lead collection page are redirected to download their resources Inbuilt Email Autoresponder – the first contact touch after your new prospect has downloaded their new resources Blog Post – used to build trust, establish authority, increase your findability on the web (SEO) and as a value-added piece of content to promote on the web helping to promote your lead magnets and any events you want to run Nurture Email and 1-Click Mailchimp Template – used to build trust with your existing and new email leads Educational PowerPoint Presentation – used to run a conversion event to turn prospects into paying clients Education Event Sign-Up Page – used to take sign-ups to your conversion event Customisable Web Pages – used to take payments for products or services you may want to offer following your conversion event Facebook Ad Copy – ad copy and images along with stepby-step videos enabling you to set up a Facebook email lead-generating ad

Grade dE Treatin xercise Thera g Post py for -V Fatigu iral/Chronic e Synd rome

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Activity Level

There are a few organic things you can do, however: Promote your blog post and include a mention of your event with a link to your sign-up page (remember even if you don’t have your own blog area, we give you a hosted link and you can edit that post to add your event details).

You can promote that blog post on local discussion forums and in local social media groups, you can also ask other local businesses to help spread the word for you, they might even include it in their own email newsletters.

TS

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

21-10-COKINETIC FORMATS WEB MOBILE 1999

2021 JULY 2021 ISSUE 89

PRINT

July Journal

138X ISSN 2397-

The July journal features our regular sections covering Journal Watch and the 10 Most Discussed Pieces of Research in the areas of Physical Therapy and Health and Wellbeing.

Main features included:

Pain Does Not Always Indicate Injury 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. https://bit.ly/3pweyZI

ES PAIN DO AYS NOT ALW INJURY TE INDICA

of pain severity t of the independen of age of fear.

(1*). is a group live in an not ideas, At the core e currently us (luckily) it’s fear-related of crime, For many overlapping fear of pain, worry, of war, of to the extent but a daily consisting pain-related anxiety, of necessarily or safety; disease, concept BSc MPhil poverty rumination, and the and its illness, abuse, Thomas sensitivity, of fear of about pain anxiety

By Kathryn thinking onslaught integration, success od that It results safety es (3*). catastrophic ce acceptance, health and assault it is understo consequenc fear-avoidan From a t of possible fear of These days or failure. there is a constant parents pain, ongoing chronic in the developmen by a distressingbefore perspective (be it from media, as: are rare. caused for most (or even , such patterns is ive triggershave to treat a of reminders figureheads) an activity of what this, Wear s nocicept pain during in anticipation or community do that, Eat as a therapist Don’t here, Mind the activity) what may happen activity. mix of central careful Instead, Do this, or or complex gear, Be to come fear of This is generated e of movement exercise much more anxiety and thorough protective us, there, etc. consequenc do know is that proven a protecting injury or your step tion, is a guise of What we activity sensitisa involves having ence pain, under the healthy, preventing physical chronic us life. However, or general pain pain. This of pain neurosci -driven keeping a better for managing etal-related of fear, and living treatment ge illness, a society musculoskel impossible osocially knowled created ing. including almost it has also pain catastrophis as biopsych strategies. This fear one It may be and as well (4*,5*). out of their a ent ing is when anxiety by a patient example to ‘talk’ emotional to start Pain catastrophis pain managem a limb (for their lower of negative before allow you pain, of moving or flexing for has a group responses to patient shoulder article will treatment your up of their painful cognitive aim nd nding and main to be made , functioning understa them to understa back). The is to increase and is thought helplessness t, pain g (1*). a graded aspects: chronic goal achievemen educatin deliver of three n and rumination therapy then to and enhance exposing a patient arisen as magnificatio ing has exercise their al pain and for example tackling avoidance psychologic -targeted Pain catastrophis from strongest movement, patterns, not necessarily the to cognition your patient outcomes of pain pain. one se (6*). and free of poor of fear per associated behaviour s of chronic plan to predictors their level review been repeatedly to pain, limitation reducing systematic and has sensitivity pain, fear and A recent seven randomised article online is) with increased of persistent risk eyZI and severity, (which included and meta-analys Read this increased pain intensity trials it.ly/3pw levels of versus pain-free controlled GY etal and higher https://b heightened exercises PSYCHOLO disability, musculoskel depressive of painful | PAIN | increased al distress and et for chronic NETIC allowing PRINT exercises

by Sullivan access 21-07-COKI MOBILE psychologic that protocolsa small, but ing are open WEB (2*). A review pain found asterisk offered catastrophis symptoms FORMATS over with an list exercises that pain benefit the marked painful reference 31% of term al. showed significant All referencesprovided in the for up to in the short statistically (1*). More are accounted links severity exercises ts in patientand between in pain pain-free variance with a was improvemen the connection achieved disability (7*). The importantly ing and pain were such as factors, reported pain catastrophis contextual experienced range of of pain to degrees being allowed ed varying from pain a recommend (ranging with/without time (ranging advised, to and recovery immediately pain scale) subsiding from pain

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Co-Kinetic

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2021;89(Jul

Pain in the Athlete 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. https://bit.ly/2Scomfi

live with

caused nal athletes professio t pain that is not sh tive and to distingui persisten Many competi chronic or allow you athlete

21-07-

COKINETIC FORMATS WEB MOBILE PRINT

| PAIN

will of in the pain, especially . This article some form discuss treat pain well as a hen we tend to damage ‘injury’ and to as pain, we person by tissue therapy message chronic of an older recently ‘pain’ and physical an image has unified between manner using develop clinic who of and shared into the h, a positive because limping in a holistic off work approac team, informed Read this with osocial been booked maybe someone can Or biopsych interdisciplinary who rs the athlete. their pain. shoulder pain for own hair across the that empowe omfi a persistent comb their It is not -making it.ly/2Sc no longer decision their arm. https://b fit athlete fear of raising of a strong, of think article online (ie. sensitisation often you no pain from central honest, I think BSc MPhil who have and suffering Thomas to be in athletes degeneration

By Kathryn pain. However, and professional disc bulges, thickening of tendons) of Trauma, of chronic degree most competitive ly Absence labral tears, in their have some 1. In the Not Necessari red athletes with no (3,4). pain somewhere Pain DoesTissue Damage tissue an athlete specific or persistent time! of we l Imaging some Indicate assume pain indicates indicators the risk of is injured, injury, body at flags or athlete increases l Do not traumatic an When an them as pathology or injury’, of an acute damage. strain think mislabelling attributing ‘sports a’ often or ankle and such as clinicians training l Labels injury’ or ‘microtraum tissue to poor ‘pathology’, cause of pain. be it a hamstring by having as the injury related al errors. We ‘overuse is caused health ion overuse that pain such findings threatening biomechanic pain is common in over-protect convey and impact habits or etal resulting it Inaccurate can adversely damage, must remember (ie. know musculoskel to invasive information but we the athlete. related to repetitive injury of and lead with have a in athletes, associated pain with the athlete s. Many athletes are occurs associated l Although and is not always (1*). Damage may be intervention presents findings loading imaging pain that ical (5,6,7*). tissue tolerance, tissue damage) ‘positive’ asymptomatic exceeds pathoanatom stress fracture, a fracture. tear or when load identifiable labelled or completely is not indicated, with no a ligament that occurs not be imaging patients such as athletes (3). l When tissue reassure pain in basis should and damage must ormed However, as tissue of trauma and clinicians as an treated an evidence-inftheir of trauma of labels for in the absence often labelled absence and provide and the use is still explanation l In the coaches damage pathology, d ‘knee pain’ alternative clinicians, highlights relevant (2).

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Working With The Long Covid Client: A Massage Therapist’s Perspective [Article] 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

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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. https://bit.ly/3x6FhyC 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.

Login or register a free account below to access the contents, key points and discussion questions that accompany the article. https://bit.ly/3wtIV5C MANUAL

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Timeless Testimonials: The Power of Reviews 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.

We’ve also produced some posters, postcards and review request leaflets that you can add your own details to using a free account on the online design platform, Canva and use to request reviews from your clients. It even includes some helpful tips on writing a review. https://bit.ly/3vRqeHN

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Marketing Metrics That Matter (and Those That 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. https://bit.ly/3zSS9KP g Marketin Which Matter Metrics ich Don’t)

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Post-Viral Fatigue Marketing Campaign

Post-Viral Fatigue is closely connected with Long-Covid and also linked to chronic fatigue syndrome (CFS) and ME. This campaign is designed to help you offer advice and services to sufferers and their carers.

The campaign contains a whole range of resources detailed below, all of which are aimed at helping you to add value and strengthen relationships with existing customers, social media followers and prospective customers. Use the resources to help you promote yourself locally and build reputation and authority while consistently adding value to your viewers and readers.

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l9 printable/downloadable client advice leaflets (which also double up as lead magnets in the Social Media campaign) l1 x A4 newsletter (great to print out (or have professionally printed) and circulate to your clients and in your local area)

Social Media and Full Site Subscribers

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A social media awareness campaign that includes value-added patient resources accessible through an email lead collection page, designed to help you collect new email leads and segment your email list. l3 1 unique and originally-designed social media posts you can use to increase engagement on your social networks, build followers AND collect new email leads through your social networks using our inbuilt email lead collection pages and offers of high-value downloads l7 videos and explainer animations l1 lead collection page where people can sign up to access the high-value lead magnet resources (everything is designed, hosted and taken care of for you) l1 lead magnet delivery page (again hosted and taken care of for you) lA pre-written automated (but editable) email autoresponder for anyone signing up to your new resources

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following subscription lA ready-to-send nurture email you can use to build authority and strengthen your relationships with your existing email contacts while also adding value lA pre-written blog post with images ready for you to publish on your website or blog to help boost the search engine optimisation of your website lA ready-to-deliver PowerPoint presentation you can use to run an education event designed to increase your profile locally (and make sales (if desired)) lA pre-built, pre-written web sign-up page to help you take sign-ups to your education event lA customisable web sign-up page designed to enable you to take payments for any upsells connected to your education event lS tep-by-step instructions on how to implement a sales-generating conversion campaign.

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5 Ways to Support Your Local Business Artwork

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After everything we’ve been through in 2020 and 2021 we thought it would be a good idea to support yo to produce some artwork you ur local business could use to encourage people FOR YOU to take actions that will help 1 to support small businesses SHARE 2 THE such as physical and manual 3 4 therapy businesses. Use these SHO LOCALP 5 resources to help people understand what they can do to help.

Print the poster out for your clinic walls and use the postcard to send to customers who may be happy to help you out. l1 x Poster - download and print out from your home computer or order professionally printed A3, A2, A1 posters through Canva l1 x Poster Christmas Themed - download and print out from your home computer or order professionally printed A3, A2, A1 posters through Canva l1 x Postcard (as above)

5

WAYS VOU

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Like, comment or share their social media posts - it helps them get seen by othe r people, who may buy from them

Tell your friend s and family abou t them Write a review for them on their Facebook page or Goog le Business listing Sign up to their email newslette r Buy a gift vouc her from them

Customer Review Request Artwork

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Customer reviews are arguably the single most important marketing activity you can do (closely followed by building a quality email list). This piece of artwork lets you add your own review links and the leaflet also includes some helpful advice for your customer on how to write a good review.

This is a no-brainer leaflet or postcard to have located in a dispenser in your reception area which you can give to patients after their appointments. l 1 x Leaflet - add your own review link and then download and print out from your home computer or order professionally versions through Canva l1 x Postcard (as above)

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