Journal Watch

The objective of this study was to the compare the efficacy of the Graston technique versus soft tissue release on patients with myofascial neck pain syndrome. In a pre-test/post-test RCT, 60 participants with ages ranging from 25 to 40 years were assigned to 3 groups. Group A (n =20) received Graston technique plus conventional treatment. Group B (n =20) received soft tissue release plus conventional treatment. Group C (n =20) received traditional treatment only.

The Graston technique was instrument-assisted soft tissue massage performed at 30–60° for 40–120s on each side till redness arises, followed by cold packs to reduce the redness. The soft tissue release involved the therapist putting one hand on the patient’s chest, so the palm touched the collarbone, and the fingers pointed toward the patient’s elbow on the same side. The other hand was placed beneath the patient’s jaw, using it as a handle and pointing the fingers toward the top of the patient’s head. A release was then made in three dimensions. The process was carried out for at least 5min. The standard treatment consisted

GRASTON TECHNIQUE VERSES SOFT TISSUE RELEASE ON MYOFASCIAL NECK PAIN SYNDROME: A RANDOMIZED CONTROLLED TRIAL. Mahgoub MSE, Abdelraouf NA, Elshafey MA et al. Ibero-American of ultrasound, hot packs and TENS, plus proprioceptive and isometric neck exercises. There were 3 sessions a week for 4 weeks. Outcome measures were cervical pain intensity using analogue visual scale, daily activities using a neck disability score, range of motion using an inclinometer, and tenderness using a pressure algometer pre-and posttreatment.

The results showed that there was a significant difference between the Graston technique and soft tissue release. Both were more successful than the control group in pain relief, functional impairment, and range of motion, with the Graston approach having a more beneficial impact.

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This is one of those papers where you want to go back and ask the authors what on earth they were thinking. For a start the interventions are cumbersome. The standard treatment alone is a case of throwing everything at the problem with the two interventions being tested as a bit of an afterthought, the descriptions of those interventions are not detailed enough to be repeated, and finally the results were obtained immediately after the intervention. How hard would it have been to include a longer term follow-up?

The purpose of the study was to compare the effects of instrumentassisted soft tissue mobilisation (IASTM) and myofascial release technique (MFR), to improve pain and mobility among patients with chronic heel pain. Sixty-six participants recruited via a convenience sample, and 33 were allocated to each treatment group, both of which were treated for 3 sessions per week for 4 weeks. Pre- and post-treatment readings were measured on the numeric pain rating scale (NPRS) and foot and ankle index (FADI).

Both groups were treated with cold packs for 7 to 10min to reduce fascia pain. The IASTM group were

EFFECTS OF INSTRUMENT ASSISTED SOFT TISSUE MOBILIZATION AND MYOFASCIAL RELEASE TECHNIQUE AMONG PATIENTS WITH CHRONIC HEEL PAIN. Arshad MU, Bashir MS, Zia W et al. Journal of Xi’an Shiyou University, Natural Science Edition 2023;19(1):774–779 treated for 7 to 10min using a GT 4 instrument. A small amount of lubricant was applied and the medial and lateral part of gastrocnemius and both sides of the Achilles tendon were treated. For the other group, MFR was done by a physiotherapist using the knuckles of the dominant hand to apply broad strokes to release superficial restrictions. Strokes were applied at 45° in relation to the calf muscle. After that, small restrictions were located and then released, deeper massage was applied using the thumb, followed by the calf muscles being shaken for 30s. In both groups NPRS and FADI improved, but there was greater improvement in the IASTM group.

Co-Kinetic comment

That both groups improved was great. The big question for clinicians is the balance between wear and tear on the thumbs against the cost of the gadgets. There are ways to protect your hands and ways to protect your bank balance, such as using the back of a dessert spoon!

This was a multicentre observational diagnostic study involving seven centres from six countries (Belgium, Brazil, Chile, the Netherlands, Portugal and Spain). All patients with a diagnosis of multiple ligament knee injuries (MLKI) who were surgically treated between January 2014 and December 2020 in the participating centres were eligible for inclusion. MLKIs were considered as injuries of at least two of the four main ligaments of the knee: anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL) and posterolateral corner (PLC). The PLC comprises the lateral collateral ligament (LCL), the popliteus tendon, and the popliteofibular ligament (PFL); injuries that involved at least one of these three structures were considered as lesions to the PLC.

Inclusion criteria were: l skeletally mature patients; l diagnosis of MLKI; l surgical treatment by a knee surgeon with experience in MLKI; and l MRI report of the knee before

Accuracy

OF MAGNETIC RESONANCE IMAGING IN THE DIAGNOSIS OF MULTIPLE LIGAMENT KNEE INJURIES: A MULTICENTRE STUDY OF 178 PATIENTS. SanchezMunoz E, Lozano Hernanz B, Zijl JAC et al. The American Journal of Sports Medicine 2023;51(2):429–436 surgery by an experienced musculoskeletal radiologist. Exclusion criteria were: l previous lesion of the knee; l previous surgery of the knee; l concomitant fractures of the knee (except for bone avulsions associated with ligament lesions, such as arcuate fractures); and l patients with incomplete data.

Detailed data on the knee injuries of 178 patients were gathered from MRI reports and surgical records. There were 127 male (71.3%) and 51 female (28.7%) patients. The mean age was 33.1± 11.9 years (range, 14–66 years). Highenergy trauma was the most usual mechanism of injury, which occurred in 90 patients (50.6%), followed by sports trauma in 69 patients (38.8%) and low-energy trauma in 15 patients (8.4%). A vascular injury was present in 5 patients (2.8%), which was not reported in 34 patients (19.1%). Nerve injuries affected 17 patients (9.6%) and were not reported in 34 patients (19.1%).

The main finding of this study is that the diagnostic accuracy of MRI was highly varied for the different knee structures in MLKIs, with PLC, meniscal and chondral lesions showing a high risk of a misdiagnosis. The ACL was the structure with the best diagnostic accuracy. MRI was more reliable in detecting the absence of meniscal and chondral lesions than in identifying them. The diagnostic accuracy of MRI was mostly influenced by the severity of the lesion and by age or sex for some knee structures.

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What’s the old medical adage – ‘Treat the findings not the films’ ? Maybe, but it’s a bit sad that we have to get cut up to accurately find what is wrong.

PREVALENCE OF MUSCULOSKELETAL SPORTS INJURIES OF HEAD, NECK AND UPPER LIMB AMONG CRICKET PLAYERS. Umar MH, Batool S, Javaid HB et al. The Therapist (Journal of Therapies & Rehabilitation Sciences) 2022;3(2):6–9

A cross-sectional study was conducted in which convenience sampling was used and data collected from 180 players in Lahore. The players ranged from U14 to national level (mean age, 21.56). Of these, 60 were batsman, 60 were bowlers, 50 all-rounders and 10 were wicket keepers. Only 5 (2.8%) reported a head injury and the same number a neck injury. Of the batsman, 35 complained of shoulder pain, 5 were diagnosed with rotator cuff injury, 5 had tendinitis and 5 had shoulder dislocations. All of the bowlers and 25 of the all-rounders had had shoulder pain. Out of the 10 wicket keepers, 5 were diagnosed with rotator cuff injury.

Co-Kinetic comment

There is a great line in this paper, “Players who were on illegal drugs [were] excluded from this study”. Would anyone admit to that or is it so common in Pakistan that it’s a reasonable question to ask? The authors only give us a partial picture here. Clearly, cricket is bad for the shoulders but there is no information on whether there was pain in the non-bowling/ throwing arm or detail about the wicket keepers who in theory don’t do much throwing. If you have this information guys, publish a follow-up.

EFFECTS OF MASSAGE THERAPY ON PAIN AND ANXIETY INTENSITY IN PATIENTS WITH BURNS: A SYSTEMATIC REVIEW AND META-ANALYSIS. Miri S, Hosseini SJ, Vajargah PG et al. International Wound Journal 2023;doi:10.1111/iwj.14089

A systematic search was conducted in the usual international electronic databases, such as Scopus, PubMed, Web of Science, and Persian electronic databases such as Iranmedex, and Scientific Information Database using keywords extracted from Medical Subject Headings such as ‘massage therapy’, ‘musculoskeletal manipulations’, ‘acute pains’, ‘burning pain’, and ‘burn’ from the earliest content to 17 October, 2022. Stata version 14 software was used to perform the meta-analysis. The duration of the study was reported in five studies, with a mean of 42.40 weeks. The duration of the intervention was reported in seven studies with a mean of 22.86min. The results of the meta-analysis showed that using various types of massage therapy interventions significantly reduced pain intensity and anxiety in the intervention groups compared with the control groups.

Co-Kinetic comment

Of the seven papers showing positive results, one used Shiatsu, two general massage with aromatic oils, two Swedish massage and two foot reflexology, which are wildly different techniques but they all work on pain and anxiety.

WHY IS THE PREVAILING MODEL OF JOINT MANIPULATION (STILL) INCORRECT?

Evans DW. Chiropractic & Manual Therapies 2022;30(1):51 OPEN

This paper starts with the prevailing model of joint manipulation as proposed in 1976 by Raymond Sandoz, a French-Swiss chiropractor who was building on earlier work on cracking joints from 1947, “A passive, manual manoeuvre during which an articular element is suddenly carried beyond the usual, physiological limit of movement without however exceeding the boundaries of anatomical integrity”. It then goes on to explain why the model is fundamentally flawed. The application of peak force will move a joint beyond the point of any resistance at the end of range with the possibility of causing damage to the capsule and ligaments.

The early research on ‘joint cracking’ that led to the development of this model is described in chronological order, alongside how this research was misinterpreted, which gave rise to the model’s flaw. A corrected model, first published by Evans and Breen in 2006, is then presented and explained. Unlike the flawed model, this corrected model makes predictions in line with all available empirical data and additionally provides reassuring answers to critics: the bottom line being that cavitation should be achieved more easily when the joint is at or near to neutral.

Co-Kinetic comment

This is well worth a read if you are a clinician performing manipulations. It’s particularly good on the history of cavitation bubble research. The main title refers to the author complaining that his earlier paper has not had greater recognition. Given that his model is safer than the original he may have a point.

MANUAL THERAPY IN MUSCLE TENSION DYSPHONIA (MTD) FOR SINGERS – RECENT REVIEWS AND A CASE STUDY. Pani S, Chatterjee I, Kumar S. World Journal of ENT & Head-Neck Surgery 2022;3(4):14–18

This is a case study of a 34-year-old female classical singer complaining of voice fatigue and a ‘hoarse’ voice who was diagnosed with muscle tension dysphonia (MTD). MTD was originally coined in 1983, and describes difficulty making sounds when attempting to speak caused by increased muscle tension of the muscles surrounding the voice box (laryngeal and paralaryngeal muscles). One of the treatments for this involves kneading the laryngeal area without voicing in order to reduce hyperfunction of the muscles and improve the quality of voice. Direct massage was applied to the medial suprahyoid, around the hyoid bone thyrohyoid space, thyroid cartilage and larynx. During the palpation the patient was asked to sustain vowel sounds. It worked – she returned to a ‘normal’ voice.

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Unlike some of the other papers we report on today, this one does have enough information for a competent therapist to repeat the treatment. Sadly it’s a bit less clear on timings and number of sessions, other than to state that the treatment should take approximately 10min and can be repeated in one session. As part of the assessment process the authors used a computerised speech lab called Dr Speech. Their tag line is, “Everyone deserves a voice”. 10/10 to whoever dreamed that up.

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This study aimed to develop an international expert consensus for the management of hamstring injuries (HSIs). A modified Delphi methodology and consensus process was used with an international expert panel, involving two rounds of online questionnaires and an intermediate round involving a consensus meeting. The questionnaire for the initial round of information gathering was sent to 46 international experts, and comprised open-ended questions covering decision-making domains in HSI. Thematic analysis of responses outlined key domains, which were evaluated by a smaller international subgroup (n =15), comprising clinical academic sports medicine physicians, physiotherapists and orthopaedic surgeons in a consensus meeting. After group discussion around each domain, a series of consensus statements were prepared, debated and refined. A questionnaire for round two was sent to 112 international hamstring experts to vote on these statements and determine level of agreement. Consensus threshold was set a priori at 70%. The main recommendations were individualised rehabilitation based on the athlete, sporting demands, involved muscle(s), and injury type and

LONDON INTERNATIONAL CONSENSUS AND DELPHI STUDY ON HAMSTRING INJURIES PART 3: REHABILITATION, RUNNING AND RETURN TO SPORT. Paton BM, Read P, van Dyk N et al. British Journal of Sports Medicine 2023;bjsports-2021-105384 severity. Early stage rehab should avoid high strain loads and rates. Loading is important but there was less consensus on optimum progression and dosage. This panel recommends rehab progress based on capacity and symptoms, with pain thresholds dependent on activity, except pain-free criteria supported for sprinting. Experts focus on the demands and capacity required for match play when deciding the rehabilitation

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end-goal and and timing of return-to-sport (RTS). Additional research is required to determine the optimal load dose, timing and criteria for HSI rehabilitation and the monitoring and testing metrics to determine safe rapid progression in rehabilitation and safe RTS. Further research would benefit the optimisation of prescription of running and sprinting, the application of adjuncts in rehabilitation, and treatment of kinetic chain HSI factors.

This paper starts by saying, “Hamstring injuries are the most common athletic injury in running and pivoting sports, but despite large amounts of research, injury rates have not declined in the last 2 decades” so we must be missing a trick somewhere. The people making these recommendations are a body of over 100 international experts but sadly the consensus is rarely 100%, so the paper helpfully includes the percentage who do agree after each recommendation.

Part 1 of the series recommends HSI classification systems evolve to integrate imaging and clinical parameters around: individual muscles, injury mechanism, sporting demand, functional criteria and patient-reported outcome measures. Part 2 is about indications for surgery and recommends the knife if there is gapping at the zone of tendinous injury and loss of tension, symptomatic displaced bony avulsions and proximal free tendon injuries with functional compromise refractory to non-operative treatment. Other important considerations for operative intervention included the demands of the athlete/patient and the expected functional outcome based on the anatomy of the injury; the risk of functional loss/performance deficit with non-operative management; and the capacity to restore anatomy and function. Consensus was not reached within the whole group but was agreed by surgeons in the cohort. The consensus group did not support the use of corticosteroids or endoscopic surgery without further evidence.

REPEATED MASSAGE IMPROVES SWIMMERS’ PERCEPTIONS DURING TRAINING SESSIONS BUT NOT SPRINT AND FUNCTIONAL PERFORMANCE: A RANDOMIZED CONTROLLED TRIAL. Carvalho FA, Batista NP, Diniz FP et al. International Journal of Environmental Research and Public Health 2023;20(3):1677

In this cross-over study, 19 male and female competitive swimmers aged between 12 and 20 years old were subjected to three 12min interventions performed over a week, which they completed between their resistance and swim training. After the intervention week, perceptive (well-being, heaviness, tiredness, discomfort, and pain), performance (sprint time, FINA points, and stroke characteristics), and functional (flexibility, squat jump, bench press, proprioception) outcomes were measured, in addition to athlete beliefs and preferences. The interventions were (i) 12min of superficial massage; or (ii) deep massage both of which were by trained physiotherapists on the arms, back and anterior thigh with sliding movements controlled by metronome; and (iii) a control group of a 12min rest period in which the subjects were free to sit, stand, or walk by the pool to simulate the actual training scenario, but were instructed not to enter the water or engage in physical activity. also maintained perceptions of wellbeing, whereas the control group got worse throughout the week. However, there was evidence of worsening of the perceptions of heaviness and pain at the main stages of the swim training for the massage groups and neither had an effect over sprint and functional performance.

Co-Kinetic comment

This is a well-presented work. The

OPEN training regime is shown as a diagram and the massage protocol is also shown using a body diagram to indicate stroke direction. It’s less clear on how they distinguish between superficial and deep strokes but that is an issue in massage research that is rarely – if ever –addressed. The results suggest that the swimmers didn’t improve their performance with massage but they felt better for it.

EFFECT OF NONINVASIVE STATIC HUMAN DATA ON MAXIMUM DATA IN EXERCISE. Wu Y, Sun Y. International Journal of Environmental Research and Public Health 2023;20(2):1612

The basic premise of this study is that obtained maximum data in exercise (Max-Ex), including maximum heart rate (HRmax), peak oxygen uptake (VO2pk), maximum power, etc, are frequently used for a variety of reasons, such as the determination of exercise intensity, the measurement of an athlete’s performance, assessment of recovery from disease, and so on.

However, very often this choice does not take into account the targeted individual. So, this study looked to determine variations in Max-Ex, according to the non-invasive static human data (Non-In data). There were more than 40 dimensions of Non-In data including anthropometric and demographic data (eg. height, weight and BMI); physical fitness levels (eg. grip

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strength, reaction times, sit and reach length); and body composition (eg. body fat percentage, water content and muscle bulk).

Sixty-one participants (32M, 29F) were recruited and underwent an incremental graded exercise test (GXT). The two data sets of Max-Ex and NonIn were correlated. The results showed a significant relationship between body composition and Max-Ex. Of the 41 types of Non-In data collected in communities, the body composition generally showed high correlation. The muscle-related body composition data had a greater effect on power, and the fat-related ones had a greater effect on HR max and VO2pk. For some types of Max-Ex, the older and younger ones showed specific differences.

This study comes from the Chinese Institute of Intelligent Machines. That doesn’t sound scary at all does it? It gives some quantifiable data to back up what should be obvious: there is no ‘one size fits all’ when it comes to exercise prescription.

EFFECT OF PLANTAR FASCIA-SPECIFIC STRETCHING AND ACHILLES TENDON STRETCHING ON SHEAR WAVE ELASTICITY OF THE PLANTAR FASCIA IN HEALTHY SUBJECTS.

Sugino Y, Yoshimura I, Hagio T et al. Foot and Ankle Surgery 2023:S1268–7731(23)00004-8

This study consisted of 14 subjects [8 men, 6 women; mean age of 30.9±4.8 years (range, 25–41 year)] with no history of plantar fascia (PF) disorders or painful episodes. All participants performed a sustained PF-specific stretch (sPFSS) on one foot and intermittent stretching (iPFSS) on the other foot. Force was applied distal to the metatarsophalangeal joints on the evaluated foot, pulling the toes upward toward the proximal side until a stretch was felt in the PF. Two weeks later, all participants performed sustained Achilles tendon stretching (sATS) on one foot and intermittent stretching (iATS) on the other foot. Sustained stretching was performed for 3min at a time. Intermittent stretching was performed 10 times for 10s each with an interval of 10s between stretches.

Shear wave elastography (SWE) measurements were performed immediately after each stretching. SWE is a non-invasive method for real-time visualisation of soft tissue viscoelastic properties. It allows for reproducible, quantitative evaluation of tendons and muscles despite limitations in the size, shape and depth of the region of interest.

The results showed that there was a difference in the PF elasticity pre- and post-tests for both stretching methods, although there was no significant difference between the types.

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If you are interested in this, there are photos in the paper which make it much clearer than the written text does.

Evaluation Of Sustained Acoustic Medicine For Treating Musculoskeletal Injuries In Military And Sports

MEDICINE.

Walters R, Kasik J, Ettel C et al.

The Open Orthopaedics Journal 2022;16: e187432502211210

This paper presents the results of an 18-question electronic survey sent to Athletic Trainers (ATs) in the USA about their use of portable, home-use ultrasound machines, known as sustained acoustic medicine (SAM). The survey included both qualitative and quantitative questions. In addition, a panel discussion about SAM effectiveness with expert ATs was held. Survey respondents (n =97) and panellists (n =142) included ATs from all National Athletic Trainers Association districts. SAM was primarily used for musculoskeletal injuries (83.9%) with a focus on healing tendons and ligaments (87.3%). SAM treatment was also used on joints (44.8%), large muscle groups (43.7%), and bone (41.4%). SAM provided clinical improvement in under 2 weeks (68.9%,) and a 50% reduction in pain medication (63%). In addition, patients were highly receptive to treatment (87.3%), and ATs had a high level of confidence for improved function and returned to work after 30 days of SAM use (81.2%).

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If you are new to the SAM devices, you are not alone. Imagine a TENS machine but using ultrasound rather than electric current. They transmit a low intensity, long duration ultrasound treatment at 1.3W (0.65W/applicator) for up to 4h. They cost between $4000 and $6000. If you want to know more seek out ‘Sustained acoustic medicine: a novel long duration approach to biomodulation utilizing low intensity therapeutic ultrasound’ by Langer MD, Lewis Jr GK in Proceedings of SPIE–The International Society for Optical Engineering 2015;9467:946701 (https://bit.ly/3kNdmD4).

HOME SELF-MASSAGE DEVICE NECESSITATES PUBLIC AWARENESS: VERTEBRAL ARTERY DISSECTION ASSOCIATED WITH A HOME MASSAGE DEVICE. Shariff E, Al Ghannam ZT, AlDamigh FA et al. Cureus 2023;15(1):e33394

This is a case study of a 43-year-old woman who presented with a history of sudden-onset dizziness, dysarthria, nausea/ vomiting, tinnitus and imbalance. Two days before her presentation, she experienced a new-onset moderate- to severe-intensity headache along with neck pain. The patient mentioned a first-time use of a home massage device 3 weeks before the headache onset. After investigations, the patient was diagnosed with vertebral artery dissection (VAD), and treatment was initiated. She was discharged in a stable condition.

Co-Kinetic comment

These devices are becoming increasingly popular, but they are not without risk. Hire a properly trained massage therapist instead.

To examine the extent of sportrelated spinal cord injury (SCI) in China, individuals admitted to the China Rehabilitation Research Centre (CRRC) between January 1, 2013 and December 31, 2019 suffering with injuries of the vertebral column with spinal cord lesions resulting from sport-related accidents were included in the study.

Of the 2448 individuals evaluated, 164 (6.7%) had sport-related SCIs. The mean age was 15.23 (±13.83) years old. Most were female (male:female ratio, 0.47:1) and aged between 4 and 70 years. Dancing was the leading cause of sport-related SCIs, accounting for 58.6% of the injuries. This was followed by water sports (14.7%) and taekwondo (4.2%). The highest proportion of individuals with SCIs was in the 4–11-year-old age group at 61.7%, and when combined with the 12–29-year-old group, accounted for 83.0% of the total SCIs. Of the 96 individuals who had dance-related SCIs, 89 (92.7%) had thoracic SCI. All individuals were female, and 85.4% of them were aged between 4 and

THE TRENDS IN SPORTS-RELATED SPINAL CORD INJURY IN CHINA. Li J, Liu J, Liu HW et al. Spinal Cord 2022;doi:https://doi.org/10.1038/s41393-022-00872-0

7 years. Of these, 42 had injured segments in T9–11. Further, 90 (93.8%) and 6 (6.2%) individuals had SCIs due to performing the bridge and handstands during practice, respectively.

For the injured water sports patients (n =24), 13 (54.2%) were injured hitting the bottom of the pool after diving; 5 (20.8%) from falling into the pool; 2 (8.3%) from being hit by waves on the beach; the other 4 patients were injured due to water skiing, jet ski accident, breaststroke training, and swimming with neck degeneration. Most of the individuals with water-sport-related SCI were men, and 75% were younger than 32 years old. Further, most of the individuals had a cervical SCI, with 18 (75.0%) having injured segments in C4–6.

There were 7 injured martial artists and 3 of those had been doing a bridge, similar to the dancers. Of the 6 climbers, 3 fell down a mountain. All 6 trampolinists fell headfirst while bouncing and all had C-spine injury.

A RETROSPECTIVE ANALYSIS OF THE INCIDENCE OF SEVERE ADVERSE EVENTS AMONG RECIPIENTS OF CHIROPRACTIC SPINAL MANIPULATIVE THERAPY. Chu ECP, Trager RJ, Lee LYK et al. Scientific Reports 2023;13:1254

This study examined the incidence and severity of adverse events (AEs) involving patients receiving chiropractic spinal manipulative therapy (SMT), with the hypothesis that <1 per 100,000 SMT sessions results in a grade ≥3 (severe) AE. A secondary objective was to examine independent predictors of grade ≥3 AEs. Patients with SMT-related AEs from January 2017 through August 2022 across 30 chiropractic clinics in Hong Kong. AE data were extracted from a complaint log, including solicited patient surveys, complaints and clinician reports, and corroborated by medical records. AEs were independently graded 1–5 based on severity (1, mild; 2, moderate; 3, severe; 4, life-threatening; and 5, death). Among 960,140 SMT sessions for 54,846 patients, 39 AEs were identified, two were grade 3 (both of which were rib fractures occurring in women age >60 with osteoporosis) and none were grade ≥4, yielding an incidence of grade ≥3 AEs of 0.21 per 100,000 SMT sessions. There were no AEs related to stroke or cauda equina syndrome. The sample size was insufficient to identify predictors of grade ≥3 AEs using multiple logistic regression. In this study, severe SMT-related AEs were reassuringly very rare.

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Rib fractures!! Is not screening for dangers one of the purposes of taking a patient history? Stick to: Can I hurt you? Can you hurt me? and if in doubt don’t do it.

Another 5 fell off a horizontal bar and 5 were doing aerobics. The most common injured segment was C4–5. Of the 3 air sports participants, 1 was paragliding, 1 skydiving and 1 had a high-altitude crash in a hot air balloon. There were also a couple of horse riders, 2 motorcyclists and a gymnast doing the dreaded bridge.

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Although this is a Chinese study it starts with a round-up of sport-related SCIs from around the world and the disturbing fact is that they are on the increase. In New Zealand, the proportion of sport-related SCI increased from 11.0% in 1993 to 22.0% in 2020, and in Canada from 9.3% in 2004 to 17.9% in 2012. The highest SCI figure was from Russia at 32.9% and the lowest in Nigeria at 1.7%. They are rising in China as well. The number of ways that humans can break themselves while engaged in an activity that is supposed to improve their health is truly frightening. What is worse is that so many of these incredibly active sporting individuals were so young and sadly the study reports that most of their injuries were measured on the high end of the American Spinal Injury Association Impairment Scale with little hope for improvement in their condition as there is currently no effective treatment for SCI.

THE EFFECTS OF OUTDOOR VERSUS INDOOR EXERCISE ON PSYCHOLOGICAL HEALTH, PHYSICAL HEALTH, AND PHYSICAL ACTIVITY BEHAVIOUR: A SYSTEMATIC REVIEW OF LONGITUDINAL TRIALS. Noseworthy M, Peddie L, Buckler EJ et al. International Journal of Environmental Research and Public Health 2023;20(3):1669

This systematic review aimed to compare the effects of exercise in outdoor environments versus indoor environments on psychological health, physical health, and physical activity behaviour. The ‘usual suspect’ databases were searched for randomised and non-randomised trials that compared multiple bouts of exercise in outdoor versus indoor environments, and that assessed at least one outcome related to physical health, psychological health, or physical activity behaviour. This identified 10 eligible trials, including 7 RCTs, and a total of 343 participants. Participant demographics, exercise protocols and outcomes varied widely. In the 10 eligible studies, a total of 99 comparisons were made between outdoor and indoor exercise; all 25 statistically significant comparisons favoured outdoor exercise. Interpretation of findings was hindered by an overall high risk of bias, unclear reporting, and high outcome heterogeneity. There is limited evidence for added health or behaviour benefits of outdoor exercise versus indoor exercise.

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In or out, shake it all about. It’s slightly better outside but one wonders how many of the outdoor types are willing to risk a dark February night on the streets of a wet and windy British city?

COMPARISON OF EFFECTS OF MANUAL PHYSICAL THERAPY AND EXERCISE THERAPY FOR PATIENTS WITH TEMPOROMANDIBULAR DISORDERS. Sarfraz S, Anwar N, Tauqeer S et al. Journal of the Pakistan Medical Association 2023;73(1):129–130

The term ‘temporomandibular disorder’ is a catch-all name used for pain and dysfunction at the temporomandibular joint. Manual therapy or exercise therapy has proven to be an effective measure for pain relief. The purpose of this study was to compare the effectiveness of manual therapy and exercise therapy in temporomandibular disorders. A convenience sample of 24 patients aged between 18 and 55 years were involved in the study. They were randomly assigned to either a manual therapy group or an exercise therapy group. They received 3 sessions of treatment per week for 6 weeks. The participants were assessed before

The aim of this study was to investigate the effects of manual therapy on pain intensity, maximum mouth opening (MMO) and disability. Searches were conducted in six databases for RCTs. Twenty trials met the eligibility criteria and were included. For pain intensity, highand moderate-quality evidence demonstrated the additional effects of manual therapy at short- and long-term. For MMO, moderate- to

The International Olympic Committee (IOC) recently released a sports-generic consensus statement outlining methods for recording and reporting epidemiological data on injury and illness in sport and encouraged the development of sportspecific extensions.

The Fédération

Internationale de Football Association (FIFA) Medical Scientific Advisory Board established a panel of 16 football medicine and/or science and after the intervention through the numeric pain rating scale (NPRS) for pain, patient-specific functional scale (PSFS) for function, Fonesca amnestic index (FAI) for the severity of condition, and millimetre mouth opening (MMO) for ranges. The manual therapy group showed a statistically significant difference in pre- and post-treatment NPRS, PSFS, FAI and MMO scores.

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Sadly neither intervention is described in sufficient detail to recreate what was done. The manual therapy was described as mobilisation with movement, soft-tissue mobilisation, myofascial release, muscle energy techniques and active isolated stretching. The exercise therapy was described as Racabado exercises, isometric exercises, strengthening exercises, resistive exercises, and stretching exercise. We need more than this.

THE EFFICACY OF MANUAL THERAPY APPROACHES ON PAIN, MAXIMUM MOUTH OPENING AND DISABILITY IN TEMPOROMANDIBULAR DISORDERS: A SYSTEMATIC REVIEW OF RANDOMISED CONTROLLED TRIALS. Vieira LS, Pestana PRM, Miranda JP et al. Life 2023;13(2):292 high-quality evidence was found in favour of manual therapy alone and its additional effects at short- and long-term. Moderatequality evidence demonstrated an additional effect of manual therapy for disability.

Co-Kinetic comment

TMJ studies are like London buses. You wait ages for one and then two come along at the same time. As in the other TMJ paper, manual therapy comes out strongly, but there are few specific details which don’t help busy clinicians much. To obtain the results the authors screened titles and abstracts of 3630 papers. Is there too much research out there?

FOOTBALL-SPECIFIC EXTENSION OF THE IOC CONSENSUS STATEMENT: METHODS FOR RECORDING AND REPORTING OF EPIDEMIOLOGICAL DATA ON INJURY AND ILLNESS IN SPORT 2020. Waldén M, Mountjoy M, McCall A et al. British Journal of Sports Medicine 2023:bjsports-2022-106405 experts, two players and one coach. With a foundation in the IOC consensus statement, the panel performed literature reviews on each included subtopic and came up with a football extension to the basic IOC model.

The main amendments from the IOC consensus statement were to use football-specific terminology, to define return-to-football after a health problem, to categorise the severity of a health problem in more detail, and to define match and peri-match exposures. The paper includes a table of the relevant terminology.

Co-Kinetic comment

One of the big complaints from researchers trying to do metaanalysis of data in our industry is the lack of consensus in data collection, which makes it difficult to pool results. This may help in the injury reporting field and, by extension, injury prevention. If you work in football and collect injury data, this paper is a must-read. It’s open access so easy to obtain. Both the IOC and FIFA can get bad press at times but, despite questions over their politics and finance, their medical departments regularly come up with good stuff. They do take their time though – this 2020 statement was not published until January 2023.