Co-Kinetic Journal Issue 91 - January 2022

1999 2022

ISSUE 91 JANUARY 2022 ISSN 2397-138X

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ISSUE 91 JANUARY 2022 ISSN 2397-138X

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CLICK ON RESEARCH TITLES TO GO TO ABSTRACT

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CLINICAL EFFECT OF END-RANGE MAITLAND MOBILIZATION IN THE MANAGEMENT OF KNEE OSTEOARTHRITIS–A PILOT STUDY. Pozsgai M, Kövesdi E, Németh B et al. In Vivo 2021;35(3):1661–1668 A total of 30 patients assessed as suffering from knee osteoarthritis (KOA) as described by the American Collage of Rheumatology, were divided into two groups. A conservative therapy group (n=15) received conservative therapy alone, and the other group received Maitland mobilisations plus the conservative therapy (n=15).

The conservative therapy included medical bath, water- and land-based exercises and TENS therapy was carried out for 20min at a total of 15 sessions over the 3-week treatment period.

TENS therapy, applied at a strength between 15 and 25mA, was applied 3 times per week for 20min during the 3-week treatment. The water-based exercises included dynamic movements of upper and lower limb, isotonic strengthening exercises of muscles around the spine and peripheral

joints, and exercises for improving balance and coordination. Land-based exercises consisted of exercises for improving knee joint ROM, isotonic strengthening and static stretching exercises for the quadriceps, hamstring and gastrocnemius–soleus muscles.

Maitland manual therapy consisted of oscillatory grade 3 or 4 end-range mobilisation. The different grades were applied depending on the level of tolerance and pain of each patient.

In full flexion, accessory techniques were added to the tibiofemoral joint.

This was repeated in extension.

Flexion and extension end-range of the patellofemoral joint was mobilised with accessory, longitudinal caudal and cranial technique of the patella following the physiological movement of the patella, respectively. All mobilisations were repeated twice at

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the rate of one oscillation per second for 2min in each session, twice a week, 6 times in total during the 3-week treatment period.

Outcomes were pain intensity, measured with visual analogue scale in general and during functional activities, passive ROM and peak muscle force during knee flexion and extension, timed up and go test and 6-minute walk test. All outcomes improved significantly in both groups but the magnitude of change was significantly greater in the group receiving the Maitland mobilisations as well as conservative therapy.

Co-Kinetic comment OK, it’s not sport, it was an elderly population and a very small sample; but it was positive for a manual therapy technique so we will take that.

SKELETAL MUSCLE REGENERATION WITH ROBOTIC ACTUATION-MEDIATED CLEARANCE OF NEUTROPHILS. Seo BR, Payne CJ, McNamara SL et al. Science Translational Medicine 2021;13(614):eabe8868 To facilitate this study the authors designed and built a customised robotic system to deliver consistent and alterable compressive forces to the leg muscles of 6- to 9-week-old female mice. They injured the legs and treated some with compressive force via the device for 14 days while another group was left to heal themselves.

Ultrasound was used to estimate tissue strain under various loading conditions. Both groups displayed a reduction in the amount of damaged muscle with the greater reduction in the compression group. The greater the force applied during treatment, the stronger the injured muscles became.

They performed a detailed histological analysis to determine why this occurred and came to the conclusion that the 4

mechanical force squeezes neutrophils and cytokines out of the injured tissue.

They confirmed this theory by injecting fluorescent molecules into the muscles and observing that the movement of the molecules was greater with force application, supporting the idea that it helped to flush out the muscle tissue.

Co-Kinetic comment Firstly, a word of thanks to the mice who were sacrificed to show that putting mechanical force into tissue speeds up muscle regeneration. For those of you whose physiology is a bit rusty, neutrophils are a type of white blood cell that help to fight infections but although they are useful early in the healing process if they hang around, they slow it down. In fact, when the

researchers depleted the mice’s neutrophil count on the third day, muscles later showed larger fibre size and greater strength compared to the ones not treated. Cytokines cause blood vessel walls to become leakier and promote healing through inflammation but if there are too many of them the vessel walls become overly porous. Any experienced massage therapist will tell you that ‘rubbing it better’ is a fact. This study starts the process of proving them right and the research team plan to validate their findings in larger animals and eventually humans, where they hope to test it on different types of injuries, age-related muscle loss, and muscle performance enhancement.

Bring it on.

Co-Kinetic Journal 2022;91(January):4-11

RESEARCH INTO PRACTICE

Journal Watch

ADDUCTOR MUSCLE INJURIES IN UEFA SOCCER ATHLETES: A MATCHED-COHORT ANALYSIS OF INJURY RATE, RETURN TO PLAY, AND PLAYER PERFORMANCE FROM 2000 TO 2015.

Lavoie-Gagne O, Mehta N, Patel S et al. Orthopaedic Journal of Sports Medicine 2021;9(9):23259671211023098 A total of 671 players with adductor muscle injury were included in this study. The data were obtained using publicly available records of athletes sustaining adductor muscle injury across the five major European soccer leagues (English Premier League, Bundesliga, La Liga, Ligue 1, and Serie A) between 2000 and 2015. Injured athletes were matched to controls by demographic characteristics and performance metrics from one season before the index timepoint. Investigations included the rate of return to play (RTP), reinjuries, player characteristics associated with RTP within two seasons, player availability, field time, and performance metrics during the four seasons after injury.

Based on time to RTP, 86% of

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injuries were mild to moderate (4–28 days missed), and 4% required surgical intervention. Players with adductor muscle injury were absent for a median of 22 days (range, 1–700 days) and 4 games (range, 1–76 games). A total of 521 (78%) players returned at the same level, with no demographic or clinical characteristics associated with RTP on the multivariable regression.

Of those returning to play, 143 (21%) experienced adductor reinjury.

After RTP, defenders demonstrated decreased field time compared with controls. As compared with controls, defenders and midfielders scored more points and goals per game during the season of the injury, whereas attackers recorded more goals and assists per game the season after injury.

Co-Kinetic comment This is a great piece of work and its most important findings are that 22% of the players did not RTP at their previous levels and that 21% reinjured themselves. Time for a serious look at the RTP protocols?

The ‘usual suspect’ databases were searched to find studies that included manual therapy techniques with or without other therapeutic interventions and with functional outcomes, such as wrist or upper limb function, pain, grip strength, and wrist ROM in patients older than 18 years with a distal radius fracture.

Eight clinical trials met the eligibility criteria; for the quantitative synthesis, six studies were included. For supervised physiotherapy plus joint mobilisation versus home exercise programme at the 6-week follow-up, the mean difference (MD) for wrist flexion was 7.1°, and extension was 11.99°. For exercise programme plus mobilisation

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CONTEMPORARY PRACTICE PATTERNS FOR THE TREATMENT OF ANTERIOR CRUCIATE LIGAMENT TEARS IN THE UNITED STATES. Cevallos N, Soriano KKJ, Lansdown DA OPEN et al. Orthopaedic Journal of Sports Medicine 2021;9(9):23259671211040891 Patient data between 2010 and 2017 were queried using the Mariner PearlDiver database to identify patients with ACL tears and their subsequent treatment. Patient characteristics were stratified by sex and age. Of 229,295 patients identified with an ACL tear diagnosis during the study period, 75% underwent ACLR. In patients aged 10 to 39 years, 84–92% underwent ACLR, whereas patients aged 50 to 59 (50%) and 60 to 69 (28%) years were less likely to have surgery after an ACL tear. Female and male patients underwent ACLR at a similar rate (75%). Within the patients who underwent ACLR, 44% underwent concomitant meniscal debridement as compared with 11% with concomitant meniscal repair. Male patients were more likely than females to undergo meniscal debridement (48% vs 40%). The frequency of meniscal repair increased from 9% in 2010 to 14% in 2017, while the frequency of meniscal debridement decreased from 47% to 41%. Within 2 years of ACLR, 6% of patients underwent revision ACLR; 4%, subsequent meniscal debridement; 1%, meniscal repair; and 1%, conversion to a total knee replacement.

Co-Kinetic comment Fifty percent of these patients had a meniscus issue surgically addressed at the same time as the ACLR repair.

EFFECTIVENESS OF MANUAL THERAPY IN PATIENTS WITH DISTAL RADIUS FRACTURE: A SYSTEMATIC REVIEW AND META-ANALYSIS. Gutiérrez-Espinoza H, Araya-Quintanilla F, Olguín-Huerta C et al. Journal of Manual & Manipulative Therapy 2021;doi:10.1080/1066981 7.2021.1992090 with movement versus exercise programme at the 12-week follow-up, the patient-rated wrist evaluation was -10.2 points, the disabilities of the arm, shoulder and hand score was -9.86 points, and grip strength was 3.9% up. For conventional treatment plus manual lymph drainage versus conventional treatment, for oedema the MD at 3–7 days was -14.58ml, at 17–21 days was -17.96ml, at 33–42 days was -15.34ml, and at 63–68 days was -13.97ml.

Co-Kinetic comment The bottom line is that adding mobilisation with movement and manual lymphatic drainage generated statistically significant differences in wrist, upper limb function and hand oedema. Sadly yet again the authors complain that the quality of some of the papers was low.

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This study explored the performance differences in athletes having massage at varying depths during POPDA, which is a regional multi-sports student event in Sleman, Indonesia. Twenty athletes (male and female) were matched in pairs. They performed a 30m sprint from a standing start followed by each intervention with a retest after each.

One group received sports massage to the posterior of each leg described as: effleurage for 2min per leg, tapotement for 1–1.5min, shaking/ vibration for 2min and more effleurage for 2min. The other group received Swedish massage which was described as: drainage for 2min, compression for 1–1.5min, tapotement for 1–1.5min, shaking/vibration for 2min. This was done 3 times with a different dose each time described as pressure that is, light, medium or heavy. For light pressure, athletes were given movements such as rubbing. At moderate pressure,

THE DIFFERENCES RESPONSE OF MASSAGE TYPES WITH VARIATION MASSAGE PRESSURE ON RUNNING SPEED IN POPDA SLEMAN ATHLETICS. Rini OPEN RGM, Purnomo E. Jurnal Keolahragaan 2021;9(2):193–201

a pressing movement using hand strength, whereas for heavy pressure, the athlete was given a pressing movement using the push/strength of the massager’s body.

The combined results showed that the sport massage treatment with medium pressure gave the best effect/response, as evidenced by the results of the most improved/best time records.

Co-Kinetic comment

MANUAL THERAPY COMBINED WITH THERAPEUTIC EXERCISE VS THERAPEUTIC EXERCISE ALONE FOR SHOULDER IMPINGEMENT SYNDROME: A SYSTEMATIC REVIEW AND META-ANALYSIS. OPEN Sharma S, Hussain ME, Sharma S. Journal of Clinical and Diagnostic Research 2021;15(4):YE10–YE17 A search of two electronic databases (PubMed and PEDro) was performed from inception until the last week of August 2020. The selected studies were assessed on methodological quality rating using the PEDro scale and the modified Downs and Black checklist for experimental and quasi-experimental studies, respectively. The extracted outcomes were pain levels, strength, ROM and shoulder pain and disability index.

The meta-analysis was done on continuous data and the data were summarised qualitatively and quantitatively. The manual therapy (MT) treatments varied between studies but included shoulder joint anteroposterior and posteroanterior mobilisations, distractions, inferior glides, mobilisation with movements and passive mobilisation of the shoulder complex.

The therapeutic exercises (TEs) also varied between studies but included individual and group class work using stretching and strength exercises, such as rowing and push-ups, for shoulder complex muscles.

Seven trials were included after evaluation (n=437). Positive effects were seen for pain when managed with MT combined with TE, whereas external rotation strength improved with TE alone. The majority of the studies (six out of seven) had low risk of bias.

Co-Kinetic comment You will have to go to the individual studies to recreate the protocols but in general the Cyriax/Maitland/Mulligan playbook was used for the MT, and for pain it works.

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A sentence in the methodology section says, “POPDA aims to improve the problem solving, breeding, and coaching of talented athletes”. Hopefully the ‘breeding’ part is a translational error. That aside, although there are some methodological and reporting issues with this paper, including the similarity between the two massage forms and the vague description of how the depths of pressure were performed and gauged, it is an excellent attempt to consider the dose of massage treatment. Well done.

FEMOROACETABULAR IMPINGEMENT SYNDROME AND LABRAL INJURIES: GRADING THE EVIDENCE ON DIAGNOSIS AND NON-OPERATIVE TREATMENT—A STATEMENT PAPER COMMISSIONED BY THE DANISH SOCIETY OF SPORTS PHYSICAL THERAPY (DSSF).

Ishøi L, Nielsen MF, Krommes K et al. British Journal OPEN of Sports Medicine 2021;55(22):1301–13010 This statement summarises and appraises the evidence on diagnostic tests, clinical information, and non-operative treatment of femoroacetabular impingement (FAI) syndrome and labral injuries. Papers were evaluated using the Grading of Recommendations Assessment Development and Evaluation framework. Twenty-nine studies were found reporting 23 clinical tests and 14 different forms of clinical information, respectively.

Restricted internal hip rotation in 0° hip flexion with or without pain was best to rule in FAI syndrome, whereas no pain in a Flexion, Adduction Internal Rotation test or no restricted ROM in flexion, adduction, and internal rotation (FADDIR) test compared with the unaffected side were best to rule out FAI. No forms of clinical information were found useful for diagnosis. For treatment of FAI syndrome, 14 randomised controlled trials were found. Prescribed physiotherapy, consisting of hip strengthening, hip joint manual therapy techniques, functional activity-specific retraining and education showed a small to medium effect size compared with a combination of passive modalities, stretching and advice. Prescribed physiotherapy was, however, inferior to hip arthroscopy. For both domains, the overall quality of evidence ranged from very low to moderate.

Co-Kinetic comment Is low-quality evidence better than no evidence? Discuss.

Co-Kinetic Journal 2022;91(January):4-11

RESEARCH INTO PRACTICE

COMPARATIVE EFFECT OF LUMBAR MYOFASCIAL RELEASE WITH ELECTROTHERAPY ON THE ELASTIC MODULUS OF LUMBAR FASCIA AND PAIN IN PATIENTS WITH NON-SPECIFIC LOW BACK PAIN. Tamartash H, Bahrpeyma F, Mokhtari dizaji M. Journal of Bodywork and Movement Therapies 2021;doi:https://doi. org/10.1016/j.jbmt.2021.10.008.

Thirty-two subjects (16 males and 16 females with a mean age of 41.25±5.249 years) with low back pain were randomised into the myofascial release group (n=16) and electrotherapy group (n=16). Subjects in the myofascial release group received 4 sessions of myofascial release in the lumbar region following a protocol described by James Earls and Tom Myers in their 2017 book, Fascial Release for Structural Balance.

The electrotherapy group received 10 sessions of electrotherapy, 1MHz continuous ultrasound for 3min, and TENS for 20min.

In both groups the main outcome

This case study had our attention when it started by praising the dogs in military operations. It then went on to say that military working dogs (MWD) are trained, no matter the handler’s handedness or shooting side, to be on the left of the handler.

The dogs are usually wanting to work ahead of their handlers and pull. The handler must therefore pull on the leash to keep the dog close. The initial acceleration (lunge) measured in police working dogs averaged 7.1 gravitational force equivalents (G-force), which equates to 2100N in a single forced tug of the leash. The handler is also wearing extra weight with kit, helmet with night vision devices, body armour, weapon and ammunition. The arm is extended forward when walking with the dog.

The shoulder is protracted, forward flexed, the elbow and wrist flexed, and the pelvis rotated with the left side anterior to the right. This asymmetry is the precursor to overuse.

The subject was a 32-year-old, active duty, right-handed MWD handler with a chief complaint of left upper trapezius and left shoulder pain that he had had for 6 years. He attributes the start to an unsolicited

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measures were decreased with a greater effect in the myofascial release group. These were low back pain severity as measured on a visual analogue scale (VAS) and the elastic modulus (the ratio of the force exerted upon a substance or body to the resultant deformation) of the lumbar myofascial tissue measured using ultrasonography at 4 points on the lumbar spine to which force was applied. These points were 2cm away from the L2–L3 and L4–L5 vertebrae on both sides of the spine. The electric modulus was measured with and without applied force and before and after treatment.

Co-Kinetic comment A good result for myofascial release. Go out and buy the Earls and Myers book so you can repeat the treatment: Earls J, Myers T. Fascial Release for Structural Balance. Lotus 2017 ISBN 978-1905367184 (Buy from Amazon: https://amzn.to/31jKlp1).

OVERUSE INJURY IN MILITARY WORKING DOG HANDLERS: A PATTERN OF BEHAVIOUR AND A PATH TO PREVENTION. Patt MW, Oh JT, Branstetter JG et al.

Military Medicine 2021;doi:10.1093/milmed/usab368 lunge by his MWD. He was initially treated with dry needling and cyclobenzaprine. Symptoms resolved but then he had repeated similar incidents over the following years. The last one was when roping to the ground out of an aircraft while carrying the dog!

Diagnosis was made of acute strain of the trapezius, levator scapula, rhomboid major and minor on the left side.

He was treated with 3min of percussion myofascial release with a percussive massage gun targeting the specific areas of pain, dry needling and electroacupuncture followed by more use of the massage gun and the application of a topical muscle rub. Twenty-four hours post-injury, his pain had decreased significantly with increased use of his left shoulder and arm. At the 10-day follow-up, the patient had minimal (1/10) discomfort with full active and passive motion, full strength, and only trace symptoms with use of a pulling motion with his left shoulder. He remained fully mission capable, with no time lost to the injury.

The prevention aspect of the study

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discusses adapting dog collars and leashes and ‘pre-hab’ for the handlers to increase flexibility, mobility, strength, balance, and proprioception especially before they start their training for MWD handlers.

Co-Kinetic comment How was the dog? This is not a one-off case. A review of Israeli female soldier dog handlers found a significant association between service in MWD units and upper extremity overuse injuries. Application of a muscle rub is massage. The massage gun is … compression massage.

Massage works OK.

Injury profile and physical activity (PA) level information were obtained from 651 participants aged between 10 and 18 years attending four Portuguese schools using a LESADO questionnaire which is a self-reported instrument that gathers information about injury profile and the biosocial questionnaire RAPIL II, which is a parent´s self-reported instrument used to measure biosocial variables.

Maturity measures consisted of calculating bone age and maturity offset measured by the TannerWhitehouse III method which examines radiographs of the left hand and wrist. Maturity offset is the time before peak height velocity (PHV) and this figure minus chronological age provides an estimate of PHV. It is a measure of chronological maturity. These data allowed the authors to create four groups of PA levels and the injuries in each group. The groups were: a nosports participation group, with no time spent in PA per week (except mandatory physical education

SPORTS INJURIES PATTERNS IN CHILDREN AND ADOLESCENTS ACCORDING TO THEIR SPORTS PARTICIPATION LEVEL, AGE AND MATURATION. Costa e Silva L, Teles J, Fragoso I. Annals of Medicine 2021;53(sup1):doi:10.21203/rs.3.rs-842540/v1 classes); a recreative sports group with at least 90min of PA per week, of which at least 60% was recreational activity; a school sports group with at least 90min of PA per week, of which at least 60% was school sports activity; and a federated sports group with at least 120min of federated activity.

With regard to the injury predictors, a sample of the results was that recreative boys had more chances of having a sprain or a fracture than a strain. Also, recreative and scholar girls had more chances of having a sprain than a strain. As maturity offset decreased, the chances of girls having a strain or a fracture when compared to sprains were higher. For body area location boys aged 10–11 years were more likely to have upper limb injuries than boys of other ages. Spine and trunk injuries were more likely to occur in federate and no-sports participation girls.

Co-Kinetic comment The ability to predict injuries and therefore prevent them is the ‘holy grail’ of sports medicine. This study is basically about probability and its most useful content is a table which gives the incidence of various injuries and the percentage of the total cohort that had them. This is what coaches and therapists should study. For example, the odds of: l a recreative boy having a sprain rather than strain were 8.84 times more than for a federate boy; l a recreative boy having a fracture rather than a strain were 7.27 times more than for a federate boy; l a recreative girl having a sprain rather than a strain were 7.46 times more than a federate girl; and l a scholar girl having a sprain rather than a strain were 20.8 times more than a federate girl.

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THE EFFECTIVENESS OF AQUATIC PLYOMETRIC TRAINING IN IMPROVING STRENGTH, JUMPING, AND SPRINTING: A SYSTEMATIC REVIEW. Heywood SE, Mentiplay BF, Rahmann AE et al. Journal of Sport Rehabilitation 2021;doi:10.1123/jsr.2020-0432 The object of this study was to systematically review the effect of aquatic plyometric training on strength, performance outcomes, soreness, and adverse events in healthy individuals.

Evidence from five databases was obtained from inception to June 2020.

A total of 19 randomised controlled trials with 633 participants (age range 14–30 years) were included. Aquatic plyometric training was most commonly

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performed in waist- to chest-deep water (12/19 studies), 2 to 3 times per week for 6 to 12 weeks (18/19 studies), with final programme foot contacts ranging from 120 to 550. Meta-analyses were not completed owing to the clinical and statistical heterogeneity between studies. Compared with land plyometric training, aquatic plyometric training exercises and dosage were replicated (15/16 studies) and showed typically similar performance gains (3/4 knee extensor strength measures, 2/4 leg extensor strength measures, 3/4 knee flexor strength measures, 7/10 vertical jump measures, 3/3 sprint measures).

In total, 2 of 3 studies monitoring muscle soreness reported significantly less soreness following training in water compared with on land. Compared with

no active training (no-exercise control group or passive stretching), most effect sizes demonstrated a mean improvement favouring aquatic plyometric training (23/32 measures). However, these were not significant for the majority of studies measuring isokinetic knee strength, vertical jump, and sprinting. The effect sizes for both studies assessing leg-press strength indicated that aquatic plyometric training is significantly more effective than no training.

Co-Kinetic comment It would appear that aquatic plyometric training provides similar results to land-based plyometrics – at least in healthy individuals – so if you want to minimise impact loading it may be an option. However, the authors do comment on the fact that the low quality of the studies limits the strength of the conclusions. How often do we have to hear this before journal reviewers and their editors start throwing low quality studies into the bin?

Co-Kinetic Journal 2022;91(January):4-11

RESEARCH INTO PRACTICE

PLANTAR FASCIITIS AND ITS HOMEOPATHIC MANAGEMENT. Divyarasi NV, Desarda R. Journal of Medical and Pharmaceutical Innovation 2021;8(38):15–20 This is a summary of plantar fasciitis: its types, epidemiology, aetiology, risk factors, intrinsic factors, pathological features, signs and symptoms, diagnosis, prevention and treatment.

The risk factors include age, foot mechanics, excessive pronation, obesity, continuous pressures on the foot in activities such as long distance running, ballet, and for workers who may spend a long time on their feet, and, of course, improper footwear.

It usually presents with insidious onset and what is known as start-up pain when sufferers first get out of bed or following long periods of non-

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weight-bearing. There can be tenderness to the anterior medial aspect of the heel described as sharp, stabbing or burning. It is usually unilateral but up to 30% of cases have bilateral presentation.

The pain can subside after a short period of walking but then return with a vengeance with prolonged weight-bearing. The Windless test, which basically stretches the plantar fascia, has greater specificity done in weight-bearing. Investigations may help diagnosis if the pain lasts more than 3 months. Treatment includes modifying activities, wearing supportive shoes, avoiding walking barefoot on hard surfaces and jumping and running activities backed up by stretching exercises.

This systematic review used a population, intervention, control (comparison), and outcomes (PICO) question to search four databases: PubMed, ScienceDirect, Web of Science, and Scopus for musculoskeletal effects (muscular or joint function) of manual therapy on the diaphragm muscle. The initial search yielded a total of 1258 studies which were whittled down to nine randomised controlled trials that met the inclusion criteria. Most of the studies were conducted on participants without a specific pathology: three of them involved healthy adults, one involved sedentary women, one involved a condition that cannot be classified as pathologic (short hamstring syndrome), one used participants with chronic non-specific low back pain, and three studies used a sample of patients with respiratory disease.

Based on the critical evaluation with the PEDro scale, the methodological quality of three articles was considered very high with a very low risk of bias. Five studies were assessed as high quality with a low risk of bias. One study was considered of moderate quality with a high risk of bias. Six of the articles were critically reviewed by the PEDro database using their scores.

The results revealed that manual therapy directed to the diaphragm has been shown to be effective in terms of the immediate increase in diaphragmatic mobility, thoracoabdominal expansion and posterior muscle chain flexibility test in adults. There were also some limited improvements at the lumbar and cervical level in the ROM and in pain. Most of the interventions involved manual diaphragm release/stretching often based on the techniques written about by Leon Chaitow.

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Co-Kinetic comment This is one of those ‘all you need to know’ papers that we like. It goes on to discuss homeopathic remedies, which in Western medicine are seen as a pseudo-therapy and many national and international health bodies have recommended the withdrawal of government funding for homeopathy in healthcare including those in the UK, France, Spain and Australia. However, it clearly works for some people and maybe that is why it needs further investigation.

EFFECTS OF MANUAL THERAPY ON THE DIAPHRAGM IN THE MUSCULOSKELETAL SYSTEM: A SYSTEMATIC REVIEW. FernándezLópez I, Peña-Otero D, Atín-Arratibel MLÁ et al. Archives of Physical Medicine and Rehabilitation 2021;S0003-9993(21)00322-1

Co-Kinetic comment This is an excellent example of a systematic review in that it applies the PICO and PEDro tools to find and evaluate studies. It also shows that manual therapy is effective in a variety of pathologies. You have to go to the individual papers for detailed descriptions of the techniques or delve into the works of Chaitow. There is a lot of choice because ‘prolific’ does not begin to describe him.

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This study starts with the premise that inadequate reporting of interventions is a problem in biomedical research resulting in delayed or absent implementation of interventions with positive clinical patient outcomes mainly because there is insufficient information provided in the published articles.

To gauge whether or not this has changed over the last few years, the authors searched six journals for trials using physical therapy interventions that were published in 2000 and 2018. The journals were Archives of Physical Medicine and Rehabilitation, Clinical Rehabilitation, Journal of Orthopaedic & Sports Physical Therapy, Journal of Physiotherapy, Physical Therapy, and Spine. They were chosen because the authors believed they had a substantial influence within the physical therapy

HAS REPORTING ON PHYSICAL THERAPY INTERVENTIONS IMPROVED IN 2 DECADES? AN ANALYSIS OF 140 TRIALS REPORTING ON 225 INTERVENTIONS. McCambridge AB, Nasser AM, Mehta P et al. Journal of Orthopaedic and Sports Physical Therapy 2021;51(10):503–509 profession. In total, 140 articles that met selection criteria evaluated 225 interventions (2000, n=61; 2018, n=164). Two independent assessors scored them using the PEDro scale and the template for intervention description and replication (TIDieR) checklist and scores of the 2000 and 2018 journals were compared.

Their conclusion was that the reporting of physical therapy interventions in randomised controlled trials has not substantially improved since the TIDieR check list was published in 2014 with the intention of improving standards. The few meaningful improvements in reporting were in exercise-based interventions

A PROPOSAL FOR A NEW CLASSIFICATION OF THE CORACOBRACHIALIS LONGUS: A RARE CASE OR A NEW, DISTINCT MUSCLE? Zielinska N, Duparc F, Polguj M et al.

OPEN Annals of Anatomy 2022;239:151825 This paper proposes that we add a new muscle to the list. The coracobrachialis muscle is the smallest of the anterior arm muscles. As the name suggests, it runs from the coracoid process of the scapula to the humerus, and is characterised by a high level of morphological variabilities. One hundred upper limbs of human cadavers (60 females and 40 males) were dissected. The coracobrachialis was found in all the specimens, but a variation that the authors are calling coracobrachialis longus (CBL) was found in 11 of 100 specimens (four women and seven men; five left and six right). The CBL may be recognised as a distal part of the coracobrachialis muscle, originating from the anteromedial surface of the humerus; however, the two muscles are distinct from each other. The distal attachment of the CBL is longer and located closer to the elbow joint. The CBL muscle may also be inserted on to various structures including the olecranon and the medial epicondyle. It is speculated that the clinical significance of the presence of the CBL may be that there is a greater chance of brachial plexus block, lateral cord compression, and maybe the compression of some branches of the lateral cord, such as the musculocutaneous nerve.

Co-Kinetic comment Just when you thought you had learned your anatomy! The coracobrachialis is reported to be a vestige of when we walked on all fours and needed stronger forelimb muscles but does a variation in 11% of a small sample population constitute enough information to name a new muscle?

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in musculoskeletal and neurological physical therapy trials. Methodological quality of the trials was not related to completeness of reporting interventions.

Co-Kinetic comment The authors of this paper looked at only six journals. The total of journal titles we have reported on in the last 15 years is, at the time of writing, 361. That’s titles not editions, that figure runs to thousands. Almost every systematic review or meta-analysis reports poor methodological quality or the lack of homogeneous statistics to allow meaningful analysis.

Combine that with this paper’s conclusions that interventions even when they appear to have a suggested benefit are not being reported fully and you have to wonder what is the point in the vast quantity of so-called research.

THE EFFECT OF AN ACUTE BOUT OF FOAM ROLLING ON RUNNING ECONOMY. Biscardi LM, Wright BD, Stroiney DA. Topics in Exercise Science and Kinesiology 2021;2(1):article 4 Sixteen trained distance runners (31.5±12.2 years; VO2max 53.6±11.0) completed two treadmill runs at selfselected 5km race pace; one session with the use of preexercise foam rolling and the other with a controlled rest period before the run. Participants were instructed to refrain from vigorous exercise, caffeine and alcohol 24 hours before testing, maintain the same nutritional habits and wear the same running shoes for each session. Running economy is the energy demand needed during a submaximal bout of running, expressed as the submaximal VO2 at a given running speed. The protocol to measure it was a 4min run with a 1% incline at the participant’s

OPEN

self-reported 5k race pace.

The 1% incline was used to reflect the energetic cost of outdoor running.

The foam rolling protocol used a high-density roller which was applied bilaterally to the quadriceps, hamstrings, calves, and gluteal muscles for a duration of 90s per muscle group. It was performed by the participant using their body weight to apply pressure to soft tissues during the rolling motion. Pressure during rolling was self-determined by the participant who was instructed to roll to the point of pressure, but not pain. On average, this process took 12min.

Running economy was improved during the session with pre-exercise foam rolling applied.

Co-Kinetic comment Foam rolling has an effect. Sixteen may not seem like a large sample but the authors applied a power analysis (G*Power, Heinrich-Heine-Universität Düsseldorf) to determine the sample size. It would be nice if more researchers told us how they had determined their sample size.

Co-Kinetic Journal 2022;91(January):4-11

RESEARCH INTO PRACTICE

THE ACTIVE FUTURE FOR THE PASSIVE THERAPIST. Nicholls DA. Journal of Orthopaedic & Sports Physical Therapy 2021;51(7):318–321 This is an essay by Dr David Nicholls a physiotherapist who started his career with a Graduate Diploma in Physiotherapy from the Wolverhampton School of Physiotherapy in England and is now a Professor in the School of Clinical Sciences at AUT University in Auckland, New Zealand. He argues that the physical therapy profession may be at an inflection point. The current debate over ‘active’ and ‘passive’ therapies highlights once again how much physical therapy practices reflect shifting cultural and social attitudes.

The so-called ‘active’ approaches to therapy are promoted as holding higher value, because they offer the “best care for the patient, with the optimal result for the circumstances, delivered at the right price”. Hands-on, passive, treatments are seen as low-value care because it is claimed that they provide little or no benefit to the patient and their risks outweigh their benefits.

However, there is little agreement about what ‘low value’ means, and much of the research suggests that the idea of value is driven by economic rather than

social factors. This approach suits governments intent on reducing public expenditure and squeezing the welfare state making the label ‘low-value care’ deeply political.

Although it claims to be patient centred, most of the research to date has ignored the consumer’s voice and the reality is that many patients want skilled, trusted, hands-on care from well-trained practitioners they respect and can afford. Dr Nicholls’ final point is tied to the pandemic. Human connection through touch is one of the most distinctive aspects of physical therapy practice, particularly in orthodox

healthcare, where so much touch is procedural and incidental. After all the Covid protocols people may just want to be passive for a while and let someone else treat them in a way that has not been possible for weeks, months, or maybe even years.

Co-Kinetic comment Can we nominate Dr Nicholls for a knighthood? At last, we have someone advocating that the basis for the hands-off treatment of patients is all about money. It’s time we started asking the patients what they want.

FASCIAL THERAPY, STRENGTH EXERCISES AND TAPING IN SOCCER PLAYERS WITH RECURRENT ANKLE SPRAINS: A RANDOMIZED CONTROLLED TRIAL. Allois R, Niglia A, Pernice A et al. Journal of Bodywork and Movement Therapies 2021;27:256–264 Thirty-six federated footballers (all male with a mean age of 26.09 years, mean weight of 73.52kg and mean height of 176cm) with a medical record of recurrent ankle sprains were recruited and randomised to the two study groups. The experimental group (n=18) received an intervention using myofascial techniques applied to the subtalar joint, eccentric training with an isoinertial device and neuromuscular taping. The control group (n=18) was given an intervention using myofascial techniques on the subtalar joint and eccentric training with an isoinertial device. Each player received two 50min sessions per week over a 4-week period from the same physiotherapist. Each myofascial

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session lasted 10min. The technique was done with the patient in supine position: the physiotherapist positioned one hand on the subtalar region and the other hand mid-foot. With tibia–tarsus traction, taking the foot to eversion, a shearing motion was performed in the talus area, using a combined and slow technique. Results were recorded at baseline, after 4 weeks of intervention, and at the end of the 4-week followup period. There were statistically significant improvements in the experimental group in ankle mobility, strength and stability. The control group exhibited improvements in all study variables. No differences in the improvement of variables were found based on the allocation of athletes to one group or another.

Co-Kinetic comment

In the real (non-research) world, therapists use a variety of techniques on the same injury to get their players back on the field. It doesn’t really matter which one or more actually does the job as long as that player returns.

This study shows that this approach works.

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PROPORTION OF CANCER CASES ATTRIBUTABLE TO PHYSICAL INACTIVITY

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INFOGRAPHIC. PAIN OR INJURY? WHY DIFFERENTIATION MATTERS IN EXERCISE AND SPORTS MEDICINE

TIME-SAVING RESOURCES FOR PHYSICAL AND MANUAL THERAPISTS

Produced by:

The PDF version of this infographic includes hyperlinks to the individual pieces of research. Click here to access https://spxj.nl/3G7xGV4

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THE INFLUENCE OF RUNNING ON LOWER LIMB CARTILAGE: A SYSTEMATIC REVIEW AND META-ANALYSIS Sports Medicine

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FASTING DRIVES THE METABOLIC, MOLECULAR AND GEROPROTECTIVE EFFECTS OF A CALORIERESTRICTED DIET IN MICE Nature Metabolism

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FUNCTIONAL TRAINING METHODS FOR THE RUNNER’S MYOFASCIAL SYSTEMS FASCIA | S-C | RUNNING 22-01-COKINETIC FORMATS WEB MOBILE PRINT

By Dr Wilbour Kelsick BSc(kin) DC, FRCCSS(C) FRCCRS(C)

The importance of fascia and the fascial system in both movement and impaired movement has grown in recent decades along with the knowledge base about it to the point now that we understand that fascia, along with muscles, is involved in force transmission, which leads us to the role of the myofascial system.

The book Fascia in Sport and Movement second edition (edited

by Robert Schleip and Jan Wilke) is a compendium of the most up-todate information about the structure and function of fascia and its impact on improving strength, mobility and performance and reducing pain and injury, with contributions from 51 leading teachers and practitioners.

This article has been extracted from Chapter 31 ‘Functional training methods for the runner’s myofascial systems’ by Dr Wilbour Kelsick and will allow you to treat your runners’ injuries and to deliver performance improvements by developing training programmes for the body as a whole and not just strengthening one isolated segment. Read this article online https://bit.ly/3pCZFFp 14

Introduction

Running is big business and preparation is paramount to success in the sport. Participation has increased exponentially in the last 3 decades at both the amateur and the professional level. On average, runners cover ~110–130km a week but, at times, can be thwarted by a variety of injuries. First, it should be mentioned that running is a complex elastic/spring-like movement involving the whole body’s gait mechanism. An improved efficiency or energy-saving motion can be achieved when close to ideal elastic bounce in the running or walking gait is attained (discussed further in Chapter 8 of Fascia in Sport and Movement). The beauty of functional myofascial training is that it can not only prevent injuries but can also increase running efficiency and myofascial tissue fatigue resistance.

This article (extracted from Chapter 31 of the book) focuses on how functional myofascial training can address the elastic strength and coordination components of the running and walking mechanism (Chapter 30). Reference will also be made to the principles of biotensegrity (Chapters 11 and 36) as a means of explaining the mechanism of running and the behaviour of the body tissues, which allow it to happen.

Briefly, biotensegrity explains how the principles of tensegrity manifest in biological systems (Chapter 11): from viruses to cells and tissues of living systems (ie. plants and animals).

Biotensegrity integrates complex anatomy and biomechanics to make sense of living systems as a functional unit. From a biotensegrity perspective, any body movement (including walking, running and sprinting) is a continuous balancing dance of tension and compression forces within the body systems.

Running injuries are related to poor running technique and coordination,

minimal or poor elastic bounce, muscle (myofascial complexes) weakness (eg. hip abductors, quadricep/knee mechanism), imbalances of myofascial complexes in running structure (eg. pelvic trunk myofascial complexes), biomechanical faults (over-pronation of feet, valgus of the knee), micro-trauma from overuse, an inadequately trained elastic myofascial net, low resistance to tissue fatigue and overall diminished body global strength relative to impact cyclic loading. All of the above can influence each other, creating a collage of epidemiological causes for running injuries. Studies show that the majority of running injuries can be summed up as micro-trauma to collagenous tissues.

It has been well documented that over 70% of recreational runners will sustain an injury during a 1-year period. For instance, more than eight out of 10 running injuries are below the knee, suggesting some common mechanism might be the culprit. Based on the biotensegrity model, evidence does not support any one segmental region but more a global involvement of myofascial– skeletal running structures. Excessive pronation as a causative factor in overuse injuries is well documented.

Also, hip and pelvic complex mechanism weakness and imbalance, or poor stabilisation, are now believed to be one of the major links to lower body running injuries: for example, iliotibial band compression syndrome and patella femoral syndrome. The aforementioned studies indicate that the causes of the majority of running injuries are related, or have some link to, inefficiency in the structural integrity of the running mechanism (the myofascial–skeletal system). It is, therefore, clear that the prevention, prehabilitation and rehabilitation of such injuries must address these causes in a practical manner. This

Co-Kinetic Journal 2022;91(January):14-24

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leads to the proposed functional approach to train the runner’s fascia from a global prospective.

However, at this point, the following questions must be addressed: lW hat are the principles of running and how do they relate to global functional training? lW hat do we mean by functional training? lW hat is the purpose of strength training for runners? lW hat do we mean by myofascial training? lW hat global functional myofascial training is specific to runners?

What Are the Principles of Running and How Do They Relate to Global Functional Training?

Walking, running and sprinting are complex elastic movements involving the entire body. They involve a cyclic exchange between potential and kinetic energy (a storage and release mechanism). The bones, tendons and ligaments are some of the stiffest springs in the body. The movement in such activities is not incremental or segmental but involves the entire body in simultaneous global action.

Hence, training runners and sprinters cannot merely include exercises, which target segmental body parts, such as muscle groups (hamstrings, calves, etc.) or core (meaning abdominal muscle strength; ie. the six-pack look). Evidence has shown that such exercises do not target the true bio-movements of running and sprinting in an effective and functional manner. In fact, this type of segmental training creates more myofacial and biotensegral imbalances setting up a platform/environment in the body’s structure/architecture making it more prone to injury and substandard performance. The concept of global functional training is geared to address biotensegrity in the body’s myofascia architecture. Since the myofascial net infiltrates the entire body, and its elastic and sensorimotor properties are crucial to running, it makes sense that the global functional training method of training is an effective and efficient approach.

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What Do We Mean by ‘Functional Training’?

Functional training is exercise that is specific to the body movement you are attempting to execute.

In more detail, functional training describes the concept of using multi-joint exercise (ie. sportspecific exercises) which more closely reproduces the movement pattern of a sport (in our case running) and can be modulated to improve the sum of parts, all of the biomechanical movement pattern or physiological profile of the sport. For example, in running, the biomechanical pattern would be stride distance or frequency and the physiological profile would be aerobic power for a distance runner.

In functional training, exercise must be global (ie. using the whole body as much as possible) and not addressing isolated body regions.

In summary, functional training could be any sport-specific activity that moves an injured, deconditioned athlete or physically dysfunctioning individual towards safe return to sport or activities as soon as feasible.

What Is the Purpose of Strength Training for Runners?

Running performance is dependent not only on a combination of aerobic and anaerobic capabilities, which vary based on the distance of the event, but also on other factors related to lower and upper body power and strength, speed and coordination.

It has been documented that force and power are strongly correlated with running performance for short distances (ie. sprints, hurdles). For example, plyometric resistance and explosive strength training have shown significant improvements in sprint training performance (sprinting is not just about speed but strength, endurance, balance, etc.).

From observation, I firmly believe that strength training can help improve the trunk–pelvic complex, and hip and lower extremity strength both concentrically and eccentrically, so enhancing the structural integrity of the body’s biotensegral architecture and thus improving running efficiency and performance.

The mechanism for this improved

RUNNING IS A COMPLEX ELASTIC/SPRING-LIKE MOVEMENT INVOLVING THE WHOLE BODY’S GAIT MECHANISM performance in distance runners is thought to be related to improved muscle and tendon stiffness and the elastic properties of the fascial net (Chapter 7). Therefore, the evidence for adapting exercises that train the fascial tissue net, as well as muscles and tendons, is paramount in decreasing and preventing running injuries and improving running economy. It should be noted that speed of running is a function of strength and coordination.

Sport-specific strength training for running must take into consideration sensorimotor factor and movement pattern behaviours (ie. using global approach to exercise design) to guarantee the most transferrable effect of the training.

By contrast, middle and long distance running have received (have undergone or conducted) few studies that suggest force and power improve performance. However, a few welldesigned studies have recently revealed that explosive strength training can improve the running economy of middle and long distance runners to a significant degree and also strengthen elastic elements such as fascia, tendons and ligaments thus making them more robust to withstand repetitive loading and injury.

What Do We Mean by Myofascial Training?

In the past, training for athletes focused mainly on conventional cardiovascular fitness, muscular strength, power and neuromuscular coordination. The classical biomechanical tradition of considering the body as functioning in separate segments, with attached levers, and concepts of linear mechanics is no longer feasible in the light of new research on myofascial function in the whole body. Humans, like other species, are complex biological and biotensegral systems. You cannot train body parts in 15

isolation and expect to have efficient global functioning.

Running, in its true form, is mostly an elastic event. The mechanism of running involves the storing of energy during the deceleration or breaking phase (during foot ground contact) and the instantaneous release of energy during the lift-off phase initiated by ground reaction force (GRF) (Fig. 1). Using an elastic recoil technique (Chapter 7) will allow the runner to be more efficient, placing less stress on the musculoskeletal system and eventually decreasing injury risk.

Training for runners must be elastically functional and global in its approach, inclusive of the entire body, and not just the lower extremities or individual muscle groups. It should be considered as complex training targeting neural adaptation, coordination, strength and proprioception modes.

There is evidence to support that different myofascial elements are affected by different loading styles and that fascia has an important role in maintaining muscle function. Typical weight training loads the muscle in

In terms of biotensegrity, a body in motion (walking, running, climbing, swimming, etc.) is a continuous well balanced harmonic dance between tension and compression of its global myofascial net and other supporting tissues.

Compression Chest Region Compression Hip Complex Region

Eccentric

Concentric Dorsiflexion

Figure 1: Some key global and compression omni-directional external forces in a moving body Schleip and Wilke (eds). Fascia in Sport and Movement. Handspring 2021

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its normal range of motion, therefore strengthening fascial tissues arranged in series with active muscle fibres. This type of loading has minimal effect on the intramuscular fibres that are arranged in parallel to active muscle fibres and also extra-muscular fascia.

This evidence reinforces that, during functional training of the runner’s fascial net, exercises must have a dynamic varied loading pattern with rhythm to have an effect on the elastic components and resilience of the body’s myofascial net.

The concepts of global functional training for the runner arise from these insights. The global functional training programme, designed in this context, will address the running mechanism from a global perspective with exercises geared to train the runner’s elastic myofascial component as well as the muscle, ligaments, bone and tendons. The functional myofascial exercise protocol for the runner is carried out with a certain amount of rhythm and an explosive component.

Special attention is paid to the sportspecific movement pattern for running.

In maintaining form, or activated structural integrity, the body is able to set up its own internal and external anchor to create the dynamic stability needed as one segment generates power and the other provides stability. This creates the alternate-movement-pattern biology designed for running. This patterning is classified as the concentric/eccentric (dynamic/structural, stability/powergenerating) switching mechanism (between concentric and eccentric myofascial contraction) required for alternate body segmental movement in walking and running (Chapter 30).

As previously described, running and walking are a simultaneous balancing dance between tension and compression in harmony with concentric and eccentric movement patterns of the entire body myofascial net and other supporting tissues. This tension and compression mechanism is always engaged during static or dynamic activity based on the principles of biotensegrity (Fig. 1). In addition, the body’s tissues (which are soft matter) exhibit auxetic properties (ie. they expand when tensioned

(stretched) as opposed to shrinkingnarrowing).

What Global Functional Myofascial Training Is Specific to Runners?

It has been documented that the manner, slow or fast, in which connective tissue is loaded will determine whether the tissue will become more elastic or react with hypertrophy (ie. volume) (Chapter 14).

In nature, kangaroos and gazelles are excellent examples of elastic storage and the release of energy during their movement patterns (Chapter 8). The human myofascial net seems to have similar elastic behaviour (ie. kinetic energy storage and release) in our daily activities of walking, running or jumping. This justifies the approach of global functional training for the runner’s myofascial net using explosive, rhythmic-type exercise movement patterns.

The Functional Fascia Training Concept

The elastic behaviour of human fascia is now documented. It stores energy and returns it quickly, as seen in cyclic movements such as walking and running (Chapter 29).

Running elastically uses less muscle power, that is, less metabolic energy (glucose) and more of the elastic fascia feature of the tissue, thus storing and returning energy back during propulsion. Global functional training for runners’ fascia is designed to train the elastic myofascia net of the entire body (ie. muscle, tendons, ligaments and bones). The modes of exercise include bouncing or plyometric movements, preparatory countermovement, unilateral movement patterns, coordination drills, and other exercises which mimic the mechanism of running (eg. single-leg hops, singleleg squats, etc.). The exercise protocol avoids slow, jerky-type movement patterns, repetitive constant-angled movements, movement with mono tempo/rhythm, muscular dominant movement, segmental isolation-type movement pattern and minimises constant loading thus encouraging variable loading of the runner’s body.

This is in line with research suggesting Co-Kinetic Journal 2022;91(January):14-24

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that the fascial system is better trained by use of a variety of vectors/angles, loads and rhythm (Chapter 24).

We cannot delve into this topic without mentioning the importance that coordination, posture and technique play in enhancing running efficiency and performance. In a correct sprinter’s posture, for example, the athlete is at a considerable height off the ground in the flight phase, with a well-positioned body preparing for the landing phase (a very important body position to maximise horizontal distance travel through the air).

Although it is not possible to discuss the concept of running technique in this context in this article, it should be noted that it is a crucial piece of the puzzle in preventing running injuries and improving performance.

Exercise Protocol for Training the Runner’s Myofascial Net

Sports conditioning programmes need to be optimally individualised and specific because the limits of peak performance are highly variable even within the same discipline of sport.

As described above, the purpose of appropriate exercises is geared to enhance sensorimotor coordination and to strengthen the elastic components of the runner’s myofascial net. Energy is stored in the eccentric phase of motion and immediately released on the concentric phase. The exercises are preceded by an eccentric pre-stretch (counter-movement) (Chapter 24) that loads the muscle, tendon and fascia, preparing it for the ensuing concentric contraction. This coupling of the eccentric–concentric muscle contraction is known as the stretch-shortening cycle, which physiologically involves the elastic properties of the connective tissues (fascia, tendon) and proprioceptive reflexes. The fact that connective tissue has a high capacity of adaptability and resilience makes it ideal for this type of training where loading forces, shearing and strain are highly variable.

Connective tissue has the ability to continuously remodel its fibrous network when specific functional strain or load is applied to it (Chapter 4).

In designing any exercise strengthening programme, there Co-Kinetic.com

are some basic exercise prescription guidelines which must be taken into consideration and a few important questions that need to be asked: Why are you doing the activity? What is the goal of the activity? Is it for fitness maintenance or for competition?

Note that the basic principles of training will also apply here [ie. principles of adaptation (acute and chronic), specificity, overload, and progressive overload, stress-rest, contraction, control, coordination, ceiling, maintenance, symmetry and overtraining]. In this context we cannot address all these principles but they are found in detail in physiological texts on training.

First, exercise prescription must consider the total demands of the programme and ensure that the volume of exercise is not excessive, which can negatively interfere with the optimal physiological adaptation and performance. It should also consider the activity movement pattern, since complex systems like our bodies do not move in a linear manner or pattern.

To ensure an effective prescription, the following should be taken into consideration: l t he concept of periodisation of the training programme and goals of training; ld eveloping a well-planned exercise recovery and rest protocol by using the principles of periodisation; and lu nderstanding the balance between strength/power (intensity), coordination and aerobic and anaerobic (volume) training.

In addition, the key resistance training programme components should be considered when designing functional fascia-type exercises. These components are: 1. N eeds analysis: this addresses questions about the myofascial net, whole-body segments to be trained, the energy/metabolic systems involved (aerobic, anaerobic), the type of muscle action (eccentric or isometric). Also the principle that the body is a complex biological system and is non–linear.

2. A cute programme variables: this deals with choice, order, number of sets, rest period between sets and

THE BEAUTY OF FUNCTIONAL MYOFASCIAL TRAINING IS THAT IT CAN PREVENT INJURIES AND INCREASE RUNNING EFFICIENCY amount of load (intensity).

3. C hronic programme manipulation: this addresses the principles of periodisation as a means of designing long-term programmes.

4. A dministrative concerns: this deals with equipment needs in the gym (free weights, machineassisted resistance isokinetics, jump platforms, etc.).

Exercise Posture

These exercises are geared more towards middle distance and recreational runners, taking into consideration the concepts of transfer training and exercise specificity. The concept of practising one movement pattern to improve the efficiency of another movement pattern is known as ‘transfer of training’. For example, a runner will get little benefit from doing high-intensity seated rowing. Split squats or walking lunges, which are more similar to the movement pattern of running, would be more beneficial.

When exercise movement patterns are similar, this principle is known as ‘exercise specificity’. Specificity in athletic or any type of training is paramount and a main guarantee that one can achieve transfer of training.

Owing to space constrains in this chapter, only eight exercises have been documented.

All exercises are performed in a ‘closed kinetic chain’ posture to increase joint compressive forces, and to improve joint congruency and myofascial co-contraction/activation, which will overall enhance the dynamic stability of the body segments targeted although the entire body is involved (the global approach). The concept of transfer of training and exercise specificity is taken into consideration.

Proper foot placement is paramount.

The ankle should be in a ‘locked’ 17

position attained by dorsiflexion. This allows a stiff but dorsiflexed forefoot to contact the ground, instantaneously transmitting the GRF up the kinetic chain. This well-timed, coordinated action of the foot creates the stiffness in the lower extremity chain required to create reactive strength to receive the GRF. Such action ensures a pre-stretch and engages the elastic components of calf. Engagement/ activation of the neuromuscular components of the trunk, pelvis, pelvic floor and lower extremities is also necessary. The exercises are not segmental but address the entire body movement pattern of running.

Exercise Mode

All exercises are performed explosively with quick repeated rhythm/tempo to enhance the elastic effect on the muscular and fascial tissues.

Pre-Exercise Preparation

This preparation should be about 15min and consists of the following to enhance general body mobility, ankle and foot ground reactiveness: l3 –5min jogging; lu pper body alternating arm action (simulating arms during running) with rhythmic breathing; l l ow-amplitude ankle/foot bouncing with initial active dorsiflexion and plantar flexion when landing on ground; l s tanding lower extremity swings from hips; lw alking lunges with quick tempo; l s ideway scissors runs – lower extremity crossovers; ld ouble- and single-ankle hops with dorsiflexion of foot landing on balls of the feet; and lh ip mobility drills – flexion and extension hip swings.

Functional Training Exercises

Some of these exercises were developed in collaboration with the coach Gary Winckler (internationally renowned athletics coach and former Illinois and Florida State women’s track & field head coach). These exercises are designed to target and exploit the elastic components in the fascia net, muscle and tendon tissues. Execution must be explosive, rhythmic and reactive. Attention to global body posture and technique execution is crucial to achieve the full benefits.

Figure 2: Extended arm overhead pull: eccentric resistance for anterior abdominals/trunk Schleip and Wilke (eds). Fascia in Sport and Movement. Handspring 2021

Figure 3: (A) Quick step-ups and (B) walking step-ups Schleip and Wilke (eds). Fascia in Sport and Movement. Handspring 2021 18

Position/Posture Stand upright, engage trunk anterior

Start Position Stand facing away from the anchor of the elastic tubing or pulley weight cables, which is anchored at the height of extended forearm overhead.

Alternatively, you can use an individual assistant (as an anchor) to hold the tubing.

Movement Technique lF lex one hip with flexed knees (eg. like running stance) with your thigh in midline and your pelvis level. lC heck your alignment then begin to march or walk against the overhead resistance. l L ift the chest and chin up and look slightly upward so you feel the tension in the anterior abdominal wall complex. l I ncrease pace from a walk to a slow jog maintaining tension on the elastic strap at all times.

The key is to be as upright as possible and to try not to over-extend the spine/ trunk but maintain good tension of the elastic strap as you move forward. You can also use cable pulley weights for this exercise.

1. Extended Arm Overhead Pull with Resistance: Rectus Abdominis and Anterior Compartment Eccentric Strengthening (Fig. 2) Purpose This exercise builds anterior trunk anchoring eccentric strength for abdominal and lateral wall muscles (transversus, internal and external obliques), which transmit forces from the back structures (mainly the thoraco-lumbar fascia). The rectus abdominis, pelvis and hip complex all work eccentrically to improve balance, coordination and force transmission during the single-leg stance in the walking movement of this exercise.

and posterior musculature, pelvic floor and hip structures. Hands are overhead with extended elbows.

Dosage lS ets: 3–6 lR eps: 10–20 steps lR est: 1–2min.

2. Quick Step-Ups (Fig. 3)

Purpose This is a closed-kinetic-chain movement to strengthen trunk, pelvis, hip, knee, ankle and foot, and to improve coordination and balance in single-leg stance.

Position/Posture Stand upright and engage anterior and posterior trunk musculature, pelvic floor, hip structures.

Start Position Stand facing a step or box.

Movement Technique lP lace the foot of your front leg on the step/box (30–35cm) with your

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Figure 4: Double-leg hops over mini-hurdles Schleip and Wilke (eds). Fascia in Sport and Movement. Handspring 2021

thigh in midline and your pelvis level, back leg on ground. lC heck your alignment then quickly push with the back leg, lifting it off the ground and pushing your body straight upward. lS tep off with the leg that was first on the box. lR epeat alternating your legs. lT he key is to push off with the back leg/leg on the ground and not the front leg/leg on the box.

Dosage lS ets: 3–6 lR eps: 10–20 lR est: 1–2min.

3. Low-Amplitude Double-Leg Hop Over Mini-Hurdles (Fig. 4)

Purpose This is a plyometric drill, which initiates the stretch-shortening cycle of the lower extremity complex. This drill assists in developing elastic strength, speed and explosive power of the lower leg and the pelvis, especially the gluteals, hamstrings, quadriceps and gastrocnemius–ankle complex.

It enhances the elastic fascial components in the trunk, pelvis, hip, knee, ankle and foot.

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Position/Posture Stand upright and engage the trunk’s anterior and posterior musculature, pelvic floor and hip structures. Set up mini-hurdles 15–30cm high about one stride length apart.

Start Position Stand upright about half a stride length in front of the hurdles with shoulders slightly forward, head up. Elbows should be at 90° and hands at your sides with thumbs up.

Movement Technique lB egin by performing a countermovement downward and jump as high as possible, flexing legs so the feet arrive under the buttocks. Bring the knees up medium high and forward for each jump to ensure maximum lift. lT o land, ensure the ankle is dorsiflexed. Jump forward again with the same cycle of leg and foot pattern. lE xecute as rapidly as possible, always moving forward. lT he key is to gain moderate

height and maximum distance without affecting repetition rate.

Dosage lS ets: 3–6 lR eps: 10–20 lR est: 1–2min.

4. Double-Leg Ankle Hops (Fig. 5) Purpose This is a plyometric drill that initiates the stretch-shortening cycle of the lower extremity complex. It helps to develop elastic strength, speed and explosive power of the lower leg and gastrocnemius–ankle complex.

It enhances the elastic myofascial

Figure 5: Double-leg ankle hops Schleip and Wilke (eds). Fascia in Sport and Movement. Handspring 2021

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Figure 6: Single-leg ankle hops Schleip and Wilke (eds). Fascia in Sport and Movement. Handspring 2021

components of the lower knee, ankle and foot.

Position/Posture Stand upright and engage the trunk anterior and posterior musculature, pelvic floor and hip structures.

Start position Stand upright with both feet on the ground and hands by your side.

Movement technique Push off the ground and immediately dorsiflex the ankle joint. The knee should be in extension. On landing, ensure your foot is dorsiflexed and land on the balls of your feet. Repeat the sequence rapidly, maintaining an extended knee. Remain basically in the same spot.

Dosage lS ets: 4 lR eps: 15–30 lR est: 2min.

5. Single-Leg Ankle Hops (Fig. 6) Purpose This is a plyometric drill that initiates the stretch-shortening cycle of the lower extremity complex. It helps

to develop elastic strength, speed and power of the lower leg and gastrocnemius–ankle complex.

It enhances the elastic fascial components of the lower knee, ankle and foot.

Position/Posture Stand upright and engage the trunk’s anterior and posterior musculature, pelvic floor and hip structures.

Start Position Stand upright with both feet on the ground and hands by your side.

Movement Technique Push off the ground on one leg, only leaping forward and immediately dorsiflexing the ankle joint. Try to land one stride length ahead on the ball of your foot. The knee should be in extension. On landing, ensure your foot is dorsiflexed and land on the push-off leg on the ball of your feet. Repeat the sequence rapidly, maintaining an extended knee and alternating legs.

Dosage lS ets: 4 lR eps: 15–30 lR est: 2min.

6. Jumping Split Lunges on the Spot (Video 1)

Video 1: Jumping split lunges (Courtesy of YouTube user CasallTraining) https://www.youtube.com/ watch?v=kVx92DcS7f0 20

Purpose This is a plyometric drill, which initiates the stretch-shortening cycle of the hip and lower extremity complexes. This drill helps to develop elastic strength, speed and power of the lower leg and pelvis, especially the hip flexors, gluteals, hamstrings, quadriceps and gastrocnemius–ankle complex. It enhances the elastic strength of fascial components in trunk, pelvis, hip, knee,

ankle and foot complexes. The goal is to attain maximum height.

Position/Posture Stand upright and engage the trunk anterior and posterior musculature, pelvic floor and hip structures, as in the previous exercises.

Start Position From a standing parallel foot position with feet shoulder width apart get into lunge posture. Step forward with the left leg with the knee flexed at 45–90°, and the hip flexed at about the same degree, and so your right back hip is now extended (to a comfortable near maximum range of motion) and the knee of the back right leg is also flexed at 45–90°. In this position you are maintaining an upright/erect and engaged trunk and pelvis. Your arm positioning is important. The right arm (on the opposite side of the leg that you stepped forward on) should be forward, flexed 40–60° at the shoulder and 90° at the elbow. The left arm (on the same side of the leg that’s in front) should be extended back at about 50–60° at the shoulder and with 90° flexion of the elbow (basically your posture should be the running stance).

Movement Technique The goal is to jump into the next lunge position landing on the same area/spot by pushing off the back leg explosively lifting your body into the air and again landing in a lunge position. Using counter-movement technique, drop down into a lunge position and stop that movement subsequently exploding upward as far as you can with a scissor-like motion.

Note while in the air you need to execute a scissor action. Quickly move the left hip which was in flexion into Co-Kinetic Journal 2022;91(January):14-24

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repeat the sequence, initiating the pushing phase on the front leg to propel the body forward. Cover about 30–40m.

Dosage lS ets: 4 lR eps: 15–30 (30–40m) lR est: 2min.

8. Alternate Leg Box Jumps (Fig. 8) extension and the extended right hip into flexion before landing again in a lunge posture but this time your right hip and leg is now in front (flexed right hip) and your left hip and leg are now in the back (extended left hip). This scissors movement (alternating leg position front and back) is repeated continuously for the desired number of reps. It is important during landing (which should be on the balls of the feet) and pushing off that the ankle complex is held in dorsiflexion posture as much as possible. This exercise can be performed by moving the forward covering distance but is much more demanding (as for quick walking lunge) for desired number of repetitions.

Dosage lS ets: 4 lR eps: 1–5 lR est: 2min.

7. Quick Walking Lunge (Fig. 7)

Purpose This is a closed-kinetic-chain movement in the lower extremity complex. It helps to develop the elastic strength, speed and power of the lower leg and pelvis, especially the hip flexors, gluteals, hamstrings,

quadriceps and gastrocnemius–ankle complex. It enhances the elastic strength of myofascial components in trunk, pelvis, hip, knee, ankle and foot.

The goal is to attain a good rhythm.

Position/Posture Stand upright and engage the trunk’s anterior and posterior musculature, pelvic floor and hip structures as in the previous exercises.

Start Position Place feet shoulder width apart, bend one leg to 90° at the hip and 90° at the knee, attaining more or less a running stance.

Movement Technique Lunge forward quickly with the nonweight-bearing leg. As soon as contact is made with the ground, recover the hind leg and use it to repeat the lunge.

Land with feet/ankle in dorsiflexion so you land on the balls of the feet in a split lunge position and immediately

Purpose This is a plyometric drill that initiates the stretch-shortening cycle of the lower extremity complex. This drill helps to develop the elastic strength, speed and explosive power of the lower leg and pelvis, especially the hip flexors, gluteals, hamstrings, quadriceps and gastrocnemius–ankle complex. It enhances the elastic fascial components in the trunk, pelvis, hip, knee, ankle and foot.

Position/Posture Stand upright and engage the trunk anterior and posture musculature, pelvic floor and hip structures.

Start Position Stand upright on one leg, with one leg in front of the other, as if taking a step.

Shoulders are oriented slightly forward and head faces upwards.

Arms are at the sides.

Movement Technique Begin the exercise by pushing off with

EXECUTION OF FUNCTIONAL TRAINING EXERCISES MUST BE EXPLOSIVE, RHYTHMIC AND REACTIVE

Figure 7: Quick walking lunge Schleip and Wilke (eds). Fascia in Sport and Movement. Handspring 2021

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Figure 8: Alternate leg jumps Schleip and Wilke (eds). Fascia in Sport and Movement. Handspring 2021

OVER 70% OF RECREATIONAL RUNNERS WILL SUSTAIN AN INJURY DURING A 1-YEAR PERIOD

the back leg. Drive the knee up to the chest to achieve maximum height and distance before landing. Quickly extend the driving foot outward. Cycle the arms in contra-lateral motion in the air for balance. Repeat the sequence using alternate legs on landing.

Dosage lS ets: 2–4 lR eps: 8–12 (40m) lR est: 2min.

Summary

Speed is a composite of strength and coordination. Walking, running and sprinting are movements in complex biological systems where the principles of biotensegrity (internal omni-directional forces, tension and continuous compression) function in a harmonic dance of balance, to maintain the integrity of the body’s architectural systems during motion.

In addition these internal forces prepare the body’s closed-kineticchain system to absorb, transmit and create movement from the external GRF. Effective training for runners must address complex global movement pattern similar to running and not individual muscle groups.

Training the myofascia net re-enforces strength and enhances elasticity of the biotensegral architecture of the running body systems. This, in turn, results in improved running economy 22

and efficiency and decreases running injuries.

Acknowledgement

All figures have been published with permission from Handspring Publications. Video 1 (courtesy of YouTube user CasallTraining) was not part of the author’s chapter in the book Fascia in Sport and Movement.

Bibliography

Owing to space limitations, we have provided a bibliography of the more recent references used in the book chapter from which this article was created. Please see Chapter 31 ‘Functional training methods for the runner’s myofascial systems’ of the book Fascia in Sport and Movement, second edition, for the full reference list.

1. Arampatzis A, Peper A, Bierbaum S et al. Plasticity of human Achilles tendon mechanical and morphological properties in response to cyclic strain. Journal of Biomechanics 2010;43(16):3073–3079 2. Buchheit M, Mendez-Villanueva A, Delhomel G et al. Improving repeated sprint ability in young elite soccer players: repeated shuttle sprints vs. explosive strength training. Journal of Strength and Conditioning Research 2010;24(10):2715– 2722 Open access https://spxj. nl/31nPkVG 3. Dumke CL, Pfaffenroth CM, McBride JM et al. Relationship between muscle strength, power and stiffness and running economy in trained male runners.

International Journal of Sports Physiology and Performance 2010;5(2):249–261 4. Ferber R, Noehren B, Hamill J et al.

Competitive female runners with a history of iliotibial band syndrome demonstrate atypical hip and knee kinematics. Journal of Orthopaedic and Sports Physical Therapy 2010;40(2):52–58 Open access https:// spxj.nl/3xStJAI 5. Ferrauti A, Bergermann M, FernandezFernandez J. Effects of a concurrent strength and endurance training on running performance and running economy in recreational marathon runners. Journal of Strength and Conditioning Research 2010;24(10):2770–2778 Open access https://spxj.nl/31q536q 6. Fletcher JR, Esau SP, MacIntosh BR. Changes in tendon stiffness and running economy in highly trained distance runners.

European Journal of Applied Physiology 2010;110(5):1037–1046 7. Franklin DW, Wolpert DM. Computational mechanisms of sensorimotor control.

Neuron 2011 3;72(3):425–442 Open access https://spxj.nl/3DofJzw 8. Hrysomallis C. The effectiveness of resisted movement training on sprinting and jumping performance. Journal of Strength and Conditioning Research 2012;26(1):299–306 Open access https://spxj.nl/3DkdgWW 9. Huijing PA. Epimuscular myofascial force transmission between antagonistic and synergistic muscles can explain movement limitation in spastic paresis. Journal of Electromyography and Kinesiology 2007;17(6):708–724 10. Kelly CM, Burnett AF, Newton MJ. The effect of strength training on threekilometer performance in recreational women endurance runners. Journal of Strength and Conditioning Research 2008;22(2):396–403 Open access https://spxj.nl/3lwezMo 11. Legramandi MA, Schepens B, Cavagna GA. Running humans attain optimal elastic bounce in their teens. Scientific Reports 2013;3:1310 Open access https://go.nature.com/3ECPCGE 12. McBride JM, Blow D, Kirby TJ et al.

Relationship between maximal squat strength and five, ten, and forty yard sprint times. Journal of Strength and Conditioning Research 2009;23(6):1633– 1636 Open access https://spxj.nl/3diVQj0 13. Mikkola J, Vesterinen V, Taipale R et al. Effect of resistance training regimens on treadmill running and neuromuscular

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performance in recreational endurance runners. Journal of Sports Sciences 2011;29(13):1359–1371 14. Scarr G. Biotensegrity: the structural basis of life, 2nd edn. Handspring Publishing 2014. ISBN 978-1-909141-841. Buy from Handspring https://spxj.nl/3ojFA7t 15. Schleip R. Fascial plasticity – a new neurobiological explanation: part 1. Journal of Bodywork and Movement Therapies 2003;7(1):11–19, 7(2): 104–116 16. Schleip R. Fascial plasticity – a new neurobiological explanation: part 2. Journal of Bodywork and Movement Therapies 2003;7(2):104–116 17. Stecco A, Gilliar W, Hill R et al. The anatomical and functional relation between gluteus maximus and fascia lata. Journal of Bodywork and Movement Therapies 2013;17(4):512–517 18. Taipale RS, Mikkola J, Nummela A et al. Strength training in endurance runners.

International Journal of Sports Medicine 2010;31(7):468–476.

RELATED CONTENT

lB iotensegrity and Human Movement: The Importance of Closed Kinematic Chains [Article] https://spxj.nl/3583B7D lF ascia: What it is and Why it Matters [Article] https://spxj.nl/31o2SAa l Connectivity: Fascia-Related Therapies [Article] https://spxj.nl/3ojTnep

THE AUTHOR Dr Wilbour Kelsick BSc(kin) DC, FRCCSS(C) FRCCRS(C) is the founder and spiritual core of the MaxFit Movement Institute. He has been working with Canadian National and Olympic teams as a member of the official medical staff for over 25 years. He has worked at ten Olympic Games on the medical staff. In addition he has been a sports medicine consultant with Olympic athletes from USA, Africa, Caribbean, and Sweden to name a few. His education and experience position him perfectly for this role. Wilbour

Co-Kinetic.com

DISCUSSIONS

l With the knowledge of fascia and connectivity, assess the injuries or niggles of some of your patients in relation to their running. Could their problems be caused by issues elsewhere along the kinetic chain? l If you have a patient who is a runner, what programme of exercises would you develop to protect them from injury and also to boost their performance? l Many runners will know of the benefit of strength and conditioning, but are they aware of the need to develop elastic bounce and how would you explain this to them?

KEY POINTS

lR unning is a complex elastic/spring-like movement involving the whole body’s gait mechanism. lA ttaining the ideal elastic bounce in the running gait delivers improved energy efficiency. lA lthough the majority of running injuries appear to occur below the knee, these injuries can be influenced by hip and pelvic complex weakness or imbalance. lR unners should not only do exercises that target different body segments, as this kind of segmental training can create further myofascial and biotensegral imbalances. lF unctional training is exercise that is specific to the body movement you are attempting to execute, and more closely reproduces the sport-specific movement pattern. lF unctional training should use the whole body as much as possible. lS trength training for the trunk–pelvic complex improves running efficiency and performance by enhancing the structural integrity of the body’s biotensegral architecture. lT he best way to prevent/treat runners’ injuries and deliver performance improvements is through global functional myofascial training. lG ood posture is important when performing functional training exercises.

Kelsick’s network of colleagues and friends, gathered in his more than 35 years as a health practitioner, expands what he can offer. He has presented extensively and conducts workshops in Europe, Australia, the Caribbean and Africa. He has been a lecturer and presenter at Ulm university summer school for several years, as well as Connect 2013 Sports Conference, and fascia congresses.

Wilbour Kelsick received his BSc in Kinesiology from Simon Fraser University, his Doctor of Chiropractic Medicine from the

Canadian Memorial Chiropractic College. His two specialties are sports medicine and rehabilitative medicine and he is a Fellow of the College of Chiropractic Sports Sciences (Canada) and the College of Chiropractic Rehabilitative Sciences (Canada).

Email: info@maxfitmovement.ca Twitter: @MaxFit Movement https://twitter.com/MaxFitMovement LinkedIn: Wilbour Kelsick https://www.linkedin.com/in/wilbourkelsick-27763819/ Website: MaxFit Movement Institute https://maxfitmovement.ca/

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Fascia in Sport and Movement, second edition Robert Schleip and Jan Wilke (editors) Handspring Publishing 2021; ISBN 978-1-912085-77-4 Buy it from Handspring https://www.handspringpublishing.com/product/fascia-in-sport-and-movement-second-edition/

Edited by Robert Schleip and Jan Wilke, Fascia in Sport and Movement, second edition, is a unique publication, whose strength lies in the breadth of its coverage, the expertise of its authorship and the currency of its research and practice base. l I t is a multi-author book with contributions from 51 leading teachers and practitioners across the entire spectrum of bodywork and movement professions. l I t provides the most up-to-date information to support success in teaching, training, coaching, strengthening, tackling injury, reducing pain, and improving mobility. l I t explains and demonstrates how an understanding of the structure and function of fascia can inform and improve clinical practice. l I t provides knowledge and understanding to enable better expert management of soft tissue injuries. l I t explores how different activities influence the body’s soft tissue matrix, and investigates the types of injuries which may occur. l I t is a truly essential resource for all bodywork professionals – sports coaches, fitness trainers, yoga teachers, Pilates instructors, dance teachers and manual therapists.

CONTENTS Section 1 Theory 1. Highlights of fascial anatomy, morphology and function 2. Surprising facts about fascial physiology and biochemistry 3. Sex hormonal effects on tendons and ligaments 4. Stress loading and matrix remodeling in tendon and skeletal muscle: Cellular mechanostimulation and tissue remodeling 5. Mechanical loading and adaptive responses of tendinous tissues 6. Nutrition and loading to improve fascia function 7. Hypo- and hypermobility 8. Elastic storage and recoil dynamics 9. Water and fluid dynamics in fascia 10. What is it good for? An evidencebased review of stretching in sport and movement 11. Biotensegrity in sport and movement 12 Myofascial continuity: Towards a new understanding of human anatomy 13 Mechanical force transmission across myofascial chains 14. Myofascial force transmission to synergistic and antagonistic muscles 15. Fascia as sensory organ

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16. Fascia and musculoskeletal injury: An underestimated association?

17. Classification of athletic injuries to muscular tissues 18. Fascia, exercise and oncology Section 2 Assessment Methods 19. Assessment of joint mobility 20. Imaging techniques (ultrasound) 21. Mechanical assessment 22. Palpation and functional assessment methods for fasciarelated dysfunction Section 3 Clinical Application 23. Integrating clinical experience and scientific evidence – Roadmap for a healthy dialog between health practitioners and academic researchers 24. Fascial Fitness 25. Basic principles of plyometric training 26. Eccentric training: The key for a stronger, more resilient athlete?

27. Foam rolling and roller massage effects and mechanisms 28. Fascial stretching 29. Food for the fascia: Molecular and biochemical processes 30. Walking: The benefit of being on two legs

31. Functional training methods for the runner’s myofascial systems 32. Shoes or no shoes during locomotion and exercise – Training potential for fascial structures of the lower extremity 33. Overarm throwing in humans 34. The secret role of fascia in the martial arts 35. The world as a playground: Ninja and parkour training 36. Anatomy Trains in motion 37. Fascial form in yoga 38. Yin yoga as a fascia-oriented practice 39. Fascia-focused Pilates training 40. Three-dimensional fasciaoriented training 41. Dance 42. Kettlebell training 43. Fascia-oriented strength training in a conventional gym environment 44. Rehabilitation in sport medicine 45. How to train fascia in soccer 46. Movement therapy for breast cancer survivors 47. Mental imagery, fascia and movement 48. Periodized fascia training for speed, power, and injury resilience

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I

mproving physical performance through effective training programmes has been the focus of research over past decades.

Maximising performance capacity of an individual, at any level of sport, is not simply a matter of training, but is a fine balance between training, competing and recovery. Stresses, both physiological and psychological, accumulated by the training load can lead to maladaptation if that balance is not achieved.

Sport specialisation has become the norm, often resulting in an increase in training specificity, frequency and intensity that can place the athlete at risk of overtraining, and injuries.

Appropriate training schedules with dedicated time for recovery, rest and optimal nutrition can help prevent problems from developing.

Demanding training and competition schedules have resulted in more recent research on recovery in order to maximise training potential and performance. This may be especially relevant for marathon and ultramarathon runners, multi-day stage events and cycling, adventure racing, and other sports that require highlevel performance in consecutive sessions including swimming and CrossFit. The average recreational or amateur athlete is not exempt from this need for recovery. The intensity and frequency may be different to that of a professional, but the loads and strain their bodies are accustomed to also result in cumulative fatigue, pain and stiffness.

Recovery is multifaceted. It is defined as “a component of sports training that through the targeted use of physiological effects means to restore the homeostasis of the body to pre-competition or training level; not only attaining that level, but to a superior one (overcompensation) which represents optimisation time for restoration” (1*). Recovery includes

DIY SPORTS RECOVERY

Massage is a useful aid to training/sport recovery and is increasingly being seen as relevant to recreational athletes as well as elite professionals. However, the traditional barriers to massage (cost, time, access to a professional) combined with the advent of doing everything at home during the Covid-19 pandemic have increased the popularity of ‘self-massage’. For the massage professional this might not seem like a great idea, but if this is what your client want to do we have to respect their choice. This article will help you to educate your patients to perform self-massage safely, even if they can’t do it as effectively as a trained professional. Read this article online https://bit.ly/3puEMvY

By Kathryn Thomas BSc MPhil both physiological and psychological components. It may involve passive methods, from external application (massage, for example) or active recovery (such as a cooldown jog or swim). Proactive recovery brings in a component of psychological and social activities that may require self-discipline – by choosing not to go out drinking and dancing at a party all night, to opting for activities that bring you joy, fun and relief from

training stress. Cryotherapy and manual therapy techniques, including massage, foam rolling and the use of massage devices, are all beneficial in aiding an athlete’s recovery. This article will discuss the popularised ‘selfmassage’ and massage devices that may be beneficial for recovery.

Recovery Massage

Multiple forms of hands-on manual therapy techniques exist. These

22-01COKINETIC | MASSAGE FORMATS WEB MOBILE PRINT All references marked with an asterisk are open access and links are provided in the reference list

MANUAL THERAPY TECHNIQUES, INCLUDING MASSAGE, FOAM ROLLING AND THE USE OF MASSAGE DEVICES, ARE ALL BENEFICIAL IN AIDING AN ATHLETE’S RECOVERY Co-Kinetic.com

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therapeutic techniques are used to treat and prevent sports pathologies and dysfunction associated with overuse and biomechanical deficits.

They are applied to alleviate hypersensitivity in myofascial tissues, promote tissue healing, decrease pain, release scar tissue and adhesions, improve joint range of motion (ROM) and functional performance, reduce delayed onset muscle soreness (DOMS), and accelerate recovery.

Manual therapy is used to restore mobility, improve motor control, reduce pain, and improve movement efficiency. The skilled techniques include manipulation and joint mobilisation, soft tissue massage, lymphatic drainage, and passive and assisted functional movement.

The benefits of manual therapy are believed to go beyond the skilled treatment to the virtues of touch and physical connection with a patient that impacts healing. The mainstay of musculoskeletal rehabilitation is often a combination of manual and exercise therapy.

On the one hand, chronic injuries can occur from repetitive strain, excessive tension, overload or overuse.

On the other hand, acute injuries are often severe and of sudden onset, for example lateral ankle sprain or knee ligament rupture. Following an injury inflammation and new cell proliferation occurs, during which fibrosis and scar formation ensues. Reduced tissue elasticity and adhesions can result, leading to soft tissue dysfunction and pain. Scar tissue can limit perfusion within soft tissues, restricting oxygen and nutrient supply, and interfering with collagen synthesis and regeneration. Ultimately this can lead to incomplete functional recovery and increased risk of reinjury.

Sports massage is pervasive within elite sport and increasingly common at age-group and amateur level.

Therapeutic massage is believed to benefit athletes by enhancing

performance, reducing injury risk and improving recovery, as well as promoting rest through biomechanical, physiological and psychological mechanisms. There is limited scientific data supporting improvements in performance and injury prevention with massage (2*,3*). A small but significant improvement in flexibility is shown with massage. This is based on increased ROM at a joint which may be beneficial for some athletes such as ballerinas or gymnasts. However, too much flexibility in some sports, such as running, has been suggested to be detrimental and can increase injury risk (3*).

Sports massage is, however, beneficial in reducing or preventing DOMS, which will in turn aid in recovery (3*). A combination of massage, cold water immersion and pneumatic compression can also be effective in reducing symptoms of DOMS, although some research indicates active recovery is superior to massage in decreasing blood lactate and facilitating recovery (3*).

Although active recovery, compression garments, and cryotherapy are all beneficial, massage has been found to be the most powerful technique for recovering from DOMS and fatigue (4*).

Traditionally, athletes have voiced their belief that massage reduces stiffness, improving performance and recovery (5*). Massage increases plasma endorphin levels, so whether its perceived benefit is due to this or a placebo effect from ‘hands-on’ therapy, the true value may be the positive influence on an athletes psychology. For many individuals, sports massage for maintenance or recovery may seem a luxury rather than a necessity. Some may also view it as something for the elite, professional athlete and not your ‘everyday’ athlete. Massage, though, may benefit anyone who is feeling tired and flat from training or has some niggles and

RECREATIONAL ATHLETES ARE ALSO REALISING THAT MASSAGE IS BENEFICIAL AND THAT IT IS NOT JUST FOR ELITE PROFESSIONALS 26

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stiffness after a heavy or long session.

However, massage can be costly, time-consuming, inconvenient and be limited by accessibility to a professional therapist. Owing to these challenges, and potentially following the advent of home exercise subsequent to Covid-19, individuals are more often looking for solutions to self-massage leading to the increased popularity in foam rollers, and massage devices or instruments to facilitate this.

1. Foam Rolling

Foam rolling (FR) has become a regular practice in a variety of sports settings. Used by both elite and recreational athletes, its popularity stems from its affordability, ease of use, and time-efficiency (‘can do it anytime, anywhere’), combined with its perceived benefit of enhancing performance and recovery. FR is a form of self-massage in which the targeted muscles are rolled and compressed using the device. Common tools include the foam roller, which come in several sizes and foam densities, as well as various roller massage bars or sticks.

The mechanisms behind FR may include mechanical effects comprising a reduction in tissue adhesion and altered tissue stiffness. It is believed that FR enhances analgesic effects and muscle recovery through neurological pathways facilitating pain-modulatory systems. Physiological responses to FR include increased blood flow and parasympathetic circulation. A psychological component is thought to improve perceptions of wellbeing and recovery through increases in plasma endorphins, and/or placebo effect (6,7*,8*,9*).

Clinical Application

Although FR is considered to improve athletic performance as well as recovery there is no consensus on its benefits – whether it’s before activity (pre-rolling warm-up) or after an intense bout of exercise (postrolling recovery). The largest average effect from pre-rolling was related to flexibility with a Hedges’ g of 0.34. This indicates that 62% of the Co-Kinetic.com

population will experience short-term improvements in flexibility when using pre-rolling as a pre-exercise warm-up (9*). Improving flexibility, in the short term, without negatively affecting performance can be achieved with pre-rolling (9*). To achieve the greatest ROM, the following FR prescriptions are advised: 1–3 sets of repetitive rolling over the length of the body part, with a total rolling duration of 30–120s per set (10). Prolonged FR of more than 5min results in subsequent decrease in vertical jump performance; however, 1min of FR results in vertical jump performance remaining unchanged (6). Therefore, if power output is a critical requirement in subsequent exercise or performance, prolonged FR (ie. 5min or more) should be avoided. Individuals should be mindful of this when prescribing FR within warm-ups.

Exercise-induced decreases in sprint, jump and strength performance can be minimised with post-rolling.

Sixty-two per cent (Hedges’ g of 0.34) and 58% (Hedges’ g of 0.21) of the population will experience accelerated recovery of sprint and strength performance respectively when using post-rolling. Compared with passive recovery, FR after exercise can facilitate a more rapid recovery (9*).

FR has been shown to be most effective in reducing muscle pain (Hedges’ g of 0.47) (9*). Muscle soreness can produce negative outcomes, including altered muscle function, reduced athletic performance and training intensity (8*). FR seems to be effective at enhancing lactate clearance and counteracting DOMS. The type of foam roller, whether it is smooth surfaced, multilevel or GRID roller, seems to influence the recovery rate with the multilevel and GRID rollers providing slightly greater effect (11*,12).

Recently vibrating foam rollers (VFRs) have been developed providing local vibration that targets a specific muscle group. Studies have shown that VFRs produce greater improvements in ROM and reduced pain perception compared to non-vibrating FR in both healthy active individuals and those

Figure 1: Example of a percussive massage device being used

FOR SHORT-TERM IMPROVEMENTS IN FLEXIBILITY, WITHOUT DECREASING MUSCLE PERFORMANCE, AS WELL AS POTENTIALLY IMPROVING SPRINT PERFORMANCE, PREROLLING IS AN EFFECTIVE WARM-UP STRATEGY with exercise-induced muscle damage (DOMS) (13,14*).

Safety and Side Effects

There are potentially no serious side effects from FR, with a low or zero attrition rate in clinical trials. However, care should be taken by athletes and individuals, as it is suggested that during FR all underlying tissue is mechanically stressed. The foam roller or stick does not discriminate across tissues, potentially leading to damage of nerve tissue, receptors, vessels, or bones. This may be a greater risk in patients with diabetes, varices or osteoporosis (15).

Conclusion

For short-term improvements in flexibility, without decreasing muscle performance, as well as potentially improving sprint performance, prerolling is an effective warm-up strategy.

Recovery rates of performance measures including speed and strength following post-rolling are significant enough to be relevant to athletes. Simply relieving 27

muscle soreness after exercise endorses the use of FR. The psychological aspect that an athlete feels less pain plays an important role in most sports, albeit in the absence of fully understanding the underlying mechanisms and physiological benefits of FR. FR research varies across intervention protocols (eg. devices, duration) combined with different exercises, outcome measures, and populations making it difficult to compare the results. The heterogeneity of study designs has resulted in no consensus on the optimal FR intervention (ie. in terms of treatment time, pressure and cadence, etc.).

The existing literature does, however, provide some evidence to support the use of FR in sports practice.

2. Percussive Massage

Recently hand-held percussive massage treatment has gained popularity in the therapeutic and athletic arena.

Different manufacturers, for example Therabody (makers of Theragun) and Hyperice (makers of Hypervolt), provide percussion devices marketed for use by therapists or for self-massage (Fig. 1). Devices can vibrate at different frequencies up to 53Hz. Depending on the tissue being treated (ie. soft tissue vs bony area) different attachment heads can be fixed to the device. Percussive massage treatment is presumed to combine the elements, and extrapolate the benefits of conventional massage and vibration therapy. In so doing it is believed that the use of a percussive massage device will reduce pain, increase blood flow, improve scar tissue, decrease lactate, reduce muscle spasm, increase lymphatic flow, inhibit the Golgi reflex, increase ROM and improve recovery. However, the research on percussive massage application is very limited.

Based on conventional massage mechanisms, percussive devices are thought to increase ROM through

biomechanical changes (ie. a reduction in muscle compliance), physiological (ie. increased blood flow), neurological (ie. reduction in perception of pain), and psychological changes (ie. increased relaxation) (16*). The assumed thixotropic effects, seen with FR or stretching may further explain the increase in ROM following percussive massage treatment (17). Percussive massage, similar to FR, induces pressure and friction to the treated area which may impact fluid viscosity and lead to reduced resistance to movement (17). Increased ROM experienced with vibration therapy may be attributed to a decrease in pain perception (13).

Thus, the benefits seen with percussive massage treatment may be explained by a decrease in muscle stiffness, as well as changes in pain perception.

Clinical Application

There is, in general, limited scientific evidence for the use of percussive massage devices, even more so in sports performance. Sports massage can improve DOMS and provide acute increases in ROM which may aid recovery. However, improvements in performance (strength, jump, sprint, endurance) and fatigue parameters are not achieved through sports massage (3*). Nevertheless, vibration therapy of the whole body (by standing on a plate) or specific muscles using a vibrating foam roller can increase ROM (13,16*), and compared to conventional massage, vibration therapy can also enhance strength parameters (18). Based on the above, can the combined effects of massage and vibration therapy be extrapolated to percussive massage devices?

In promoting a dynamic warmup the effectiveness of hand-held percussion massage, administered for 5min, had no effect on performance measured by vertical jump height (19).

These findings on muscle performance

are similar to the results seen with conventional massage (3*), but differ from the findings on vibration therapy (13), where an increase in strength has been shown.

During lower extremity resistance training, inter-set FR may actually hinder performance and increase perceived exertion (20*). However, percussive massage performed between consecutive sets of bench press, did not show differences in movement velocity (an optimal indicator of an athlete’s state of physical fatigue indicative of altered neuromuscular qualities); there was, however, an improved response in muscle endurance, with a greater number of repetitions per set (21*).

Percussive massage has shown a potential effect in reducing stiffness and restoring muscle compliance thereby creating an environment for muscle recovery between sets during resistance training (22*). In addition to this, 2min of percussive massage applied to the lower limbs following eccentric overload exercise has proven to reduce the effects of DOMS, potentially facilitating muscle recovery (22*).

Following a single, 5min percussive massage treatment to the calf muscle, dorsiflexion ROM was significantly increased (+5.4°). As no changes in maximum voluntary contraction torque of the plantar flexors were shown, it was surmised that percussive massage treatment as a warm-up regimen could optimise flexibility without compromising muscle performance (16*). There are emerging studies showing similar results with increased ROM to the knee and hip following 5min of percussive massage.

Side Effects and Safety

Rhabdomyolysis is a serious and potentially life-threatening syndrome caused by damaged skeletal muscle

TRADITIONAL BARRIERS TO MASSAGE (COST, TIME, ACCESS TO A PROFESSIONAL) COMBINED WITH THE ADVENT OF HOME THERAPY DURING COVID-19, HAVE INCREASED THE POPULARITY OF ‘SELF-MASSAGE’ 28

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IASTM treatment

Localised inflammation Microvascular morphology ↑ Poor vascularity ↓ Arteriole-sized blood vessels ↑ Tissue Perfusion ↑

Tissue resident mesenchymal stem cell ↑ Extracellular matrix fibroblasts ↑ Fibronectin activity ↑ Collagen synthesis and realignment ↑ Growth factor

↑

Tissue turnover and regeneration

↑

Oxygen and nutrients

Figure 2: Mechanism of IASTM on soft tissue injury. Adapted from Kim et al. Therapeutic effectiveness of instrument-assisted soft tissue mobilization for soft tissue injury: mechanisms and practical application. Journal of Exercise Rehabilitation 2017;13 (1):12–22 (26*)

and the release of myoglobin, potassium and proteases into the bloodstream (23*). Although there are many causes and risk factors associated with rhabdomyolysis, one should be mindful when using percussive massage devices. Safety and education of sports professionals and the public is imperative.

Monitoring proper use of percussive massage devices, as well as observing indications and contraindications can reduce the risk of serious side effects.

Conclusion

Hand-held percussive massage devices, such as the Hypervolt, Theragun or other muscle guns, may be effective in increasing ROM, reducing markers of fatigue and reducing the effects of DOMS. These devices may not improve performance as they are unable to increase muscle activation and force output. Individuals can use percussive massage devices as part of a structured warm-up before exercise to acutely increase ROM without negatively impacting force output or muscle activation.

Since these devices reduce perceived pain and release tight or restricted fascia, it is speculated they may be Co-Kinetic.com

useful in a rehabilitation setting; however, more research on treating specific musculoskeletal injuries and understanding the devices mechanism of action is needed.

3. Instrument-Assisted Soft Tissue Mobilisation

Instrument-assisted soft tissue mobilisation (IASTM) is a manual therapy intervention used for the detection and treatment of soft tissues.

A proposed definition is that IASTM is “a skilled intervention that includes the use of specialised tools to manipulate the skin, myofascia, muscles, and tendons by various direct compressive stroke techniques” (24*).

The instruments are usually made of stainless steel with bevelled edges and contours that can conform to different anatomical areas and allow for deeper penetration (25). There are many companies manufacturing IASTM tools such as Graston®, HawkGrips®, RockTape®, Técnica Gavilán®, ERGON, Functional and Kinetic Treatment with Rehab (FAKTR)®, Adhesion Breakers®, augmented soft tissue mobilisation or ASTYM®, and Fascial Abrasion Technique™.

Each company has its own treatment

approach with slightly different instrument designs.

The ergonomic design of the instrument allows the clinician to apply the appropriate pressure throughout the affected area [See Fig. 1 in Kim et al.

Therapeutic effectiveness of instrumentassisted soft tissue mobilization for soft tissue injury: mechanisms and practical application. Journal of Exercise Rehabilitation 2017;13 (1):12–22 (26*; https://bit.ly/3y3rWZE)]. The mechanical advantage allows deeper tissue penetration without the painful compressive forces in the clinician’s thumb, hand and wrist. The therapist is able to detect soft tissue irregularities, such as tissue restrictions or adhesions, more easily. This is due to the increased vibratory perception in the hand holding the instrument (27*). The small hand-held devices are advertised for self-massage, coining the term ‘selfmyofascial release’ and promoting increased flexibility, reduced pain, faster healing and recovery times.

Instruments effectively break down fascial restrictions, adhesions and scar tissue. Micro-trauma caused by the deep pressure initiates an inflammatory response at a cellular level. The result being an increase in fibroblast 29

proliferation, collagen synthesis and remodelling of disorganised collagen fibre matrix (24*,25). The stimulation of mechanosensitive neurons by skin deformation created via the instrument results in a neurophysiological effect.

This accounts for improved local tactile sense and a decrease in pressure pain threshold (26*). Additionally, a vascular response increases tissue perfusion and the proportion of arteriole-sized blood vessels in the treated area (26*).

The mechanism of IASTM is illustrated in Figure 2.

Clinical Application

When combined with a rehabilitation programme, IASTM treatment can positively affect recovery of soft tissue function following tendon injury, including Achilles, patellar and lateral elbow tendinopathy (28*,29*,30*,31).

One session per week for 4 weeks resulted in a 23–44% increase in lower extremity functional (LEF) scores in basketball players with patellar tendinopathy (29*). In patients with Achilles tendinopathy, one to two sessions per week for 8 weeks resulted in more than a doubling of walking distance and significantly improved LEF scores (30*,31). McCormack et

al. showed that combining eccentric exercises with IASTM for 12 weeks significantly improved Victorian Institute of Sport Assessment for Achilles (VISA-A) scores for patients with Achilles tendinopathy, even up to 26 and 52 weeks’ follow-up (32*).

The extent of structural and functional changes in tendons or muscles induced by IASTM, and its effect on future injuries or injury prevention, is unclear as yet (26*).

Optimal musculoskeletal function is dependent on sufficient joint ROM, and reduced flexibility can increase an athletes risk to both acute injuries and overuse syndromes. The extensibility of soft tissues improves with IASTM by treating their restrictions, and the heat generated by friction from the instrument, decreases tissue viscosity.

Applying two sessions of IASTM for 3–4 weeks can significantly improve hamstring and shoulder ROM in athletes (33*,34,35,36).

Pain reduction effects of IASTM have been proven in studies involving patients with musculoskeletal conditions, as well as in athletes involved in volleyball, triathlon, football and distance running. One to two sessions applied over 4–6 weeks has

shown to significantly reduce pain and in some cases completely resolve the painful symptom (26*,37*,38*,39*).

In sports rehabilitation, IASTM should not be used in isolation. Soft tissue mobilisation should involve both functional movements and strengthening to facilitate adaptation and remodelling of tissues. When IASTM is applied in sports rehabilitation, it generally follows six different steps detailed in Table 1 (26*).

Safety and Side Effects

The most common side effects that were reported included bruising and tenderness following IASTM treatment. Long-standing soft tissue injuries seem to result in greater bruising, together with bleeding.

Side effects can be minimised using cryotherapy. Relative contradictions for the use of IASTM include cancer, kidney dysfunction, pregnancy, rheumatoid arthritis, varicose veins, osteoporosis, lymphedema, fracture, chronic regional pain syndrome, and use of certain medications (eg. anticoagulants, steroids, or nonsteroidal anti-inflammatory drugs) (26*). Absolute contradictions include open wounds, unhealed suture sites, thrombophlebitis,

Table 1: Instrument-assisted soft tissue mobilisation (IASTM) treatment programme for soft tissue recovery Adapted from Kim et al. Therapeutic effectiveness of instrument-assisted soft tissue mobilization for soft tissue injury: mechanisms and practical application. Journal of Exercise Rehabilitation 2017;13 (1):12–22 (26*).

30

Step

Objective

Protocol

1. Examination

Current condition must be assessed

Discussion, pain and disability scores, active/ functional or sports specific movements, ROM tests, palpation

2. Warm-up

Increase the blood supply, as well as heating and increasing plasticity of the tissues

10–15min with light jogging or by using a stationary bicycle, upper body ergometer, or elliptical machine, or 3–5min with hot pack or ultrasound

3. IASTM

Remove scar tissues, and facilitate synthesis and realignment of new collagen

30° to 60° for 40–120s

4. Stretching

Correct the shortened tissue, and prevent reinjury

3 repetitions of 30s

5. Strengthening exercises

Strengthen the treated tissue, and prevent reinjury

High repetition with low-load exercise

6. Cryotherapy

Reduce pain, control residual inflammation, and preventing secondary cell hypoxic injury

10–20min

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uncontrolled hypertension, skin infection, haematoma, myositis ossificans and unstable fractures (26*).

Conclusion

IASTM is simple, practical and requires only a short period of time for a single treatment. IASTM can be effective in improving soft tissue function and ROM in acute or chronic sports injuries, while reducing pain. This may be a helpful tool in the field of sports rehabilitation and athletic training.

Future research into the mechanisms of IASTM and its effects on other musculoskeletal injuries is needed.

Summary

We as professionals often don’t like patients and athletes taking matters and treatments into their own hands!

This may be based on concerns about an individual doing more harm than good and potentially injuring themselves or aggravating an injury by not fully understanding their anatomy, physiology, or the technique and treatment dose recommended with

KEY POINTS

devices. Realistically, we may also be concerned about loss of contact with patients and loss of income should athletes choose to self-massage for recovery. Active individuals and athletes are often looking for ways to better their performance or try something new to reduce pain even when the research behind such devices may be lacking. As professionals we can advise on optimal and superior recovery strategies, for example therapeutic massage; we can educate and advise on safety and correct use of self-massage devices; ultimately, however, the individual may choose a DIY approach which is something that we may have to accept.

References Owing to space limitations in the print version, the references that accompany this article are available at the following link and are also appended to the end of the article in the web and mobile versions. Click here to access the references https://bit.ly/3puEMvY

lM aximising performance is not simply about training, but a fine balance between loading and recovery. lF ollowing physiological and psychological stresses of training, recovery aims to restore homeostasis to the same level as before or preferably a superior one. lS ports massage is beneficial in reducing or preventing delayed onset muscle soreness (DOMS), which will in turn aid in recovery. lA lthough active recovery, compression garments, and cryotherapy are all beneficial, massage has been found to be the most powerful technique for recovering from DOMS and fatigue. lM assage can be costly, time-consuming, inconvenient and be limited by accessibility to a professional therapist; combined with the advent of home therapy during Covid-19, ‘self-massage’ has become increasingly popular. lF oam rolling is used by both elite and recreational athletes, it is affordable, easy to use, time-saving (‘can do it anytime, anywhere’) and beneficial for recovery. lF oam rolling can reduce pain and accelerate recovery of sprint and strength performance, in addition to clearing lactate and counteracting DOMS. lP ercussive massage using a hand-held device can increase range of motion (ROM) and facilitate muscle recovery while reducing the symptoms of DOMS. l I nstrument-assisted soft tissue massage (IASTM) can increase ROM and reduce pain but has not been tested on outcomes associated with sports recovery. lE ducation, technique and care are needed should an individual choose to ‘self-massage,’ as these modalities can produce side effects and serious consequences. lH eterogeneity across studies using these modalities combined with small sample sizes and varied treatment strategies make it challenging to form a consensus on optimal recovery protocols.

Co-Kinetic.com

DISCUSSIONS

l What advice or concerns would you give an individual who wants to self-manage their recovery using either foam rolling, percussive massage devices or IASTM? l Do you feel there is a risk of individuals ‘over-doing’ self-massage treatment, potentially doing more harm than good? l Do you use any of these devices in your practice to aid in manual therapy treatments? l Do you feel moving away from a ‘hands-on’ approach to treatment may hinder the psychological or physiological component of recovery?

RELATED CONTENT

l I s Massage an Effective Sports Recovery Strategy?

[Article] https://bit.ly/3GmAJJ5 lM assage for Tendon Pain [Article] https://bit.ly/3DxYawV l How to Unpick Postural Locks [Article] https://bit.ly/3qDYDY5 l Cancer, Exercise and Massage [Article] https://bit.ly/2ONYEve

THE AUTHOR Kathryn Thomas BSc Physio, MPhil Sports Physiotherapy is a physiotherapist with a Master’s degree in Sports Physiotherapy from the Institute of Sports Science and University of Cape Town, South Africa. She graduated both her honours and Master’s degrees Cum Laude, and with Deans awards. After graduating in 2000 Kathryn worked in sports practices focusing on musculoskeletal injuries and rehabilitation. She was contracted to work with the Dolphins Cricket team (county/provincial team) and The Sharks rugby teams (Super rugby). Kathryn has also worked and supervised physios at the annual Comrades Marathon and Amashova cycle races for many years. She has worked with elite athletes from different sporting disciplines such as hockey, athletics, swimming and tennis. She was a competitive athlete holding national and provincial colours for swimming, biathlon, athletics, and surf lifesaving, and has a passion for sports and exercise physiology. She has presented research at the annual American College of Sports Medicine congress in Baltimore, and at South African Sports Medicine Association in 2000 and 2011. She is Co-Kinetic’s technical editor and has taken on responsibility for writing our new clinical review updates for practitioners.

Email: kittyjoythomas@gmail.com

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Frontiers in Physiology 2018;9:403 Open access https://bit.ly/3Gg7wiT 5. Schilz M, Leach L. Knowledge and perception of athletes on sport massage therapy (SMT). International Journal of Therapeutic Massage & Bodywork 2020;13(1):13–21 Open access https://bit.ly/3DqK3JT 6. Phillips J, Diggin D, King DL et al. Effect of varying self-myofascial release duration on subsequent athletic performance.

Journal of Strength and Conditioning Research 2021;5(3):746–753 7. Cheatham SW, Kolber MJ, Cain M et al. The effects of self-myofascial release using a foam roll or roller massager on joint range of motion, muscle recovery, and performance: a systematic review.

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International Journal of Sports Physical Therapy 2015;10(6):827–838 Open access https://bit.ly/2ZXNSIQ 8. Pearcey GEP, Bradbury-Squires DJ, Kawamoto J-E et al. Foam rolling for delayed-onset muscle soreness and recovery of dynamic performance measures. Journal of Athletic Training 2015;50(1):5–13 Open access https://bit.ly/32SEp6H 9. Wiewelhove T, Döweling A, Schneider C et al. A meta-analysis of the effects of foam rolling on performance and recovery.

Frontiers in Physiology 2019;10:376 Open access https://bit.ly/3IsJwuA 10. Behm DG, Alizadeh S, Hadjizadeh Anvar S et al. Foam rolling prescription: a clinical commentary. Journal of Strength and Conditioning Research 2020;34(11):3301– 3308 11. Adamczyk JG, Gryko K, Boguszewski D. Does the type of foam roller influence the recovery rate, thermal response and DOMS prevention? PLoS One 2020;15(6):e0235195 Open access https://bit.ly/3IBcGbl 12. Cheatham SW, Stull KR. Roller massage: comparison of three different surface type pattern foam rollers on passive knee range of motion and pain perception. Journal of Bodywork and Movement Therapies 2019;23(3):555–560 13. Cheatham SW, Stull KR, Kolber MJ. Comparison of a vibration roller and a nonvibration roller intervention on knee range of motion and pressure pain threshold: a randomized controlled trial. Journal of Sport Rehabilitation 2019;28(1):39–45

14. Romero-Moraleda B, González-García J, Cuéllar-Rayo Á et al. Effects of vibration and non-vibration foam rolling on recovery after exercise with induced muscle damage.

Journal of Sports Science & Medicine 2019;18(1):172–180 Open access https://bit.ly/3DwsisJ 15. Freiwald J, Baumgart C, Kühnemann M et al. Foam-rolling in sport and therapy – potential benefits and risks.

Sports Orthopaedics and Traumatology 2016;32(3):258–266 16. Konrad A, Glashuttner C, Reiner M et al.

The acute effects of a percussive massage treatment with a Hypervolt device on plantar flexor muscles’ range of motion and performance. Journal of Sports Science and Medicine 2020;19(4):690–694 Open access https://bit.ly/3rK7bkm 17. Behm DG, Wilke J. Do self-myofascial release devices release myofascia? rolling mechanisms: a narrative review. Sports Medicine 2019;49(8):1173–1181.

18. Lee C-L, Chu I-H, Lyu B-J, Chang W-D, Chang N-J. Comparison of vibration rolling, nonvibration rolling, and static stretching as a warm-up exercise on flexibility, joint proprioception, muscle strength, and balance in young adults. Journal of Sports Sciences 2018;36(22):2575–2582 19. Kujala R, Davis C, Young L. The effect of handheld percussion treatment on vertical jump height. International Journal of Exercise Science: Conference Proceedings 2019;8(7) 20. Kerautret Y, Guillot A, di Rienzo F. Evaluating the effects of embedded selfmassage practice on strength performance: A randomized crossover pilot trial. PLoS

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One 2021;16(3):e0248031 Open access https://bit.ly/3dnrThC 21. García-Sillero M, Jurado-Castro JM, Benítez-Porres J et al. Acute effects of a percussive massage treatment on movement velocity during resistance training. International Journal of Environmental Research and Public Health 2021;18(15):7726 Open access https://bit.ly/302TCBg 22. García-Sillero M, Benítez-Porres J, García-Romero J et al. Comparison of interventional strategies to improve recovery after eccentric exercise-induced muscle fatigue. International Journal of Environmental Research and Public Health 2021;18(2):647 Open access https://bit.ly/31whxtu 23. Chen J, Zhang F, Chen H et al.

Rhabdomyolysis after the use of percussion massage gun: a case report. Physical Therapy 2021;101(1):pzaa199 Open access https://bit.ly/3lEPAqf 24. Cheatham SW, Baker R, Kreiswirth E. Instrument assisted soft-tissue mobilization: a commentary on clinical practice guidelines for rehabilitation professionals.

International journal of sports physical therapy 2019;14(4):670–682 Open access https://bit.ly/31E8J4g 25. Lambert M, Hitchcock R, Lavallee K et al. The effects of instrument-assisted soft tissue mobilization compared to other interventions on pain and function: a systematic review. Physical Therapy Reviews 2017;22(1–2):76–85 26. Kim J, Sung DJ, Lee J. Therapeutic effectiveness of instrument-assisted soft tissue mobilization for soft tissue injury:

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Journal of Exercise Rehabilitation 2017;13 (1):12–22 Open access https://bit.ly/3y3rWZE 27. Ge W, Roth E, Sansone A. A quasiexperimental study on the effects of instrument assisted soft tissue mobilization on mechanosensitive neurons. Journal of Physical Therapy Science 2017;29(4):654– 657 Open access https://bit.ly/3rGtozK 28. Sevier TL, Stegink-Jansen CW. Astym treatment vs. eccentric exercise for lateral elbow tendinopathy: a randomized controlled clinical trial. PeerJ 2015;3:e967 Open access https://bit.ly/3opG5gq 29. Black DW. Treatment of knee arthrofibrosis and quadriceps insufficiency after patellar tendon repair: a case report including use of the Graston technique.

International Journal of Therapeutic Massage & Bodywork 2010;3(2):14–21 Open access https://bit.ly/3GkuKVa 30. Papa JA. Conservative management of Achilles tendinopathy: a case report.

The Journal of the Canadian Chiropractic Association 2012;56:216–224 Open access https://bit.ly/302u8E4 31. Park J-H, Oh E-Y, Lee H-J et al. A case report on a patient of Achilles tendinitis treated with Gyeon-mak Chuna, Korean medicine and Graston technique. Journal of Korean Medicine Rehabilitation 2015;25:103–110 (in Korean with English abstract) 32. McCormack JR, Underwood FB, Slaven EJ et al. Eccentric exercise versus eccentric exercise and soft tissue treatment (astym) in the management of insertional Achilles tendinopathy. Sports Health

2016;8(3):230–237 Open access https://bit.ly/3DvpgVJ 33. Laudner K, Compton BD, McLoda TA et al. Acute effects of instrument assisted soft tissue mobilization for improving posterior shoulder range of motion in collegiate baseball players. International Journal of Sports Physical Therapy 2014;9(1):1–7 Open access https://bit.ly/3lEzcWT 34. Kim D-H, Kim T-H, Jung D-Y et al. Effects of the Graston technique and self-myofascial release on the range of motion of a knee joint. Journal of the Korean Society of Physical Medicine 2014;9(4):455–463 (in Korean with English abstract) 35. Markovic G. Acute effects of instrument assisted soft tissue mobilization vs. foam rolling on knee and hip range of motion in soccer players. Journal of Bodywork and Movement Therapies 2015;19(4):690–696 36. Heinecke M, Thuesen S, Stow R. Graston technique on shoulder motion in overhead athletes. Journal of Undergraduate Kinesiology Research 2014;10(1):27–39 37. White KE. High hamstring tendinopathy in 3 female long distance runners. Journal of chiropractic medicine 2011;10(2):93–39 Open access https://bit.ly/3lEQfb6 38. Daniels CJ, Morrell AP. Chiropractic management of pediatric plantar fasciitis: a case report. Journal of Chiropractic Medicine 2012;11(1):58–63 Open access https://bit.ly/3rK8u2K 39. Lee J-H, Lee D-K, Oh J-S. The effect of Graston technique on the pain and range of motion in patients with chronic low back pain. Journal of Physical Therapy Science 2016;28(6):1852–1855 Open access https://bit.ly/3DuwngX.

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22-01-COKINETIC | HOLISTICHEALTH FORMATS WEB MOBILE PRINT All references marked with an asterisk are open access and links are provided in the reference list

H

istorically, a therapist would have been in fear of their patient leaving their rooms with marks or lacerations, visible bruising on their body due to the treatment technique. Nowadays, however, it seems more common for patients to happily display large red circles on their bodies, ‘placed’ there by their therapist! Essentially, exhibiting a number of large ‘hickies’ is no longer taboo!

What may have catapulted cupping therapy into the ‘Western medicine’ limelight was the Rio Olympic games in 2016 where many athletes were observed to have large red circles on their skin – including the 23-time Olympic gold medallist Michael Phelps, the greatest swimmer of all time. It is common for athletes to try new treatments to help to improve their performance, recovery or relieve pain – some of which may not be fully supported by strong scientific evidence. Cupping therapy, however, is nothing new. This technique using suction cups has its origins in traditional Asian medicine dating back thousands of years. Even the ancient Egyptians have been documented to using cupping therapy in 1550bc.

By creating a suction – or negative pressure – this technique is thought to release soft tissues, drain excess fluids and toxins, loosen adhesions, lift connective tissue and bring blood flow to an area of stagnant skin or muscle. The negative pressure can be created manually, with a hand-help pump and valves, or with heat from a flame or steam. It is performed with one of several kinds of cups, such as bamboo cups, glass, plastic, or earthen cups, placing them on the desired acupuncture points on patients’ skin, with the purpose of curing the diseases, or relieving pain.

Over time, different techniques 32

THE DEBATE ABOUT CUPPING THERAPY

By Kathryn Thomas BSc MPhil

In recent years, cupping for therapeutic purposes has been growing in popularity, with an increasing number of high profile athletes displaying the tell-tale red circular marks. This article describes how cupping is performed, what it is used for, the theories about how it works and looks at what evidence there is about whether cupping is effective. This will allow you to decide whether you would like to add cupping to your therapeutic tool box and for what purposes you might use it. Read this article online https://bit.ly/3lFoCyU have been developed; however, the principle of applying a cup to create suction over a painful area is common to all techniques. In ‘wet cupping’, the skin is pierced, and blood flows into the cup, whereas ‘dry cupping’ doesn’t involve piercing the skin. As suggested above, mechanically, cupping increases blood circulation. Physiologically, it activates the immune system and stimulates the mechanosensitive fibres, leading to a reduction in pain. Cupping is an inexpensive, non-invasive (if dry cupping is performed) and low risk (if performed by a trained practitioner) modality, which potentially could be added to your arsenal of treatment modalities.

So, is your cup half full or half empty when it comes to using or recommending this treatment technique? The bottom line may

be that there is some evidence for cupping, but it is of low quality or not statistically significant. A wide variety of studies, with different techniques, cupping ‘doses’ and patient conditions

CUPPING IS THOUGHT TO WORK THROUGH SUCTION TO CREATE NEGATIVE PRESSURE THAT RELEASES SOFT TISSUES, DRAINS EXCESS FLUIDS AND TOXINS, LOOSENS ADHESIONS, LIFTS CONNECTIVE TISSUE AND BRINGS BLOOD FLOW TO AN AREA OF STAGNANT SKIN OR MUSCLE Co-Kinetic Journal 2022;91(January):32-39

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make it difficult to draw conclusions about the consistency of the efficacy and direction of causality. This article will discuss what is and is not known about cupping therapy.

For the purpose of this article we will focus on cupping therapy in the management of pain relief and musculoskeletal conditions rather than any medical conditions such as hypertension, psoriasis, herpes, etc.

What is Cupping Therapy?

Cupping therapy is done by applying small round cups made of glass, bamboo, ceramic or plastic to the area of pain. The rolled rim of the cup ensures a tight seal to preserve the negative pressure created. The cup is placed firmly over the area to be treated and a negative pressure is created by heat/flame or by vacuum pumps (for example manual pumps).

The negative pressure, or suction, ensures the cup stays in place and pulls the underlying skin into the cup. Lubricants can be used to allow movement of cups, without breaking the vacuum seal, permitting a greater area to be treated.

Common areas of treatment are neck, back, chest, abdomen and buttocks, and areas of large muscle groups. Cupping is traditionally done in sets of four, six or ten cups at a time, with treatment lasting from 5 to 20 minutes. This can be done once or twice a week, bearing in mind that the side effects of erythema, oedema and ecchymosis can take several days to resolve between sessions.

Different Types of Cupping Treatment

Cupping can broadly be classified into wet and dry cupping. However, different authors have made further subcategories depending on the power of the suction, method of cupping, materials used inside cups, and the area being treated, for example (1*,2*). It may seem confusing that there are so many diverse types of cupping, or names for cupping techniques – bear in mind the basic principles are the same. The different classifications are briefly explained below.

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1. Technical Types

This classification is based on the cupping technique used: l Dry cupping – also known as static or retained cupping (3*). Fire, manual pump or electrical suction generates the negative pressure within the cup, which is usually kept in place for up to 15 minutes (1*).

With a manual pump the negative pressure created inside the cup is determined by the number of suctions: the negative pressure increases as the number of pumps increase. When fire or flame is used, the longer the exposure the greater the negative pressure (suction) created. The suction leads to the bulging or drawing up of the skin into the cup (1*). lF lash cupping – also known as empty cupping (3*). The cup is applied, with light to medium pressure, for short duration of less than 30 seconds to stimulate the area. It can be done using one or more cups and is performed as quick repeated suctions. This technique may be recommended in young people and female patients (1*). lW et cupping – also known as full cupping, bloodletting and bleeding cupping. This is used in traditional Eastern medicine (3*). It involves scrapping the skin or making small lacerations with a surgical blade such that the suction draws blood into the cup. This clearly caries many risks and side effects with it and is not commonly done in Western practices. lM assage cupping – this can also be called moving, dynamic or gliding cupping. As suggested the cups are moved over a larger treatment area using oil to facilitate glide without losing their suction. This can be used in both young and elderly patients (1*).

2. Strength of Suction

This classification is in accordance with the level of negative pressure created within the cups. l L ight cupping pressure: 100 to <300 millibar (mbar). The therapist can generate this with 1 to 2 full manual pumps. It is mainly used for children and the elderly or on areas

CURRENTLY, THE EVIDENCE BASE FOR THE USE OF CUPPING IS VERY LIMITED, BUT THERE DOES SEEM TO BE SOME LOW-QUALITY EVIDENCE TO SUGGEST THAT IT MAY BE OF BENEFIT FOR CERTAIN ARTHRITIC CONDITIONS

where there is skin sensitivity, such as the face. Light cupping pressure can be used with massage, dry and flash cupping.

The advantage is cupping marks are rarely created; however, the efficacy of the treatment may be compromised (1*). l Medium cupping pressure: 300–500mbar. This is a form of ‘general’ purpose technique. It is generated by 3 to 4 full manual suction pumps. Medium cupping will leave marks on the treated area and is not recommended for people with sensitive or fragile skin (1*,4*). lS trong cupping pressure: >500mbar. It is usually generated by 5 or more full manual pumps. It can cause inflammation, dermatitis, skin burns and pain, and is therefore not used on children and the elderly (1*). lP ulsatile cupping pressure: as the name suggests, involves pulses of pressure. This has to be created by a mechanical device where a pulse is generated every 2 seconds. It creates a light pressure of 100–200mbar and its use has been tested for symptomatic 33

relief of pain in patients with knee osteoarthritis (KOA) (5*).

3. Methods of Suction

This classification is based on how the negative pressure within the cup is generated. lF ire cupping is performed with glass, ceramic and bamboo cups that have no valves, which prevents any airflow. Paper or cotton (presoaked in 95% alcohol) is lit or inserted and lit. The fire uses up the oxygen within the cup creating a negative pressure. This technique caries a high risk of patient burns (1*,7*). lM anual vacuum cupping creates negative pressure by using a manual suction pump. Manual vacuum cupping has been shown to be superior to fire cupping, as it generates a greater blood flow with less risk of injury (7*,8*). lE lectric vacuum cupping uses an electric suction pump, where negative pressure can be easily adjusted and controlled, and connected to several cups at once.

It is also used with the pulsatile cupping method (8*).

4. Added Therapy Types

This is a form of combination therapy (1*,2*).

lN eedle cupping is a combined use of acupuncture and cupping.

Smaller, shorted needles are used for safety reasons and should be avoided over the abdomen and chest region (1*,8*). lH ot cupping or moxa cupping uses a combination of heat and a herb called moxa (dried mugwort leaves).

The process involves warming the needle with moxa and covering it with a cup. A thin aluminium layer can be used as a barrier to prevent the hot moxa needle burning the skin (1*). lH erbal cupping (also known as medicinal cupping) is where the therapist boils a herb solution for 30 minutes, then soaks bamboo cups for 5 minutes before applying them. To avoid burns the cup is left for 1 or 2 minutes to cool slightly before application (3*). lM agnetic cupping uses specific cups that have magnets within them.

Commonly applied to treat larger joints and joint related pain, it is presumed that the electromagnetic stimulation from the magnets enhances cupping therapy (8*). l L aser cupping is where an acupuncture laser probe is inserted inside the cups stimulating specific acupuncture points. This is known as ‘double therapy’ as one can

SEVERAL DIFFERENT CUPPING TECHNIQUES CAN BE USED: DRY, FLASH, WET AND MASSAGE CUPPING 34

receive cupping therapy and laser acupuncture simultaneously (8*). lE lectric stimulation cupping uses transcutaneous electrical nerve stimulation (TENS) with cupping.

The dual effect (as with laser cupping) saves time and is believed to have an additive effect. It is used to treat specific points of pain and muscle pain (8*). lW ater cupping is where the therapist fills a third of the cup with warm water and a burning piece of cotton wool will be inserted into the cup before applying it to the patient (1*). lA quatic cupping is a treatment of applying cups and performing aquatic therapy at the same time, as it is presumed muscles can be worked and stretched more effectively underwater. It is used for rehabilitation and musculoskeletal problems (8*).

How Cupping Works

How can the benefits of cupping therapy be explained? Well, that may be tricky: several different hypotheses have been proposed but the mechanism of action still remains unknown. It is not unreasonable to suggest or rule out that the method has only a placebo effect (1*,9*).

To understand how cupping works, it may be necessary to combine the effects of cupping with the proposed theories for its mechanism of action.

The effects of cupping can (1*): l i ncrease endogenous hormone production at the brain level to improve pain control; le nhance blood circulation and remove waste and toxins from the body – this is achieved through improved microcirculation promoting capillary endothelial repair, accelerating granulation and angiogenesis locally; l f acilitate muscle relaxation (as a result of the actions mentioned above); l r emove noxious materials from skin microcirculation and interstitial spaces; l r educe low-density lipoprotein (LDL) and can therefore be assumed to aid in improving cardiovascular health;

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l c an significantly decrease total cholesterol as well as the LDL/ high-density lipoprotein (HDL) ratio; lower the number of lymphocytes by increasing number of neutrophils, which is one of the antiviral mechanisms proposed to reduce pain scores; l i ncrease parasympathetic activity and relax muscles, when loss of blood (wet cupping) is combined with vasodilation; l i ncrease the number of red blood cells; l i mprove subcutaneous blood flow and stimulate autonomic nervous system; l r eportedly restore sympathovagal balance and might be cardio-protective by stimulating the peripheral sympathetic and parasympathetic nervous system; l c ause a significant reduction in blood sugar in diabetic patients; ld rain excess fluids and toxins, loosen adhesions and revitalise connective tissue; l i ncrease blood flow to underlying skin and muscles, stimulating peripheral nervous system and reducing pain; and l c ontrol high blood pressure.

The theories proposed look at the physiological, biological and mechanical changes that occur during cupping. Six main theories are published: three of these address the biological and mechanical basis of pain relief from cupping. These include the pain gate theory, the conditioned pain modulation, and the reflex zone (and will be explained in more detail below). The remaining three proposed mechanisms explain the beneficial effects of an increase in blood circulation, immunomodulatory effects and the removal of toxins and waste products (1*),(8*). The exact mechanism is not understood but there might be a harmonious interplay between them. These possible interactions are demonstrated in the graphical abstract (Possible mechanism of action theories; https://bit.ly/3p4tfDw) and Figure 2 (Links between cupping therapy effects and mechanisms of action theories; https://bit.ly/3rfTGIP) Co-Kinetic.com

in Al-Bedah et al. (1*).

The ‘pain gate theory’ proposes that cupping therapy influences pain signals between the treatment site and the brain. This is based on a neuronal hypothesis whereby cupping influences nociceptors. The largediameter (A-beta) nociceptive nerve fibres stimulate inhibitory cells and tend to inhibit transmission of pain signals, transmitted by small-diameter (A-delta and C) and large-diameter fibres. Thus, pain intensity is expected to be reduced when large nerve fibres are stimulated by touch or pressure or vibration during cupping (1*,8*). More research is needed to validate the application of this theory in cupping therapy, but greater explanation is available at Al-Bedah et al. (1*).

Conditioned pain modulation, is also known by the term ‘diffuse noxious inhibitory controls’. This theory assumes that ‘pain inhibits pain’, or one type of pain masks another.

Activation of the spinal-medullaryspinal pathway, which is triggered by a distant noxious stimulus, causes inhibition of the primary pain stimulus, thus reducing the patient’s pain (1*).

The reflex zone theory proposes that there is an existing link between one organ of the body and another one, which is mediated by the interaction of nerves, chemicals, and muscles. A change in an organ can be detected by a distal manifestation.

For example, vasoconstriction can result in skin becoming cold and pale, whereas vasodilation results in warm, red skin. Animal studies have shown that somatic stimulation of the skin or the peripheral joints could affect changes on the cardiovascular, urinary and gastrointestinal functions.

These reflexes can be either excitatory or inhibitory in terms of organ function. Therefore, the stimulation of skin receptors during cupping therapy could eventually lead to an improvement in the blood circulation through the neural connections to an affected organ (1*,8*).

Nitric oxide (NO), a signalling gas molecule, mediates vasodilation and regulates blood flow and volume. NO therefore regulates blood pressure, contributes to immune responses, controls neurotransmission, shares

in cell differentiation and has many more physiological functions. Cupping therapy could cause the release of NO from endothelial cells, inducing a cascade of biological changes (1*).

Cupping is likely to affect the immune system in three ways.

Firstly, cupping creates artificial local inflammation which irritates the immune system. Secondly, cupping activates the complementary system. Thirdly, cupping increases the level of circulating immune products such as interferon and tumour necrosis factor. Cupping increases the flow of lymph through its effect on the thymus. Cupping seems to improve the therapeutic outcomes in patients with autoimmune conditions, which may be due to the activation of the immune system. Strengthening ones immunity through cupping has been the subject of recent research around the world (1*).

Removal of toxins, uric acid, lipoprotein, serum glutamic oxaloacetic transaminase, iron and heavy metals could be explained by blood detoxification theory relevant to wet cupping. Overall, the above mentioned mechanisms of cupping therapy could not explain all its effects and further research is warranted to develop more theories concerning this traditional treatment technique (1*,8*).

Common Clinical Indications for Cupping Therapy

The use of cupping therapy has been increasing steadily because of its perceived improvement in health outcomes. This has resulted in a number of primary studies and systematic reviews being conducted; however, in many cases there is vast diversity in conditions, populations, treatment type, duration, short-term follow-up, as well as issues with small sample size, different inclusion criteria and varied assessment tools. This heterogeneity often results in insufficient detail for consensus on treatment efficacy, safety and protocol (1*,2*,9*,10*). For the purpose of this article we will focus on musculoskeletal-related conditions that could benefit from cupping therapy, and exclude its use in treating medical conditions such as hypertension, diabetes, skin conditions, wound healing, etc.

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Table 1: Positive results for cupping therapy Sourced from Azizkhani et al. (14*).

Conclusion

SMD (95% CI)

I2

There were significant differences in pain relief favouring cupping therapy compared with the control group (VAS 100cm)

- 0.84 (-1.22, - 0.46)

54.7%

Cupping therapy was clinically superior to the control group in patients with neck pain

- 0.60 (- 0.86, - 0.35)

16.4%

Cupping therapy increased the quality of life in patients with neck pain compared with the control group

- 0.56 (- 0.20, - 0.92)

51.4%

CI, confidence interval I2, variation in SMD attributable to heterogeneity SMD, standardised mean difference

1. Low Back Pain

It is well known that low back pain (LBP) is one of the most common complaints in clinical practice, with an annual prevalence of 38% in the general population (11). Management can include bed rest, medication, physical therapy, traction, education, exercise therapy and alternative treatments. Traditionally, cupping therapy has been used for both acute and chronic LBP, with studies showing significant reduction in pain intensity scores and improvement in functional outcome tools compared to usual care or medication (11,12*).

A three-armed randomised controlled trial (RCT), by Teut et al.

(13*) investigated the use of two different forms of cupping (dry pulsatile and minimal) compared to medication (paracetamol) on patients with chronic LBP. Based on visual analogue scale (VAS) scores, both forms of cupping were found to be effective compared to the control group after 4 weeks of therapy. After 12 weeks, only subjects in the pulsatile cupping group reported benefits in pain and quality of life scores (13*).

A meta-analysis concluded that cupping therapy was more effective compared to other modalities on reducing VAS scores, and Oswestry pain disability index scores. However, this positive effect was not seen on the

McGill present pain index score (11).

A recent study by Silva et al. found that dry cupping therapy was similar to sham therapy in terms of reducing pain or improving physical function, functional mobility, trunk range of motion, perceived overall effect, quality of life, psychological symptoms or medication use in people with non-specific chronic LBP (9*). They concluded that until there is greater evidence of efficacy, clinicians should rethink their use of dry cupping and inform their patients of the uncertainty of benefit should they choose to consider this intervention. This study, however, only conducted one session of cupping on their subjects (9*).

Despite the limitations and lack of high-quality research, the available literature supports the use of cupping therapy in patients with LBP, with a call for future RCT studies.

2. Neck Pain

Neck pain is a very common symptom and a frequent reason for patients to visit a clinic. It has been reported that up to 50% of the general population suffer from neck pain at any time, and quite often this is non-specific (14*). A recent systematic review by Azizkhani et al. showed positive results from cupping therapy in relieving non-specific neck pain, which we have summarised in Table 1 (14*).

The evidence currently available indicates that cupping is effective for patients with chronic non-specific neck pain. Reduction in pain scores, improvement in disability scores and quality of life indices was seen with cupping compared to no treatment or active controls (physical therapy, nonsteroidal anti-inflammatory drugs, heat pack therapy and acupuncture) (15*).

In conclusion, the current evidence supports the use of cupping therapy to treat neck pain, but it is not conclusive because of the low quality of available studies.

3. Arthritis

Arthritis is a general term for a manifestation of many joint disorders such as osteoarthritis, gout, rheumatoid arthritis and others. Cupping therapy has been used to reduce the joint pain associated with osteoarthritis (OA), gout and ankylosing spondylitis.

Li et al. concluded that “only weak evidence supports the hypothesis that cupping therapy can effectively improve the treatment efficacy and physical function in patients with knee osteoarthritis (KOA)” (16). The meta-analysis showed that in terms of pain, stiffness and physical function, a combination of cupping therapy and Western medicine (physical therapy and use of analgesics) may be more effective compared to Western medicine alone in patients with KOA (16). Cupping alone has weak evidence to support the beneficial effects on reducing pain and improving physical function in patients with KOA (17).

Ankylosing spondylitis (AS) is a chronic inflammatory disorder that causes back pain. Five RCTs have assessed the efficacy of cupping therapy on pain, stiffness, physical function, disease activity and serum erythrocyte sedimentation rate in AS. It can be concluded that the use of a combination therapy of cupping and Western medicine was more effective compared to Western medicine alone (18).

GREAT CARE NEEDS TO BE TAKEN WITH WET AND FIRE CUPPING AS THESE TECHNIQUES INVOLVE A RISK OF SCARRING/ INFECTION AND BURNS 36

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At present there is weak evidence to support the use of cupping therapy for pain management in different types of arthritis. Further research, with better design and methodological protocol, is required.

4. Carpel Tunnel Syndrome

Carpal tunnel syndrome is the compression or entrapment of the median nerve within the carpal tunnel and usually presents with pain, numbness, burning and reduced grip strength. Cupping therapy has been shown to be beneficial when used in combination with physiotherapy or alone. Mohammadi et al. used modified cups (to accommodate the anatomical shape of the wrist) at pressures of 50mmHg for a 4-minute duration (19). A total of 10 sessions on alternate days was performed.

There was a significant improvement in the symptom severity scale and reduction in the distal sensory latency in the cupping group compared to the control group (19).

5. Fibromyalgia

Fibromyalgia is a condition characterised by chronic pain, fatigue, sleep and cognitive disturbances as well as somatic and psychological distress. A study reported cupping therapy produced greater efficacy than usual care in terms of reduction in pain intensity and improvement in quality of life (20*). Some research has shown that cupping therapy can significantly reduce pain scores, specifically when in combination with other treatments such as antidepressants and acupuncture (21).

Further research with better quality studies is needed to determine the effectiveness of cupping in this group of patients.

6. Musculoskeletal Pain

There is initial scientific evidence, mostly from chronic non-specific neck and back pain, that dry cupping may reduce musculoskeletal pain. In myofascial pain with myofascial trigger points, manual therapy is supported by moderate evidence, whereas evidence for dry needling and cupping is not greater than placebo (22). However, as dry cupping is non-invasive and Co-Kinetic.com

low risk (if performed by a trained individual) as well as inexpensive this could be a therapeutic modality to add to your armoury (23,24).

7. Sports Injuries and Athletes

Despite the recent re-emergence of the use of cupping for athletes, the supporting evidence for its efficacy and safety remains scarce.

Different sporting populations have been studied including footballers, handball players, swimmers, gymnasts, and track and field athletes of both amateur and professional nature. Across the studies, treatment was performed once and up to 20 times, daily or at weekly intervals, with or without combination therapy such as acupuncture. The results varied across symptom intensity to functional and recovery measures and experimental outcomes.

Beneficial effects of cupping were reported in reducing pain and disability, increasing range of motion and reducing creatine kinase when compared to mostly untreated control groups. Risk of bias in these trials has been reported (25,26*).

It is common for athletes to try new treatments that may relieve pain, whether or not they are supported by scientific evidence. At present no explicit recommendation for or against the use of cupping for athletes can be made. More research is necessary (25,26*).

8. Migraines

In Chinese medicine, migraine has traditionally been treated with cupping therapy. In comparison to drugs, wet cupping had a higher total effective rate. The results from a meta-analysis showed that wet cupping plus drug treatment could quickly relieve pain and significantly improve a patients’ quality of life (27*). Dry cupping combined with acupuncture showed greater efficacy than acupuncture alone; however, neither were statistically significant in improving the subjects’ symptoms and pain. It was concluded, however, that the quality of evidence was low and greater research was required to confirm the efficacy of cupping for migraine (27*).

Contraindications, Cautions and Complications of Cupping Therapy

The negative pressure created by cupping therapy alone may be contraindicated in certain physical areas or on certain population groups. Additionally, wet cupping with scarification may carry higher risks too (2*). High-risk treatment areas include cupping over veins, arteries, nerves, inflamed and injured skin, body orifices, eyes, lymph nodes, varicose veins, bone fractures and sites of deep vein thrombosis (DVT) (2*). Table 2 is a summary of the contraindications for wet cupping therapy sourced from Ahmedi et al. (28*).

As one can imagine, strict infection control measures must be taken into consideration, especially with wet cupping. Disinfection of the patient’s skin and appropriate personal protective equipment is required. The use of disposable cups, vacuum pumps and disposable surgical blades is necessary to avoid cross-transmission of infection.

The safety of cupping therapy is generally under-reported in research papers. The commonly recognised side effects are erythema, oedema and ecchymosis. These may be exacerbated by excessive use 37

Table 2: Contraindications to cupping therapy Sourced from Ahmedi et al. (28*).

Absolute contraindication

Relative contraindication

Caution

Cancer

Active infection

Active psoriasis

Organ failure (heart, renal, hepatic)

Severe chronic disease (eg. heart disease)

Keloid scarring

Bleeding disorder (eg. haemophilia)

Pregnancy, puerperium

Anti-platelet therapy

Anti-coagulant therapy

Active cellulitis/erysipelas/abscess

Recent wet cupping session or

Peripheral vascular disease

Undiagnosed/suspicious lump

recent blood donation

Anaemia

Ulcer

Menstruation

Thrombophlebitis

Medical emergency

Pacemaker

Children

Deep vein thrombosis Cauda equina Stroke – unstable or evolving Fracture site Suspected osteomyelitis or septic arthritis Life-threatening asthma Chemotherapy

of alcohol and suction pressure, prolonged exposure to cupping therapy, sensitive skin especially in elderly people, and the use of fire (2*).

Possible complications of cupping are listed below (2*). lP reventable complications: l burn l scar formation l bullae formation l abscess and skin infection l pruritus l anaemia l panniculitis lN on-preventable complications: l headache l dizziness l vasovagal attack l tiredness l Koebner phenomenon l nausea l insomnia.

Conclusion

Cupping therapy is an ancient complimentary type of therapy that is used widely across the world for a variety of conditions, most prominently in pain-related problems. There are several theories that endeavour to explain how it works, although this question remains mostly unanswered.

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There is emerging evidence of the promising benefits of cupping therapy; future research is required focused on greater homogeneity across treatment populations, conditions and protocols in order to produce conclusive outcomes on efficacy and safety.

At present the current evidence suggests that cupping therapy may be effective in treating common chronic painful conditions for a short period.

Yet, most of the available studies have major limitations such as small sample size, different outcome assessment tools, duration of treatment, treatment regimens, and risk of bias.

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KEY POINTS

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Effects of cupping therapy in amateur and professional athletes: systematic review of randomized controlled trials. The Journal of Alternative and Complementary Medicine 2018;24(3):208–219 26. Musumeci G. Could cupping therapy be used to improve sports performance?

Journal of Functional Morphology and Kinesiology 2016;1(4):373–377

lC upping therapy is an ancient form of treatment, traditionally used in a wide variety of medical and pain-related conditions. lD ifferent types of cupping can be classified according to technique (wet, dry, massage, flash), amount of pressure generated within the vacuum, method of suction, or type of combination therapy. lS everal theories exist attempting to explain how cupping works including the pain gate theory, diffuse noxious inhibitory control theory, reflex zone theory, nitric oxide theory, activation of immune system theory and blood detoxification theory. However, the exact mode of action still remains unknown. lC upping therapy may be effective in treating chronic low back pain: some studies have been shown to be effective compared to other modalities for reducing VAS and Oswestry pain disability index scores. lC upping is effective for patients with chronic non-specific neck pain: reduction in pain scores, improvement in disability scores and quality of life indices compared to no treatment or active controls (physical therapy, nonsteroidal anti-inflammatory drugs, heat pack therapy, and acupuncture) have been shown. lT here is low-quality evidence suggesting cupping therapy may benefit certain arthritic conditions, fibromyalgia patients and migraine sufferers. lB eneficial effects of cupping have been reported in the athletic population in reducing pain and disability, increasing range of motion and reducing creatine kinase when compared to mostly untreated control groups. lA cross most areas of musculoskeletal and pain conditions, further research is required, focusing on greater homogeneity across treatment populations, conditions and protocols in order to produce high-quality, conclusive outcomes on efficacy and safety. lC upping therapy carries a risk of complications from burns, scaring, anaemia and infection apart from the usual side effects of erythema, oedema and ecchymosis.

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Open access https://bit.ly/3FMJP1g 27. Seo J, Chu H, Kim C-H et al.

Cupping therapy for migraine: a PRISMA-compliant systematic review and meta-analysis of randomized controlled trials. Evidence-Based Complementary and Alternative Medicine 2021;2021:7582581 Open access https://bit.ly/3CWitnt 28. Ahmedi M, Siddiqui MR. The value of wet cupping as a therapy in modern medicine – an Islamic perspective.

WebMedCentral Alternative Medicine 2014;5(12):WMC004785 Open access https://bit.ly/3cRAGbm.

RELATED CONTENT

lT he Myofascial Vacuum Cupping Manual https://bit.ly/3nSW7z5

DISCUSSIONS

lH ave you had experience (as a patient or practitioner) with cupping therapy? lW hat type of cupping would you use in your practice?

(For example: dry, wet, pulsatile, massage, aqua, combination, etc.) lW ould you currently endorse the use of cupping therapy, given the lack of extensive good-quality research? If yes, would this be limited to certain conditions/populations?

THE AUTHOR Kathryn Thomas BSc Physio, MPhil Sports Physiotherapy is a physiotherapist with a Master’s degree in Sports Physiotherapy from the Institute of Sports Science and University of Cape Town, South Africa. She graduated both her honours and Master’s degrees Cum Laude, and with Deans awards. After graduating in 2000 Kathryn worked in sports practices focusing on musculoskeletal injuries and rehabilitation. She was contracted to work with the Dolphins Cricket team (county/provincial team) and The Sharks rugby teams (Super rugby). Kathryn has also worked and supervised physios at the annual Comrades Marathon and Amashova cycle races for many years. She has worked with elite athletes from different sporting disciplines such as hockey, athletics, swimming and tennis. She was a competitive athlete holding national and provincial colours for swimming, biathlon, athletics, and surf lifesaving, and has a passion for sports and exercise physiology. She has presented research at the annual American College of Sports Medicine congress in Baltimore, and at South African Sports Medicine Association in 2000 and 2011.

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

Email: kittyjoythomas@gmail.com 39

By Tor Davies, physiotherapistturned Co-Kinetic founder 22-01-COKINETIC | MARKETING FORMATS WEB MOBILE PRINT

MEDIA CONTENTS Overview of the Patient Information Subscription and the Branding Upgrade [Co-Kinetic Marketing Compendium] PDF Document https://spxj.nl/3pdX5W8

I

n this article we’ll look at three key elements of your physical therapy marketing strategy: 1. Helping Your Physical Therapy Business To Be Seen (https://spxj.nl/31m28vw) 2. Helping Your Physical Therapy Business To Be Found (https://spxj.nl/3ofEIkf) 3. Helping Your Physical Therapy Business To Be Heard (https://spxj.nl/2ZP4faI).

1

Helping Your Physical Therapy Business To Be Seen

Your Website/ Online Profile

The first thing in any business lifecycle is to give people a place to find out more about you, think of it as an online brochure, and the two most obvious ways of doing this is by building a website and/or setting up a Business Facebook page (preferably both, as they can serve in different ways). l A website should give a customer all the information they might want to know about what you can do: ‘features’ (qualifications/experience/ services you can provide); and how it can help them: ‘benefits’. l It should also give them everything they need to know in order to book and attend an appointment – ranging from what to expect when they arrive, what clothes to wear and what will happen during the session. l It’s also important to tell people how to find your clinic, where they can park, what public transport is available to them (if relevant) and an interactive telephone number 40

Being SEEN Being HEARD Being FOUND Running a physical therapy business involves not only working on your patients but also working on your business. One of the key business activities is marketing, and many people avoid this because they don’t know what to do or where to start. This article has broken it down into simple, easy steps and shows you how to make the biggest impact for minimal time and budget, so that your business can be seen, found and heard. Read this article online https://bit.ly/3DyN1MH and map link so they can call you or navigate to you using one-click on a mobile device. l Your website should also feature social proofing. This should primarily come in the form of genuine customer testimonials or reviews but could also include logos of businesses, sports clubs or associations who utilise your services.

Don’t Over-Invest In, or Over-Think Your Website A simple but effective website really shouldn’t cost you any more than £500–£1000 – and you really only need 5 or 6 pages: 1 Home page – including social proofing (see article ‘Timeless Testimonials’ below).

2 About You page – this should focus on qualifications and experience (in other words ‘features’).

3 Services You Offer page – this is all about benefits, what you can offer and how it will benefit your reader.

4 Contact Us page – but don’t use a horrid impersonal contact form, instead include a Google map with an interactive link showing people how to get to your treatment area, make sure to include your address

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on that page and also an interactive (clickable) contact number (you can always set up a virtual number and redirect it to your mobile phone, or use a virtual assistant).

FAQs – frequently asked questions area (optional but can be useful for boosting confidence and building trust). You could also include this FAQ area on one of your other pages if you didn’t want to create a dedicated page.

Blog area (optional extra but useful for search engine optimisation ie. being found by Google).

On one or more of the above pages you should feature testimonials and social Co-Kinetic Journal 2022;91(January):40-44

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proofing. This absolutely should include customer reviews and testimonials but it could also feature logos of businesses, sports clubs, or other organisations who use your services (make sure you check with those organisations before you put their logo on your site).

Testimonials are a very simple but powerful way to convert prospects into paying clients as well as increase your visibility through search engines like Google. I’ve written an article specifically about how important testimonials are at this link (‘Timeless Testimonials: The Power of Reviews’ https://spxj.nl/3DGT0zZ) and we’ve even created a review leaflet that you can add your review link to, print out and give to your customers .

2

A Business Facebook Page

A Facebook Business page can certainly, in the early days of your business, be used as a temporary website, just try and make sure you include as much of the information that I recommended you include on your website as possible. It can give you some valuable breathing space to build a brand, logo and identity before investing in a website.

It offers several other opportunities: l It allows you to present a more informal and personable view of your business. l It’s a great way to introduce new therapists or new services. l By publishing good educational content, it’s a great way to build reputation and authority. l It offers multi-media opportunities to inform and educate which in turn builds trust. l You can use it to collect email leads and build your email list (don’t worry you’re not going to spam them!). l The Recommendations section acts as a form of social proof.

There’s a more detailed article on the topic of why and how to use social media as a physical therapy business owner at this link (‘Should I Use Social Media for my Physical Therapy Business?

If So, Why and How?’ https://spxj.nl/2SSfskN).

Co-Kinetic.com

Figure 1: Your branding goes here...

3

Getting Your Name Out and About

There’s a popular saying which originated from the 1980s film, Field of Dreams, which goes “if you build it, they will come”. Unfortunately although this might work for the baseball field it refers to in the film, it certainly doesn’t work for websites or Facebook pages! You’ve got to give people a reason to come and find you.

This is where helpful educational resources like patient leaflets, exercise handouts, cheat sheets and infographics come in handy. This is something we include in all four of our subscriptions and I wrote an article about the various different ways you can use these resources to make you and your business more visible ‘Getting the most from your Patient Information Leaflets’ https://bit.ly/3dv3F50.

Of course it doesn’t matter where you obtain these resources, they could come from anywhere, but the principles behind how you use them still apply.

The point is that you can distribute these resources both online as well as in print forms, making sure to include your own branding such as your logo and business details.

They are a fantastic way of adding value to your reader while also very subtly promoting your business (Fig. 1).

In online format you could: l post them on your social networks; l include a link to specific resources in local discussion or help forums; and l feature them on your own website.

In print format you could:

l share them with local businesses; l give them to sports shops to distribute as value-adds on their counters; l pin them to local notice boards; l offer them to GP practices; and l take them to sports meet-ups or share them with local sports groups.

For lots more ideas and inspiration click on the ‘Overview of the Patient Information Subscription’ PDF in the Media Contents box.

Some Practical Implementation Tips

l Get a logo created on the freelance graphic design site Fiverr.com (https://www.fiverr.com/) – you’d be amazed at what you can get for a very small investment. Again you can rebrand/update it once you’re up and running and have a bit more money in the bank. l If you are building a website from scratch I’d recommend using a WordPress template.

Wix and Squarespace are also frequently used but WordPress sites give you more flexibility and control, and are likely to be much cheaper in the

YOUR WEBSITE IS AN IMPORTANT PLACE FOR PEOPLE TO FIND OUT MORE ABOUT YOU 41

our Clinic growthe subscriptions (https://landing.co-kinetic.com/ pricing). They can save you a huge amount of time and take muchneeded pressure off you and your team to come up with a regular supply of social media that achieves the goals of a good social media strategy.

Helping Your Physical Therapy Business To Be Found

Figure 2: Timeless testimonials: the power of reviews – key points Credit: Co-Kinetic 2021

long run. There are loads of freely available templates and again you can use someone on Fiverr.com to build a WordPress website for you. Use the reviews as a way of selecting your freelancer. l Another route you could take is to use a service like MSK Sites (https://msksites.co.uk/) who will build and maintain the site for you for a small monthly subscription.

This means you won’t be stuck trying to get changes made to your website from unreliable web developers because unfortunately there’s a lot out there! l Publishing testimonials and reviews on your site – personally I prefer to use an embeddable ‘widget’ to publish reviews people have left on either my Google Business page or my Facebook Business page.

The widget I use is called Embed Social (https://embedsocial.com/) but there are many other widgets out there too that do similar things.

There are also free plans available. l If you want a source of ready-made social media content that is both educational, informative and adds value by offering links to even more high-value content such as patient leaflets and exercise handouts then take a look at our Social Media or

THE ONLY WAY YOU CAN BUILD A RELIABLE COMMUNICATION CHANNEL IS

BY BUILDING YOUR OWN EMAIL LIST 42

This section is about making it as easy as possible for people to find your business through the search engines, primarily (at least currently) that means Google.

There are five key things you can do here, listed in order of priority: 1 Set up a Google My Business profile if you haven’t already. THIS IS A BUSINESS-CRITICAL MARKETING ACTIVITY FOR EVERYONE! Here’s an article explaining why it’s so important: ‘Why is Google My Business Important for Your Business?’ (https://spxj.nl/3xOvApP), and here’s where you can do it: ‘Stand out on Google with a free Business Profile’ (https://spxj.nl/3DhBpgA).

2 Start (and continue) to build a bank of customer reviews specifically on your Google Business Listing and also ideally on your Facebook page. As we mentioned earlier testimonials are extremely powerful – I wrote an article explaining why (‘Timeless Testimonials: The Power of Reviews’ https://spxj.nl/3DGT0zZ) and also included a link to a ready-made leaflet which you can add your review links to, and then handout to your clients asking them to write you a testimonial.

There’s also lots of practical tips on how to implement this. In short, testimonials on Google help you get found and help you to appear in search engine results. Figure 2 shows you some key points.

3 Search Engine Optimisation (SEO). This involves making sure you’re ticking all the boxes you possibly can to help the search engines find your website. Some

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of this is making sure you have the right elements set up on your website like good meta data for your key pages and site maps so the search engine crawlers can find and index your site. This probably requires the input of a specialist (try and find someone who comes recommended as there’s a lot of ‘shysters’ (unscrupulous/fraudulent people) around who will take advantage and charge a lot of money).

If your SEO specialist seems to be doing their job well, you could invest in some paid Google ads to help boost your search engine ranking for certain key words.

Publish regular new content on your website such as blog posts which support your bigger picture SEO strategy - so helping you be found for your key words. Again a good SEO expert can help to advise you on this as it should be done with a bigger picture SEO strategy in mind.

Helping Your Physical Therapy Business To Be Heard

This section is all about building an audience which you can galvanise into action when you need to make things happen for your business. If you have listened to any of my webinars, you will know that I deem building an active, engaged email audience, the single most important marketing activity you can do on an ongoing basis.

I frequently refer to your email list being like your very own golden goose.

Feed, nurture and care for it, and it will lay you golden eggs whenever you ask it. Abandon it or let it stagnate and all the effort you’ve put into building that list up until that point will be lost.

When I work with businesses looking to buy physical therapy businesses, it’s one of the ‘under the hood’ aspects I recommend those investors look at. The more larger, more active and more engaged a business’s email list, the more quickly and effectively it can be galvanised into revenue generating streams and the better the business’s growth prospects, so if you’re considering selling your business some time down the line,

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better to be investing in building and nurturing that list now, because it’s not an activity that can be done overnight, quite the contrary.

Building trust and demonstrating consistency happens over a period of time.

Social Media Audiences Don’t Count!

If you’ve been on any of my webinars you will also know that I don’t classify a social media following as a legitimate audience. Why? Because you’re not in control of communicating with that audience, the platform owner is!

If Facebook wanted to stop people seeing your posts (which incidentally they’ve been doing increasingly for about the last 5–8 years), they can. If they want to remove the opportunity for you to private message people, they can. Basically they can do what they want.

The only way you can build a reliable communication channel is to build it in a way that you control and that you own, and the quickest, most scalable way to do that (ie. workload is not significantly impacted by growth), is by building your own email list. You can still use the social networks to help you do that (and you definitely should) but the holy grail is be in complete control of your communication channels, and that means email.

There Are Two Key Aspects to Building an Engaged Email Audience

1

ollecting new email leads C (ie. building your email list) which requires the following three things. a. An email lead collection form. b. A useful, informational downloadable give-away that people feel is worth giving you their email address for. In marketing lingo that’s referred to as a ‘lead magnet’, ie. something that attracts (email) leads. A ‘lead’ is simply a prospective client for your business. c. A way to promote the existence of that informational giveaway to encourage people to sign up for it (this is where social media comes in useful,

Co-Kinetic.com

Social Media Post With Link To Sign-Up Page

Email Sign-Up Page

Lead Magnet Delivery

Figure 3: Email lead collection process

Figure 4: Example of a simple nurture email

Figure 5: Email list building and email nurture among physical therapists

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especially when combined with some paid advertising to get your lead magnet in front of the right demographic of prospective customer). Figure 3 shows the email lead collection process.

The second stage is consistently nurturing that email audience to build trust, establish authority and reputation and develop a sense of reciprocity (the desire to give back) in your audience. This can be much

more simply done than most people appreciate. All it requires is short, regular emails with links to valueadded resources (yes, this is another place that our patient advice leaflets come in very handy! There’s a reason why they’re included in all the Co-Kinetic subscriptions). Here’s an article which discusses the benefits of having an engaged email audience: ‘Turning Email Leads into Paying Customers: Using

BUILDING AN ACTIVE, ENGAGED EMAIL AUDIENCE IS THE SINGLE MOST IMPORTANT MARKETING ACTIVITY YOU CAN DO ON AN ONGOING BASIS 43

the Powerful Hidden Influences of Nurture Emails’ (https://spxj.nl/38FWzbI). Fig. 4 shows how simple an email I’m talking about...

Luckily for you, 88% of physical therapists still aren’t bothering to do this currently (Fig. 5) ... which gives you a distinct advantage to get ahead of the game!

Email List Building Through Co-Kinetic Subscriptions

This physical activitycampaign is openaccess so you could run it yourself if you wanted to (even without a sub).

1 We’ve produced a bunch of educational and fun social media highlighting the many benefits of exercise for health - you would set this up to post out of Co-Kinetic and onto your social networks.

Some of these posts promote the availability of additional downloadable resources giving specific physical activity advice for a range of different medical conditions.

2 When someone clicks on those links in those social media posts, they’re taken to the following page > https://spxj.nl/3Db1XjT (go on, click the link to see what I mean), which gives them more details about the resources on offer. As you can see, everything is focusing on adding value to your reader.

When they fill out the form (go ahead you can do it), they are automatically redirected to the promised downloadable resources.

Better still, both the email signup page, the page featuring the downloads and the downloadable leaflets themselves, will ALL feature your branding and contact details, making it look like you’ve created everything. Pretty cool huh?

Some Practical Implementation Tips

l If you don’t feel confident building email lead collection pages and creating the juicy give-away lead magnets and social media posts to raise awareness of these giveaways, that’s exactly what we offer 44

in the Social Media and Clinic Growth subscriptions from Co-Kinetic.

You can find more info here > https://bit.ly/3lHPga2). l Make sure you use an email marketing platform to send your emails through, even if you only have 10 or 20 people on your email list to start with. This enables you to ‘segment’ your audience based on which emails they open and click on so you can start to build a picture of who is interested in what, in order for you to be able to target them in future with increasingly relevant content. I tend to recommend Mailchimp because it’s widely known and it’s free for up to 2,000 unique contacts (I have also connected Co-Kinetic to Mailchimp meaning any email leads you collect through the Co-Kinetic campaigns can be automatically transferred straight into Mailchimp). l Segmentation is a fancy word for figuring out who’s interested in what. Some people will be more interested in for example your back pain resources, than they are in your running injury resources. Others might be more interested in chronic pain than they are in golfing injuries.

The more information you have about your audience, the better you can target your emails so that you’re sending the resources each group of people is most likely to be interested in. l Utilise the power of paid advertising, particularly through social networks like Facebook, to build email audiences of people that are most likely to become your prospective customers, that could be age groups, gender or a whole range of different interests. l Realistically you need to be emailing your email list with helpful value-add resources at least once a month, ideally once every two weeks but remember, these are NOT biblelength clinic updates, they’re short simple emails, with value-added resources, just like the one in Fig. 4. l I wrote an article here with ideas for ‘25 Ways to Grow Your Email List’ (https://spxj.nl/2KdQgCs).

Happy marketing

KEY POINTS

lY our website/online profile is an important place for people to find out more about you. lA simple website with only 5 or 6 pages can be very effective and will not cost much. lA Business Facebook page provides opportunities that a website isn’t designed for. lE ducational resources that you distribute for free in exchange for an email address give people a reason to get to know you. lH elp people to find you with a ‘Google My Business’ profile and search engine optimisation. lK eep your email audience engaged by continuing to collect new leads (email addresses) and nurturing your audience with short, regular emails with links to valueadded resources, such as patient advice leaflets. lU se segmentation to identify who is interested in what to target your audience with information that is specifically of interest to them. lC o-Kinetic has all the resources to help you to implement this advice.

RELATED CONTENT

lT urning Prospects into Paying Clients: Building and Implementing a 12-Month Marketing and Sales Plan [Article] https://bit.ly/3j1SQtH lM arketing Metrics that Matter (And Which Don’t) [Article] https://bit.ly/3zSS9KP lH ow to Get More Patients Without Being Salesy [Article] https://spxj.nl/3df6KGp

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 2022;91(January):40-44

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Post-Viral Fatigue Syndrome and Chronic Fatigue Syndrome

M

any people may experience chronic (long-term) fatigue; however, this is not necessarily chronic fatigue syndrome (CFS), which is also known as myalgic encephalomyelitis (ME). Some degree of post-viral fatigue (PVF) or debility is a fairly common occurrence after any type of viral infection.

Fortunately, in most cases, this is short lived and there is a steady return to normal health over a period of a few weeks.

When fatigue and flu-like symptoms persist for a longer period of time once the acute infection is over, a diagnosis of post-viral fatigue syndrome (PVFS) might be more appropriate, which has many similarities to CFS. With PVFS, there is research evidence to indicate that what is initially a perfectly normal immune system response to the acute infection has not abated after the infection is over. It is also possible that, as happens with CFS, there is a problem with the way that energy production takes place at a cellular level in structures called mitochondria.

The situation with persisting fatigue following coronavirus infection appears to be rather more complicated than what happens with other viral illnesses.

It could also be more serious as fatigue and lack of energy are turning out to be very characteristic long-term symptoms of coronavirus infection, termed long Covid.

The precise explanation for what causes post-infection/viral fatigue remains uncertain. But one of the reasons why people have fatigue, loss of energy, muscular aches and pains, and generally feel unwell when they have an acute infection is the production of chemicals called cytokines by the body’s immune system. These immune system chemicals form part of the front-line attack on any viral infection. It is also interesting to note that in people who develop serious respiratory complications from coronavirus infection, this may be due to an overactive immune

Co-Kinetic.com

response involving what is being termed a ‘cytokine surge’ (or cytokine storm).

DIAGNOSING PVFS/CFS

Although one of the main symptoms of PVFS/CFS is severe and prolonged mental and physical fatigue, there is also a range of other symptoms that can include: ● Headaches ● Widespread muscular and/or joint pain ● Sleep disturbance ● Unrefreshing sleep may include hypersomnia in the early post-infection stage, fragmented sleep and restless legs syndrome later on. In more severe cases, there may be a reversal of normal sleep rhythm (ie. being awake at night but sleeping during the day). ● Difficulties with concentration and memory (‘brain fog’). Cognitive dysfunction involving short-term working memory, concentration and attention span, information processing, and wordfinding ability ● Post-exertional malaise – feeling fatigued and ill after activities. The malaise symptoms (a general feeling is discomfort, illness or unease) are amplified by physical and/or mental exertion with a delayed impact – later the same day, the next day, or even later.

The amount of activity that provokes symptom exacerbation can be very minimal ● Sore throats and tender glands ● Dizziness and balance problems, feeling faint ● Odd sensations like pins and needles and numbness ● Sensitivity to light and noise ● Digestive disturbance ● Poor temperature control including increased sensitivity to hot and cold, sweating, feeling feverish.

Different people experience some symptoms more than others. For example,

45

pain can be a big problem for some and not others. Symptoms fluctuate in severity, throughout the day, day to day, and/or week to week. The pattern may change over time. There is a substantial and sustained reduction in both physical and mental activity. This has a major effect on all aspects of daily living. Exacerbations and relapses can be caused by infections, trauma and other stressors, including menstruation.

There is no agreed diagnostic criteria for PVFS/CFS. Diagnosis is based on a cluster of characteristic symptoms, as mentioned above, along with the exclusion of other possible explanations.

Most PVFS/CFS studies stipulate that a diagnosis should only be made after 6 months of symptoms. In clinical practice this should normally be regarded as the endpoint of the diagnostic process, starting from 6 weeks and working through a process of elimination of other possible causes of symptoms and piecing together a picture of the patient’s condition through a series of consultations.

SEVERITY OF SYMPTOMS

The severity of PVFS/CFS can roughly be divided into three levels: ● Mild cases. You can care for yourself and can do light domestic tasks, but with difficulty. You are still likely to be able to do a job but may often take days off work. In order to remain in work you are likely to have stopped most leisure and social activities. Weekends or other days off from work are used to rest in order to cope. ● Moderate cases. You have reduced mobility and are restricted in most activities of daily living. The level of ability and severity of symptoms often varies from time to time (peaks and troughs). You are likely to have stopped work and require rest periods. Sleep at night tends to be poor and disturbed. ● Severe cases. You are able to carry out only minimal daily tasks such as face washing and cleaning teeth. You are likely to have severe difficulties with some mental processes, such as concentrating. You may be wheelchairdependent for mobility and may be unable to leave your home except on rare occasions. You usually have severe

46

prolonged after-effects from effort. You may spend most of your time in bed. You are often unable to tolerate any noise and are generally very sensitive to bright light.

WHO DEVELOPS PVFS/CFS?

CFS can affect anyone. It is estimated that CFS affects about 1 in 300 people in the UK, possibly more. It is about three times as common in women as in men. The most common age for it to develop is in the early twenties to mid-forties. In children the most common age for it to develop is 13–15 years old but it can develop at an earlier age. The current data suggest that the risk of longcovid following Covid-19 infection seems to be higher for women and also rises with age – particularly those over 50.

WHAT CAUSES PVFS/CFS?

PVFS/CFS is a complex condition and there is, as yet, no consensus on a single cause.

We often see people who have developed PVFS/CFS following viral infections, such as glandular fever, and bacterial infections, such as pneumonia. Other people can identify a period of stress leading up to the start of the illness. A combination of infection and stress is also common. Hence, the recent concern that the new Covid-19 virus could potentially result in survivors developing CFS if not properly managed in their recovery.

UNDERSTANDING PVFS/CFS: THE BIOPSYCHOSOCIAL MODEL

‘Biopsychosocial’ is a term we use to understand the various factors that affect or are affected in people with PVFS/CFS: these are biological, psychological and social.

Using this term does not mean we believe your illness is psychological (it’s NOT all in your head!), as many health conditions influence us in all three areas. As you will have experienced, PVFS/CFS causes many different symptoms and influences many different parts of your life.

For example, when you have PVFS/CFS you are: ● Physically unwell and experience, for example, fatigue and pain – these are biological symptoms. ● You may feel less like your normal self and this can lead to feelings of unhappiness, frustration, confusion, anger, anxiety, depression, etc. – these are psychological effects.

● You may not feel able to see friends as much – your social circumstances are being affected.

Whatever is happening to your body physically (eg. fatigue, pain, dizziness) is also having a knock-on effect psychologically (changing the way you feel and behave) and socially (changing your activity, working life, and ability to see friends). It is important to understand how PVFS/CFS affects these aspects of your life (not just the physical symptoms) in order to help you improve the quality of your life.

1. Precipitating (Triggering) Factors

There are many possible precipitating factors that may ‘set off’ PVFS/CFS, such as a viral illness or accident, an accumulation of stress, a sudden unexpected loss or accident. It is unlikely there will be just one trigger to your PVFS/CFS, although this is possible. Many triggers may come together at the same time, overloading the body physically and mentally. These triggers may have accumulated over time or be sudden and overwhelming.

2. Perpetuating (Maintaining) Factors

Those factors that caused PVFS/CFS at the beginning are not always the same as those that are causing your symptoms to continue.

Being aware of things that make symptoms worse right now is very important. This may include ‘overdoing’ it, arguments, poor sleep, low mood, cold weather, other health conditions, etc.

Of course, there may also be things that you find help your symptoms, such as recognising external and internal strengths, i.e. family support, ability to practise relaxation.

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PHYSICAL THERAPY

3. Predisposing (Pre-existing) Factors

Finally, sometimes we can recognise preexisting problems that may have increased your risk of developing PVFS/CFS. This may include a lifestyle that allowed you very little time to rest or relax, a biological vulnerability to illness, difficulty saying ‘no’ to requests, extremely high expectations or being a ‘perfectionist’, or a prolonged exposure to stress and trauma.

Predisposing factors do not cause your PVFS/CFS but make it more likely that PVFS/CFS will be triggered. Of course not all predisposing factors affect everyone, but it is worth looking at them in case they do add something to your understanding of your current problems.

WHAT IS THE OUTLOOK (PROGNOSIS)?

In most cases, PVFS/CFS has a fluctuating course. There may be times when symptoms are not too bad and times when symptoms flare up and become worse (a setback). The outcome is very variable and there is currently no effective method for predicting how the illness will progress or whether it will improve or resolve for any individual person.

Early diagnosis and symptom management have been shown to be hugely helpful in treating this condition.

There is also evidence that all of the following can support improvement: ● a balanced approach to rest and activity often termed pacing; ● improving sleep patterns, called sleep hygiene; ● energy management advice to teach you how to make the best use of your energy

The Biopsychosocial Model of Disease

My long-term health conditions are biological in origin, but the impact has been felt physically, psychologically and socially. My long-term health condition can’t be treated just through the biological medical model alone...

BIO ● Pathology ● Science treatments ● Disease ● Symptoms ● Tests ● Doctor

SOCIAL

PSYCHO ● Depression ● Anxiety ● Identity ● Stress ● Tears ● Guilts

● Hobbies ● Family ● Isolation ● Money

● Career ● Friends ● Burden

“The medical support keeps me alive, but it is the psychological and social support that enables me to live”

levels in your day to day life, without making your symptoms worse; ● addressing unhelpful attitudes, such as perfectionism if they are causing increased distress. Cognitive behavioural therapy techniques can help in this area, but are not a cure for PVFS/CFS; ● improving stress management and relaxation techniques; ● reasonable adjustments at work or in education; and ● setting manageable goals to move forward.

The information contained in this article is intended as general guidance and information only and should not be relied upon as a basis for planning individual medical care or as a substitute for specialist medical advice in each individual case. ©Co-Kinetic 2021

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Sleep Hygiene for Post-Viral/Chronic Fatigue Syndrome

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any people with post-viral fatigue syndrome (PVFS) or chronic fatigue syndrome (CFS) find they have difficulties with sleep. Poor sleep habits (often referred to as ‘hygiene’) can make these difficulties worse. Obtaining healthy sleep is important for both physical and mental health. It can also improve productivity and overall quality of life Below are some essentials of good sleep hygiene. The most important point to remember when trying to get to sleep is not to try too hard. Worrying about sleep is much more tiring than just being awake.

BEFORE BED

● Establish a regular routine each night.

This helps to ‘cue’ your body and mind to sleep. ● Eating and drinking for the last few hours before bed is likely to stimulate your body, so try to do these things earlier in the evening. Steering clear of food that can be disruptive right before sleep.

Heavy or rich foods, fatty or fried meals, spicy dishes, citrus fruits, and carbonated drinks can trigger indigestion for some people. When this occurs close to bedtime, it can lead to painful heartburn that disrupts sleep. ● Read or watch television outside the bedroom, the bedroom should be associated with sleep and perhaps sex. It should be a quiet calm space. ● Try not to watch scary movies or shows with distressing content, these increase your adrenalin and stimulate wakefulness. Comedies are good as endorphins will be released which can help you to relax. ● Set your alarm each night and aim to get up at the same time each morning

irrespective of how much sleep you had during the night. ● Taking a warm bath and/or having a massage are good for inducing sleep. ● Avoid vigorous exercise prior to bed.

Yoga and stretching are good nonaerobic forms of exercise. ● Meditation and deep breathing exercises are also good techniques to calm your mind and body in preparation for sleep. ● Avoid stimulants such as caffeine and nicotine close to bedtime. When it comes to alcohol, moderation is key.

While alcohol is well known to help you fall asleep faster, too much close to bedtime can disrupt sleep in the second half of the night as the body begins to process the alcohol.

ONCE IN BED

● Try to turn your mind away from the day’s activities, any worries you may have or what you will do in the future. This is not the best time to think of these things.

Think about pleasant places or events or use your imagination to conjure up relaxing images. ● If you find that you are unable to sleep while in bed, perform your relaxation routine as good relaxation can be as restful as good sleep. ● If you cannot get to sleep, GET UP after 20 minutes, don’t lie there tossing and turning and becoming anxious watching the clock – this will only wake your body more with increased adrenalin and anxiety. Get up and go and do something boring and relaxing to allow your body to feel sleepy again. Have some boring books or videos on hand. ● The environment in which you sleep is important. Try and ensure your bedroom

is quiet, well-ventilated, dark and a comfortable temperature. ● Even if you did not sleep well, try and get up at the usual time. If your sleep hours vary too much it will become harder to get to sleep the next night. This is very similar to the effects of jet-lag.

ADDED TIPS

● Avoid day time naps or keep them to no more than 30 minutes and before 3pm.

If you are sleeping excessively in the day you may need to reduce your sleeping hours gradually. It will be too difficult to cut down by several hours immediately.

If you are tired during the day, yoga, stretching, taking time for some breathing exercises and meditation or simply putting your feet up will help your body recover and may be less confusing for your ‘sleep clock’ than sleeping through the day and becoming a night owl. ● Ensure adequate exposure to natural light. This is particularly important for individuals who may not venture outside frequently. Exposure to sunlight during the day, as well as darkness at night, helps to maintain a healthy sleep–wake cycle. ● Make sure that the sleep environment is pleasant. Your mattress and pillows should be comfortable. The bedroom should be cool – between 15 and 19°C (60 and 67°F) – for optimal sleep. Bright light from lamps, mobile phones and TV screens can make it difficult to fall asleep, so turn those lights off or adjust them when possible. Consider using blackout curtains, eye shades, ear plugs, ‘white noise’ machines, humidifiers, fans and other devices that can make the bedroom more relaxing.

The information contained in this article is intended as general guidance and information only and should not be relied upon as a basis for planning individual medical care or as a substitute for specialist medical advice in each individual case. ©Co-Kinetic 2021

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Co-Kinetic Journal 2022;91(January):XX-XX

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PHYSICAL THERAPY

Managing Post-Viral Fatigue Syndrome and Chronic Fatigue Syndrome

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here is no known cure for post-viral fatigue syndrome (PVFS) or chronic fatigue syndrome (CFS), although careful management may help to ease symptoms. Healthcare professionals can help to reduce some of the symptoms by having your GP prescribe medication and other therapies. However, some people face the challenge of living with these ongoing symptoms for some time.

There is good news in that we know that these symptoms can gradually improve in many people. We also know that learning ways to manage the condition can help people to make improvements.

A team of professionals is needed for treatment, advice, support and counselling; that team very importantly should also include your family and close friends.

TREATING PVFS/CFS

There are a number of interventions that may be considered for PVFS/CFS. 1. Manage Your Symptoms with Medication Medication can be used to manage your symptoms where possible, for example painkillers, anti-nausea medication and antidepressants.

2. Manage Your Quality of Life and Function ● Sleep. It is likely that you will be given advice about your sleep. Any changes to your sleep pattern (for example, having too little, or even too much, sleep) may actually make your tiredness (fatigue) worse. This includes sleeping in the daytime, which should ideally be avoided. Any changes to your sleep pattern should be done gradually. ● Rest. Setting aside times to rest (rather than actual sleep) is very beneficial. You

should introduce rest periods into your daily routine. These should ideally be limited to 30 minutes at a time and be a period of relaxation. ● Relaxation. Relaxation can help to improve pain, sleep problems and any stress or anxiety you may have. There are various relaxation techniques (such as guided visualisation or breathing techniques) which you may find useful when they are built into your rest periods. ● Pacing. This means balancing periods of activity and rest and becoming aware of which activities demand most from you. You should aim to stop activities before you feel the impact so that you have enough energy in reserve. Doing too much on a good day may make you feel the impact later. It can take time to change your usual activities but pacing is very important in managing your condition in the long term. ●Diet. It is very important that you have a well-balanced diet. You should try to avoid any foods and drinks to which you are sensitive. Eating small, regular meals that contain some starchy foods is often beneficial. Avoiding spikes and drops in blood sugar will help manage your energy levels and make you feel more settled.

3. Physical Activity and Exercise Some people find that carefully adding some physical activity into their PVFS/CFS management plan can be beneficial. If you feel ready to try this, you should follow a personalised activity programme overseen by a professional in a specialist ME/CVFS team.

4. Cognitive Behavioural Therapy (CBT) CBT is a talking therapy that can help you

manage your problems by changing the way you think and behave. It’s most commonly used to help with anxiety and depression but can be useful for other mental and physical health problems.

5. Manage Your Mental Health Counselling and support groups can be used to help manage your mental health.

6. General Support Depending on the severity of illness, other support may be needed – for example, carers, nursing support, equipment and adaptations to the home to help overcome disability.

If you are employed, your doctor will be able to advise you about whether you should take time off work; and, if you take time off work, when you may be ready to go back to work. It may be that you need to work doing slightly different hours or even with different duties. If you have an occupational health department at work, they are likely to be involved with you also regarding work and going back to work if you take time off.

7. Manage Setbacks or Relapses It can be common to have setbacks when symptoms become worse for a while. These can have various triggers – for example, poor sleep, infection or stress.

Your doctor may discuss with you strategies which may help during a setback.

These may include relaxation techniques, talking with your family, and finding the right balance between activity and rest, if possible.

However, it may be necessary for you to reduce or even stop some of your activities and increase the amount of rest you have during a setback.

Following a setback you should usually be able gradually to return to your previous activity level.

The information contained in this article is intended as general guidance and information only and should not be relied upon as a basis for planning individual medical care or as a substitute for specialist medical advice in each individual case. ©Co-Kinetic 2021

PRODUCED BY:

Co-Kinetic.com

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