Co-Kinetic Journal Issue 93 - July 2022

1999

2022

ISSUE 93 JULY 2022 ISSN 2397-138X

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PRACTICAL

12-13

WELLBEING POSTERS WITH CANVA TEMPLATES

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MALE PELVIC DYSFUNCTION: ARE KEGEL EXERCISES A HELP OR A HINDRANCE?

46-51

SALES IS NOT ABOUT SELLING, BUT ABOUT BUILDING TRUST AND EDUCATING

50-51 MARKETING WORKSHEETS

35-45

14-25

CALF MUSCLE STRAIN INJURIES

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UPPER QUADRANT ASSESSMENT FOR MYOFASCIAL DYSFUNCTION: PART 1

JOURNAL WATCH

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ISSUE 93 JULY 2022 ISSN 2397-138X

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CLICK ON RESEARCH TITLES TO GO TO ABSTRACT OPEN

This is about an active 9-year-old girl who fell off the top of a jungle gym, head and shoulder first. The diagnosis was metaphyseal-diaphyseal fracture with displacement of the left humerus, her non-dominant side. She is described as being active, spending about 5 hours a week doing various physical activities. At the time of first treatment she was no longer complaining about pain; however, weakness in isometric resisted tests at the glenohumeral joint (GHJ), and tissue stiffness resulting from the surgeries, resulted in reduced active and passive ROM in the left shoulder. Numbness and tingling were also present in posterior and anterior aspects of the hand.

A physical assessment noted some observations about postural behaviour, with bilateral elevation of shoulders,

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MASSAGE THERAPY EFFECTIVENESS IN REHABILITATION ON HUMERAL SHAFT FRACTURE IN A CHILD: A CASE STUDY. Geoffroy-Legeay H. International Journal of Therapeutic Massage & Bodywork 2022;15(1):54–65 increased lordosis, and kyphosis, and anteriorly rotated left GHJ. The drop arm test was positive indicating a possible supraspinatus tear. It could also show myofascial trigger point referrals limiting the child to hold the arm in the abducted position; however, the child was able to sustain the abducted position with the full can test. Gerber’s lift-off sign indicated weakness for the subscapularis tendon, the child being unable to resist the therapist’s pressure by extending the elbow. Also, Apley’s inferior scratch test indicated limitations in shoulder medial rotation and adduction and highlighted a winging scapula.

In addition to physiotherapistprescribed strengthening exercises, massage treatment commenced 19 days after she had stopped wearing a sling for support. There were 7

sessions of 45 minutes. The actual protocol changed dependent on the girl’s progress but included manual lymph drainage, myofascial release, effleurage and petrissage and frictions to her surgery scars.

Co-Kinetic comment We have a number of case studies in this edition. They are always welcome because the evidential gold standard of a double blind randomised controlled trial is almost impossible to achieve for any form of manual therapy on real patients. A good case study shares clinical practice and has the only result that matters – did the patient get better or not. An added bonus with the good ones is that they promote ideas that readers can try. This is one of those. It is detailed in the assessment of the consequences of the injury and subsequent surgery and gives an in-depth timed description of the treatment protocol that others can repeat.

EFFECTS OF TIME-OF-DAY ON REPEATED SPRINT PERFORMANCE OF AROMATHERAPY MASSAGE APPLIED YOUNG FUTSAL PLAYERS. Bayer R, Eken Ö. Pakistan Journal of Medical & Health Sciences 2022;16(02):384–389 Twelve male athletes (age, 20.50±1.78 years; height, 171.92±2.23cm; weight, 67.92±2.42kg; BMI, 23.06±0.77), who exercised regularly for 5 days a week and had played futsal for at least 4 years, participated in the study. In the leadup to the study they were asked to continue with their normal exercise activity but to avoid strenuous activities for the 24 hours before the start.

All took part in the three protocols which were completed 72 hours apart.

Repeated sprint tests (RST) of 6×20m were done at 09.00 in the morning, 13.00 in the afternoon, and

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17.00 in the evening. RST values were calculated using a combination of the fastest sprint time, total sprint time and percent change from the first sprint to the last sprint.

There was a non-massage protocol (NM) during which the subjects jogged at a low tempo for 15 minutes.

A Swedish massage protocol (SM) during which subjects jogged at 40% of maximal heart rate for 5 minutes then received 10 minutes of massage using baby oil. An aromatherapy massage protocol (ATM) during which the protocol was the same as the SM but using lavender oil. For both of the massage protocols 5 minutes were allocated to the upper limbs and 5 to the lower. Techniques were effleurage, friction, petrissage and pressure

applications.

The results showed that there was a statistical difference between RST values observed at different times of the day after NM, SM and ATM protocols.

The ATM protocol was found to be more effective particularly when applied in the evening.

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Co-Kinetic comment Although there is a lot to appreciate in the study and the idea of assessing the performance differences at certain times of the day was a good one, it suffers from a common fault in massage research in that there is no attempt to work out the dose of the treatment.

Effleurage, petrissage, etc, are not in themselves a measure of dose, they are delivery system for putting force into tissue and that depends on the depth at which the therapist is working. There is no mention of this in the study.

Co-Kinetic Journal 2022;93(July):4-11

RESEARCH INTO PRACTICE

Journal Watch INJURIES PATTERN AND HEART RATE VARIATION IN ELITE JUDO ATHLETES: A KOREAN PROSPECTIVE COHORT STUDY. Park KJ, Jeong DN. Science & Sports 2022;doi:10.1016/j. scispo.2022.03.001

Data were collected from 2018 on elite judo athletes at the Korean Training Institute.

The athletes were assessed by sports medicine doctors, and data were stratified according to sex, weight class and injury location. Measurements were recorded concerning heart rate, total power, low frequency, high frequency and low frequency/high frequency ratio. The study included 213 elite judo athletes whose 593 injuries (annual average, 2.78 injuries/athlete) were recorded. In general, injury rate was similar between the lightweight and heavyweight classes.

When all athletes were considered, most injuries occurred in the lower extremities (38.79%), followed by the upper extremities (30.69%), trunk (23.44%), and head and neck area (7.08%). Injury severity was significantly different among the weight classes and body regions. The association between injury incidence rates was statistically significant in total power and low frequency. Heart rate variation was found to affect injury incidence. Low total power and low frequency increased the risk of sports injury.

Co-Kinetic comment Hopefully coaches, around the world not just in Korea, will use this to build injury prevention programmes. As an added bonus, if you want to improve your language skills the English and French versions are alongside each other in one paper.

A total of 44 patients took part in this trial. All had shoulder pain and prolonged immobilisation due to shoulder rotator cuff surgery or fracture of the proximal humerus. They were split evenly between a myofascial and control group. Both undertook Codman pendulum exercises, latissimus dorsi and external rotator muscle strengthening exercises, shoulder rotation exercises with a ball on a table, active mobility exercises in flexion and abduction with shoulder ladder and shoulder mobilisation exercises with 0.5, 1 and 2kg medicine balls.

The control group were treated with passive, active-assisted, and active movements in flexion, abduction and rotation movements within the patient’s pain threshold. The myofascial group received 15-minute sessions of what is described as myofascial release above the levator scapulae, subscapularis, Co-Kinetic.com

A RARE ANATOMICAL FINDING OF UNDESCRIBED ACCESSORY PALMARIS LONGUS IN THE DISTAL FOREARM: A CASE REPORT. Allahham S, Alyazji ZTN, Aljassem G et al. Plastic and Reconstructive Surgery–Global Open 2022;10(4):e4240

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A 24-year-old man presented to the Emergency Department of Hamad General Hospital, Doha, Qatar, with right forearm laceration with multiple cut structures for which he was admitted for exploration and repair.

Intraoperatively, flexor digitorum superficialis of the third, fourth and fifth digits, flexor carpi radialis, and palmaris longus were injured‚ and all of them were repaired. However, an aberrant muscle – which was also injured – was noted. It originated from the distal third of the radius on its medial aspect to insert into the palmar fascia; pulling this muscle’s tendon resulted in tightening of the palmar fascia in the same way as the palmaris longus.

Co-Kinetic comment It is nice to be told every now and then that our anatomy knowledge is not quite right. Muscle anomalies are not uncommon. This study has lots of pictures so if you are involved with hand care its worth a look.

EFFICACY OF MYOFASCIAL THERAPY AND KINESITHERAPY IN IMPROVING FUNCTION IN SHOULDER PATHOLOGY WITH PROLONGED IMMOBILIZATION: A RANDOMIZED, SINGLE-BLIND, CONTROLLED TRIAL. Sumariva-Mateos J, León-Valenzuela A, Vinolo-Gil MJ et al. Complementary Therapies in Clinical Practice 2022;48:101580 pectoralis major and minor, as well as what is described as superficial myofascial release on the trapezius, supraspinatus, deltoid, infraspinatus, and teres major and minor muscles.

Outcome measures were the QuickDash questionnaire, visual analogue scale for pain and ROM of the shoulder measured at baseline, weeks 4, 8 and 12. The results showed a significant improvement in functionality and ROM in both groups, although only at the 12-week point did the myofascial group achieve a clinically

and statistically significant reduction in pain.

Co-Kinetic comment It is not clear how many treatment sessions each group received. In the discussion they state, “The variables were measured once a month until 4 months of treatment”, yet the results section only gives data up to the 12-week mark. That’s a pity, because it looks like both types of hands-on treatment work.

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SPORTS CHIROPRACTIC MANAGEMENT OF OSTEOARTHRITIC KNEE PAIN IN A MASTERS LEVEL TRIATHLETE/RUNNER: A CASE REPORT. Smith G. Chiropractic Journal of Australia 2022;49(1):57–70 A 51-year-old, female Master’s level triathlete and distance runner, presented with right knee pain of 6 months’ duration. It had caused her to stop running. An MRI scan revealed severe medial osteoarthritis with subchondral bone oedema at the medial femoral condyle, full thickness chondral loss and mild pes anserine bursitis, indicating grade 4 on the Kellgren–Lawrence classification scale of knee osteoarthritis.

She had a past medical history of a car crash at the age of 22 which resulted in hip and sacrum fractures.

Radiological examination of this area 2 years ago revealed normal bone density and a deformation of the left ischium. Since she started running 7 years ago, she has had multiple lower limb stress fractures. Her only

medication was hormone replacement therapy, and she reported no red flag issues.

A comprehensive clinical examination revealed muscle weakness of the gluteus medius, iliopsoas and rectus femoris muscles, various ROM discrepancies between her left and right sides, and a different shoe wear pattern on the right to the left. Her running patterns show signs of lumbopelvic instability (contralateral hip drop) and overstriding.

Management included 6 weeks of running gait retraining, specific corrective exercise prescription and monitoring and gradual progression of exercises and running load. At the end of 6 weeks, the athlete reported subjective improvements in knee pain and running capacity.

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Co-Kinetic comment The author reports that the athlete had visited another therapist who had basically fobbed her off with, “Don’t run”.

She was able to cycle or swim for 1 hour daily but stated that her goals were to: “Be able to run”, stating “I could go through life not cycling, but not running”. Her knee OA is not going to get better but this report shows that examination and treatment of everything else going on in her kinetic chain was able to get her back to running. Great work by her more enlightened therapist.

COMPARING THE EFFECTS OF COLD THERAPY AND HAND AND FOOT MASSAGE ON POSTOPERATIVE PAIN AMONG PATIENTS WITH MAJOR SURGERIES. Miri A, Masoudi R, Kheiri S et al. Journal of Multidisciplinary Care 2021;10(3):95–98 The present study aimed at comparing the effects of cold therapy and foot and hand massage on postoperative pain (POP) among patients with major surgeries. Ninety patients who underwent thoracoabdominal surgery were randomly assigned to one of the following groups: (i) control, (ii) cold therapy, and (iii) foot and hand massage. Participants in the control group received routine care services, whereas participants in the cold therapy group received the same care plus 20-minute local cold therapy (an ice bag on the surgical incision) three times a day for 48 hours, and participants in the massage group received routine care plus twenty-minute hand and foot massage three times a day for 48 hours. POP was assessed before and 48 hours after the study intervention using the McGill pain questionnaire.

The results showed that there was no significant difference among the groups respecting the pre-test mean score of POP. The mean score of POP

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significantly decreased in all groups and the amount of decrease in the intervention groups was significantly more than the control group.

Co-Kinetic comment Sadly the massage protocol is not described but it does reduce pain. This supports previous research especially a paper from 2018 on pain reduction with massage following tibial shaft fracture [Pasyar N, Rambod M, Kahkhaee FR. The effect of foot massage on pain intensity and anxiety in patients having undergone a tibial shaft fracture surgery: a randomized clinical trial. J Orthop Trauma 2018;32(12):e482–e486]

EFFECTIVENESS OPEN OF MAITLAND AND MULLIGAN MOBILIZATION IN CERVICAL RADICULOPATHY PATIENTS. Niaz M, Zafar A, Sadiq U et al. Pakistan BioMedical Journal 2022;5(2):77–79 Two hundred patients (124 males, 76 females), aged 30 years or above and diagnosed with cervical radiculopathy were randomly allocated to either a 2-week programme of Maitland mobilisation or Mulligan mobilisation.

Post-treatment pain levels were reduced, and ROM increased in both groups with a greater increase in the Mulligan group.

Co-Kinetic comment Three cheers for any paper that shows the effectiveness of manual therapy techniques and this one does, but why oh why is the only description of the techniques “small magnitude oscillating and distracting movements” for Maitland and “MWM … accessory mobilisation to a peripheral joint by a physical therapist while the patient generates active movements simultaneously”.

Not good enough.

Co-Kinetic Journal 2022;93(July):4-11

RESEARCH INTO PRACTICE

Fifty subjects aged 18–50 years with a history of pain, paraesthesia and numbness of less than 3 months in the upper limb with cervical or periscapular discomfort were treated with rotations, lateral glides in neutral, posteroanterior glides, posteroinferior medial glides, anterosuperior anterior glides, and anterosuperior anterior glides at Maitland grade 3 or 4 for 30 seconds each. They also received 5 minutes of cervical traction, cervical stabilisation exercises, isometric exercises to the cervical area and exercises to the scapulothoracic muscles. For good measure Kinesio tape was applied

EFFECT OF KINESIO TAPING IN PATIENTS WITH CERVICAL RADICULOPATHY: A LONGITUDINAL STUDY. Pajnee K, Kalra S, Yadav J. Journal of Clinical & Diagnostic Research 2022;16(3):KC01– KC04 from the occiput along the extent of the patient’s area of discomfort or paraesthesia.

There were three treatment sessions spread over 4 weeks. Neck disability index (NDI), numeric pain rating scale (NPRS) and disability of the arm, shoulder and hand (DASH) questionnaire were the outcome measures taken at 0, 2 and 4 weeks. All the variables showed significant improvement between different intervals.

Co-Kinetic comment Don’t believe everything you read. The patients improved, which is great for them, but there is no way of knowing if this was down to the tape.

Maybe the title of this work should be “Throwing the book at patients with cervical radiculopathy”.

EFFECT OF KOREAN MEDICINE TREATMENTS FOR FAT PAD SYNDROME OF KNEE JOINT: A CASE REPORT. Lee JH, Lee SK, Park EY et al. Journal of Acupuncture Research 2022;39(1):53–58 A 49-year-old female presented with bilateral knee pain that was worse on the right. She was not taking any medication, had no family history, had no underlying diseases, and received no other treatment for knee pain. MRI scans revealed that on the right she had soft tissue oedema in the anterior suprapatellar fat pad and Hoffa’s fat pad, medial collateral ligament injury, and tendinosis of the patellar tendon. She was diagnosed with fat pad syndrome, given the absence of any other articular condition/disease. An MRI of the left knee showed no major abnormality

except for a sprained anterior cruciate ligament.

Her treatment was a cocktail of Korean medicine techniques, acupuncture and electric acupuncture for 15 minutes twice a day, pharmacopuncture (1ml of Shinbaro a purified extract from a mixture of six oriental herbs) also twice a day. Three daily doses of another herbal medicine, a session a day of Chuna therapy (a form of manual manipulation similar to chiropractic) to relieve tension in the muscles around the knee joint and hamstring. She also received myofascial release and muscle energy technique

The objective in this study was to determine which of several exercise prescription methods, without direct professional supervision, might best instruct adolescents to correctly engage in upper limb motor execution on outdoor flexion– extension equipment. A total of 54 adolescents from a middle socioeconomic level in northwest Spain participated. They were randomly assigned into three groups who received either video instruction, instruction via images or written panel instructions. Observational methodology in videographic analysis was used to evaluate the mistakes participants made in motor execution with each instructional method.

Participants who relied on video instructions committed fewer errors than those who relied on panel instructions. The video method prevented loss of information that occurred when instructional images were used.

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around the knee joint and hamstring muscle and deep fascial meridian therapy, which involves herbal medicine steam therapy for 30 minutes.

The treatments lasted for a month by which time the woman reported much reduced pain and improved function.

Co-Kinetic comment Three cheers for the Korean Health System because it put in some effort here. Can anyone tell us if this is normal or just because someone was writing a paper on it? From the patient’s point of view it doesn’t matter which of this encyclopaedia of treatments worked but for the rest of us it would be nice to know. Some more research please.

EFFECT OF TEACHING METHOD ON EXERCISE EXECUTION IN ADOLESCENTS’ USE OF OUTDOOR FITNESS EQUIPMENT. Gutiérrez-Santiago A, Paramés-González A, Prieto-Lage I. Perceptual and Motor Skills 2022;doi:10.1177/00315125221098635

Co-Kinetic comment What a great study. The authors suggest including a QR code on outdoor fitness equipment in open-air parks to permit users to download an explanatory video to their mobile phones. It’s the way forward.

Co-Kinetic.com

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IS MASSAGE AN EFFECTIVE INTERVENTION IN THE MANAGEMENT OF POST-OPERATIVE SCARRING? A SCOPING REVIEW. Scott HC, Stockdale C, Robinson A et al.

Journal of Hand Therapy 2022;S0894-1130(22)00005-9 Scarring is a normal part of the wound healing process, but aberrant wound healing can result in hypertrophic scarring which is characterised by an excess of collagen formation and appears erythematous, raised and thick within the boundaries of the original wound.

The changes in cosmetic appearance, continuing pain, loss of movement due to contracture or adhesion and persistent pruritis can significantly affect an individual’s quality of life and psychological recovery following the injury. Those with scars are more likely to experience anxiety and depression, with individuals feeling stigmatised and seeking to hide their scars from others, thereby affecting their ability to participate in social and work activities.

To answer the question about the efficacy of massage for scars, the usual medical databases plus ProQuest Dissertations & Theses Global, and the Joanna Briggs Institute were searched from inception to December 2020. Twenty-five studies met the inclusion criteria, reporting

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on a combined sample of 1515 participants, although only two directly addressed hand or wrist scars (92 participants). All the studies reported favourable outcomes for scar massage including reducing pain, increasing movement and improving scar characteristics. However, the quality of the studies judged by a PEDro score indicate a variable quality of evidence. One of the main issues in pooling results was that across the 25 studies, a total of 45 different outcome measures were used.

Co-Kinetic comment According to this paper there are 312.9 million operations performed annually worldwide. That is a lot of surgical scars and the incidence of hypertrophic scarring following surgery is reported as between 40 and 94%. Scar massage is a potentially cost effective and an easily implemented intervention by those trained to do so.

LOW LYING PUBIC TUBERCLE: A PREDICTOR OF DEVELOPMENT OF INGUINAL HERNIA. Verma M, Purohit N, Vashisht MG et al.

IP Journal of Surgery and Allied Sciences 2022;3(4):107–111

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This case control study was conducted using 100 patients with an inguinal hernia and 100 healthy individuals as controls. All were males. The two groups were statistically comparable in respect to age, height and weight. All were subjected to ultrasonography of the inguino-scrotal region, kidney, urinary bladder, prostate and any abdominal lump. They were asked to lie supine so that their anterior superior iliac spines were level. A line was drawn on the anterior abdominal wall connecting the two. Then the pubic tubercle on the side of hernia was marked by palpation and the vertical distance between this point and the marked line measured. Similar measurements were done on controls. The mean value of distance was significantly greater in the hernia group suggesting that people with a low-lying pubic tubercle are at high risk of developing inguinal hernia.

Co-Kinetic comment Many (if not all) of the therapists reading this will have gone through the embarrassment of being shown how to palpate the symphysis pubis (if you haven’t, Google it). This shows that there is good reason for doing it. How you prevent a hernia in the at-risk group is another matter.

CASE REPORT: VERTEBRAL ARTERY DISSECTION AFTER USE OF HANDHELD MASSAGE GUN. Sulkowski K, Grant G, Brodie T. Clinical Practice and Cases in Emergency Medicine 2022;6(2):159–161

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A 27-year-old female presented to an Emergency Department in Las Vegas with a 2-week history of progressively worsening headache, neck pain and dizziness. She denied any recent trauma but had recently begun using a hand-held massage gun on her neck over the preceding 3 weeks. During her physical examination, vital signs were all within normal limits, demonstrated full ROM of the neck without pain, had no audible carotid bruit, no notable swelling, ecchymosis, or midline cervical spinal tenderness to palpation. She had a Glasgow coma scale of 15 and was alert and oriented to person, place and time. She had a normal cranial nerve exam, full strength in the upper and lower extremities, normal reflexes and no ataxia. She had a negative Romberg test and normal, rapid alternating movement testing and finger-to-nose testing. Her blood and electrolyte count were normal.

A CT scan demonstrated no notable abnormalities but a CT angiogram revealed a long segment of irregular stenosis of the right vertebral artery extending from the second to the fifth cervical vertebra, most compatible with a vertebral artery dissection. It was concluded that she had damaged herself with repeated use of a handheld percussive massage gun.

Co-Kinetic comment Arterial dissection is a potential cause of stroke. Vertebral artery dissection usually occurs with minor trauma but has been seen with cervical manipulation. Maybe it is time that massage guns came with a health warning.

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Co-Kinetic Journal 2022;93(July):4-11

RESEARCH INTO PRACTICE

NANOMATERIALS AND RESEARCH ON THE REPAIR OF BASKETBALL SPORTS LIGAMENT INJURY. Xing Z. Journal of Nanomaterials 2022;1797629

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This article mainly studies the repair effect of nanomaterials on basketball sports ligament injuries. Nanofibre scaffolds were implanted in sports-injured rabbits, and their healing, growth and proliferation of damaged cells was observed along with the compatibility of nanofibres with cell tissues, so as to determine if nanomaterials have an impact on sports injury repair and the interaction between nanomaterials and cells. Twenty healthy rabbits were given sports related ligament injuries and epidermal wounds. Ten of them were implanted with a nanofibre scaffold and the others used as a untreated control.

The results showed that the implantation of nanofibre scaffolds can greatly accelerate cell proliferation and differentiation and promote the healing of sports-damaged tissues; nanofibre scaffolds have good histocompatibility, so the use of nanomaterials can promote the repair of sports ligament injury in basketball sports.

Co-Kinetic comment Apparently the use of nanomaterials to reconstruct artificial ligaments is the current research hotspot of sports injury repair. Basically biodegradable polymer fibres are weaved together to make a thread and then a 3D printer is used to create the implant. It is the stuff of science fiction. Despite the title, the paper has little to do with basketball.

In fact we didn’t know rabbits played basketball. Do they play in the NBA (National Bunny Association)?

A COLLEGE STUDENT WITH CHEST AND NECK PAIN. Tsai TY, Lee CW, Lee YK et al. Annals of Emergency Medicine 2022;79(6):e115–116

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A healthy, 21-year-old college student presented to the emergency department with acute chest and neck pain. He was afebrile, with a blood pressure of 115/57mmHg, a pulse rate of 99 beats/min, a respiratory rate of 16 breaths/min, and a peripheral oxygen saturation of 99%. A physical examination revealed a supple, tender neck without palpable crepitus, and his breathing sounds were vesicular symmetrically. Following an ultrasound scan of his neck and a chest X-ray he was diagnosed with spontaneous pneumomediastinum (SPM) and cervical subcutaneous emphysema. He was discharged after symptom management and prophylactic antibiotics 4 days later, and was asymptomatic at 1-month follow-up.

Co-Kinetic comment This is one of the conditions you may never see but you should be aware off. Pneumomediastinum is defined as free air within the mediastinum, not associated with trauma.

Usually, it causes severe chest pain below the sternum, that may radiate to the neck or arms and breathing difficulties which together are described in some of the literature as ‘frightening’. The pain may be worse with breathing or swallowing. It can be brought on by asthma, vomiting and exercise and has recently been reported in Covid-19 patients. It can also be spontaneous, as it seems to have been here (although the chap reported that he had visited a karaoke club so maybe he was a tad over exuberant in his performance). It is most prevalent among males aged 5–34: the prime sporting population.

PREVALENCE OF AND PREVENTION FOR WORK-RELATED UPPER LIMB DISORDERS AMONG PHYSICAL THERAPISTS: A SYSTEMATIC REVIEW. Waller E, Bowens A, Washmuth N. BMC Musculoskeletal Disorders 2022;23(1):453

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Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a search was made of PubMed, CINHAL, EMBASE and Google Scholar for articles about work-related upper limb disorders (WRULDs) among physical therapists (PTs). Two hundred and eleven studies were assessed. They had sample sizes from 29 PTs to 2593 PTs with a majority of these studies having a higher female to male ratio. They were spread across numerous geographical locations including Nigeria, India, USA, UK, Korea, Australia, Italy, Kuwait and Israel.

Twelve studies were included in the review. Thumb disorders had the highest prevalence (7.6–52.5%), followed by wrist and hand disorders (5–66.2%), shoulder disorders (3.2–45.2%), and elbow disorders (4–16%). Reported risk factors included treating a high volume of patients and frequent performance of manual therapy techniques. Consequences included interference with PTs’ personal and professional activities while coping strategies involved alterations to the work environment, techniques used, and workload.

Co-Kinetic comment This should be a wake up call to for all PTs. Look after yourself. The study states that most PTs adopt a reactive strategy more frequently than a preventive one. By then it is too late. There are ways around using your vulnerable joints or at least reducing the load going through them.

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Nine healthy men aged between 20 and 30 years old were recruited and randomly assigned to a control group (n=5) and massage group (n=4). All were physically fit, without injury and had not received a massage in the previous week. Before the exercise protocol, participants performed a standardised 5-minute warm-up on a treadmill at a speed of 6km/h. Then, they did a knee extension and flexion isokinetic exercise on an isokinetic dynamometer at 180°/s with the goal of 30 consecutive repetitions or until participants reach voluntary tiredness. Following this they did a 10-minute standardised cool-down by stretching both the calf and thigh muscles.

Then, a 10-minute massage was performed on the rectus femoris muscle of the quadriceps and the biceps femoris muscle of the hamstrings of the dominant thigh.

The control group did not receive a massage and were requested to rest for 10 minutes in the seated position.

Heart rate was recorded as the beat-to-beat interval (R-R interval) by a heart rate monitor device for 5 minutes while lying quietly in the supine position. During the recording, participants were not allowed to talk or to move their bodies. Ectopic beat artefacts correction threshold level ±0.25s was conducted. Heart rate variability (HRV) spectral analysis was performed at baseline, pre-exercise, post-

ACUTE MASSAGE STIMULATES PARASYMPATHETIC ACTIVATION AFTER A SINGLE EXHAUSTIVE MUSCLE CONTRACTION EXERCISE. Mat Isar NEN, Abdul Halim MHZ, Ong MLY. Journal of Bodywork and Movement Therapies 2022;30:105–111 exercise and immediately post-intervention. The HRV was presented as low-frequency (LF) peak (Hz), power (ms2), power (normalised unit; n.u.), and high-frequency (HF), peak (Hz), power (ms2), power (n.u.) as well as LF/HF ratio. Spectral power analysis showed there were no significant differences in the LF indices and LF/HF ratio with massage. HRV normalisation data revealed a within-subject difference with massage. What this means in English is that massage caused an immediate parasympathetic activation during recovery from a single, exhaustive muscle contraction exercise.

Hence, massage may be used to potentiate recovery.

Co-Kinetic comment Twenty men were originally recruited but 11 dropped out, which is a pity because it leaves a tiny sample on which to base conclusions. The massage protocol is well described with the depth graded as medium. The autonomic nervous system with its two main divisions, the parasympathetic nervous system and sympathetic nervous system, is responsible for regulating all unconscious bodily functions such as heart rate, blood pressure, digestion, respiration, metabolic and endocrine responses, among others, so a beneficial alteration is a positive intervention.

Another tick in the ‘good’ box for massage.

AN EXAMINATION AND CRITIQUE OF SUBJECTIVE METHODS TO DETERMINE EXERCISE INTENSITY: THE TALK TEST, FEELING SCALE, AND RATING OF PERCEIVED EXERTION. Bok D, Rakovac M, Foster C. Sports Medicine 2022;doi:10.1007/s40279-02201690-3 The talk test (TT), feeling scale (FS) and rating of perceived exertion (RPE) are selfreported subjective measurements of training intensity. This review is intended to provide basic information on reliability and construct validity of the three.

The key points are that self-reported subjective methods are easy-to-use tools for prescribing exercise intensity without the need for prior exercise testing.

The TT and RPE are reliable and valid measures for demarcation of first and second ventilatory or lactate thresholds and can, therefore, be used to elicit homeostatic disturbances associated with moderate, heavy and severe intensity domains during continuous exercise.

Studies about the validity of the FS to demarcate moderate and heavy intensity domains during continuous exercising show equivocal findings, but its use is certainly welcome for controlling the exercise intensity in sedentary and low-active individuals.

The TT and RPE can effectively be used to prescribe and monitor intensity for continuous exercise up to 60 minutes in the moderate intensity domain and up to 30 minutes in the heavy intensity domain, while the FS can be used to control for the intensity of exercise that would provide better adherence to long-term exercising.

Co-Kinetic comment As the authors point out, there are numerous objective methods to determine exercise intensity, but they all require anchor measurements prior to the exercise. These don’t, so they may be more practical. According to the USA Center for Disease Control the TT is exercise you can do while talking but not singing.

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Co-Kinetic Journal 2022;93(July):4-11

RESEARCH INTO PRACTICE

MINIMALLY INVASIVE FASCIOTOMY FOR SYMPTOMATIC TIBIALIS ANTERIOR MUSCLE HERNIA. Maffulli N, Quaranta M, Poeta N et al.

The Surgeon 2022;doi:10.1016/j.surge.2022.01.005 Twenty-two consecutive athletes/ patients (17 males and 5 females) (median age 24.5 years; range from 16 to 35 years) who had undergone fasciotomy for management of leg pain secondary to a unilateral muscle hernia (MH) of the tibialis anterior muscle were enrolled in this study. The sport activity was running in 5 patients, ballet in 3, martial arts in 3, keep fit aerobics in 3, soccer in 1, badminton in 3, squash in 3, and cross training in 1. The median duration of symptoms before surgery was 11 months (from 6 to 27 months).

The reason for their referral was given as MH in 5 patients, chronicexercise-induced compartment syndrome in 4, post-traumatic subperiosteal haematoma in 2, tibialis anterior tendinopathy in 1, peroneal tendinopathy in 1, chronic muscle strain in 1. No precise diagnosis had been formulated in the remaining 8 patients.

All patients had been managed conservatively with compression stockings, bandages, Kinesio taping, strapping, various physiotherapy modalities, restriction of the inciting exercise and rest for a median of 8 months (range from 6 to 11 months).

All patients referred pain during prolonged sporting or working sessions

and generally became asymptomatic within a few minutes with rest. In all but three patients, careful gentle palpation of the area of the hernia identified the hernial orifice. For MH in the tibialis anterior, with the patient on an examination couch and the legs hanging from the edge of the couch, the active dorsiflexion of the foot makes the hernia more evident. The actual diagnosis of MH was confirmed by imaging.

Treatment was day-case fasciotomy surgery, weight-bearing as comfortable using elbow crutches for 14 days, then over the next 4–6 weeks patients were prompted to gradually return to walking, jogging, and agility training.

Sport-specific training was allowed at 8 weeks, sport participation was allowed not before 14 weeks. Before surgery, patients were unable to practise sport activity with continuity, and their daily physical activities were affected. At the last follow-up, (median time of 23 months; range, 12–49 months), 16 of 22 patients (73%) had returned to sport and or normal physical activities. Of these, 11 had returned to pre-injury levels, two had reached higher levels of sport compared to their pre-injury status, and three had returned to sport

at lower level but their normal physical activities were not affected.

Co-Kinetic comment For the surgeons among you there is a full description of the op and lots of pictures. For the rest of us the best thing about this paper is that it gives an insight into the condition.

Tibialis anterior muscle herniation often presents as a distinct palpable swelling or nodule over the muscle especially with weight-bearing and muscle contraction and as the list of referral conditions shows, it can often be mistaken for something else.

SURVEY OF CONFIDENCE AND KNOWLEDGE TO MANAGE PATELLOFEMORAL PAIN IN READERS VERSUS NONREADERS OF THE PHYSICAL THERAPY CLINICAL PRACTICE GUIDELINE. Willy RW, Hoglund LT, Glaviano NR et al.

Physical Therapy in Sport 2022;55:218–228 The object of this exercise was to determine if physical therapists took any notice of clinical practice guidelines (CPG). It was an online survey of mainly USA therapists who were asked Likert-based or open-ended questions regarding the diagnosis, prognosis, risk factors, and management of individuals with patella femoral pain (PFP), as well as confidence for managing individuals with PFP, especially the ability to identify beneficial and non-beneficial interventions. The responses were dichotomised into participants

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who read (READERS) and did not read (Non-READERS) the CPG for the management of individuals with PFP. The survey completion rate was 82% leaving 494 participants who completed the survey. Of these, 48.8% and 51.2% were classified as READERS and NonREADERS, respectively.

The results showed that most respondents held inaccurate beliefs about risk factors and prognosis; however, READERS’ beliefs better aligned with the CPG than Non-READERS’. Most respondents correctly agreed that hip and knee

exercise was the recommended treatment strategy; yet Non-READERS believed in implementing unsupported passive treatments.

READERS reported greater confidence in managing individuals with PFP, delivering evidence-based interventions, identifying less beneficial treatments, and locating evidencebased resources than Non-READERS.

Co-Kinetic comment.

Be honest, how well do you know the clinical practice guidelines for your industry? In the UK they are published by the National Institute for Health and Clinical Care Excellence (NICE). Check out https://www.nice.org.uk/ There are a lot of them.

11

MEN’S PELVIC HEALTH

Many men are affected by issues to do with pelvic health including: Sexual dysfunction Urinary incontinence Faecal incontinence Chronic pelvic pain Prostate cancer Erectile dysfunction and premature ejaculation – affects % of men % and respectively Pelvic floor exercises can cure/improve symptoms in % more than of cases

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Approximately % of men suffer from chronic pelvic pain – treatments can improve symptoms and reduce pain in % of sufferers and include: l Physical therapy l Trigger point therapy l Acupuncture

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l Physical therapist l Friends l General practitioner/primary l Men’s health charities health care provider and support groups The information contained in this poster 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 2022

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Calf Muscle Strain Injuries Calf muscle strain is a common sporting injury that can result in significant downtime for the athlete and also has a risk of recurrence if not managed properly. This article will allow you to understand why certain injuries occur to different parts of the calf muscle, and how to assess and treat calf muscle injury for your patient’s optimal return to sport with minimal risk of reinjury. Risk factors and prevention are also discussed allowing you to minimise your athlete’s risk of injury in the first place.

Read this article online https://bit.ly/3yeSqHN

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

C

alf muscle strain injury (CMSI) is one of the most common muscle injuries in high-performance athletes, across a variety of sporting disciplines. It is an injury that contributes to substantial downtime for the athlete, with a high mean time to return to play (RTP), more than three months in some cases.

Further compounding the impact of CMSI can be the occurrence during critical periods in the competitive season, athletes’ susceptibility to recurrence and subsequent lower limb injuries, for example hamstring strain (1,2,3*,4). Published research on lower-body injury has provided frequent updates on the rehabilitation of high-profile areas, such as the hamstring muscle and Achilles tendon.

Despite its prevalence, and CMSI being problematic across a number of sports, there is a dearth of research to adequately guide clinicians. The past decades have seen a focus of research on epidemiology and risk factors associated with CMSI. Although this evidence is valuable in developing prevention strategies, it forms only one component of dealing with an athlete with calf strain. As yet, only a low level of research using randomised

CALF MUSCLE STRAIN INJURY (CMSI) IS ONE OF THE MOST COMMON MUSCLE INJURIES IN HIGHPERFORMANCE ATHLETES, ACROSS A VARIETY OF SPORTING DISCIPLINES 14

clinical trials is available regarding clinical decision-making, causation, assessment and management.

In the absence of quantitative research, integrating perspectives and experiences from expert clinicians may be a valuable tool. Hence, the addition of qualitative research may be a powerful instrument to fill the gaps and guide practice. For CMSI, it would seem critical that better guidelines directing identification, management and prevention be established because failed management (ie. a recurrent CMSI) results in an average two-week longer RTP, and the risk of subsequent CMSI is elevated for months (2,5,6*). This article aims to highlight the current perspectives and practices (from both quantitative and qualitative evidence) to guide CMSI diagnosis, management and prevention.

A Bit of Perspective

In the late 1800s when calf strain injuries were first described it was known as ‘tennis leg’ owing to the occurrence associated with the sport.

Although still notable in tennis, calf strain has since been reported with far greater numbers in sports including American football, Australian football, basketball, soccer and running, for example. It is more prevalent among athletes aged 22 to 28 years of age, more frequently affects men and has a recurrence rate of approximately 19–31% (3*,5,6*,7*). Most often rehabilitation is conservative, with a recovery period that ranges from Co-Kinetic Journal 2022;93(July):14-25

PHYSICAL THERAPY

immediate RTP to multiple months of missed training or playing time (3*,4,7*,8*).

It appears that injury to the individual triceps surae muscles may be sport- or activity-dependent.

The predominant CMSI in American football is isolated gastrocnemius strain, whereas in Australian football isolated soleus muscle strain is more common (6*,9*). In addition to this, gastrocnemius strain is associated with high-intensity running, acceleration, and deceleration activities – thereby being activity dependant. Soleus strain, however, is more likely to occur during steady-state running activities (6*). This observation may be substantiated by the fibre composition of the muscles and their respective biomechanical functions. The gastrocnemius muscle, responsible for knee flexion and ankle plantar flexion, is dense in fast-twitch muscle fibres, adapted for rapid contraction and response. However, the soleus muscle is dense in slow-twitch muscle fibres and regulates plantar flexion, in a postural control manner, during the gait cycle.

Pathophysiology

Gastrocnemius Strain

When the gastrocnemius muscle is fully stretched, a sudden contraction of the tensioned muscle can rupture the medial head at the musculotendinous junction. Thus the common pathogenesis of a gastrocnemius tear involves knee extension with a sudden, ballistic ankle/foot movement from dorsiflexion to plantarflexion. Since the medial head of the gastrocnemius muscle has a greater contribution to muscle activity it is more prone to injury than the lateral head. Studies have shown a 2:1 ratio of tears to the medial head compared with the lateral head (7*,10*).

Soleus Strain

The mechanism for soleus rupture is associated with overuse, and is thus a subacute injury. It may be caused by repetitive, passive dorsiflexion of the foot with the knee bent (10*). This posture is often observed in runners when running uphill. Most often a soleus strain is of gradual onset and a cumulative effect; however, acute strain can manifest in fatigued athletes (10*).

Plantaris Strain

An isolated rupture of the plantaris muscle is relatively rare but can occur at the proximal muscle belly or the midportion of the plantaris tendon (10*). Similar to a gastrocnemius tear, the pathogenesis involves knee extension with ballistic foot plantar flexion. In the case of an isolated lesion athletes can retain a full range of motion (ROM) without loss of strength. Most often a plantaris injury is diagnosed with concomitant traumatic knee injuries, including lesions of the anterior cruciate ligament or the posterolateral corner (7*,10*).

Subjective Assessment and Presentation

During the initial examination of CMSI, steps should be taken to firstly identify the primary muscle involved (eg. soleus vs gastrocnemius); this may be determined by a combination of patient and injury history, examination and what triaging actions (eg. immediate immobilisation, imaging) were performed.

Table 1: Initial subjective examination (Adapted from Green B, McClelland JA, Semciw AI et al. The assessment, management and prevention of calf muscle strain injuries: a qualitative study of the practices and perspectives of 20 expert sports clinicians. Sports Medicine – Open 2022;8(1):10:doi:10.1186/s40798-021-00364-0 (8*)) Domain

Key areas

Baseline outcomes

1. Presenting injury

i. History of onset

The presence (yes/no) of an inciting incident. If yes, the mechanism of injury The duration of symptom onset: immediate; cumulative; days

ii. Self-reported symptoms

Symptom qualities and intensity: pain; unresolved ‘tightness’ or ‘cramping’; paraesthesia; numbness Location(s) of symptoms: focal; diffuse Perceived level of severity or functional impairment

i. Intrinsic factors

Non-modifiable factors: history of CMSI; chronological age; training age; ethnicity; other injury history, including recurrences (foot, ankle, knee, spine, hamstring, quadriceps, adductor) Modifiable factors: mobility; strength-power capacities; fitness/conditioning to running and ballistic activities

ii. Other predisposing factors

Recent period of relative off-loading or immobilisation (eg. illness, surgery, injury); monitoring or ‘wellness’ flags: fatigue, recovery, sleep, illness; impairments or functional restrictions related to current clinical/ sub-clinical state: 1st MTPJ, plantar fascia, ankle, Achilles, knee, bone stress, spinal

i. Extrinsic factors

Demands of the sport: playing position, playing style, stage of the season; recent and long-term history of training and competition

ii. Other contextual factors

Change in footwear and/or orthotics Potential for training error: large changes in exposure or unaccustomed stimuli (eg. running surface; eccentric exercise)

2. The injured athlete

3. The injury context

CMSI, calf muscle strain injury; MTPJ, metatarsophalangeal joint.

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1. Acute Strain of the Gastrocnemius

l Mechanism of injury (described above). l Possibly an audible pop at the time of the injury. l Dull to severe pain and swelling in the posterior lower limb within 24 hours. l Pain can be latent, manifesting only after the athlete tries to stand, walk, or plantar flex the foot. l Unable to perform a heel raise on

the affected side. l Tenderness at the musculotendinous junction, in severe cases a palpable defect in the medial head. l Mild to severe ecchymosis can appear at the rupture site.

2. Soleus Strain

l Typically subacute. l Presents with muscle tension and tightness. l Poorly localised pain on palpation. l Gradual pain development over the course of days to weeks.

l Mild swelling and disability. l Tenderness deep within the lateral calf, distal to the gastrocnemius muscle. l Muscle contraction tested is with the knee in maximal flexion, such that the soleus muscle becomes the primary contributor to plantar flexion.

3. Isolated Plantaris Strain l Rare and often clinically indistinguishable from a gastrocnemius strain.

Table 2: Initial objective examination (Adapted from Green B, McClelland JA, Semciw AI et al. The assessment, management and prevention of calf muscle strain injuries: a qualitative study of the practices and perspectives of 20 expert sports clinicians. Sports Medicine – Open 2022;8(1):10:doi:10.1186/s40798-021-00364-0 (8*)) Domain

Key areas

Baseline outcomes

1. Observation

i. Local observation

Relative calf bulk (size, shape); observable signs of severe CMSI; observable signs of other injury (eg. contusion, Achilles rupture or tendinopathy)

ii. Other structures

Relative muscle bulk (size, shape) compared to contralateral limb: posterior gluteus maximus, hamstrings, quadriceps Altered gait pattern

i. Tenderness

Discrete location if discernible: gastrocnemius (medial, lateral), soleus (usually more distal and lateral), Achilles tendon; pain; maximum length of tenderness (cm); symptom quality Palpable defect indicates a possible muscle retraction with complete fibre disruption Palpable contractions that are spasmodic and involuntary indicate muscle cramps

ii. Tactile qualities

Focal spasm; palpable defect or deformity: Achilles tendon, medial gastrocnemius, superficial triceps surae confluence; evidence of direct injury where relevant (eg. contusion)

2. Palpation

3. Stretch tolerance

Non-weight-bearing ROM (°); pain; other symptoms; symptom quality i. Passive dorsiflexion: KF, KE ii. Knee-to-wall lunge Weight-bearing ROM and asymmetry (cm); pain; other symptoms; symptom quality

4. Isolated function

iii. Straight-leg stretch at wall

Weight-bearing ROM asymmetry (cm); pain; other symptoms; symptom quality

i. Isometric contraction: KF, KE

Non-weight-bearing plantar flexion: capacity, pain, other symptoms With KE isolate gastrocnemius With KF isolate soleus contraction

ii. Single-leg calf raise: KF, KE

Weight-bearing plantar flexion: capacity, pain; other symptoms; symptom quality; antalgic strategy Graded as appropriate: (a) double-leg, (b) double-leg concentric, single-leg eccentric, (c) single-leg calf raise Look for sickle sign and toe clawing during calf raises Bent-knee calf raise isolates soleus muscle

5. Dynamic capacity i. Plyometric function

ii. Locomotive activities

Capacity; pain; other symptoms; symptom quality; antalgic strategy Graded as appropriate for jumping and hopping: (a) double-leg vertical, (b) single-leg vertical, (c) single-leg horizontal Capacity; pain; other symptoms; symptom quality; antalgic strategy Graded as appropriate: (a) walking, (b) submaximal jogging, (c) linear run through, (d) cutting and change of direction, (e) sprinting, (f) maximum acceleration from inert position

Notes: °, degrees measured using goniometer; antalgic strategy, observable presence of antalgic strategy (yes/no); capacity, the ability to perform the task (yes/no); KE, knee position in extension; KF, knee position in flexion; pain, check: (1) presence (yes/no) and (2) extent (VAS:x/10); other symptoms, eg. ‘tightness’, ‘cramping’, or neural symptoms elicited; symptom quality, eg. focal versus diffuse.

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PHYSICAL THERAPY

l Imaging is required for a definitive diagnosis. l Possible audible pop at time of injury. l Patient may retain full ROM without reduction in strength.

Table 1 shows what to consider in an initial subjective examination of a patient with suspected calf strain.

Clinical presentations that could have some signs and symptoms similar to CMSI include direct injuries like a contusion, delayed onset muscle soreness, other lower leg muscle strains and an Achilles tendon tear or tendinopathy. Posterior leg pain can originate from other muscles including the popliteus, peroneus longus and deep posterior compartment or lateral compartment (including tibialis posterior, flexor hallucis longus, flexor digitorum longus, peroneals). Medial gastrocnemius tenderness is common on palpation and can be normal, even in uninjured athletes (7*,8*).

Although the diagnosis of calf strain is often based on clinical findings, imaging is valuable to confirm the location of the strain and the grade of the injury. The information may help to guide the choice and duration of rehabilitation, and influences RTP considerations. Imaging may detect intramuscular fluid collection or connective tissue defects which are associated with delayed RTP. In elite sports, the decision-threshold for imaging is low (8*). It is preferred to wait 24–48 hours post-injury to confirm if it is warranted and to gain a thorough impression of injury severity before presenting biases inherent in imaging results. Magnetic resonance imaging (MRI) may be used as the gold standard, followed by ultrasound (which has the benefits of ease of use and rapid results), to establish the extent of disruption and injury pathology. However, over time the most valuable prognostic information comes from the rate of functional progression (8*). The use of imaging can be counter-productive as many athletes present with tissue changes that may not have been pathological, symptomatic or related to the current injury. The degree of tissue change seen during imaging does not Co-Kinetic.com

THE GASTROCNEMIUS MUSCLE, RESPONSIBLE FOR KNEE FLEXION AND ANKLE PLANTAR FLEXION, IS DENSE IN FAST-TWITCH MUSCLE FIBRES, ADAPTED FOR RAPID CONTRACTION AND RESPONSE positively correlate with symptom severity (11,12). This can result in catastrophising, overly cautious rehabilitation programmes and a negative psychological bearing on the athlete (8*).

Objective Assessment and Physical Examination

The initial objective examination should be used to refine the clinical impression of injury location, severity and directed

immediate management – this includes what have they done since the injury, were they immobilised, did they cease or continue play, etc. (Table 2).

Traditionally, muscle strains have been graded, but one should not be defined or limited by the grade initially given upon diagnosis – see Table 3.

Injury grades for CMSI and recovery times in Meek et al. (7*; https://bit.ly/3xLDPU7). Although the injury grade may guide rehabilitation

Baseline examination Rate and maintenance of symptom resolution: 1. Palpation tenderness 2. Stretch intolerance 3. Isolated calf function 4. Dynamic calf capacity

Periodic clinical re-evaluation

During rehabilitation 1. Performance-related factors (eg. strategy, competition schedule, position) 2. Cumulative recovery from rehabilitation 3. Psychological readiness

At the time of return to play

Final return to play prognosis

1. Injury type: index versus recurrent CMSI 2. Mechanism of injury 3. Clinical +/– imaging findings 4. Aetiology: risk domains, risk and predisposing factors 5. Eventual demands of competition/sport

Objective milestones, where relevant: 1. Foundation strength-endurance, motor control 2. Loaded strength and power capacities 3. Plyometric function 4. Running activities (velocity- and endurance-based) and fitness capacities 5. Tolerance of injury mechanism, if relevant

1. Data-informed consensus among key stakeholders: Athlete, coach, medical and fitness staff

Figure 1: Evaluating prognosis after calf muscle strain injury (CMSI)

Numbered points refer to the primary themes and/or concepts that influence decision-making at each stage.

(Green B, McClelland JA, Semciw AI et al. The assessment, management and prevention of calf muscle strain injuries: a qualitative study of the practices and perspectives of 20 expert sports clinicians. Sports Medicine – Open 2022;8(1):10:doi:10.1186/s40798-021-00364-0 (8*), reproduced under the Creative Commons Attribution 4.0 International License, https://bit.ly/3bjavN7)

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THE DESIGNATED GRADE OF MUSCLE INJURY MAY GUIDE BUT SHOULD NOT DEFINE OR LIMIT REHAB/RTP DECISIONS and RTP, many athletes improve at different speeds, based on multiple factors including age, past injury history, motivation and fear. The grade should not hold someone back nor should it push an individual on if they are not ready to RTP within the given time frame.

Typically, once assessed and diagnosed, the very next questions are:

Injury onset

When can I run again? When can I play sport again? Will I be ready for next weeks game? Initially, one shouldn’t feel pressured into giving definitive timelines and a prognosis in the early stages. It is necessary to disseminate information to the athlete and any interested parties. At baseline, early expectations should be stated broadly; for example information about RTP can

Clinical and functional progression

be described as ‘none’ (ie. following an on-field assessment), ‘short’ (possibly a week or two) versus ‘extended’ (possibly 6–8 weeks) (8*).

During rehabilitation, the prognosis can be refined, using functional progression milestones and ongoing assessment. The rate of resolution of pain-free walking is a good indicator of progress.

Identifying other potential risk factors and concomitant impairments may hinder progress through rehabilitation (8*). The final prognosis should be confirmed at the time of RTP and should be a consensus. Rather than

Shift from medical to performance model

Injury prevention

Foundation calf and lower limb function Loaded strengthening Loaded power, plyometrics and ballistic exercises Locomotion Acute injury l Prevent further structural damage (ie. worsening the pathology) l Effective therapeutic loading as early as is clinically reasonable (eg.

NWB and WB plantar flexion) l Normalise walking pattern (if relevant) l Educate stakeholders: anticipated prognosis, functional progression milestones & contraindications

Early rehabilitation l Actively resolve basic signs, symptoms & impairments l Redevelop foundation calf function & capacity (eg. single-leg calf raise strengthendurance, Smith machine strength) l Progress locomotion, including stair climbs and walking drills l Address other modifiable deficits or factors that may impact risk of recurrent CMSI and/ or other subsequent injuries

Intermediate rehabilitation l Sustained resolution of signs & symptoms l Return to running l Progressive rate of loading while building running volume & intensity (eg. plyometrics and ballistic exercises, run drills, power sled)

Return to Return full training to play l Reintegrate to full l Consensus training over ≥1 reached among session, pending stakeholders for injury severity final RTP clearance, l Prioritise sportsto meet the related calf capacities: primary outcome: strength, endurance, (1) return at an power, plyometric elite standard qualities of performance l Running fitness, immediately, & volume and intensity (2) no adverse of sports-related events at RTP (eg. running activities – recurrent CMSI including graded or a different exposure to the subsequent injury) mechanism of injury l Balance exposure (if any) between onfield and offfield activities (eg. loaded calf strengthening and running)

Post return to play l Mitigate the risk of adverse events during the ‘high-risk’ window l Transition to ongoing injury prevention model involving individualised athlete monitoring, load management & exercise selection

1 2 34 56 ATHLETE MONITORING

Figure 2: Overview of optimal management of CMSI, following six phases

NWB, non-weight-bearing; RTP, return to play; WB, weight-bearing.

(Green B, McClelland JA, Semciw AI et al. The assessment, management and prevention of calf muscle strain injuries: a qualitative study of the practices and perspectives of 20 expert sports clinicians. Sports Medicine – Open 2022;8(1):10:doi:10.1186/s40798-021-00364-0 (8*), reproduced under the Creative Commons Attribution 4.0 International License, https://bit.ly/3bjavN7) 18

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PHYSICAL THERAPY

pathology and/or re-imaging being the determining factor, RTP should be based on performance-related factors, psychological factors of the athlete, residual fatigue, competition readiness, and limited training chronicity (13,14,15).

Thus, a staged approach may more accurately determine prognosis (Fig. 1). This approach may (i) prevent injury recurrence due to overly aggressive rehabilitation or premature RTP; (ii) prevent unnecessarily conservative RTP time frames due to ongoing assessment; and (iii) allow performance-related factors to be considered and planned for (8*,16*).

Rehabilitation and RTP

Very, very rarely is surgery required in the management of CMSI. Nonoperative management is effective for the majority of CMSIs. The early stages of treatment may follow a ‘PEACE and LOVE’ protocol (https://bit.ly/34SQIyK) (17*). Over the course of rehabilitation, the

clinical management may shift focus from a medical mindset (protect the injury, prevent further damage, bleeding, sweeling, pain) to prioritising performance and then preventing reinjury after RTP. It is believed that best management should be context/sport-dependant, individualised and strongly influenced by the athlete’s intrinsic characteristics and external factors (8*). Irrespective of injury characteristics, early loading of CMSI results in faster recovery and may reduce pain and improve confidence (18*,19). It has been suggested that management should progress through six phases with the ultimate goal being successful RTP – which is deemed as (1) RTP as soon as possible; (2) restoration of athletic performance to the expected level; and (3) no adverse events, be it reinjury or other subsequent lower limb injury (Fig. 2) (8*).

Rehabilitation Principles 1. Early Loading

Early loading is perceived to fast-track

THE SOLEUS MUSCLE IS DENSE IN SLOW-TWITCH MUSCLE FIBRES AND REGULATES PLANTAR FLEXION, IN A POSTURAL CONTROL MANNER, DURING THE GAIT CYCLE

Table 3: Early loading exercises for CMSI rehabilitation (Adapted from Green B, McClelland JA, Semciw AI et al. The assessment, management and prevention of calf muscle strain injuries: a qualitative study of the practices and perspectives of 20 expert sports clinicians. Sports Medicine – Open 2022;8(1):10:doi:10.1186/s40798-021-00364-0 (8*)) Early loading Examples

Objective Normalise gait pattern

First step to restoring normal movement patterns

Find their optimal starting point for loading

How much load ? Find their barrier and work just below it, this may change daily Start loading on day 2 or 3 Isometric only, exercise band work only Or if they can do double-leg calf raises, start there with two-leg weight-bearing exercises Or if they can do single-leg calf raises, start there with single-leg weight-bearing exercises

Prescribe multiple loading bouts throughout the day

Aim for 4 loading sessions per day, pain free and without detriment the following day

Use activation exercises to prevent inhibition

Gastrocnemius especially is highly susceptible to pain inhibition and wasting Activation can be non-weight-bearing and isometric

Foundation exercises build to dynamic actions of muscletendon unit

Once 2 sets 15 repetitions slow and controlled single-leg calf raises can be done, add: l 1 set of oscillations ‘up top’ ‘middle’ ‘down below’ to plantar grade l Oscillations off a step in full dorsiflexion l ‘ Drop and catch’ at different positions Retraining balance and proprioceptive function, the foot intrinsic muscles and deep lower leg muscle exercises will aid in improving dynamic control

Condition uninjured bodyparts

Do not allow de-training of other muscles where possible. Keep their routine simple modify the activity

Avoid excessive eccentrics and passive stretching in the early stages

Pain may inhibit the athlete recovery physically and emotionally

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Achieve accepted strength threshold Eg. Single-leg calf raise capacity and/or loaded calf strength

Tolerant of repeat hopping Eg. Vertical hop test for a number of repetitions or duration

Absence of other clinical signs and symptoms Eg. Weight-bearing dorsiflexion range of motion

✓ Begin n

running

✗ Further n

rehabilitation required

Figure 3: Determining readiness to run after CMSI

(Green B, McClelland JA, Semciw AI et al. The assessment, management and prevention of calf muscle strain injuries: a qualitative study of the practices and perspectives of 20 expert sports clinicians. Sports Medicine – Open 2022;8(1):10:doi:10.1186/s40798-021-00364-0 (8*), reproduced under the Creative Commons Attribution 4.0 International License, https://bit.ly/3bjavN7)

symptom resolution and disability associated with CMSI (18*,19).

Illustrations of some of the exercises mentioned in Table 3 can be found at Green and McClelland et al. (8*).

The single-leg calf raise underpins advanced functional rehabilitation and should, therefore, follow strict cues (See Video 1 and Green and McClelland et al. (8*)): 1. Perform work along the axis of the second metatarsal.

2. Maintain neutral foot and ankle positions throughout the prescribed range.

3. Control the loading rate (eg.

1 second up; 1 second down).

Things to watch for as indicators of poor calf muscle function or control/ recruitment include sickle sign (progressive inversion or adduction of the foot), clawing toes (excessive reliance on deep foot flexors), and reduced eccentric control (8*). Poor calf or lower limb control may be evident through the entire kinetic chain; athletes may extend their lumbar spine during calf raises or they won’t be stiff in their pelvis (gluteal muscles) and quadriceps. These signs highlight other areas that need to be addressed during the strengthening phase of rehabilitation (8*).

Table 4: Loaded strengthening exercises for calf muscle strain rehabilitation (Adapted from Green B, McClelland JA, Semciw AI et al. The assessment, management and prevention of calf muscle strain injuries: a qualitative study of the practices and perspectives of 20 expert sports clinicians. Sports Medicine – Open 2022;8(1):10:doi:10.1186/s40798-021-00364-0 (8*))

Loaded strengthening Examples

Objective Maximising capacity is first priority

Straight-leg or bent-knee calf raises Small loads with 10–15 or 10–12 reps Increasing loads, reduce reps to 3 or 4 sets of 6–8 reps

Sport-specific strengthening

Strength-endurance required for prolonged running and work (eg. Australian football, football/soccer) versus maximum force-generating capacity for shorter durations (eg. rugby, sprinters)

Consider horizontal and lateral load capacity

Particularly in sports with rapid acceleration or cutting (eg. rugby) l Leaning-tower position calf raises

Single-leg strength is foundation for dynamic exercises

Fewer double-leg exercises as dynamic movement involves all single-leg activity l Single-leg jumping and hopping

Soleus strength is critical for all athletes

Soleus strength capacity and endurance is critical for problem calves, severe calf strains (even if gastrocnemius strain), athletes with history of calf injuries, or lower limb injuries

Load compound exercises

In preparation for movement and sport, incorporate entire kinetic chain, gluteal, hamstring, quadricep and hip flexor muscles l Squats, lunges, pulleys

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2. Loaded Strengthening

Once an early benchmark of singleleg calf raise capacity (body-weight only, 20–25 repetitions continuous) is achieved, then adding load can progress (20). Common starting points include a Smith machine and seated calf raise machine. Progression can be made by increasing loads and moving from a flat foot surface to an inclined surface to alter the ROM. See Table 4 for further details regarding loaded strengthening exercises.

It is believed that eccentric loading can be augmented with heavy isometric strengthening at various MTU lengths and altered whole-body positions (eg. ankle dorsiflexion, knee flexion, trunk lean) (8*).

3. Loaded Power, Plyometrics and Ballistic Exercises

Firstly, this involves re-exposing the calf to volume and its ability to contract and work repeatedly in a sport-specific manner. Secondly, this ensures that the muscle can generate sufficient force at sufficient speed (the rate of loading) to safeguard its spring-like mechanism.

The calf is the first point of loading in the kinetic chain, which is maybe not considered critical in rehabilitation.

Proximally, multiple muscles and structures can jointly absorb the loads of dynamic movement; however, the calf muscle requires sufficient elastic properties to tolerate the running loads alone. Plyometrics and explosive

exercises (loaded and unloaded) are necessary to restore elastic function. Dynamic exercises involving predominantly vertical actions, should be followed by exercises involving greater horizontal, lengthening, and stiffness demands (8*).

Two main exercise streams have been identified: 1. r epeated stretch-shortening-cycles (SSCs) over small length excursions (or pseudo-isometric), associated with a rhythmic MTU action (eg. single-leg pogos); and 2. s ingle or several SSCs over larger length excursions (eg. single-leg countermovement jump, forward hopping) associated with an accelerative MTU action (8*).

A novel concept would be to develop both instantaneous and repeated power of the calf MTU for sports that require both of these qualities, such as Australian football, soccer and long sprinters. This may, however, present a clinical challenge owing to the competing adaptations that these qualities require (8*).

4. Running Rehabilitation

Running prematurely has been cited as a leading cause of early recurrent CMSI (8*,21*). A slight delay in commencing running, may result in a lower risk, without negatively impacting rehabilitation time frames (13). The

Table 5. Objective testing options to evaluate power qualities at RTP after CMSI

(Sourced from Green B, McClelland JA, Semciw AI et al. The assessment, management and prevention of calf muscle strain injuries: a qualitative study of the practices and perspectives of 20 expert sports clinicians. Sports Medicine – Open 2022;8(1):10:doi:10.1186/s40798-021-00364-0 (8*)) Vertical

Horizontal

Instantaneous

SL CMJ SL DJ SL concentric-only jump SL box-jump height

Single hop for distance Resisted acceleration Resisted SL push off

Repeated

SL CMJ: 5–10 reps SL hopping: reps or time Loaded squat jumps

Forward hops in-series: 5–10 reps SL bounding distance: reps or time Broad jumping Resisted SL catch-ups

CMJ, countermovement jump; DJ, drop jump; SL, single leg.

Co-Kinetic.com

Video 1: How good is your calf function?

What is the norm & common compensations?

(Courtesy of YouTube user Physiotutors) https://youtu.be/apRDvOLqTrE

three primary elements for ‘running readiness’ include strength, hopping capacity and the absence of other clinical signs and symptoms (Fig. 3). A more comprehensive build-up before running may enhance outcomes, without extending RTP timeframes (8*,13).

Low-load locomotion should be started as early as possible, in the form of ‘normal gait’ walking, stair ascents, toe walking, loaded walking using kettlebells or dumb-bells, bear-crawls, lunge-walk drills. Normally running drills can be performed at walking speeds including ladder-based drills, ‘under-overs’, ‘ecky-shuffle’, side skips and grapevine on their toes. In preparation for running, visualisation and verbal queues using words like ‘pitter patter’ may help prevent the athlete from plodding initially (8*).

Prescribing an athlete to ‘jog, slowly’ may do more harm initially.

Slower continuous running can result in plodding, which produces high impact forces in the calf and can predispose to fatigue-related recurrence of injury.

Submaximal run throughs (60% effort; 8×80m) may be more productive when starting running again. Increasing the number of sets of shuttle runs (3 sets of 8×80m submaximal runs) can be a way of building volume without plodding or sprinting (8).

Six ‘rules of thumb’ have been identified as a guide to running rehabilitation after CMSI: 1. Initially run on alternate days.

2. Avoid ‘plodding’ early.

3. Do not progress volume and intensity on consecutive days.

4. Schedule off-field exercises (eg.

21

loaded strengthening) after running.

5. Shape running progressions to meet the demands of the sport – don’t overshoot with excessive volume.

6. Avoid sudden changes in conditions, such as the surface and footwear (8*).

Over time, running rehabilitation can involve gradual exposure to greater volume and intensity, with prescriptions aligned to rehabilitate the entire spectrum of activities performed in the sport, including sprinting (not early due to the high contractile forces), cutting, acceleration and endurance.

Table 6: Clinical checklist to determine RTP following CMSI

(Adapted from Green B, McClelland JA, Semciw AI et al. The assessment, management and prevention of calf muscle strain injuries: a qualitative study of the practices and perspectives of 20 expert sports clinicians.

Sports Medicine – Open 2022;8(1):10:doi:10.1186/s40798-021-00364-0 (8*))

✓or ✗

RTP criteria Symptom resolution and psychological readiness

l Self-reported symptoms: VAS 0/10 (pain, tightness, ‘cramping’ sensation) l Self-perceived readiness & confidence to return to performance

Residual clinical signs and impairments

l Palpation tenderness: VAS 0/10, length: 0cm l Weight-bearing ankle dorsiflexion ROM: normalised knee-to-wall lunge (cm) and straight-leg stretch, asymmetries ≤10% l Single-leg calf raise test from the floor*: capacity (≥30 repetitions), asymmetry ≤10%

Normalised strength-power qualities

l Loaded strength: sport-specific benchmark (knee extended, knee flexed) l Power: normalised vertical and horizontal calf function; instantaneous and repeated tests; asymmetries ≤10%

Reconditioned for exposure to sport demands

l Running conditioning: total volume, volume across speed bandwidths, accelerations, decelerations l Intensity of running and other dynamic activities: cutting, reactive agility, jumping, maximum velocity, maximum acceleration l The mechanism of injury

Successful re-integration into full training

l Return to full training for ≥1 session, pending the length of the rehabilitation period l Consensus among stakeholders about readiness to perform at the required level (eg. elite vs sub-elite vs amateur)

VAS, visual analogue scale, whereby ‘0’ represents no symptoms and ‘10’ represents the maximum of symptom severity. ✓, achieved during rehabilitation; ✗, not achieved and further rehabilitation may be required. *Note: testing single-leg calf raise capacity from the floor (rather than a step) was perceived to limit the potentially significant impact of individual variation in ankle dorsiflexion ROM. 22

RTP Decisions

As mentioned earlier, while endeavouring to establish a prognosis for an athlete, fixing a date or time for RTP can be very challenging.

Ongoing assessment is required but ultimately the decision to RTP should be a consensus between the athlete, therapists, coach and other stakeholders (22*). RTP is essentially weighing up the risk of ‘do I wait and rehab longer’ or ‘if I RTP now will I re-injure myself or be ok?’ Ideally an athlete will have had a time of full return to training to gauge load tolerance and functional improvement.

Objective testing may be of value to aid RTP decisions, bearing in mind side-to-side asymmetries often exist even in healthy individuals which may confound outcomes (4). Objective tests assessing instantaneous and repeated power capacities are useful following CMSI (Table 5).

Experts have compiled a checklist that may aid in determining RTP readiness, with emphasis that decisions should be strongly guided by exposure to sport-specific activities (Table 6) (8*,15).

A recent study of elite Australian football players showed that not all calf strains responded to the same time frames for RTP. Calf strains from running activities needed longer recovery periods than calf strains from non-running activities, irrespective of the muscle injured (6*). It may be assumed that running activities involving high-intensity and steady-state running, acceleration, deceleration, or cutting has greater tissue disruption of the muscle-tendon unit and thus require longer times for RTP (6*).

Risk Factors and Injury Prevention for CMSI

Athlete reinjury is always a concern, but especially with CMSI, which has a recurrence rate of approximately 19– 31% (2,3*,5). Reinjuries are associated with even longer recovery times and often involve older, more experienced players (7*). Premature RTP increases the risk of reinjury as tissues have not completely healed (5). An appropriate rehabilitation timeline must consider other factors including, sport-specific Co-Kinetic Journal 2022;93(July):14-25

PHYSICAL THERAPY

demands, player position, seasonality, and athlete psychology (5,23*).

A study by Green and Lin et al.

(14) showed reinjuries to be almost exclusively following soleus muscle strain (91.4%). The cumulative incidence for reinjury was highest within 2 months of the index/primary strain (46.9%) (14). Interestingly, having a history of previous CMSI at the time of the index/primary strain was the only predictive factor for reinjury. The strongest risk factor for reinjury is a recent history of CMSI, followed by a past history of CMSI. Increased risk of reinjury persists beyond 15 weeks after RTP. Increasing age is an independent risk factor for calf muscle strain with an odds ratio of 1.6 (2).

An identification of the risk factors, combined with aetiological factors, may be a practical approach to injury prevention, as a single factor acting alone is rarely the cause (24*,25*,26*).

The potential impact of intrinsic and extrinsic factors acting on the individual and their exposure include: 1. Intrinsic factors 1.1. Non-modifiable l increasing age l decreased training age l history of CMSI l history of lower limb injury l ethnicity l genetics l general hypermobility lo ther injury history or sub-clinical state 1.2. Modifiable l increased body mass index (BMI) l decreased calf strength l decreased co-ordination l decreased compound strength l decreased calf power capacities l decreased function during ballistic and plyometric activities l decreased running capacities l increased fatigue (acute and cumulative) l running biomechanics or technique l knee-to-wall lunge l distal impairments l proximal impairments 2. Extrinsic factors 2.1. Activity related l preseason period Co-Kinetic.com

l demands of sport l player position/role l competition schedule l training errors (running workload) l recent immobilisation l equipment (footwear) l environment (surface) 2.2. Non-activity related l performance culture l coach expectations (8*,27,28,29,30).

The four most-prevalent factors that may have a significant impact on injury recurrence (and their reasons) include: l increased age: this is the result of decreased tissue quality (atrophy), stiffness, decreased fascia length and reduced recoverability; l previous CMSI: due to inhibition, decreased strength and power capacity, altered tissue dynamics, decreased tissue length and extensibility; l other injury history: decreased capacity altered mechanics, persistent deficits (in lumbar spine, hip, knee, ankle or foot); and l exposure history: recent immobilisation or interruption training (surgery or illness), novel or unfamiliar stimuli, training design, match schedule/congestion, decreased training chronicity (8*).

A universal injury prevention programme does not exist for calf muscles. The barrier to implementing traditional prevention strategies for CMSI is that ‘protective’ calf qualities undergo fluctuations. Screening and ongoing athlete monitoring of all or any of the above risk factors should underpin optimal management. This approach permits individualised prevention using load management and exercise selection strategies, while considering the multitude of factors that impact an athlete’s risk profile (eg. behavioural qualities, training design, individual skill, coach expectations/ club culture and environmental factors) (25*,31,32). Overall, chronic and uninterrupted exposure to the athlete’s sport combined with specific activities involved in that sport are considered the most important strategies for resilience to CMSI (8*).

Historically, research has shown

that pre-participation stretching may improve ROM and muscle compliance, which was believed to protect against muscle strain. Although stretching supports muscle performance in elastic movements like hops or leaps, it is associated with decreased muscle power in concentric contractions such as steady-state cycling or jogging (33,34*). For this reason, the benefits of stretching alone are unclear. However, combining stretching with dynamic and sport-specific pre-participation drills may be able to restore stretchinduced performance loss (34*).

Conclusions

CMSI is a common condition. In high-performance athletes, calf strain contributes to missed practice, playing time or competition. Timely diagnosis and treatment can improve outcomes and can facilitate earlier return to sport. Optimised clinical reasoning at the time of injury, using a structured approach diagnosis and estimating prognosis is advised. Management following CMSI should involve

A UNIVERSAL INJURY PREVENTION PROGRAMME DOES NOT EXIST FOR CALF MUSCLES, SO THE APPROACH SHOULD BE TAILORED TO THE INDIVIDUAL 23

transitioning the athlete through phases extending beyond specific calf strengthening, to general strength and sport-specific work, dynamic ballistic and plyometric work, and progressive running rehabilitation. Early loading, within the athlete’s ability, is deemed safe and promotes early symptom relief and faster recovery. The final RTP decision should be a consensus, driven and informed by the athlete, therapists and their entire support team. A universal prevention programme may not be possible owing to diversity in calf demands between sports and individuals. A multifaceted approach involving individualised load management and exercise selection, as well as sportspecific training, and greater ‘on-field’ conditioning could provide the best preventive effect.

References

1. Toohey LA, Drew MK, Cook JL et al. Is subsequent lower limb injury associated with previous injury? A systematic review and meta-analysis. British Journal of Sports Medicine 2017;51:1670–1678 2. Orchard JW, Chaker Jomaa M, Orchard JJ et al. Fifteen-week window for recurrent muscle strains in football: a prospective cohort of 3600 muscle strains over 23 years in professional Australian rules football.

British Journal of Sports Medicine 2020;54:1103–1107 3. Green B, Pizzari T. Calf muscle strain injuries in sport: a systematic review of risk factors for injury. British Journal of Sports Medicine 2017;51:1189–1194 Open access https://bit.ly/3QRaP6n 4. Prakash A, Entwisle T, Schneider M et al.

Connective tissue injury in calf muscle tears and return to play: MRI correlation. British Journal of Sports Medicine 2018;52:929– 933 5. Green B, Lin M, McClelland JA et al.

Return to play and recurrence after calf muscle strain injuries in elite Australian football players. The American Journal of Sports Medicine 2020;48:3306–3315 6. Green B, Lin M, Schache AG et al. Calf muscle strain injuries in elite Australian Football players: a descriptive epidemiological evaluation. Scandinavian Journal of Medicine & Science in Sports 2020;30:174–184 Open access https://bit.ly/3xJnZta 7. Meek WM, Kucharik MP, Eberlin CT et al. Calf strain in athletes. JBJS Reviews 2022;10(3):doi:10.2106/JBJS. RVW.21.00183 Open access https://bit.ly/3xLDPU7 8. Green B, McClelland JA, Semciw AI et al. The assessment, management and prevention of calf muscle strain 24

injuries: a qualitative study of the practices and perspectives of 20 expert sports clinicians. Sports Medicine – Open 2022;8(1):10:doi:10.1186/s40798-02100364-0 Open access https://bit.ly/3NcMSmH 9. Werner BC, Belkin NS, Kennelly S et al. Acute gastrocnemius-soleus complex injuries in national football league athletes.

Orthopaedic Journal of Sports Medicine 2017;5:232596711668034 Open access https://bit.ly/3HGmFMm 10. Fields KB, Rigby MD. Muscular calf injuries in runners. Current Sports Medicine Reports 2016;15(5):320–324 Open access https://bit.ly/3yowF9Wx 11. Gibbs NJ, Cross TM, Cameron M, Houang MT. The accuracy of MRI in predicting recovery and recurrence of acute grade one hamstring muscle strains within the same season in Australian Rules football players. Journal of Science and Medicine in Sport 2004;7:248–258 12. Walton MJ, Mackie K, Fallon M et al.

The reliability and validity of magnetic resonance imaging in the assessment of chronic lateral epicondylitis. The Journal of Hand Surgery 2011;36:475–479 13. Stares J, Dawson B, Peeling P et al.

How much is enough in rehabilitation?

High running workloads following lower limb muscle injury delay return to play but protect against subsequent injury.

Journal of Science and Medicine in Sport 2018;21:1019–1024 14. Green B, Lin M, McClelland J et al.

Which factors are predictive of return to play and re-injury following calf muscle strain injury? Journal of Science and Medicine in Sport 2019;22(S2):S19 15. Orchard J, Best TM, Verrall GM. Return to play following muscle strains. Clinical Journal of Sport Medicine 2005;15:436– 441 16. Green B, Schache A, McClelland J et al.

263 Expert opinion on the assessment and management of calf muscle strain injuries in sport. British Journal of Sports Medicine 2021;55(S1):A102 (poster abstract) Open access https://bit.ly/3bkmpqd 17. Dubois B, Esculier JF. Soft-tissue injuries simply need PEACE and LOVE. British Journal of Sports Medicine 2020;54(2):72–73 Open access https://bit.ly/3sKxBRU 18. Bayer ML, Hoegberget-Kalisz M, Jensen MH et al. Role of tissue perfusion, muscle strength recovery, and pain in rehabilitation after acute muscle strain injury: a randomized controlled trial comparing early and delayed rehabilitation. Scandinavian Journal of Medicine & Science in Sports 2018;28:2579–2591 Open access https://bit.ly/3Nbka5S 19. Bayer ML, Magnusson SP, Kjaer M. Early versus delayed rehabilitation after acute muscle injury. New England Journal of Medicine 2017;377:1300–1301 20. Hébert-Losier K, Wessman C, Alricsson M, Svantesson U. Updated reliability and

normative values for the standing heelrise test in healthy adults. Physiotherapy 2017;103:446–452 21. Bertelsen ML, Hulme A, Petersen J et al. A framework for the etiology of running-related injuries. Scandinavian Journal of Medicine & Science in Sports 2017;27:1170–1180 Open access https://bit.ly/3OADZnY 22. Ardern CL, Glasgow P, Schneiders A et al. 2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern. British Journal of Sports Medicine 2016;50:853–864 Open access https://bit.ly/3xPa3xK 23. Ekstrand J, Krutsch W, Spreco A et al. Time before return to play for the most common injuries in professional football: a 16-year follow-up of the UEFA Elite Club Injury Study. British Journal of Sports Medicine 2020;54:421–426 Open access https://bit.ly/3bdqEnf 24. Waller JA. Injury: conceptual shifts and preventive implications. Annual Review of Public Health 1987;8:21–49 Open access https://bit.ly/3QDkvRI 25. Bahr R. Understanding injury mechanisms: a key component of preventing injuries in sport.

British Journal of Sports Medicine 2005;39:324–329 Open access https://bit.ly/3NxMfEI 26. Bertelsen ML, Hulme A, Petersen J et al. A framework for the etiology of running-related injuries. Scandinavian Journal of Medicine & Science in Sports 2017;27:1170–1180 Open access https://bit.ly/3OADZnY 27. Nilstad A, Andersen TE, Bahr R et al.

Risk factors for lower extremity injuries in elite female soccer players. The American Journal of Sports Medicine 2014;42:940–948 28. Orchard JW. Intrinsic and extrinsic risk factors for muscle strains in Australian football. The American Journal of Sports Medicine 2001;29:300–303 29. Ekstrand J, Hägglund M, Waldén M. Epidemiology of muscle injuries in professional football (soccer). The American Journal of Sports Medicine 2011;39:1226–1232 30. Hägglund M, Waldén M, Ekstrand J. Risk factors for lower extremity muscle injury in professional soccer. The American Journal of Sports Medicine 2013;41:327–335 31. Verhagen EALM, van Stralen MM, van Mechelen W. Behaviour, the key factor for sports injury prevention. Sports Medicine 2010;40:899–906 32. Jacobsson J, Timpka T. Classification of prevention in sports medicine and epidemiology. Sports Medicine 2015;45:1483–1487 33. Witvrouw E, Mahieu N, Danneels L, McNair P. Stretching and injury prevention: an obscure relationship.

Sports Medicine 2004;34:443–449

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34. McHugh MP, Cosgrave CH. To stretch or not to stretch: the role of stretching in injury prevention and performance. Scandinavian Journal of Medicine & Science in Sports 2010;20(2):169–181 Open access https://bit.ly/3xP1G5d.

Media Contents

Immediate Treatment of Soft Tissue Injuries is all about PEACE and LOVE [Poster and Patient Leaflet] https://bit.ly/34SQIyK

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lS yndesmosis Injury Part 1: Diagnosis and Evaluation [Article] https://bit.ly/3ezk6PI lS yndesmosis Injury Part 2: Treatment and Rehabilitation [Article] https://bit.ly/3coR6aH lH amstring Injury Part 1: Anatomy, Function and Injury [Article] https://bit.ly/2UncJj8 lH amstring Injury Part 2: Rehabilitation [Article] https://bit.ly/33p2fUu

DISCUSSIONS

lD o you use any specific tests or have any key pointers from a patient’s subjective assessment to differentiate between a gastrocnemius or soleus muscle strain? lW hat verbal and visual cues do you use to guide your patient to correctly performing calf raises (double- or single-legged)? lW hat dynamic and plyometric exercises do you find beneficial in progressing an athlete from basic strength exercises to running and sport-specific activities?

KEY POINTS

lC alf muscle strain injury (CMSI) is a common condition; in highperformance athletes, calf strain contributes to a substantial absence from competition. lT here is a high risk of reinjury following CMSI, extending beyond 15 weeks following return to play (RTP). lP layer age and history of a calf strain or other leg injury are the strongest risk factors for calf strain injury and reinjury. lD iagnosis is largely clinical, supported by MRI and ultrasound. l L oading early can fast-track symptom resolution and disability associated with CMSI. lS ingle-leg calf raise, performed correctly, underpins advanced functional rehabilitation. lA n athlete should transition through rehabilitation phases extending beyond specific calf strengthening, to general strength and sportspecific work, dynamic ballistic and plyometric work, and progressive running rehabilitation. lT he final RTP decision should be a consensus, driven and informed by the athlete, therapists and their entire support team. lA universal prevention programme may not be possible owing to diversity in calf demands between sports and individuals. lA multifaceted approach involving individualised load management and exercise selection, as well as sport-specific training, and greater ‘on-field’ conditioning could provide the best preventive effect.

Co-Kinetic.com

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 25

Male Pelvic Dysfunction: Are Kegel Exercises a Help or a Hindrance?

Everyone knows that women have to do pelvic floor exercises to prevent them from becoming a ‘leaky lady’ later in life. However, it is less well publicised that men (and not just older men) can benefit from pelvic floor muscle training for managing a variety of men’s pelvic health issues, such as urinary incontinence, chronic pelvic pain syndrome and sexual dysfunction. Reading this article will enable you to assess your patient’s pelvic floor muscles and provide an appropriate strengthening programme or myofascial mobilisation to aid release of hypertonic muscles. One of the most important things to do, though, is to create enough noise about the subject so that men know that effective therapies exist and that they then will come forward to discuss and seek treatment for these debilitating conditions that affect both physical and mental health. Read this article online https://spxj.nl/3AknYyO

By Kathryn Thomas BSc MPhil

M

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

26

en are definitely not exempt from the pelvic floor issues or complications that are so well documented and discussed with women. From a younger age, possibly because of pregnancy and postpartum complications, women are educated and advised on pelvic floor exercises and how to prevent or treat issues such as incontinence and prolapse (be it a complication of ageing, surgery, pregnancy or trauma). Women may feel more comfortable talking about their pelvic health issues, seeking advice and guidance (whether from friends, or professionals). Is it a possible hang-over from historic times where ‘stoic’ men did not discuss their concerns or health problems – especially anything involving the pelvic region? Sexual performance seems to ‘define’ men, to the point where they are unable to confidently voice their problems and seek advice and help for fear of failure or embarrassment. And yet it is such a common problem, not only in elderly men. The medical profession may be to blame, in part, where exposure, education and even scientific research has focused more on women’s pelvic health issues than men.

Pelvic floor dysfunction refers to a broad collection of symptoms and anatomic changes related to or resulting in abnormal function of the pelvic floor muscles (PFMs). The disordered function of the PFMs corresponds to diminished activity (hypotonicity), or increased activity (hypertonicity) or inappropriate coordination, or a combination of all these

factors. The clinical aspects of pelvic floor dysfunction can be urologic, gynaecologic (in women), or colorectal, and are often interrelated.

Research shows that pelvic floor muscle training (PFMT) is beneficial in managing urinary incontinence (UI), sexual dysfunction and pelvic pain syndromes in men. PFMT became popularised not only owing to its perceived efficacy but the non-invasive ease of use in a daily routine, in a group, supervised or non-supervised, home-based rehabilitation programme. To maximise the benefits of Kegel exercises or PFMT, patients must exercise the correct muscles, with the correct timing and duration of contraction for sufficient effect. Due to the complexity of the anatomy in the pelvic region, additional strengthening, mobilising and treatment options may be advised depending on a patient’s condition. Interestingly, in men it seems that chronic PFM strengthening may potentially aggravate symptoms or increase pelvic pain, and relaxation of overactive PFMs may need to be the treatment focus. Thus a generic prescription of PFMT, with generic instruction to ‘stop the flow of urine’ may not be the best protocol for all men with pelvic floor dysfunction.

This article will discuss the benefits, areas of application or concern and practicalities of using PFMT in men with pelvic dysfunction: specifically UI, chronic pelvic pain syndrome, and sexual dysfunction.

Co-Kinetic Journal 2022;93(July):26-34

PHYSICAL THERAPY

UI Following Radical Prostatectomy

The most common treatment for localised prostate cancer is radical prostatectomy (RP). Unfortunately, post-operative UI, which can persist for 2 years or longer, is a common consequence of the surgery, occurring in up to 60% of cases. UI is also associated with significant reductions in overall health-related quality of life. Given the associated psychosocial, functional, and economic adversity caused

by UI as a consequence of RP, accelerating the recovery of urinary control is a major priority for patients and clinicians (1*).

The PFMs are composed of the internal sphincter, levator ani, coccygeus, striated urogenital sphincter, external anal sphincter, ischiocavernosus and bulbospongiousus.

Normally, these muscles work in a coordinated fashion to promote urinary control. Although not well understood, post-RP UI may result from internal sphincter injury and/or an onset of bladder detrusor hyperactivity, which can result in urge incontinence through pressure on the bladder wall.

Thus, continence becomes dependent on the pelvic floor musculature that supports the external urethral sphincter, and hence why voluntary conditioning of these muscles is considered a primary, non-invasive UI management strategy post-RP (1*).

Although surgical procedures or implants may be an option for post-prostatectomy UI, PFMT is the most highly recommended initial conservative treatment (2*). PFMT is intended to improve urinary control by increasing the strength, endurance and coordination of the PFMs and functional activation of the external urethral sphincter.

Chronic performance of PFMT may cause hypertrophy of the periurethral striated muscles, a resultant stiffening and

PELVIC FLOOR DYSFUNCTION REFERS TO A BROAD COLLECTION OF SYMPTOMS AND ANATOMIC CHANGES RELATED TO OR RESULTING IN ABNORMAL FUNCTION OF THE PELVIC FLOOR MUSCLES strengthening of the PFMs and connective tissues, and an inhibition reflex of the detrusor muscles (1*). PFMT has been shown to reduce the symptoms of UI and improve incontinence in the first 3 months following surgery (3*).

Some evidence shows PFMT is better than no treatment as it may reduce UI episodes, whereas other studies show early PFMT can significantly reduce continence recovery time (2*,3*,4).

As a stand-alone therapy, PFMT is an effective treatment; however, ideally, PFMT can be incorporated into a multimodal treatment approach using biofeedback, electrical stimulation, behavioural strategies, lifestyle changes, and as part of a more general physical activity programme to improve physical function (5*,6*,7*). Success may vary; cure rates for PFMT range from 16 to 27% and improvement rates from 48 to 80.7% (taken from studies of women with UI) (5*).

Pelvic floor muscle function is assessed by several methods, including visual observation, digital palpation, electromyography (EMG), manometry, or real time ultrasound (RTUS). Before PFMT, an evaluation of the PFM can provide valuable baseline standards about strength, coordination and control. Visual observation can be used to

Table 1: Perfect grading system for assessment of pelvic floor muscles Adapted from Laycock & Jerwood. Pelvic floor muscle assessment: the PERFECT scheme. Physiotherapy 2001;87:631–642 (9) PERFECT acronym

Assessment

Notes

Power

Assess using the modified Oxford scale

0 No contraction 1 Flickering or pulsation 2 Poor tension without lifting the vaginal walls 3 Moderate tension with vaginal walls lifting without resistance

with lifting of vaginal walls leading to join fingers in the vaginal 4 Contraction without therapist resistance 5 Strong contraction leading to join fingers in the vagina against resistance

Endurance

How long can the muscle hold a maximal voluntary contraction (MVC)?

Assessed in seconds (0–10) as the ability to maintain an MVC until it falls to 50% of MVC

Repetitions

How many of the MVCs can be performed until fatigue?

Number of MVCs (0–10) of the length defined in the Endurance section

Fast

How many fast muscle contractions can be performed before fatigue?

Every Contraction Timed

Every PFM contraction should be recorded

Includes a 4s rest between contractions

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assess a correct PFM contraction, which is seen by perineal and/or testicular elevation without holding one’s breath or recruiting surrounding abdominal or gluteal muscles.

Assessing the PFMs of male patients can be an invasive process that causes discomfort by digital rectal examination (DRE). RTUS can be used clinically to examine male pelvic floor function, and its use would be enhanced once it has

(a) Modified butterfly pose

(b) Deep squat with a block

(c) Modified child’s pose Tosun et al. Are clinically recommended pelvic floor muscle relaxation positions really efficient for muscle relaxation?

International Urogynecology Journal 2022;doi:10.1007/ s00192-022-05119-3 (14) Figure 1: Efficient positions for pelvic floor muscle relaxation

been established by DRE that a true pelvic floor contraction is occurring (8). The PERFECT scheme for the assessment of PFMs was developed by Laycock and Jerwood and validated for women, but a modification of this could be used during the DRE of males to assess power (or ‘pressure’ – an indication of strength), endurance and repetition of contraction of the PFMs (Table 1) (9).

The first step in PFMT is to ensure the patient can identify their PFMs and to contract and relax them independently. This can be facilitated using verbal cues, or initially during a digital assessment to contract around a finger, and visual or auditory biofeedback or electrical stimulation (5*,10*). There are four main verbal instructions for patients: 1. Contract your muscles around the examiner’s finger and try to pull up and in.

2. Imagine trying to prevent the passing of bowel gas by tightening the ring of muscles around the anus without tensing the muscles of legs or buttocks. A closing and lifting sensation should be felt.

3. Imagine moving the penis up and down without moving any other part of the body.

4. While sitting up right on a firm chair, with your feet on the floor, imagine lifting your testicles up off the seat base (5*).

The verbal instruction used may alter the area of pelvic floor activation. EMG and ultrasound showed that the greatest dorsal displacement of the mid-urethra and skeletal urethral sphincter activity was achieved with the instruction “shorten the penis.” Instruction to “elevate the bladder” induced the greatest increase in abdominal EMG and intra-abdominal pressure (IAP). “Tighten around the anus” induced greatest anal sphincter activity. Instructions that optimise activation of muscles with a potential to increase urethral pressure, without increasing abdominal EMG/IAP, are likely to be ideal for pelvic floor rehabilitation (11).

Patients tend to recruit other muscles, such as the rectus abdominis or gluteal muscles. In addition, they substitute a straining-down Valsalva manoeuvre, which threatens to worsen the condition (5*). Therefore, it is important to watch for the use of other muscles and to help patients to contract PFMs selectively while relaxing ancillary muscles.

Once patients demonstrate the ability to properly contract and relax the PFMs, they are given instructions for daily practice and exercise. A basic regimen consists of 3 sets of 8–12 contractions sustained for 8–10 seconds each, performed 3 times a day. Patients are encouraged to practice daily for 15 to 20 weeks. Specific exercise regimens vary considerably in frequency and intensity, and the ideal exercise regimen has not yet been determined (12*).

PELVIC FLOOR MUSCLE TRAINING IS BENEFICIAL IN MANAGING URINARY INCONTINENCE, SEXUAL DYSFUNCTION AND PELVIC PAIN SYNDROMES IN MEN 28

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Short, quick exercises lasting 1–2 seconds per contraction is one approach; followed by longer, sustained contractions of 5–10 seconds. A high level of concentrated effort with each muscle contraction is encouraged to build strength. This should be followed by total relaxation of the muscle between consecutive contractions. Thus, contraction and relaxation should follow a 1:1 or 1:2 ratio. This allows recovery between contractions and facilitates optimal strength development.

Exercise sessions should be spaced throughout the day, typically in 2 to 5 sessions per day to avoid muscle fatigue. Exercising in the prone position initially is the least challenging. However, progressing to more functional positions of sitting and standing, or even while walking, should be a goal (12*). Table 2 shows a typical PFM exercise session (5).

A recent study by Scott et al. showed the majority of post-prostatectomy men with UI have pelvic floor overactivity in addition to pelvic floor underactivity (13). As opposed to pure Kegel-type strengthening exercises, a personalised pelvic programme aimed at normalising pelvic floor function may be advised for these patients, thus incorporating PFM relaxation. A study conducted on women with UI showed that the most efficient position for PFM relaxation was the modified butterfly pose, followed by modified deep squat with a block, and modified child’s pose, respectively (Fig. 1) (14). The order was also the same for abdominal muscle relaxation. Interestingly the rectus abdominis was the most affected muscle during PFM relaxation. The extent of relaxation of the rectus abdominis muscle increased as the extent of PFM relaxation increased. Efficient PFM relaxation techniques may be beneficial in males with hypertonic or overactive PFMs (14).

A recent study by Milios et al. began PFMT 5 weeks before RP surgery as a preventive ‘prehabilitation’ measure (15*). The PFMT group targeted both slow- and fast-twitch muscle fibres with 10 slow contractions (10s duration) and 10 fast contractions (1s duration). These were performed six times per day, giving a total of 120 contractions per day.

This intensive PFMT performed before surgery improved post-surgical PFM function and decreased UI compared to the control group; hence, there may be value in performing pelvic floor exercises in a preventive manner.

The most common reasons for poor outcomes with PFMT may be (i) inability to identify PFMs or not exercising correctly, and (ii) patient adherence during and afterwards in the maintenance phase. A dedicated maintenance programme supporting continence for over 18 months has been proven effective, with 74.4% of patients maintaining continence at 18 months after primary rehabilitation for post-RP UI (16*). See ‘3.3 Characteristics of the maintenance programme’ for full details of the PFMT maintenance programme in Terzoni et al. (16*; Link 1).

Chronic Pelvic Pain Syndrome

Male chronic pelvic pain syndrome (CPPS) is defined as pain, pressure or discomfort localised in the pelvic region, perineum or genitalia lasting for more than 3 months. This is in the absence of uropathogenic bacterial infection.

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As a result of the multifactorial aetiologies and system inter-relationships, CPPS is a complex condition and can be difficult to decipher (17*). Studies have shown that the average time from the onset of pain and symptoms suggestive of CPPS until the initial physical therapy evaluation was 33 months (range, 2 months to 9 years) (17*).

This delay may be related to emotional and psychological concerns, not wanting to acknowledge the issue or fear of embarrassment. Sadly, such delays in getting help may result in chronic pain syndromes developing as well as further atrophy of PFMs, which then exacerbate the problem.

Pelvic pain may be caused by one or more different conditions and seriously affects the individual’s work, family and social life (18*). It is not known whether there are differences in the pelvic floor and genitourinary pain sensitivity; however, there is an increased expression in somatic pain sensitivity in the extragenital region. As mentioned, the aetiology is not fully understood, but it is acknowledged to have a complex, multifactorial natural history, that is resistant to treatment (18*). In addition to pain, symptoms include bladder or bowel dysfunction, sexual dysfunction, systemic or constitutional symptoms, depression and anxiety. Consequently, quality of life of patients with CPPS can be seriously and adversely affected.

An internationally validated classification system, the UPOINT, has been developed to facilitate identification of domains and clinical findings in men with CPPS (19). This

Table 2: Typical pelvic floor muscle exercise sessions Cho ST, Kim KH. Pelvic floor muscle exercise and training for coping with urinary incontinence. Journal of Exercise Rehabilitation 2021;17:379–387 (5) Position

Exercise

Lying

l Fast: 5 reps of squeezes for 1–2s l Slow: 5 reps of squeezes for 5–10s

Sitting

l Fast: 5 reps of squeezes for 1–2s l Slow: 5 reps of squeezes for 5–10s

Standing

l Fast: 5 reps of squeezes for 1–2s l Slow: 5 reps of squeezes for 5–10s

Do two exercise sessions each day, on in the morning and one in the evening, for a total of 60 exercises

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classification system comprises six domains, assessing: l the Urinary system (voiding and storage); l the Psychosocial state (depression and catastrophising); l specific Organs (bladder and prostate other than infection); l Infectious disease process (urine and expressed prostatic secretions); l the Neurological system (focal and systemic); and l Tenderness of pelvic floor skeletal muscle.

External obliques

Latissmus dorsi Internal obliques Adductor complex

Thoracolumbar fascia

Abdomino pelvic area

Gluteus maximus

Figure 2: External myofascial mobilisation (EMM) areas Ajimsha MS, Ismail LA, Al-Mudahka N et al. Effectiveness of external myofascial mobilisation in the management of male chronic pelvic pain of muscle spastic type: a retrospective study. Arab Journal of Urology 2021;19:394–400 (28*), reproduced under the Creative Commons Attribution 4.0 International License, https://bit.ly/3bjavN7

A detailed description of a physical therapy examination for male CPPS is available at ‘Table 1: Clinical Descriptions of the Six UPOINT domains in male CPPS’ in ArchambaultEzenwa et al. (17*; Link 2;).

Physical therapy treatment has traditionally been recommended for patients who fit the ‘T’ domain with tenderness of the PFMs. However, recent reports acknowledge that more than 20% of patients with CPPS present with symptoms across multiple domains (17*). Thus, physical therapy may benefit CPPS patients who may not specifically have painful muscle spasm on examination.

Involvement of the musculoskeletal system has been systematically reported: tenderness, hypertonicity and dyssynergia of the levator ani and PFMs are common findings (17*,18*,20*). Dyssynergia is an inconsistent contraction or the inability to relax the PFMs during straining or bearing down. Hence, the literature is correct in defining CPPS as a bio-neuromusculoskeletal psychosocial disorder, which emphasises the importance of physical therapy, PFMT, myofascial trigger point release and cognitive behavioural therapy in order to provide a positive outcome (18*,20*,21).

A multimodal approach to management has been suggested for these patients.

Physical therapy treatment may consist of myofascial and trigger point release to the pelvic floor and lower quadrant musculature, visceral manipulation including the prostate, nerve and viscero-vascular manipulation, craniosacral therapy, exercise therapy, mental and muscle relaxation training, visualisation/imagery of pelvic floor relaxation, biofeedback and electrical stimulation (17*,18*,20*,22*).

Treatment modalities may include: l visceral manipulation: prostate, bladder, kidney, liver, inguinal canal, colon/sigmoid, omentum, common bile duct; l myofascial release/trigger point release: iliopsoas, levator ani, obturator internus, adductors, quadratus lumborum, gluteal/piriformis, paraspinals; l nerve manipulation: femoral, sciatic, pudendal nerves, dura, brachial plexus; l mobilisation: rib, thoraco-lumbar, sacrum, and coccyx; l neuromuscular re-education: postural retraining, levator ani (contract relax with myofascial release during relaxation phase); l exercises: stretching lower extremities, core strengthening exercises; l self-care: relaxation with breathing exercise/visualisation pelvic relaxation, eating habits, voiding habits, seating options; l craniosacral: temporal, parietal bone; l visceral vascular manipulation: pudendal artery, aorta, internal and external iliac arteries; and l biofeedback/pelvic muscle re-education.

As mentioned above, in addition to exercises to strengthen the PFMs, physical treatment of the pelvic floor includes biofeedback treatment and electric muscle stimulation and bladder training (23). Even in patients where other treatments have failed, it has been shown that pelvic Co-Kinetic Journal 2022;93(July):26-34

PHYSICAL THERAPY

floor physical therapy (which includes myofascial release, massage, pelvic floor exercises and stretches, biofeedback and electrical stimulation) improves symptoms in as many as 72% of CPPS patients (24). Examples of therapeutic exercises used in pelvic pain patients as part of a more extensive rehabilitation programme are shown in ‘Fig. 3: Therapeutic exercises for pelvic pain’ in Vural 2018 (18*; Link 3).

Myofascial manual therapy (MMT) to the pelvic area may be performed by an expert physical therapist, with an aim to release myofascial constraints at painful trigger points (20*).

Treatment should be focused on easing articular rigidity in the area, releasing and stretching shortened muscles, ensuring soft tissue elasticity and strengthening weak muscles; the goal is to restore balance of musculoskeletal components, to allow optimal painless functioning and to reduce discomfort (25). Manual therapy may improve blood flow to the pelvic area, thus addressing a suggested underlying mechanical ‘fault’ of reduced blood flow in these patients (25,26,27*). Manual treatment of myofascial trigger points has been proven to reduce pain and so should be beneficial for CPPS patients. The efficacy of myofascial physical therapy treatment has been shown in a study where focused MMT improved the clinical condition and pain in 60% of women with CPPS compared to improvement in 20% of women with CPPS who received general massage (27*).

The application of pelvic myofascial mobilisation or therapy can be external or internal (28*). The external myofascial mobilisation (EMM) and fascial manipulation to the pelvis and surrounding areas involves the application of a load and a long duration stretch intended to restore optimal length, decrease pain and improve function by restoring tensional balance (Fig. 2). Evidence is accumulating regarding the administration of internal myofascial mobilisation; however, this procedure is less comfortable and is culturally sensitive for many patients as it involves rectal application (29). EMM performed in the lumbopelvic area, led to a significant reduction (69%) in the chronic prostatitis symptom index scores. Pain symptoms were reduced by 82%. Interestingly, the urinary and quality of life scores improved on average by 50%, possibly as a consequence of reduced pain and improved muscle function. This indirect technique may be specifically advantageous in males with ‘spastic’, hypertonic pelvic floors, with pain and tenderness in these muscles (28*).

Most of the studies conducted to date focusing on the myofascial concept used a multitude of approaches of internal and external trigger points with the goal of relieving muscle tension and pain. The techniques included direct pressure, proprioceptive neuromuscular techniques, deep tissue mobilisation, myofascial and trigger point mobilisation procedure (20*,21,29,30).

Pelvic floor exercises and bladder training could improve coordination and functioning of PFMs (31). In addition, the rationale for treating CPPS patients with MMT is based on pathological findings in the pelvic floor, which attest to a malfunction of the PFMs. A general lack of randomised controlled clinical trials (RCTs) exist in this CPPS domain, and thus identifying male patients for whom these interventions would be clinically effective is still challenging or performed Co-Kinetic.com

Video 1: A Sample pelvic floor exercise from pfilates.com (Courtesy of YouTube user Pfilates) https://youtu.be/Ao4TQ5EILPw

on a trial and error basis (32,33).

Sexual Dysfunction

Sexual function is essential for good health and wellbeing in men. Sexual dysfunctions are extremely prevalent in men, ranging from 10 to 52% (34). The most prevalent sexual impairments in men are erectile dysfunction (ED) and premature ejaculation (PE).

Comorbidities to male CPPS include sexual dysfunction, anxiety and depression. Issues of sexual dysfunction may also be a consequence of pelvic muscle dysfunction in men caused by injury or surgery, or as a consequence of some prostate cancer treatments, or a weakening of the pelvic floor with ageing. Certain pain triggers, associated with behaviours and lifestyle, can in turn affect sexual performance. The relationship between male sexual function, pelvic pain and pelvic floor function is complex and only beginning to be appreciated.

PFMs are important in improving sexual function (34,35,36). In males, it has been reported that contraction and relaxation of the PFMs are associated with mechanisms of erection and ejaculation (34,36). An erection and thus increased penile rigidity are dependent on activity from the bulbospongiosus and ischiocavernosus muscle. Thus, it may be assumed that by improving PFM function, one might improve sexual performance and outcome (36).

The underlying cause of ED may differ among patients, and so warrants different treatment approaches. Physical therapy treatment may comprise: (i) education, information, pain management, advice on functional activities, behavioural changes including varying sexual positions; and (ii) rehabilitation using manual therapy techniques, normalisation of the muscle tone, and improving muscle relaxation. Supporting tools may include biofeedback, and electrical stimulation (34).

PREHABILITATION PELVIC FLOOR MUSCLE TRAINING CAN IMPROVE THE RETURN TO URINARY CONTINENCE AFTER RADICAL PROSTATECTOMY 31

Table 3: Advanced pelvic floor muscle exercise prescription Santa Mina D, Au D, Alibhai SMH et al. A pilot randomized trial of conventional versus advanced pelvic floor exercises to treat urinary incontinence after radical prostatectomy: a study protocol. BMC Urology 2015;15:94 (1), reproduced under the Creative Commons Attribution 4.0 International License, https://bit.ly/3bjavN7 Week 1

2

3

Position/pose

Reps

Sets

Hold (sec)

Kegels

Lying and sitting

10–12

3

5–10

Pfilates

Butterfly

5

3

3–5

Hypopressive

Diaphragmatic breathing (lying)

3

3

Fully inhale and exhale

Kegels

Lying and sitting

10–12

3

5–10

Pfilates

Butterfly

5

2

5–8

5

Bridge

5

2

3–5

5

Hypopressive

Standing

3

3

Kegels

Lying, sitting and standing

10–12

2

8–10

Pfilates

Butterfly

5–10

2

8–10

5–10

Bridge

5–10

2

5–8

5–10

Lunge

5–10

2

3–5

5–10

Standing

3

2

10–15

Kneeling

3

2

5–10 8–10

Kegels

Lying, sitting standing

10–12

3

Pfilates

Butterfly

8–10

2

10

8–10

Bridge

8–10

2

10

8–10

Lunge

8–10

2

5–8

8–10

Standing

3

1

10–20

Kneeling

3

1

10–15

Hypopressive

5

Downward kneel

3

1

10–15

Kegels

Lying, sitting standing

10–12

3

8–10

Pfilates

Butterfly

10–12

2

10

10–12

Bridge

10–12

2

10

10–12

Lunge

10–12

2

10

10–12

Standing

3

1

10–30

Kneeling

3

1

10–20

Downward kneel

3

1

10–20

Sitting

3

1

10–15

Kegels

Lying, sitting standing

10–12

3

8–10

Pfilates

Butterfly

10–12

3

10

10–12 10–12 10–12

Hypopressive

6–12

Hypopressive

Kegels 12–24

Pfilates

Hypopressive

32

5

5–10

Hypopressive

4

Pulses (Pfilates only)

Exercise

Bridge

10–12

3

10

Lunge

10–12

3

10

Standing

3

1

10–30

Kneeling

3

1

10–30

Downward kneel

3

1

10–30

Sitting

3

1

10–30

Lying, sitting and standing

10–15

3

8–10

Butterfly

10–15

3

10

10–15

Bridge

10–15

3

10

10–15

Lunge

10–15

3

10

10–15

Standing

3

1

10–30

Kneeling

3

1

10–30

Downward kneel

3

1

10–30

Sitting

3

1

10–30

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The efficacy of using PFMT in treating ED has been proven in RCTs (37). Following 3 months of intervention, 40% of men had regained normal erectile function, whereas 35.5% had a significant improvement from baseline. In this study, patients were instructed to tighten their PFMs as strongly as possible (as if to stop flatulence from escaping).

Attention is placed on the capability to ‘draw back the penis and lift the scrotum’ to ensure activation of the bulbocavernosus and ischiocavernosus muscles. Emphasis was placed on attaining three maximum contractions, in three positions (lying prone, sitting, and standing), twice daily. Followed by submaximal pelvic floor contractions while walking, in order to help increase muscle endurance.

Subjects were also instructed to strongly constrict their PFMs after urinating, while still poised above the toilet, thus working the bulbocavernosus muscle (37).

A recently published study examining the effects of a 12-week PFM rehabilitation programme on males suffering from lifelong premature ejaculation, reported significantly improved symptoms and sustained benefits in 74% and 66% of patients at a 2-year and 5-year follow-up, respectively (38).

Before commencing treatment, it is vitally important to assess a patient’s expectations and anticipations of treatment.

It has been shown that there is a direct relationship between PE and anxiety (34). If necessary, physical therapy can be accompanied by a psychological consultation.

PFMT for PE may involve four stages: 1. Raised awareness of PFMs. 2. Performing selective PFM contractions.

3. Education on scheduling the PFM contraction during a pro-orgasmic phase (patients were asked to masturbate at home in order to schedule the PFM contractions during the pro-orgasmic phase to prevent ejaculation); this is based on the assumption that appropriately timed contraction can inhibit the ejaculation reflex.

4. General strengthening of the PFMs. Men with hyperactive PFMs and myofascial trigger points may complain of pain in the testicles, crotch, tip of the penis and abdomen. Some men express an inability to reach an erection, suffer PE or inability to climax due to pain or fear of postejaculatory pain. PFM training can generate or exacerbate pain in men with hyperactive/overactive PFMs. Chronic activation or continuous contraction of a muscle can result in the shortening of the surrounding connective tissue. This may result in compression of adjacent structures including pelvic nerves. Although studies support the efficacy of PFMT for improving sexual dysfunction, care should be taken in patients with overactive PFMs. Myofascial mobilisation and relaxation techniques (described earlier) may be beneficial in these patients. PFMT should be supervised to manage pain levels, and relaxation techniques for the pelvic floor should be included.

Future Considerations

There is a growing body of literature demonstrating that PFM contraction is optimised with co-activation of the abdominals and other regional muscles (1*,39). Despite their requirement Co-Kinetic.com

for optimal pelvic floor activation, transverse abdominis, rectus abdominis and the diaphragm are often neglected in PFMT. Relevant points include: l Relaxation of the abdominal wall during PFM contraction only elicits 25% of the maximal voluntary contraction of the pelvic floor. l Poor pelvic floor tonic activity (autonomic contraction), and subsequent risk of UI, is evident with impaired transversus abdominus contraction. l ‘Deep belly’ breathing that emphasises diaphragmatic contraction and relaxation may improve PFM activation and reduce IAP (shown in women with UI) (1*,39).

Future PFMT programmes should incorporate techniques that not only optimise PFM responsiveness but also the facilitation from other regional muscles. The fundamental elements of Pilates (an exercise that focuses on core strength, stability, flexibility, and muscle control, as well as posture and breathing) can incorporate targeted pelvic floor activation, known as ‘Pfilates’ (pelvic floor Pilates) (40*,41).

Pfilates includes several static poses that activate the transversus abdominus, hip adductors, gluteal, and PFMs with instructions to pulse (small range of motion) with short, maximal effort contractions of the engaged muscles (Video 1). Traditional Pilates has been shown to improve PFM strength in healthy women comparably to PFMT (41).

‘Hypopressive’ exercises emphasise engaging the transversus abdominus muscle, with conscious coordination of the diaphragm. This diaphragmatic breathing is hypothesised to increase PFM tone and subsequently cause urethral constriction (42,43*,44). Hypopressive techniques incorporate the use of deep breathing followed by a short breath-hold resulting in relaxation of the diaphragm, decreasing IAP, and reflex contraction of the PFMs. This method unconsciously maximises contraction and subsequently improves re-conditioning of the PFMs (42,45).

Steps to follow are: 1. Have the patient start with a slow diaphragmatic inspiration.

2. This is followed by total expiration.

3. After glottal closure, the patient should gradually contract the abdominal wall muscles, with superior displacement of the diaphragm (referred to as diaphragmatic aspiration).

4. Attention must be drawn to distension of the ribs, breathing and body position, such that pelvic floor movement is unconscious.

RCTs have shown that a hypopressive exercise programme demonstrates increased tonic activity, strength and size of the PFMs via ultrasonography imaging (43*). Greater maximal voluntary contraction of the pelvic floor has been reported when PFMT and its surrounding muscles are simultaneously worked (ie. transversus abdominus, hip adductors, gluteal, diaphragm) (39,44). Synergistic training of lumbo-pelvic, abdominal and PFMs (including Pfilates and hypopressive exercises) present a newer approach to the rehabilitation of pelvic floor dysfunction. An example of a detailed rehabilitation programme is shown in Table 3 (1*).

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KEY POINTS

l The disordered function of the pelvic floor muscles corresponds to diminished activity (hypotonicity), or increased activity (hypertonicity) or inappropriate coordination, or a combination of all these factors. l Owing to the complexity of the anatomy in the pelvic region, additional strengthening, mobilising and manual therapy treatment options may be advised depending on a patient’s condition. l Pelvic floor physical therapy should include a complex multi-faceted treatment approach in males with pelvic pain, urinary and/or incontinence and sexual dysfunction; focusing on musculoskeletal dysfunction, emotional and behavioural involvement. l Pelvic floor physical therapy is proven to be simple, safe, and non-invasive and should be employed as a preferred approach in the management of male pelvic and sexual dysfunction. l Correct contraction or isolation of the pelvic floor muscles can be facilitated using verbal cues, rectal digital insertion, visual or auditory biofeedback or electrical stimulation. Verbal instructions for males differ to that of female patients. l Pelvic floor muscle strengthening should involve different contraction durations, intensities, positions and ultimately be incorporated into functional exercise activities. l Chronic pelvic floor muscle strengthening may potentially aggravate symptoms or increase pelvic pain, and relaxation of overactive pelvic floor muscles may need to be the treatment focus. l Specific positions have been identified to induce pelvic floor relaxation, as well as deep breathing exercises and the use of manual therapy and myofascial release of the pelvic structures. l The most common reasons for poor outcomes with male pelvic floor muscle training may be inability to correctly identify and contract pelvic floor muscles and poor patient adherence during and/or afterwards, where a dedicated maintenance plan is recommended. l Management should not only focus on pelvic floor strengthening, but relaxation and stretching techniques, as well as conditioning of the entire lumbo-sacral-pelvic region.

LINKS Link 1:

Link 1: ‘3.3 Characteristics of the maintenance programme’ in Terzoni S, Ferrara P, Bellati G et al. Maintenance exercises for urinary continence after rehabilitation following radical prostatectomy: follow-up study. International Journal of Urological Nursing 2022;16:40–47 (16*; https://bit.ly/3y1ynwp)

Link 2:

Link 2: ‘Table 1: Clinical Descriptions of the Six UPOINT domains in male CPPS’ (https://bit.ly/3OOsTfw) in Archambault-Ezenwa et al. A comprehensive physical therapy evaluation for male chronic pelvic pain syndrome: a case series exploring common findings. Journal of Bodywork and Movement Therapies 2019;23:825– 834 (17*; https://bit.ly/3AhSvgJ)

Link 3:

Link 3: ‘Figure 3: Therapeutic exercises for pelvic pain’ (https://bit.ly/3I84K1f) in Vural M. Pelvic pain rehabilitation. Turkish Journal of Physical Medicine and Rehabilitation 2018;64:291–299 (18*; https://bit.ly/3nnJPgZ)

34

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

Related Content:

l Pelvic Floor Training for Stress Urinary Incontinence: An Clinical Update [Article] https://bit.ly/3yscack

DISCUSSIONS

lD o you find treating male patients with pelvic dysfunction more challenging than treating a female patient requiring pelvic floor manual therapy or muscle strengthening? If yes, discuss the reasons why with your colleagues. Is this a cultural issue, embarrassment, should you be referring to a specialist pelvic physical therapist, or is the challenge practical – knowing what to prescribe or how to instruct the patient? lD o you use relaxation techniques to reduce pelvic floor hypertonicity? lW hat tools do you use to keep a patient motivated and engaged to continue their pelvic floor muscle training programme into the maintenance phase?

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

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

Email: kittyjoythomas@gmail.com

Co-Kinetic Journal 2022;93(July):26-34

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Male Pelvic Dysfunction: Are Kegel Exercises a Help or a Hindrance?

References

1. Santa Mina D, Au D, Alibhai SMH et al.

A pilot randomized trial of conventional versus advanced pelvic floor exercises to treat urinary incontinence after radical prostatectomy: a study protocol. BMC Urology 2015;15:94 Open access https://bit.ly/3NtawM3 2. Ha YS, Yoo ES. Artificial urinary sphincter for postradical prostatectomy urinary incontinence – is it the best option?

International Neurourology Journal 2019;23:265–276 Open access https://bit.ly/3QShltg 3. Anderson CA, Omar MI, Campbell SE et al. Conservative management for postprostatectomy urinary incontinence.

Cochrane Database of Systematic Reviews 2015;1:CD001843 Open access https://bit.ly/39VBePw 4. Filocamo MT, Li Marzi V, Del Popolo G et al. Effectiveness of early pelvic floor rehabilitation treatment for postprostatectomy incontinence. European Urology 2005;48:734–738 5. Cho ST, Kim KH. Pelvic floor muscle exercise and training for coping with urinary incontinence. Journal of Exercise Rehabilitation 2021;17:379–387 Open access https://bit.ly/3bBm3LK 6. Szczygielska D, Knapik A, Pop T et al.

The effectiveness of pelvic floor muscle training in men after radical prostatectomy measured with the insert test. International Journal of Environmental Research and Public Health 2022;19:2890 Open access https://bit.ly/3u72n9k 7. Kannan P, Winser SJ, Fung B et al.

Effectiveness of pelvic floor muscle training alone and in combination with biofeedback, Co-Kinetic.com

electrical stimulation, or both compared to control for urinary incontinence in men following prostatectomy: systematic review and meta-analysis. Physical Therapy 2018;98:932–945 Open access https://bit.ly/3Nlzlta 8. Nahon I, Waddington G, Adams R et al. Assessing muscle function of the male pelvic floor using real time ultrasound.

Neurourology and Urodynamics 2011;30:1329–1332 9. Laycock J, Jerwood D. Pelvic floor muscle assessment: the PERFECT scheme.

Physiotherapy 2001;87:631–642 10. Cho KJ, Kim JC. Management of urinary incontinence with underactive bladder: a review. International Neurourology Journal 2020;24:111–117 Open access https://bit.ly/3bvh8Mw 11. Stafford RE, Ashton-Miller JA, Constantinou C et al. Pattern of activation of pelvic floor muscles in men differs with verbal instructions. Neurourology and Urodynamics 2016;35:457–463 12. Newman DK, Borello-France D, Sung VW. Structured behavioral treatment research protocol for women with mixed urinary incontinence and overactive bladder symptoms. Neurourology and Urodynamics 2018;37:14–26 Open access https://bit.ly/3Aa0pZh 13. Scott KM, Gosai E, Bradley MH et al. Individualized pelvic physical therapy for the treatment of post-prostatectomy stress urinary incontinence and pelvic pain.

International Urology and Nephrology 2020;52:655–659 14. Tosun ÖÇ, Dayıcan DK, Keser İ et al. Are clinically recommended pelvic floor muscle relaxation positions 34i

really efficient for muscle relaxation?

International Urogynecology Journal 2022;doi:10.1007/s00192-022-05119-3 15. Milios JE, Ackland TR, Green DJ. Pelvic floor muscle training in radical prostatectomy: a randomized controlled trial of the impacts on pelvic floor muscle function and urinary incontinence. BMC Urology 2019;19:116 Open access https://bit.ly/3AfmB4B 16. Terzoni S, Ferrara P, Bellati G et al. Maintenance exercises for urinary continence after rehabilitation following radical prostatectomy: follow-up study.

International Journal of Urological Nursing 2022;16:40–47 Open access https://bit.ly/3y1ynwp 17. Archambault-Ezenwa L, Markowski A, Barral JP. A comprehensive physical therapy evaluation for male chronic pelvic pain syndrome: a case series exploring common findings. Journal of Bodywork and Movement Therapies 2019;23:825–834 Open access https://bit.ly/3P4kAwj 18. Vural M. Pelvic pain rehabilitation.

Turkish Journal of Physical Medicine and Rehabilitation 2018;64:291–299 Open access https://bit.ly/3nnJPgZ 19. Nickel JC, Shoskes DA. Phenotypic approach to the management of the chronic prostatitis/chronic pelvic pain syndrome. BJU International 2010;106:1252–1263 20. Grinberg K, Sela Y, Nissanholtz-Gannot R. New insights about chronic pelvic pain syndrome (CPPS). International Journal of Environmental Research and Public Health 2020;17:3005 Open access https://bit.ly/3ORsHMB 21. Anderson RU, Wise D, Nathanson BH. Chronic prostatitis and/or chronic pelvic pain as a psychoneuromuscular disorder – a meta-analysis. Urology 2018;120:23–29 22. Masterson TA, Masterson JM, Azzinaro J et al. Comprehensive pelvic floor physical therapy program for men with idiopathic chronic pelvic pain syndrome: a prospective study. Translational Andrology and Urology 2017;6:910–915 Open access https://bit.ly/3yptGxQ 23. Pena VN, Engel N, Gabrielson AT et al.

Diagnostic and management strategies for patients with chronic prostatitis and chronic pelvic pain syndrome. Drugs & Aging 2021;38:845–886

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24. Anderson Ru, Wise D, Sawyer T, Chan C. Integration of myofascial trigger point release and paradoxical relaxation training treatment of chronic pelvic pain in men.

Journal of Urology 2005;174:155–160 25. King H. Manual therapy may benefit women with interstitial cystitis and pelvic floor pain. Journal of Osteopathic Medicine 2013;113:360–361 26. Kotarinos RK. Myofascial pelvic pain: rationale and treatment. Current Bladder Dysfunction Reports 2015;10:87–94 27. FitzGerald MP, Anderson RU, Potts J et al. Randomized multicenter feasibility trial of myofascial physical therapy for the treatment of urological chronic pelvic pain syndromes. Journal of Urology 2009;182:570–580 Open access https://bit.ly/3HYZj4P 28. Ajimsha MS, Ismail LA, Al-Mudahka N et al. Effectiveness of external myofascial mobilisation in the management of male chronic pelvic pain of muscle spastic type: a retrospective study. Arab Journal of Urology 2021;19:394–400 Open access https://bit.ly/3OPrF3F 29. Anderson R, Wise D, Sawyer T et al.

Safety and effectiveness of an internal pelvic myofascial trigger point wand for urologic chronic pelvic pain syndrome. The Clinical Journal of Pain 2011;27:764–68 30. Anderson RU, Wise D, Sawyer T et al.

Equal improvement in men and women in the treatment of urologic chronic pelvic pain syndrome using a multi-modal protocol with an internal myofascial trigger point wand. Applied Psychophysiology and Biofeedback 2016;41:215–224 31. Rosenbaum TY, Owens A. Continuing medical education: the role of pelvic floor physical therapy in the treatment of pelvic and genital pain-related sexual dysfunction (CME). The Journal of Sexual Medicine 2008;5:513–523 32. George SE, Clinton SC, BorelloFrance DF. Physical therapy management of female chronic pelvic pain: anatomic considerations. Clinical Anatomy 2013;26:77–88 33. Bruckenthal P. Chronic pelvic pain: approaches to diagnosis and treatment.

Pain Management Nursing 2011;12:S4–10 34. Yaacov D, Nelinger G, Kalichman L. The effect of pelvic floor rehabilitation on males with sexual dysfunction: a narrative review.

Sexual Medicine Reviews 2022;10:162– 167 35. Stein A, Sauder SK, Reale J. The role of physical therapy in sexual health in men and women: evaluation and treatment. Sexual Medicine Reviews 2019;7:46–56 36. Cohen D, Gonzalez J, Goldstein I. The role of pelvic floor muscles in male sexual dysfunction and pelvic pain. Sexual Medicine Reviews 2016;4:53–62 37. Dorey G, Speakman MJ, Feneley RCL et al. Pelvic floor exercises for erectile dysfunction. BJU International 2005;96:595–597 38. Pastore AL, Fuschi A, al Salhi Y et al.

PD49-04: 5 years follow-up outcomes of pelvic floor rehabilitation protocol in subjects with lifelong premature ejaculation: the definitive long-term evaluation. Journal of Urology 2022;207(5S) [Poster abstract] 39. Sapsford R. Rehabilitation of pelvic floor muscles utilizing trunk stabilization. Manual Therapy 2004;9:3–12 40. Crawford B. Pfilates: pelvic floor Pilates (website; http://www.pfilates.com) 2022 41. Culligan PJ, Scherer J, Dyer K et al. A randomized clinical trial comparing pelvic floor muscle training to a Pilates exercise program for improving pelvic muscle strength. International Urogynecology Journal 2010;21:401–408 42. Stüpp L, Resende APM, Petricelli CD et al. Pelvic floor muscle and transversus abdominis activation in abdominal hypopressive technique through surface electromyography. Neurourology and Urodynamics 2011;30:1518–1521 43. Bernardes BT, Resende APM, Stüpp L et al. Efficacy of pelvic floor muscle training and hypopressive exercises for treating pelvic organ prolapse in women: randomized controlled trial. Sao Paulo Medical Journal 2012;130:5–9 Open access https://bit.ly/3xZ0D30 44. Madill SJ, McLean L. Quantification of abdominal and pelvic floor muscle synergies in response to voluntary pelvic floor muscle contractions. Journal of Electromyography and Kinesiology 2008;18:955–964 45. Resende APM, Stüpp L, Bernardes BT et al. Can hypopressive exercises provide additional benefits to pelvic floor muscle training in women with pelvic organ prolapse? Neurourology and Urodynamics 2012;31:121–125.

Co-Kinetic Journal 2022;93(July):26-34

MANUAL THERAPY

UPPER QUADRANT ASSESSMENT FOR MYOFASCIAL DYSFUNCTION: Myofascial dysfunction can be the cause of many patients’ problems resulting from alterations in freedom and quality of body movement. The correct treatment can only be embarked on after proper and careful assessment, which has to be extensive and wide ranging because of the complex nature of fascia and its interplay with other body systems. This two-part article has been extracted from Chapter 14 ‘Upper quadrant assessment’ (which also has a contribution from Eduardo Castro-Martín) from the author’s book Myofascial Induction™ – An anatomical approach to the treatment of fascial dysfunction Volume 1: The Upper Body (Handspring Publishing). In the last issue of Co-Kinetic, Part 1 discussed the global functional assessments of stability and mobility of the upper quadrant. Part 2 of the article, here, discusses neurofascial components, neural tests, viscerofascial components as well as the lymphatic and superficial circulatory system of the upper quadrant. Reading this article (along with Part 1 in the April 2022 issue of CoKinetic) will allow you to develop a complete understanding of the fascial involvement in your patient’s problem upper quadrant and so together with the patient decide on the best treatment pathway. Read this article online https://bit.ly/3yEGbWJ Introduction

As we have understood more about the role of fascia in the body, we have realised that dysfunction of the myofascia (the fascia that separates and contains every muscle in the body) can be the cause of many patients’ pain and movement problems. Naturally, specific methods of treatment for myofascial dysfunction have been developed, one such being Myofascial Induction Therapy™. To quote the author, Andrzej Pilat: “Myofascial Induction Therapy [MIT] is a therapeutic concept in manual therapy that is aimed at the functional restoration of the altered fascial system. MIT is a process of evaluation and treatment in which the practitioner transfers a slight force (traction and/or compression) to the target tissue, facilitating the recovery of the dynamics of the fascial system.”

As you will see from the full description on page 45, the author’s book Myofascial Induction™ – An anatomical approach to the treatment of fascial dysfunction Volume 1: The Upper

Co-Kinetic.com

Body (Handspring Publishing) is a tour de force summarising the current knowledge of fascia and the principles of Myofascial Induction, before going on to discuss practical applications of Myofascial Induction in the upper body. We are delighted to bring you an extract of this book, Chapter 14, ‘Upper Quadrant Assessment’, which discusses how to assess the upper quadrant of the body for myofascial dysfunction. Part 1, published in the last issue of Co-Kinetic [2022;92(April); https://bit.ly/3I2KZIz], began with an Introduction to the principles of clinical reasoning before moving on to the Characteristics of the Upper Quadrant, and then a description of The Assessment Process, which discussed History Taking, Functional Assessment and Global Functional Assessment of stability and mobility of the upper quadrant. In Part 2 of the article, here, we continue with the assessment process, discussing Neurofascial Components, Neural Tests, Viscerofascial Components as well as The Lymphatic and Superficial Circulatory System of the Upper Quadrant.

The Assessment Process (Continued)

By Andrzej Pilat RPT

An accurate diagnosis of dysfunctions and pain syndromes of the upper quadrant is difficult because of its complex anatomy and biomechanics.

The diagnosis has to be precise. The pain, for example, may be non-specific (with considerable overlap of its sensory distribution) and difficult to identify, and there may be person-to-person variations. Note that neural entrapment can generate neuroprotective and neuroeffector responses with significant consequences for body mechanics.

The cervical plexus and the brachial plexus are in charge of the innervation of the upper quadrant.

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

Neurofascial Components

AN ACCURATE DIAGNOSIS OF DYSFUNCTIONS AND PAIN SYNDROMES OF THE UPPER QUADRANT IS DIFFICULT BECAUSE OF ITS COMPLEX ANATOMY AND BIOMECHANICS 35

C3 C4 C5 C6 C7

A B C D E

C8 T1

F G H I J K L M N O P Q

Figure 1: Brachial plexus distribution Handspring Publishing 2022

A, Dorsal scapular nerve; B, subclavian nerve; C, suprascapular nerve; D, lateral pectoral nerve; E, upper subscapular nerve; F, axillary nerve; G, radial nerve; H, thoracodorsal nerve; I, lower subscapular nerve; J, musculocutaneous nerve; K, median nerve; L, ulnar nerve; M, medial cutaneous nerve of arm; N, medial cutaneous nerve of forearm; O, medial pectoral nerve; P, long thoracic nerve; Q, supraclavicular nerve.

The cadaver is placed in supine and the arm is in abduction to 90°. The sternocleidomastoid and pectoralis muscles have been removed. The circled area is the brachial plexus.

Figure 2: Right lateral view of the neck and arm Handspring Publishing 2022

A B C D E F G

I

J K L

Anterior

A Supraclavicular nerves B Superior lateral cutaneous nerve of arm (cutaneous branch of axillary nerve) C Intercostobrachial nerve D Medial brachial cutaneous nerve E Inferior lateral brachial cutaneous nerve (radial nerve) F Lateral antebrachial cutaneous nerve (musculocutaneous nerve) G Cutaneous antebrachial medial nerve (C8–T1) H Cutaneous antebrachial posterior nerve (radial nerve) I Cutaneous antebrachial lateral nerve (radial nerve) J Ulnar nerve K Palmar and digital branch (ulnar nerve) L Palmar and digital branch (median nerve)

A B D E F G H I

K

L

Figure 3: Cutaneous sensory innervation of the upper limb Handspring Publishing 2022

36

Posterior

The Cervical Plexus The cervical plexus is a network of nerve fibres of the anterior rami of the first four spinal nerves (C1–C4) which arises from the spinal cord through the intervertebral foramina of the cervical spine. These nerves meet in front of the transverse processes of the first three cervical vertebrae in the posterior triangle of the neck (for more information see Chapter 15 of the book: (for more information see Chapter 15 of the book Myofascial Induction™ – An anatomical approach to the treatment of fascial dysfunction Volume 1: The Upper Body), half-way up the sternocleidomastoid muscle, and rest upon the levator scapulae and scalenus medius, splenius cervicis muscles and the deep layer of the deep fascia of the neck. The plexus is divided into superficial and deep branches.

The superficial (cutaneous) branches are sensitive (1), and supply the skin of the neck, upper thorax, scalp, and ear (2). The nerves reach the skin in the middle of the posterior border of the sternocleidomastoid muscle (Erb’s point) (3). The superficial branches are: l the lesser occipital nerve (C2), which innervates the skin and the posterosuperior region of the scalp behind the auricle; l the great auricular nerve (C2–C3), which innervates the parotid gland and the area behind the ear; l the transverse cervicis (C2–C3), which innervates the anterior triangle of the neck; and l the supraclavicular nerves (C3–C4), which innervates the skin of the superolateral part of the thorax (over the clavicle, outer trapezius, and deltoid).

The deep (muscular) branches are located deep to the sensory branches (4) and are as follows: l the ansa cervicalis (C1–C3) which innervates the infrahyoid muscles (sternohyoid, sternothyroid, omohyoid), which depress the hyoid bone during speech and swallowing; and l the phrenic nerve (C3–C5, primarily C4) which passes over the anterior Co-Kinetic Journal 2022;93(July):35-45

MANUAL THERAPY

Table 1: Median nerve entrapment syndrome Guo & Wang 2014 (6), Gunther et al. 1993 (7); Handspring Publishing 2022 Arm and forearm

Causes

A Supracondylar process syndrome (median nerve entrapment through Struthers’ ligament)

Anatomical variables

B Pronator teres muscle (dysfunction when moving the forearm from pronation to supination)

Heavy manual tasks

D

C Biceps brachii lacertus fibrosus

Myofascial restriction of the antebrachial fascia Heavy manual tasks

E

D Compression in pronator syndrome (fibrous arch of the flexor digitorum superficialis)

Wrist and hand

Causes

E Carpal tunnel

Heavy manual tasks Repetitive strain injury Palmar fascia restriction Decreased mobility of the median nerve

A B C

A

B

Repetitive strain injury

Repetitive strain injury Myofascial restriction of the antebrachial fascia

Table 2: Radial nerve entrapment syndrome Miller & Reinus 2010 (8); Handspring Publishing 2022 Forearm

Causes

A Radial tunnel

Repetitive strain injury (sports) Lateral epicondylalgia

B E ntrapment of the superficial branch of the radial nerve (Wartenberg’s syndrome)

Intense manual work (thumb) Repetitive strain injury De Quervain’s syndrome Tightfitting bracelet

NEURAL ENTRAPMENT CAN GENERATE NEUROPROTECTIVE CHANGES TO THE BODY MECHANICS Co-Kinetic.com

37

Table 3: Ulnar nerve entrapment syndrome Spinner 2006 (9); Handspring Publishing 2022 Arm and forearm

Causes

A Ulnar tunnel syndrome

Heavy manual tasks Repetitive strain injury

A

Medial epicondylalgia B Deep aponeurosis of the epitrochlear musculature

B

Heavy manual work Repetitive strain injury Spasticity

C

Wrist and hand

Causes

C Guyon’s canal

History of pisiform fracture symptoms Repetitive microtrauma (cyclists)

scalene muscle into the thorax between the subclavian artery and vein; it also supplies the sensory innervation of the pericardium and mediastinum and the motor innervation of the diaphragm.

The Brachial Plexus (5) The brachial plexus is an intercommunicating network of nerves with a complex intraneural and interneural anatomy (Figs. 1 & 2). The plexus begins with the roots, which are continuous with the ventral branches of the spinal nerves. In the most common configuration of the plexus, there are five roots: C5, C6, C7, C8 and T1.

Continuing peripherally, the roots form three trunks: the upper (roots of C5 and C6), middle (root of C7) and lower (roots of C8 and T1) trunks. The nerve roots pass between the anterior and medial scalene muscles and along with the subclavian artery enter the base of the neck where they converge to form the three trunks, each of which divides into two branches in the posterior triangle of the neck. The root divisions continue toward the axilla combining to form the cords of the brachial plexus.

Each trunk is separated into an anterior and posterior division, resulting in a total of six divisions.

The divisions form three cords: lateral (consisting of the anterior divisions of 38

the upper and middle trunks), posterior (consisting of the three posterior divisions) and medial (consisting of the anterior division of the inferior trunk).

On the lateral side of the axilla, each cord is divided into two terminal branches: the musculocutaneous nerve and the lateral root of the median nerve (lateral cord); the axillary nerve and the radial nerve (posterior cord); and the ulnar nerve and the medial root of the median nerve (medial cord).

The upper branches of the plexus that arise in the neck, rather than in the axilla, include the dorsal scapular nerve, the suprascapular nerve and long thoracic nerves, and the subclavian nerve (4).

The branches of the lateral and medial cords innervate the anterior muscles of the upper limbs, and the branches of the posterior cord innervate the posterior muscles. This pattern can also be expressed in terms of plexus divisions: the anterior divisions innervate the anterior muscles and the posterior divisions innervate the posterior muscles of the upper limb; the ulnar nerve is the only nerve derived from the medial cord.

A knowledge of the distribution of sensitive areas is very useful in the therapeutic process and will help the practitioner to identify referred symptoms (including multifocal symptomatology). The sensory

distributions of the branches of the brachial plexus are illustrated in Figure 3.

Nerve Entrapment Syndrome Nerve entrapment syndrome can be a cause of pain and/or dysfunction in the upper quadrant (see Chapter 8 of the book for a more detailed discussion of this topic). A knowledge of the nerves that may be involved, their anatomy, motor and sensory functions, and the aetiology of their dysfunction helps the practitioner to manage these complex problems. Nerve entrapment may be responsible for several pain syndromes in the thorax, shoulder, and upper extremity.

Tables 1–3 show the locations of the most common entrapments of the brachial plexus and its branches.

Tables 4–6 summarise the main aspects of sensory and motor distribution of the components of the brachial plexus, as well as the most common deficiencies. Figure 4 shows the distribution of areas affected by radiculopathy.

Neural Tests

When assessing for myofascial dysfunctions it is recommended that neural tests be carried out in order to determine whether or not neural entrapment is involved in Co-Kinetic Journal 2022;93(July):35-45

MANUAL THERAPY

Table 4: Peripheral nerves – 1

Handspring Publishing 2022

Peripheral nerve

Nerve roots

Terminal branches

Motor innervation

Sensory distribution

Deficiency

Median nerve

C5–T1

Recurrent branch

Deep layer of ventral forearm muscles: lfl exor pollicis longus lfl exor digitorum profundus (radial portion) l pronator quadratus

Deep part of the joint capsule of the distal, radiocarpal, and carpal radioulnar joints

Deep pain with nociceptive features on the anterior aspect of the elbow and the proximal third of the forearm (10)

All muscles of the thenar eminence except the adductor pollicis

Lateral aspect of the palm

Anterior interosseus nerve

Palmar cutaneous branch

Palmar cutaneous nerve (A)

Kiloh–Nevin syndrome (anterior interosseous nerve syndrome – failure to make the “OK” sign) (11*)

A

Recurrent branch Palmar digital branch

Palmar cutaneous branch (B)

Neuropathic signs and symptoms in the thenar eminence (pronator teres syndrome) (10)

Palmar surface and fingertips of the lateral three and half digits

Intermittent paresthesia or pain in the index, middle and ring fingers, palmar and wrist area (12*) (carpal tunnel syndrome)

B

Digital cutaneous branch (C)

Red Flags: Assessment of Neural Components (22) The following is a list of red flags that should be kept in mind when performing an assessment of neural components: l cancer; l unexplained weight loss; Co-Kinetic.com

Lack of sensation over the areas innervated by the median nerve Weakness in resisted abduction of the thumb or atrophy of the abductor pollicis brevis muscle

C

the patient’s symptomatology. The basic neural tests relating to possible neural entrapment of the brachial plexus components are summarised in Figure 5, Table 7 and Figure 6. How to perform neural tests is not explained in this book, and the reader is referred to the extensive specialised literature on this subject.

Innervation of the thenar and middle palmar areas

l immunosuppression; l prolonged use of steroids; l intravenous drug use; l pain that is increased or unrelieved by rest; l fever; l significant trauma related to age; l bladder or bowel incontinence; l urinary retention (with overflow incontinence); l saddle anaesthesia; l major motor weakness in the upper extremities; l fever; l vertebral tenderness; l limited spinal range of motion; and l neurologic findings persisting beyond one month.

Viscerofascial Components

It is not within the scope of this book to provide a detailed analysis of either viscerofascial anatomy or the clinical approaches for treating viscerofascial structures. This is an extremely complex issue that requires extensive analysis.

However, in clinical practice, in relation to the thoracic region, the practitioner should be aware of the need to identify signs and symptoms originating from the viscerofascial system (particularly in relation to respiratory disturbances) and should be able to recognise red flags.

Viscerofascial Dysfunction Criteria in Myofascial Induction Approaches Fascial dysfunctions and entrapments 39

Table 5: Peripheral nerves – 2 Peripheral nerve

Nerve roots

Radial nerve

C5–T1

Handspring Publishing 2022

Terminal branches

Motor innervation

Sensory distribution

Nociceptive pain at the lateral aspect of the elbow and at the proximal third of the dorsum of the forearm (radial tunnel syndrome)

Extensor and supinator muscles of

Superficial sensory branch

the upper extremity Innervates the triceps brachii and the extensor muscles in the forearm

Superficial sensory branch

Deficiency

Weakness in extension of the wrist and fingers Dorsum of the wrist Lateral dorsal surface of the hand Dorsum of the thumb

Pain, paresthesia, and dysesthesia on the back of the first commissure of the hand (14)

Dorsum of the index and middle fingers (13,14)

Deep motor branch

can create disorder in the viscerofascia and subsequently lead to the formation of, for example, gastrointestinal or breathing dysfunctions. This does not merely suggest the presence of specific pathologies (eg. visceral) but rather disorder in the dynamics of movement between and within the viscera, as well as between the viscerofascial and myofascial structures. Stiffness or decreased mobility of viscera may encourage the formation of fibrosis.

An example of this process is the response of Kupffer cells (stellate macrophages), through the process of mechanotransduction, recognising an increasing tension in the cellular environment. This process has also been linked with sleep abnormalities, fatigue and mood disorders (23).

Through the mechanoreceptors, 40

Dorsal wrist crease Extensor carpi radialis (15) brevis, supinator, extensor digitorum, extensor carpi ulnaris, abductor pollicis longus, extensor pollicis brevis, extensor pollicis longus, extensor digiti minimi, and extensor indicis

the fascial system is in a continuous process of response, adjustment, and feedback (24) which is: l somatosomatic; l somatovisceral; l viscerovisceral; l viscerosomatic; l psychovisceral (stress and secretion of cortisol and adrenaline versus slowing peristalsis, increase in hydrochloric acid production, etc.); and l visceropsychic (vagus nerve response, alteration of cognitive– behavioural response).

Visceral dysfunction has the potential to change the body’s overall mechanosensitivity (illness behaviour) through neuroimmunological mechanisms. One example is the release of cytokines in the brain

Lability of some of the innervated muscles

stimulated by a vagal response related to liver toxicity (25*, 26*).

The Lymphatic and Superficial Circulatory System of the Upper Quadrant

As mentioned in Chapter 10 of the book, the lymphatic system is a network of tissues and organs which helps the body to expel toxins, waste, and other unwanted materials (Fig. 7). This extensive system takes care of three major body functions: l drainage of excess interstitial fluid (regulation of tissue pressure) and proteins back to the systemic circulation; l regulation of immune responses by both cellular and humoral mechanisms; and l absorption of lipids from the digestive system (27*).

Co-Kinetic Journal 2022;93(July):35-45

MANUAL THERAPY

Table 6: Peripheral nerves – 3 Peripheral nerve

Nerve roots

Ulnar nerve

C8–T1

Handspring Publishing 2022

Terminal branches

Motor innervation

Sensory distribution

Deficiency

Intermittent paresthesia (tingling, burning, hypersensitivity) in the little finger and at the ulnar border of the ring finger.

Deep pain in the medial aspect of the elbow (16*) Cubital tunnel syndrome

Palmar cutaneous branch

Skin of the medial half of the hand and the distal part of the forearm

Dorsal cutaneous branch

Skin of the medial dorsal side of the hand, the posterior side of the little finger and part of the ring and middle fingers (15,16*)

Muscular superficial branch

Palmar side of the little finger and half of the ring finger (17*)(top image)

Muscular deep branch

Intrinsic muscles of the hypothenar area (13)

Local nociceptive pain and motor disability of the innervated muscles (12*) Guyon’s canal syndrome

Fascia provides support for the glandular tissue of the breasts in the form of a ‘net’ consisting of bands called suspensory ligaments (or Cooper’s ligaments) (Fig. 7.2), which pass through the breast from the skin up to the pectoralis major muscle fascia. The structure of the superficial fascia (see Chapter 3) also creates compartments in which fat nodules develop. In this way, the quantity, shape, size, interrelation between the fat lobes and the shape of the structure (for example the volume and shape of the breasts) is defined by the lobes within the fascial compartments.

The right thoracic duct drains most of the right upper quadrant Co-Kinetic.com

area of the substances which come from the lymph nodes (Fig. 7.1). The lymph nodes are small structures that work as filters for harmful substances.

They contain immune cells that can help fight infection by attacking and destroying germs that are carried in through the lymph fluid. The node system consists of anterior (pectoral) nodes which drain the anterior chest wall and breasts, posterior (subscapular) nodes which drain the posterior chest wall and part of the arms, lateral (brachial) nodes which drain most of the arms, and central (midaxillary) nodes which receive drainage from the anterior, posterior, and lateral lymph nodes. In cases of

infection, injury or cancer, the nodes in that area may swell or enlarge as they work to filter out the affected cells. Thus, the lymphatic system can also contribute to the development of diseases such as lymphoedema, cancer metastasis and diverse inflammatory disorders (28*). It is useful to refer to the breast quadrants when describing the location of findings. They are distinguished as follows: the upper inner quadrant, the upper outer quadrant (tail of Spence), which extends into the axillary area (most breast tumours occur in this quadrant), the lower inner quadrant, and the lower outer quadrant (Fig. 7.3).

41

Table 7: Global functional assessment – neural test

Handspring Publishing 2022

Test

Aim

Description

Interpretation (positive sign)

Neurodynamic test for the mandibular nerve

This is a neural tension test which is used to detect altered neurodynamic or neural tissue sensitivity

Right mandibular branch test: l upper cervical flexion l left upper cervical lateral flexion l left laterotrusion with open mouth (10mm)

The symptoms of irritation of the mandibular ramus appear to be recognised by the patient

Specific pretreatment neurological assessment is needed to exclude the presence of possible serious pathology, such as vertebral artery dissection, injury to the spinal cord or cervical myelopathy, neoplasm, systemic disease (herpes zoster, ankylosing spondylitis, inflammatory arthritis, rheumatic arthritis) (19*)

Reproduction of the symptoms coincides with a response of limited mobility Structural differentiation tests are applied to sensitise and desensitisze the nerve

C5

C8

Figure 4: Distribution of areas affected by radiculopathy between levels C5–C8 Handspring Publishing 2022 The darkest colours indicate the areas of intense irradiated pain. The clear areas indicate areas of dull pain, which can also be related to sensations of paraesthesia and sensory impairment. Harting 1997 (18)

Functional assessment

Global functional tests

Neural tests

von Piekartz 2007 (20) Geerse & Piekartz 2015 (21)

The assessment of the upper quadrant should include a clinical breast examination (CBE); the National Cancer Institute (2019) stresses the value of the CBE and recommends: l a manual check for unusual texture or lumps; and l an assessment of any suspicious area.

C6

C7

References

Clinical analysis

Visceral tests

The utility of the CBE has been questioned for several years because it was considered that there was little evidence to support it (29*). However, recent research confirms the great effectiveness of this procedure (30*, 31*). “Our recent work discovered a significant, linear relationship between palpation force and CBE accuracy” (30*).

Red Fags: Lymphatic and Superficial Circulatory System The following is a list of red flags for the lymphatic and superficial circulatory system:

Circulatory tests

Specific functional tests

Figure 5: Neural test applied to the neck Handspring Publishing 2022

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MANUAL THERAPY

NEURAL TESTS ARE NECESSARY TO DETERMINE WHETHER OR NOT NEURAL ENTRAPMENT IS INVOLVED IN THE PATIENT’S SYMPTOMATOLOGY

Median nerve tension test

Radial nerve tension test

Ulnar nerve tension test

Figure 6: Upper limb neural tests Handspring Publishing 2022

Global functional tests

Functional assessment

Neural tests

Visceral tests

Circulatory tests

Specific functional tests

A A B C D 3

1

2

Figure 7: Lymphatic system of the upper quadrant Handspring Publishing 2022 1, The right lymphatic duct (A). The green colour indicates its area of drainage. 2, Sagittal view of the lymphatic system of the upper quadrant with an ultrasound scan of the breast. The white lines on the scan are Cooper’s ligaments. 3, The quadrants of the left breast. A, Upper inner quadrant; B, upper outer quadrant; C, lower inner quadrant; D, lower outer quadrant; red oval, axillary tail of Spence

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l haemoptysis; l acute breathlessness; l pleuritic chest pain; l obstruction of the airways; l blurred vision; l high fever; l respiratory rate of more than 30 breaths per minute; l high blood pressure; l persistent unilateral hearing loss or tinnitus; l facial nerve palsy; l blood-stained mucous; l epiphora; l cerebrospinal fluid leak; l dysphonia persisting for longer than 4 weeks; l dysarthria; l dysphagia; l odynophagia; l myocardial infarction; l aortic syndromes; l pneumothorax; l upper cervical instability; l cervical arterial dysfunction; l acute fracture;

l acute soft tissue injury; l ligamentous instability; l osteoporosis; and l recent surgery.

Conclusion

l In practice, the assessment process will depend on the experience and skills of the individual practitioner, the patient’s profile, and the demands of the therapeutic procedures. l The specific functional tests are explained in Chapters 15, 16 and 17 which focus on clinical dysfunctions of specific areas. l The patient’s expectations, fears, and beliefs influence how the assessment is conducted. These aspects must be considered in order to achieve a correct interpretation of the tests. l The patient’s understanding of the process is essential to treatment planning.

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

DISCUSSIONS

l With a colleague, test your knowledge of the innervation of the upper quadrant. Which nerves are responsible for pain in different cutaneous areas? l What red flags do you look out for when assessing a patient’s upper body pain – do you need to add more to your list? l Think about your usual assessment process. What will you do differently after reading this article?

Related Content

KEY POINTS

l An accurate diagnosis of dysfunctions and pain syndromes of the upper quadrant is difficult because of its complex anatomy and biomechanics. l The diagnosis has to be precise, which can be challenging because the pain may be non-specific, with overlap of its sensory distribution. l Neural entrapment can generate neuroprotective changes to the body mechanics. l The cervical plexus and the brachial plexus innervate the upper quadrant. l A good knowledge of the neural network and the areas the nerve branches innervate is crucial for identifying the cause of referred symptoms and unpicking multifocal symptoms. l Nerve entrapment may be responsible for several pain syndromes in the thorax, shoulder, and upper extremity. l When assessing for myofascial dysfunctions it is recommended that neural tests be carried out in order to determine whether or not neural entrapment is involved in the patient’s symptomatology. l Viscerofascial dysfunctions consist of disorder in the dynamics of movement between and within the viscera, as well as between the viscerofascial and myofascial structures. l Visceral dysfunction has the potential to change the body’s overall mechanosensitivity (illness behaviour) through neuroimmunological mechanisms. l Assessment of the lymphatic system and superficial circulatory system is recommended in the area affected by fascial dysfunction, as the lymphatic system interacts closely with the fascial system.

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l Upper Quadrant Assessment for Myofascial Dysfunction: Part 1 [Article] https://bit.ly/3I2KZIz l Functional Training Methods for the Runner’s Myofascial Systems [Article] https://bit.ly/3Femm9m l Fascial Stretch Therapy™ for the Lower Body [Article] https://bit.ly/2GTUPB3 l ScarWork: A Different Approach to Working with Scars [Article] https://bit.ly/2VtBbA9 l Fascia: What it is and Why it Matters [Article] https://bit.ly/3hLRByw l Connectivity: Fascia-Related Therapies [Article] https://bit.ly/3Knrudu

THE AUTHOR Andrzej Pilat RPT is a Physiotherapist and specialist in manual therapy, creator of the Myofascial Induction approach, and lecturer on postgraduate and Masters degree programmes in numerous universities in Spain and other European countries as well as in Central and South America. He is the author of the book Myofascial Induction, and co-author of books and papers on manual therapy published in Britain, Spain, Italy and the USA. Director of the Tupimek School of Myofascial Therapies, Madrid, Spain, Dr Andrzej Pilat has also undertaken pioneering research on fascial anatomy using non-embalmed cadaver dissections and has used his expertise as a photographer to capture the inner beauty of the body in pictures.

Email: tupimek@hotmail.com Website: https://tupimek.com/ Co-Kinetic Journal 2022;93(July):35-45

MANUAL THERAPY

Myofascial Induction™ – An anatomical approach to the treatment of fascial dysfunction Volume 1: The Upper Body Andrzej Pilat

Handspring Publishing 2022; ISBN 978-1-913426-33-0 Buy it from Handspring https://www.handspringpublishing.com/product/myofascial-induction-vol-1/ Myofascial Induction™ – An anatomical approach to the treatment of fascial dysfunction describes the properties of the fascial network and provides therapeutic solutions for different types of fascial dysfunction.

The material is presented in two volumes: Volume 1 analyses in depth the theoretical aspects related to fascia and focuses on the therapeutic procedures of Myofascial Induction Therapy (MIT™) for the upper body; and Volume 2 summarises and expands on the theoretical aspects and explains the therapeutic procedures of MIT for the lower body.

Volume 1 is divided into two parts: Part 1 – The Science and Principles of Myofascial Induction; and Part 2 – Practical Applications of Myofascial Induction – the Upper Body.

Part 1 defines the fascia as a complex biological system before discussing its multiple characteristics.

Part 2 is the practical part. Here the reader will find a wide range of manual therapeutic procedures which can be selected and used to build up the MIT treatments. These processes are explained in detail and are richly illustrated, in full colour, with diagrams and photographs of their practical application in the body and in the treated samples of dissected tissues.

Each chapter opens with an introduction offering to the reader some philosophical background as a reminder that philosophy allows us to relate the strictly scientific with the empirical. Praxis and empiricism are the basis of science.

The author invites you to join the scientific fascial adventure that allows us to uncover areas of knowledge which may have been forgotten or which are not yet recognised as being related and which might still reveal relevant information. Once discovered, these facts can help us to better understand the kinesis of our body and so help the individual to change their body image and to improve their quality of life.

CONTENTS

Foreword Preface Online videos Acknowledgments Glossary PART 1 The science and principles of Myofascial Induction Chapter 1 Introduction: Why this book?

Chapter 2 Definition and characteristics of fascia and the fascial system Chapter 3 Anatomy and functional aspects of fascia Chapter 4 Embryological aspects of the fascial system Chapter 5 Histological aspects of the fascial system Chapter 6 The concept of tensegrity: Fascia as a tensegrity structure Chapter 7 Movement and force transmission in the fascial system Chapter 8 The neurodynamics of fascia Chapter 9 Fascial trauma and dysfunction Chapter 10 The assessment process

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Chapter 11 The objectives of Myofascial Induction Therapy Chapter 12 Scientific evidence relevant to the MIT approach PART 2 Practical applications of Myofascial Induction – the upper body Chapter 13 Myofascial Induction Therapy Therapeutic considerations Basic techniques and procedures Chapter 14 Upper quadrant assessment Chapter 15 Craniofacial and neck dysfunctions related to the fascial system Craniofacial region Craniocervical structures MIT procedures for common craniocervical and neck dysfunctions Chapter 16 Dysfunctions related to the thorax complex MIT procedures for common dysfunctions of the thorax complex Chapter 17 Upper extremity dysfunctions related to the fascial system MIT procedures for common upper extremity dysfunctions

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UPPER QUADRANT ASSESSMENT FOR MYOFASCIAL DYSFUNCTION: References

1. Cervical, brachial, and lumbosacral plexuses. In: Brazis PW, Masdeu JC, Biller J (eds) Localization in clinical neurology, 8th edn. Wolters Kluwer Health 2021; Ch3: pp83–100. ISBN 978-1975160241 (Print £138.86 Kindle £131.92) Buy from Amazon https://amzn.to/3a9Gyil 2. Peripheral neuroanatomy and focal neuropathies. In: Campbell WW, Barohn RJ (eds) DeJong’s the neurologic examination, 8th edn.

Lippincott Williams & Wilkins 2019; Ch46: pp671–696. ISBN 978-1496386168 (Print £101.91 Kindle £98.57) Buy from Amazon https://amzn.to/3I14SQ8 3. Landers JT, Maino K. Clarifying Erb’s point as an anatomic landmark in the posterior cervical triangle. Dermatologic Surgery 2012;38(6):954–957 4. Thompson JC. Netter’s concise orthopaedic anatomy, 2nd edn.

Elsevier 2016. ISBN 9780323429702 (Print £31.77 Kindle £29.69) Buy from Amazon https://amzn.to/3OTtzjO 5. Bowen BC, Pattany PM, Saraf-Lavi E et al. The brachial plexus: normal anatomy, pathology and MR imaging. Neuroimaging Clinics of North America 2004;14(1):59– 85 6. Guo B, Wang A. Median nerve compression at the fibrous arch of the flexor digitorum superficialis: an anatomic study of the pronator syndrome. Hand (NY) 2014;9(4):466–470 Open access https://bit.ly/3uhho8n 7. Gunther SF, DiPasquale D, Martin R. Struthers’ ligament and associated median nerve variations in a cadaveric specimen.

Yale Journal of Biology and Medicine 1993;66(3):203–208 Open access https://bit.ly/3bB1YW4 8. Miller TT, Reinus WR. Nerve entrapment syndromes of the elbow, forearm, and wrist.

AJR American Journal of Roentgenology 2010;195(3):585–594 Open access https://bit.ly/3OTmRKA 9. Spinner RJ. Outcomes for peripheral nerve entrapment. Clinical Neurosurgery 2006;53:285–294 10. Rehak DC. Pronator syndrome. Clinics in Sports Medicine 2001;20(3):531–540 11. Akhondi H, Varacallo M. Anterior interosseous syndrome. StatPearls Publishing 2019. PMID 30247831 Open 45i

access https://bit.ly/3a4kxS0 12. Sluiter JK, Rest KM, Frings-Dresen MH. Criteria document for evaluating the work-relatedness of upper-extremity musculoskeletal disorders. Scandinavian Journal of Work, Environment & Health 2001;27(Suppl. 1):1–102 Open access https://bit.ly/3a1i6zF 13. Johnson EO, Vekris MD, Zoubos AB et al. Neuroanatomy of the brachial plexus: the missing link in the continuity between the central and peripheral nervous systems.

Microsurgery 2006;26(4):218–229 14. Robson AJ, See MS, Ellis H. Applied anatomy of the superficial branch of the radial nerve. Clinical Anatomy 2008;21(1):38–45 15. Drake RL, Vogl AW, Mitchell AWM et al.

Gray’s Atlas of Anatomy (Gray’s Anatomy), 3rd edn. Churchill Livingstone 2020.

ISBN 978-0323636391 (Print £50.09 Kindle £33.99) Buy from Amazon https://amzn.to/3Afkeyp 16. Mazurek MT, Shin AY. Upper extremity peripheral nerve anatomy: current concepts and applications. Clinical Orthopaedics and Related Research 2001;383:7–20 Open access https://bit.ly/3udG5CG 17. Robertson C, Saratsiotis J. A review of compressive ulnar neuropathy at the elbow.

Journal of Manipulative and Physiologic Therapeutics 2005;28(5):345 Open access https://bit.ly/3a14NiI 18. Harting JK. The global spinal cord ’97.

Radiculopathies. University of Wisconsin Medical School 1997 19. Bier JD, Scholten-Peeters WGM, Bart Staal J et al. Clinical practice guideline for physical therapy assessment and treatment in patients with nonspecific neck pain.

Physical Therapy 2018;98(3):162–171 Open access https://bit.ly/3brZjOj 20. von Piekartz HJM. Craniofacial pain: neuromusculoskeletal assessment, treatment and management. ButterworthHeinemann 2007. ISBN 978-0750687744 (Print £67.49 KIndle £59.40) Buy from Amazon https://amzn.to/3ntoBi4 21. Geerse WK, von Piekartz HJ. Ear pain following temporomandibular surgery originating from the temporomandibular joint or the cranial nervous tissue? A case report. Manual Therapy 2015;20(1):212– 215

22. Waddell G. The back pain revolution, 2nd edn. Churchill Livingstone 2004. ISBN 978-0443072277 (Print £50.06 KIndle £50.06) View on Amazon https://amzn.to/3Ac7JDN 23. Aouizerat BE, Dodd M, Lee K et al. Preliminary evidence of a genetic association between tumor necrosis factor alpha and the severity of sleep disturbance and morning fatigue. Biological Research for Nursing 2009;11(1):27–41 24. Vaticon D. Sensibilidad miofascial libro de ponencias XIX. Jornadas de la Escuela Universitaria de Fisioterapia 2009;24–30 (in Spanish) 25. Olsen AL, Bloomer SA, Chan EP. Hepatic stellate cells require a stiff environment for myofibroblastic differentiation. American Journal of Physiology. Gastrointestinal and Liver Physiology 2011;301(1):G110–118 Open access https://bit.ly/3bH7NRG 26. Bilzer M, Roggel F, Gerbes AL. Role of Kupffer cells in host defense and liver disease. Liver Intational 2006;26(10):1175–1186 Open access https://bit.ly/3OQ0WDP 27. Cueni LN, Detmar M. The lymphatic system in health and disease. Lymphatic Research and Biology 2008;6(3–4):109– 122 Open access https://bit.ly/3nsJ46v/ 28. Mallick A, Bodenham AR. Disorders of the lymph circulation: their relevance to anaesthesia and intensive care. British Journal of Anaesthesia 2003;91(2):265– 272 Open access https://bit.ly/3QVoKbo 29. Nelson HD, Tyne K, Naik A et al.

Screening for breast cancer: an update for the U.S. Preventive Services Task Force. Annals of Internal Medicine 2009;151(10):727–737, W237–242 Open access https://bit.ly/3yxXxEF 30. Laufer S, D’Angelo AD, Kwan C et al.

Rescuing the clinical breast examination: Advances in classifying technique and assessing physician competency. Annals of Surgery 2017;266(6):1069–1074 Open access https://bit.ly/3yvHXJx 31. Nelson HD, Fu R, Cantor A et al.

Effectiveness of breast cancer screening: systematic review and meta-analysis to update the 2009 US Preventive Services Task Force Recommendation. Annals of Internal Medicine 2016;164(4):244–255 Open access https://bit.ly/3noQpUJ. Co-Kinetic Journal 2022;93(July):35-45

SALES IS NOT ABOUT SELLING, BUT ABOUT BUILDING TRUST AND EDUCATING I work with a LOT of physical and manual therapists to help them grow their businesses, and those businesses come in all shapes, forms and sizes. But the one success factor that stands head and shoulders above the rest, and most often sorts the businesses that are thriving from those that are just surviving, is the commitment to adding genuine value at every customer (or prospect) touch point.

This helps them to establish (and explicitly demonstrate) authority and expertise while also building a deeper level of trust with their clients. And as this article will demonstrate, trust pays in many different ways. It’s probably the single most valuable currency, particularly within healthcare. It drives what people are prepared to pay for their appointments, how loyal they are to your business, how likely they are to recommend you to family and friends, and how often they will take actions to support your business. We end the article with some suggestions of strategies you can use to build trust with not only your clients, but also prospective ones. Read this article 46

By Tor Davies, Co-Kinetic founder

W

e all know that people buy from people and businesses that they trust because we do it all the time. Take a moment to think about the purchases you make (or services you employ) because you trust the person or business involved. Think about the interactions you’ve had with those businesses, and the ways in which they’ve earned your trust.

Here are some trust-driven sales statistics to illustrate the point: l 92% of consumers are more likely to trust non-paid recommendations than any other type of advertising. l 92% of people will trust a recommendation from a peer. l 82% seek recommendations from friends and family before making a purchase. l 88% of consumers trust user reviews as much as personal recommendations. l 70% of people will trust a recommendation from someone they don’t even know.

And if you’re not convinced how important ‘social proof’ in the form of reviews and testimonials are, these

statistics should give you an idea: l 87% of buying decisions begin with research conducted online before the purchase is made. l The average consumer reads 10 online reviews before making a purchase decision. l Buyers require an average of 40 online reviews before believing a business’s star rating is accurate. l 85% of consumers think that online reviews older than 3 months aren’t relevant. l And interestingly…91% of customers say they’d give referrals, but only 11% of businesses ask for referrals.

So before you go out and pay for an ad in your local newspaper, reflect on this, investing a little bit of time building up your customer testimonials and reviews is likely to give you a better return on investment. Better still, use a selection of your customer testimonials in your ads.

Trust Pays Handsomely

Customers who trust you will spend more money with you, are more likely to sign up to loyalty programmes, Co-Kinetic Journal 2022;93(July):46-51

ENTREPRENEUR THERAPIST

TO BE SEEN AS A CREDIBLE AND TRUSTED ADVISOR, EVERY TOUCH YOU HAVE WITH A CUSTOMER SHOULD PROVIDE ADDED VALUE Sharon Gillenwater are more likely to put their own reputation on the line to refer you to other customers thereby growing your word of mouth business and will help you acquire new business by posting positive reviews and engaging more often with your social media.

There’s something else too, a recent Dale Carnegie study found that 71% of respondents said they would rather buy from someone they trusted over one who gave them the lowest price (1). And, even if you do muck up, as long as you hold your hands up and

Trust in a Practical Context

admit to it, if you have trust in the first place, you have a much better chance of retaining or rebuilding that trust, than someone who doesn’t yet trust you.

Customers show they trust a business by (2): l making more purchases (71%) l recommending you to friends (61%) l joining a loyalty programme (41%) l posting positive reviews or comments on social media (40%).

Just the other day, while on a ‘Tor on Tour’ trip where I spend time connecting with other professionals in our industry, I met a couple at my campsite who ran a sustainable energy business installing heat pumps, solar and wind energy solutions all around the UK. We were pitched next to each other in our respective vehicles (Womble – my small but awesome campervan – and their much more spacious motorhome) and we got chatting. Eventually we ended up talking about our businesses, the impact of inflation and our various successes and frustrations.

I was particularly interested in their business as my plan in the not too distant future is to buy and re-wild (increase the biodiversity of) as large a piece of land as I can acquire in the southwest of England, and adapt (or build) an accompanying property to be as energy self-sufficient as possible.

In short, through our conversations I became invested in helping them to succeed (much like a physical therapist would be when they got to the root cause of what was truly motivating a patient to seek their help).

As a result, I promised when I was due to drive back down the M5 a couple of weeks later, that I would stop at theirs and spend a day drilling into where they might be able to reduce some of the technology barriers they felt were holding them back or costing them unnecessary money.

In other words, over our two relatively short evening exchanges (about 45 mins each), they trusted me enough to let me delve into the guts of their business and make some recommendations. And I happily noted that I needed to look no further for a company to install my future sustainable energy solution because I would 100% trust them to have my interests at heart (of course I will do the appropriate due diligence) and that’s a £15–20k investment. And it all comes down to trust.

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So What Exactly Is Trust and How Do You Build It?

Trust ultimately boils down to the customer’s belief that someone is acting with their best interests at heart.

The Oxford Language Dictionary defines it as firm belief in the reliability, truth, or ability of someone or something.

So, you build trust by demonstrating reliability, truth and ability – which is exactly what I outlined in the introduction to this article as being the difference between the businesses I’ve worked with that thrive, versus those that just survive.

I would say there are a few additional nuances that help to build trust: l Reliability – keep your promises and don’t overpromise. l Honesty – truthfulness, sincerity, or frankness: be honest about what you can and can’t do. l Authenticity – being real, genuine and true: don’t try and be something you’re not. l Objectivity – put aside your personal beliefs or feelings, in the interest of doing the right thing for your clients. l Responsiveness – be quick to react to something or someone in a positive way: if you make a mistake, don’t try and cover it up, be honest, hold your hands up and rectify it in the best way you can. l Consistency – be consistent in your efforts/work – if you’re wanting to demonstrate you’re invested in your customers then demonstrate it consistently. Nurture emails are an excellent example here. There’s no point in sending just one email, you need to consistently demonstrate that investment in adding value, for it to build trust.

The 6 Principles of Persuasion

If you’ve been on any of my webinars, you’ll have heard me talk about the 6 Principles of Persuasion, which form the backbone of the excellent book entitled Influence: Science and 47

demonstrate the close relationship between trust and sales.

If you want to explore this in more detail, there’s a great whiteboard animation which you can find here (https://bit.ly/3xX1S3V).

The Four Principles of Trust-Based Selling

BEST WAY TO SELL SOMETHING: DON’T SELL ANYTHING. EARN THE AWARENESS, RESPECT AND TRUST OF THOSE WHO MIGHT BUY Rand Fishkin Practice by Robert Cialdini (if you haven’t read it, it’s well worth a read).

He demonstrated that there were 6 shortcuts or rules of thumb that individuals use to guide their decision making:

1

2 3

eciprocity – the desire to R repay kindness – this is why giving people small free treatments or offering valueadded education workshops can be so powerful because they build a sense of reciprocity, the desire to return the favour.

Scarcity – people want more of those things they can have less of. This is a powerful influencer but make sure to make the reason for that scarcity genuine and transparent.

Authority – the idea that people follow the lead of credible, knowledgeable experts.

The better you demonstrate expertise, the more likely people are to do what you ask (a key one for physical therapy!).

So, state your value clearly and in detail, leaving no room for confusion or doubt, don’t just suggest it but not directly express it.

onsistency – people like to be 4 Cconsistent with the things they

5 6

have previously said or done (the more trust you build, the more commitment to consistency you’ll get: eg. referring you, joining loyalty schemes, writing a review etc). Consistency is activated by looking for, and asking for, small initial commitments (which is again why trial/sample appointments and education workshops work so well in a physical therapy context).

Liking – people prefer to say yes to those that they like and trust – in other words everything we’ve discussed above.

Consensus (often referred to these days as social proof) – particularly when they are uncertain, people will look to the actions and behaviours of others to determine their own (this is why customer testimonials are so powerful).

Employing these shortcuts in an ethical manner can significantly increase the chances that someone will be persuaded by your request or proposition, and they also clearly

While researching for this article, I came across another article that particularly resonated with me, and I think it will with you too – it was called ‘Don’t Treat Clients Like Competitors!

The Four Principles of Trust-Based Selling’ (3).

It’s hard to summarise because the whole article is so good, and I would definitely encourage you to read it in full, you’ll find the in the References section below.

What follows is a direct extract: Trust-based Selling™ is a principled way of approaching the commercial relationship between two parties. It is not a methodology, or a process model; it can coexist with existing methodologies or processes, as long as they are not manipulative or selfish.

People – including sophisticated clients – are overwhelmingly disposed to buy what they need to buy anyway, from someone they trust. They trust people who are trustworthy – worthy of trust. Trustworthiness can be defined as behaviour in accord with certain principles.

There are four principles and they need to be applied across all stages of the sales process, all aspects of selling, and all characteristics of the client/professional relationship.

Those principles are: l Client focus for the sake of the client; l Medium to long-term perspective; l A habit of collaboration with the client; and l Transparency in all things with the client.

SALES IS NOT ABOUT SELLING ANYMORE, BUT ABOUT BUILDING TRUST AND EDUCATING Siva Devaki

Being trustworthy means, above all else, having the client’s best interests at heart. One way to demonstrate this is to be open with them in all mutual affairs. Conversely, the biggest reason a client might suspect we don’t have

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their best interests at heart is a sense that we are hiding something. So make sure your policies are right and then don’t hide anything.

The solution isn’t to keep secrets; it’s to explain reality to them. You gain three benefits by being transparent: l You show you’ve got nothing to hide; l You distinguish yourself by so doing; l If your policies are weak, wrong or inconsistent, you’ll find out fast and have to fix them so they’re stronger—in which case, repeat the first two benefits.

Why do we resist transparency?

Again, the culprit is the competitive mindset we bring to bear in selling.

In this case, we are afraid that if we share certain information, the “other party” – in this case, a potential client – will use that information against us, or we will lose advantage. That is the language of competition, not of trusted relationships.

We must stop viewing our clients as our competitors. What we fear, we empower. If we treat our potential clients as competitors during the sales process, we will end up with competitors.

The cycle has to stop with us. We need to sell from principles of trust, rather than from principles that create more competitors in the very process of gaining clients. Trust begins in the

GREAT SALESPEOPLE ARE RELATIONSHIP BUILDERS WHO PROVIDE VALUE AND HELP THEIR CUSTOMERS WIN Jeffrey Gitomer sales process, if we have the courage to put it there.

and goals I’ve outlined in this article, please call me on it!

Source: ‘Don’t Treat Clients Like Competitors! The Four Principles of Trust-Based Selling’ published on trustedadvisor.com (3).

References 1. https://bit.ly/3O3ptFB 2. https://adobe.ly/3zKKosH 3. https://bit.ly/3xWd0hu

In Summary

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.

There is no question that sales trust takes time to develop and that it can be shattered very quickly. But hopefully it’s also very clear from this article, that if you do take time to build and maintain that trust, it will serve you and your business better than any other strategy out there. You need to consistently focus on adding value, being reliable, dependable, honest, and honourable. This is the not-sosecret secret to developing sales trust.

This is what I aspire so strongly to deliver with my business, Co-Kinetic.

I seek to be 100% authentic, honest and genuine about my subscriptions, my discounts and offers, and me and my team’s business practice. I strive hard to practice what I preach and with courage I put it out there that if you see or read something I’ve said, that you think contravenes the principles

How Can Co-Kinetic Help You Build Trust?

I was particularly keen to write this article because everything I produce on your behalf is aimed at building trust.

Through Co-Kinetic I strive to deliver two forms of content: 1. High-quality, engaging professional development content, that helps you to stay at the top of your game clinically.

2. Equally high-quality patient-facing marketing content, designed specifically to help you build trust and establish authority and expertise, ranging from: sharable patient leaflets; engaging, educational social media; pre-written blog posts and nurture (trust-building) customer emails; to ready-to-present educational workshops.

Why have I committed the last 22 years of my life to this? Because as I said in the abstract, I’ve worked with 100s of physical therapy businesses to help them to grow their customer base and turnover, and hands down, in my experience, focusing on building trust and establishing authority, and then giving prospects genuine opportunities to become a paying customer, is what works.

Co-Kinetic.com

Join us on Facebook: www.facebook.com/CoKinetic/ Connect with Tor: www.facebook.com/cokinetic.tor

It’s honest, it’s transparent, it’s authentic and it genuinely has the client’s best interests at heart, which is why I so often refer to it as completely unsalesy.

It may not sound as sexy as some of the ‘get rich quick’ marketing schemes you’ve undoubtedly seen (which never work). And it’s not a one-hit-wonder because it does require consistent (albeit small because we provide as much as we can for you) efforts applied regularly. But long term, it will pay big dividends. Perhaps more importantly, it’s a marketing strategy and approach that we, as healthcare professionals, can feel comfortable about.

You are a business, I am a business, and we both need customers, it’s the only way we can continue to afford doing what we do, and helping more people with our services. So don’t feel uncomfortable about asking people to pay fairly for a genuine, honest, authentic service that makes their world a better and more comfortable place.

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HAN Activities that Physical and Manual G DY UIDE

Therapists Can Use to Build Trust

out regular educational value-adding email newsletters et involved in relevant health discussions on local social 1 Send 7 Gnetworks with links to useful resources – top of my list! Easiest way to or discussion forums (Facebook is a good one and nurture and keep your (hopefully growing) email list warm, build trust and establish authority – but note that consistency is key: when you start, you need to keep going. Scheduling several at a time will help!

encourage user reviews and testimonials – stick to 2 Aonectively or two sources max so you don’t spread them too thinly: Google definitely, followed by either Facebook or a wellknown, well-established customer review platform in your country, like TrustPilot in the UK.

helpful value-adding blog posts on your website 3 Publish – also good for your SEO (and being found on Google specifically).

educational workshops and/or team up and contribute 4 Run to someone else’s – great way to get in front of people and

demonstrate your expertise and therefore powerful authority and trust-building activities. Make sure the education session matches your ideal demographic: a menopause workshop if your target is middle-aged women; a running injury presentation or gait analysis if your demographic is runners… you get the idea.

or low-cost opportunities for new customers 5 Otoffertry free out your services, or for existing customers to try

new services that they don’t currently use. Face-to-face interaction is the gold standard trust-building exercise. But make sure you have transition to paying customer strategy in place and be strong about applying it. This could be an introductory 30-minute massage, gait assessments, bike fits, posture analyses – whatever you have in your repertoire that can lead in to a paid appointment.

reate value-adding opportunities for new and existing 6 Ccustomers to visit your business – education sessions are one opportunity, but others include Open Clinic events, Meet the Team, Introduce a New Team Member/Service/Facilities etc. – just make sure there’s something compelling to draw in your audience, and again make sure there’s an incentive to make a purchase.

also NextDoor in the UK), and share helpful resources like links to information leaflets.

et involved with local events, they could be sports events, 8 Ghealth events, fetes, fayres, open days – offer free advice, print out information leaflets, give short treatments if appropriate.

up with other local businesses or organisations that 9 Team compliment your business offering and offer value-adding

tools and resources that represent a win-win. For example, give cycle injury information leaflets to your local cycle shop, tennis leaflets to local tennis clubs, hand out running injury leaflets at running meets – just make sure not to tread on the toes of any competing professionals who may already have a formal relationship with these organisations/businesses. Other businesses could include health food shops, sports shops.

Encourage referrals from fellow professionals in related professions who already have the trust of their clients – ideas include sports coaches (eg. tennis, cricket, golf), personal trainers and Yoga instructors would be an excellent fit, holistic health professionals, health coaches, nutritionists, etc. Agree an introductory discount for their clients – so there’s a win-win for them, you could offer to give them a cash referral fee, but services-in-kind like free massages or treatments would give you better opportunities to build on the relationship.

11 opportunities to strengthen relationships with both your Don’t be afraid to look outside the box for left-of-field

customers as well as the businesses around you (you’re bound to have friends or contacts running local businesses for starters).

Could you get local pubs, restaurants, cafes to offer a free ‘something’ to your clients on your email list? “Take this coupon and you’ll get a free coffee at…” This is a great way to offer extra value to your customers, at no cost to you, while also helping out fellow local businesses, building reciprocity on all sides. There are lots of different ways to use this approach.

12 (some will drop off, not all will work, but learning who and

As you build stronger relationships with your local businesses what does is part of the process), you could do shared email promotions and collaborate on increasing number of activities.

Marketing is all about strengthening relationships and making people aware of the ways in which you can improve their quality of life – if you do that with the customers’ best interest at heart, with a long-term customer view and with honesty, integrity and transparency at the forefront, not only will the sales take care of themselves but you’ll also have a healthier, more robust business, and a much happier, more supportive working environment and community.

Really good things can happen with good marketing

Marketing Opportunities for Physical Therapists l Introductions

l Introductory Offer – Come and Try Us Out l Free Discovery Sessions – calls, appointments, online l Welcome Our New Team Member Offer l Open Clinic Evening/Day – meet the team, try out some free sessions

l New Equipment/Services – Electrotherapies, Gait Analysis, Bike Fit Assessments

l Education Events

l Sports Injury Prevention/Management/Treatment – Running, Cycling, Swimming, Skiing, Football/Soccer, Rugby l Health Awareness – Men’s Health, Women’s Health, Disease Prevention/Health Promotion, Post-Viral Fatigue l Common MSK Conditions – Back Pain, Shoulder Pain, OA/RA

l Celebrations

l Big Birthdays/Anniversaries – you, the team, your business l Clinic Renovations/Improvements/Extensions l Holidays/Public Occasions – national events, Valentines,

l Business Programmes

l Clinic Membership Packages l ‘Thank You for Your Loyalty’ Schemes l ‘Refer a Friend’ Schemes l ‘We Miss You’ Past Patient Re-Engagement

l Referral Partnerships – local personal

CHE AT SHEE T

trainers, yoga and Pilates teachers, health and wellbeing professionals

l Local Events/Communities

l Sports Events – 10k/half/marathons, cycle events, triathlons, sea and snow events

l Fetes, Fayres, Markets l Networking Groups l Online Discussion Forums l Online Social Network Pages l Support Your Local Business Promotion – collaborate up

with other local businesses, co-promotions, offer discounts and freebies, health fayres

Mother’s Day

Promotional Methods Offline

l Direct Address Mailing – postcards/ mailshots/letters (‘old school’ arguably works better than ever these days) l Print Publications – newspapers, local magazines, Parish Council newsletters: where possible get editorial coverage l Posters and Leaflets – distributed through local businesses, organisations l Noticeboards – libraries, supermarkets, community centres, retail stores l Local Radio l Local Display Ad Opportunities – buses, billboards, trains

Online

l E mail – your email list (this is why it’s important!), collaborate with other business partners to co-promote l Organic Social Media – local groups, networks (that’s why being part of them before you need to promote yourself is a wise investment in time) l Paid Social Media (Ads) – focus on a clear target audience to maximise your return l Blog Posts – yours and third parties l Websites/Banner Ads – yours and third parties

Really good things can happen with good marketing

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