Co-Kinetic Journal Issue 99 - January 2024

1999

2024

ISSUE 99 JANUARY 2024 ISSN 2397-138X

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s most of us undoubtedly speed into 2024, I can’t help but reflect not just on the excitement that the year will bring, but also on the 25-year journey that many of us have shared together.

Yup! I started sportEX medicine 25 years ago, all the way back in 1999, and the next April issue will be our 100th issue, quite a milestone when so many other publishers have fallen by the wayside during that time.

It's been a tapestry of shared stories, with the experience of enduring Covid together being one that will particularly stick out in my memory!

In June last year, as most of you will know, I had to make arguably the hardest professional decision of my life, to completely shut down my old content platform and ask my customers to continue supporting me while I rebuilt it from scratch.

I was close to shutting down the whole business if I’m honest.

Three things kept me going: 1. I couldn’t let the last 25 years of total and utter dedication result in nothing.

2. I felt at long last I had exactly the knowledge and experience I needed to create the perfect physical therapy marketing platform.

3. I couldn’t let you guys down or betray your confidence in me.

Your trust, support and motivation has been the cornerstone of both mine and Co-Kinetic's growth, particularly in the last 6 months, but also over the last 25 years, and that’s something I simply cannot express enough gratitude for.

And over the last 6 months, with this continued support, my developer and I have thrown ourselves into building you Co-Kinetic 2.0. It's more than a platform; it's our collective leap into the future of physical therapy marketing – a future that I promised to shape with you.

The significance of the timing is not lost on me, the fact that we are launching this new platform just as we enter our 25th year of business. It feels like someone, somewhere, always had a plan!

Your voice has quite literally been the architect of this platform. Every feature, from the content creation and the technology development has been built to streamline your efforts and deliver a massive bang for its buck. It’s my attempt at giving the small business ‘David’s’ the chance of a fair fight against the big business ‘Goliaths’, who traditionally dominate the game of marketing.

I wanted to build a content and technology solution which puts the human connection right back into the heart of physical therapy, and which shows you how to execute a marketing strategy that’s not only effective but is also one that you can be proud of.

So, as I roll out Co-Kinetic 2.0, please come and explore what we’ve built. It’s only with your support that I will be able to keep growing this solution going forward. Co-Kinetic 2.0 is ready for you, and together, we're ready for the future.

Here’s to a thrilling 2024.

Very warm wishes

what’s inside PRACTICAL

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INTRODUCING CO-KINETIC 2.0.

A COMPREHENSIVE MARKETING PLATFORM FOR PHYSICAL THERAPISTS

JOURNAL WATCH

12-13

CLINIC POSTERS

14-18 WHAT IS FIBROMYALGIA? THE SAGA CONTINUES

19-26 FIBROMYALGIA? AN UPDATE ON DIAGNOSTIC TOOLS AND NONPHARMACOLOGICAL MANAGEMENT

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

TECHNICAL is published by Centor Publishing Ltd 88 Nelson Road Wimbledon, SW19 1HX, UK https://Co-Kinetic.com

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LONG JANUARY 2024 ISSUE 99 ISSN 2397-138X

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DISCLAIMER While every effort has been made to ensure that all information and data in this magazine is correct and compatible with national standards generally accepted at the time of publication, this magazine and any articles published in it are intended as general guidance and information for use by healthcare professionals only, and should not be relied upon as a basis for planning individual medical care or as a substitute for specialist medical advice in each individual case. To the extent permissible by law, the publisher, editors and contributors to this magazine accept no liability to any person for any loss, injury or damage howsoever incurred (including by negligence) as a consequence, whether directly or indirectly, of the use by any person of any of the contents of the magazine.

Copyright subsists in all material in the publication. Centor Publishing Limited consents to certain features contained in this magazine marked (*) being copied for personal use or information only (including distribution to appropriate patients) provided a full reference to the source is shown. No other unauthorised reproduction, transmission or storage in any electronic retrieval system is permitted of any material contained in this publication in any form.

The publishers give no endorsement for and accept no liability (howsoever arising) in connection with the supply or use of any goods or services purchased as a result of any advertisement appearing in this magazine.

CLICK ON RESEARCH TITLES TO GO TO ABSTRACT

EFFECTS OF OPEN EXERCISE INTERVENTIONS ON COGNITIVE FUNCTIONS IN HEALTHY POPULATIONS: A SYSTEMATIC REVIEW AND META-ANALYSIS. Zhang M, Jia J, Yang Y et al.

Ageing Research Reviews 2023;92:102116 The data for this study came from a search of PubMed and the Web of Science. It unearthed 54 randomised controlled trials which examined the effects of FITT-VP variables on five cognitive domains: global cognition, executive function, memory, attention, and information processing. FITT-VP principles are exercise frequency (how often), intensity (difficulty), time (duration of each bout of exercise), type (of exercise), volume (total amount of exercise per intervention), and progression (change in difficulty in an exercise programme).

Moderation analyses assessed the effects by age and by each exercise variable. Exercise benefitted overall cognition and all sub cognitive domains.

Aerobic and resistance exercise showed the greatest benefits on global cognition and executive function respectively, whereas mind-body exercise benefitted memory. Among all populations, older adults showed the greatest benefits of exercise on global cognition, executive function, and memory compared with controls.

Co-Kinetic comment

Chronic exercise intervention is now called a non-pharmacological therapy. Pretentious? Whatever you call it, to exercise is smart and it makes you smarter.

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= OPEN ACCESS

THE IMPACT OF SPORT HYPNOSIS ON VOLLEYBALL ATHLETE PERFORMANCE: AN EMPIRICAL STUDY. Hasyim AH, Amirzan, Muhammad et al. Journal Sport Area 2023;8(3):360–370 This study used an experimental approach to investigate the effect of hypnosis training on the handling of mental factors in 20 volleyball players (aged 15–18 years) from clubs affiliated to the Indonesian Volleyball Federation. It used a one-group pretest-posttest design. Players were given a playing skills test from the American Association for Health, Physical Education, Recreation, and Dance including four test items, namely volleyball, service, passing, and set-up, before and after an intervention of sports hypnosis which is described as a cutting-edge discovery and development in the world of hypnosis. It is a form of awake hypnosis determined by mental training procedures based on three combined techniques: open-eyed hypnosis, traditional closed-eyed hypnosis, and self-hypnosis.

The overall result was that hypnosis was found to improve athletes’ volleyball playing skills.

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Co-Kinetic comment

I will click my fingers and you are back in the room.

Seriously, the idea of exploring hypnosis as a performance enhancer is a great one. Sadly this paper is big on statistics and low on reproducibility. To find out more about sports hypnosis you have to go to one of the cited papers: Straub WF, Bowman JJ. A review of the development of sport hypnosis as a performance enhancement method for athletes. Journal of Psychology & Clinical Psychiatry 2016;6(6):00378 https://bit.ly/4a1cBvg. Even that is a bit vague stating that the definition of hypnosis depends on the hypnotist but according to the American Psychological Association’s Div. 30 (Society of Psychological Hypnosis), “hypnosis is a procedure during which a health professional or researcher suggests while treating someone, that he or she experience changes in sensations, perceptions, thoughts or behaviour”. When it comes to defining sports hypnosis there is a similar controversy. Psychologists seem to favour cognitive and behaviour definitions; however, exercise and sport scientists present a more applied or coach-oriented definition. The bottom line is it is hypnosis directed towards improving sports performance.

RESISTANCE EXERCISE LOWERS BLOOD PRESSURE AND IMPROVES VASCULAR ENDOTHELIAL FUNCTION IN INDIVIDUALS WITH ELEVATED BLOOD PRESSURE OR STAGE I HYPERTENSION. Bank NF, Rogers EM, Stanhewicz AE et al. American Journal of Physiology-Heart and Circulatory Physiology 2023 doi: 10.1152/ajpheart.00386.2023 The purpose of this study was to examine the effect of a 9-week resistance exercise training (RET) plan for individuals with high blood pressure (BP).

Twenty-six adults (54±6 years old; 16 females, 10 males) engaged in either 9 weeks of 3 days/ week RET (n =13) or a non-exercise control (CON; n =13). Pre- and post-intervention measures included peripheral and central systolic and diastolic BP. The results showed that RET caused significant reductions in both BP measurements.

Co-Kinetic comment

There is a lot more information in this paper about carotidfemoral pulse wave velocity, cardiovagal baroreflex sensitivity cardiac output, total peripheral resistance, heart rate variability, and C-reactive protein, if such details are your thing. For the rest of us the headline result will suffice. Resistance training lowers BP, which according to the GOV.UK website kills 75,000 people in the UK and according to the USA Centres for Disease Control and Prevention nearly 700,000 in America per year.

Co-Kinetic Journal 2024;99(January):4-8

RESEARCH INTO PRACTICE

Journal Watch Physical Therapy

HAMSTRING INJURY TREATMENTS AND MANAGEMENT IN ATHLETES: A SYSTEMATIC REVIEW OF THE CURRENT LITERATURE. Poursalehian M, Lotfi M, Zafarmandi S et al. JBJS Reviews 2023;11(11):e23.00161

Scopus, PubMed, Web of Science and Embase were searched to identify studies evaluating any treatment option for the management of hamstring injuries in athletes. Eligible studies were appraised for quality using Joanna Briggs Institute and risk of bias 2 tools. A total of 30 studies with 1195 participants were included.

Of the reviewed studies, treatments varied from aggressive rehabilitation, platelet-rich plasma (PRP) injections,

manual techniques and various exercise protocols to modalities such as high-power laser and non-steroidal anti-inflammatory drugs. Evidence suggested benefits from treatments such as extensive muscle lengthening during eccentric actions, progressive agility, and trunk stabilisation. PRP injections produced mixed results regarding return to sport and reinjury rates. Stretching exercises, sometimes combined with cryotherapy, showed benefits.

EFFECTIVENESS OF MANUAL THERAPY AND SPECIFIC EXERCISE CONDITIONING ON CLINICAL OUTCOME MEASURES AMONG PARTICIPANTS WITH SUBACROMIAL IMPINGEMENT SYNDROME. Kanthanathan S, Rajappa S, Subhashini AS et al. Critical Reviews in Physical and Rehabilitation Medicine 2023;35(3):1–18 This study aimed to investigate the combined short-term effect of manual therapy and eccentric exercise conditioning on clinical outcomes in the acute phase of subacromial impingement syndrome (SIS). A total of 126 subjects with SIS of 3 months’ duration were divided into two groups of 63 participants each.

The experimental group received manual therapy and eccentric exercise; the control group received concentric exercise, spread over 3 weeks, followed by a home programme for another 9 weeks.

Pain intensity, shoulder elevation range, abductor and external rotator muscle strength, and regional function were obtained at baseline, after 10 sessions of treatment, and follow-up at 12 weeks.

After the first session and by the end of 3 weeks, a global rating of change questionnaire was administered to determine self-perceived improvement.

The results showed that there were statistically significant differences in both groups; all outcomes improved after treatment and during follow-up. However, on intergroup analysis, significant improvement was observed with pain intensity, elevation ROM, and external rotator muscle strength after treatment, and external rotator muscle strength and SPADI score at follow-up by 12 weeks in the experimental group. The between-group comparison revealed that pain reduction by 3 weeks, external rotator muscle strength by 3 and 12 weeks, had resulted in a large effect size.

Co-Kinetic comment

Exercise works but manual therapy is the icing on the cake.

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Co-Kinetic comment

It is nice to have a review of treatments for common injuries but what they all tend to show is that there is no one size fits all. Nor is there are magic bullet. This one, however, does give a thumbs up to rest, ice, compression and elevation in the acute stage and muscle strengthening and flexibility in later stages.

IMMEDIATE EFFECTS OF KINESIO-TAPING AND JOINT MOBILISATION ON SHOULDER IN OVER-HEAD ATHLETES WITH GLENOHUMERAL INTERNAL ROTATION DEFICIT. Singh A, Makhijani Y, Sharma M et al. Central European Journal of Sport Sciences and Medicine 2023;42:85–94 OPEN The purpose of this study was to compare efficacy of Kinesio taping (K-taping) and joint mobilisation as immediate interventions for treating athletes with glenohumeral internal rotation deficit (GIRD). Thirty-two asymptomatic players were recruited from basketball, volleyball and handball who had a loss of shoulder internal rotation ROM (IR ROM) of 10° or more on their dominant compared to non-dominant side.

They were randomly assigned to one of two groups: K-taping (n=16) or joint mobilisation (n=16). Participants in the taping group were treated with K-tape for inhibition of the external rotators of the shoulder and participants in the joint mobilisation group were treated with grade 4 Maitland’s mobilisation technique for

increasing GIRD. Shoulder internal and external ROM were measured before and after the intervention. Both the methods produced significant improvement in IR ROM. No significant change was found on comparing both the groups. There were no significant differences between the results of the three sports.

Co-Kinetic comment

Both are equally effective in improving IR ROM, now all you have to do is fix the underlying muscle imbalance.

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Although the title suggests a common practice in ice hockey, many other sports indulge in something similar, such as the morning shoot-around in basketball and baseball. The aim of this opinion piece is to summarise the pros and cons to help coaches decide if it is worth it.

There are various reasons given as to why it started. There is a suggestion that players from the Toronto Maple Leafs wanted to test the quality of skate sharpening or a much more likely explanation that the all-conquering Soviet team of the 1970s did it, and then the Philadelphia Flyers did it the year they won the league so everyone followed suit, making it an accepted ritual based on superstition. Then in 2017, the Columbus Blue Jackets went on a 17-game winning streak without doing it, which resulted in a lot of coaches having a rethink.

Many coaches were using it for lastminute tactical input, but the downside is the energy expended. Another reason given is for muscle activation pre-game but this does not come with

DEBUNKING THE MYTH OF MORNING SKATE ON GAME DAY. Brocherie F, Perez J. Frontiers in Sports and Active Living 2023;5:1284613 a backing of scientific evidence given the time delay between the morning activity and game time. However, there is scientific data about the workload.

A study found that the morning skates amounted to 34% of the training load in the American Hockey League which is a feeder league to the NHL. Circadian rhythm and its biological and hormonal responses have also been studied but the variance in individual responses is too great to come to a consensus. An argument against the morning skate is that players can get extra sleep. However, that is also subject to individual difference, although there is some evidence for improved performance in basketball when players get more sleep.

The article concludes by giving a number of points to consider when making a decision about a morning activity or not. It includes a decision-making tree (an algorithm to

Europeans). Consider: l competition calendar and density of schedule; l previous days (training or not, travel or not) and game time; l players’ chronotype, habits and preferences; l individual on-ice playing time/workload (eg. low vs high playing time players) and status (fatigued, injured); l technical staff needs (eg. opponent-specific tactical preparation); and l off-ice/court alternatives (eg. meetings, video sessions, resistance or (resisted) sprinting exercise).

Co-Kinetic comment

This is a thought-provoking piece and a must-read for people whose sports do a game day morning activity. The bottom line is that there is no confirming science either way but many players – including basketball legend Michael Jordan – swear by superstitious behaviour so if it works for your players, carry on.

IS TEAM-LEVEL INJURY ANALYSIS GIVING US THE FULL STORY? EXPLORING A PLAYER-SPECIFIC APPROACH TO ANALYSING INJURIES. Bitchell L, Stiles VH, Robinson G et al. International Journal of Performance Analysis in Sport 2023 DOI: 10.1080/24748668.2023.2275940 The starting point for this study is that injury rates within Rugby Union are typically represented as the teamlevel injury incidence, encouraging comparisons between research and accommodating the evaluation of the effectiveness of injury management strategies aimed at reducing teambased injury rates. This is usually done by calculating the team-level injury incidence by summing the injuries sustained by each player to produce a total number of injuries for the whole team, and then dividing by a standardised team-based estimate of match exposure (ie. 15 players exposed for 80 minutes). However, this recommendation is unlikely to account for differences in match exposure between players owing to replacements, head injury assessments and sin bins. Player-specific differences in exposure could consequently influence the analysis of team-level exposure and, in turn, the calculation of team-level injury incidence.

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So, this study looked at team-level and player-specific injury incidence using different match exposure calculations. Match time-loss injuries and match exposure using Global Positioning System (GPS) was collected across three seasons (2016/17– 2018/19). Team-level and player-specific injury incidence were calculated using standard match length and GPS exposure. The probability of one or two or more injuries was calculated using the Poisson probability. A total of 487 injuries were sustained by 111 players.

Team-level injury incidence across three seasons using standard match length was lower than the injury incidence using GPS (59.5 vs 95.7 injuries/1000 match hours, respectively).

More than 84% of players fell outside the 95% confidence intervals for the team-level injury incidence each season.

When exposed to a lower number of match hours, at the same incidence the probability of only one injury was higher. When exposed to a higher

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number of match hours, at the same incidence the probability of sustaining two or more injuries was higher.

Therefore the conclusion was that the standard match length underestimates the team-level injury incidence if the entire player cohort has not provided consent.

In addition, team-level injury incidence is a poor representation of the underlying injury incidence of players.

Co-Kinetic comment

The phrase, “Lies, damned lies, and statistics” was popularised by the author Mark Twain who wrote the Adventures of Tom Sawyer and Huckleberry Finn although he attributed it to the British Prime Minister Benjamin Disraeli. It is as relevant now as it was in the 1800s. It means treat anything with numbers and percentages with a pinch of salt, a phrase that dates back to Roman times which shows that people have been trying to pull the wool over our eyes for a very long time (and that’s another idiom about deception).

Co-Kinetic Journal 2024;99(January):4-8

RESEARCH INTO PRACTICE

THE ASSESSMENT OF PLANTAR PRESSURE DISTRIBUTION IN PLANTAR FASCIITIS AND ITS RELATIONSHIP WITH TREATMENT SUCCESS AND FASCIAL THICKNESS. Ulusoy A, Cerrahoğlu L, Örgüç Ş. Kastamonu Medical Journal 2023;3(3):139–143 This study starts with the premise that patients with plantar fasciitis modify their gait patterns because of the heel pain. It aimed to investigate whether there was a significant difference in the plantar pressure distribution after pain relief owing to successful treatment response in plantar fasciitis.

Forty-nine patients aged >18 years with a history of unilateral plantar fasciitis for at least 6 months were included in the study. The diagnostic criteria included pain in the first step of the heel in the morning, worsening pain with inactivity, prolonged activity and loading, tenderness at the insertion of the proximal plantar fascia, a positive windlass test and a negative tarsal tunnel test. An MRI was performed before and 1 month after treatment.

The maximum thickness of the proximal plantar fascia where it attaches to the calcaneus was measured using electronic callipers on fluid-sensitive MRI sequences in the sagittal and coronal planes.

Twenty-three physical therapists were interviewed in the Netherlands from March to May 2021. Two researchers analysed the interviews and derived relevant codes. After an iterative process of comparing, analysing, conceptualising and discussing the codes, themes were identified through a thematic framework, and illustrated with meaningful quotations. Three major themes were identified: Humane, Tacit and Responsive. It appeared that patient values unconsciously play a major role in daily practice and are associated with humanity, not technical or procedural aspects of the encounter. Responsive denotes that all values require interaction in which aligning with the individual patient forms the basis of treatment. Barriers for being responsive are identified as subthemes: Choices, Trust, Diverseness and Boundaries.

Co-Kinetic.com

Participants were randomly assigned to receive different treatment regimens: 3 sessions of extracorporeal shock wave therapy involving 2000 shocks, 15 sessions of laser therapy at 8J/cm² with a wavelength of 830nm, or 15 sessions of continuous ultrasound therapy (US) at a frequency of 1mHz and intensity of 2W/cm². In addition, all participants were instructed to perform a series of home exercises, including self-mobilisation and stretching of the plantar fascia, calf stretching, ankle eversion, and strengthening exercises for plantar flexion and dorsiflexion using resistance bands.

At the 1-month follow-up, participants were divided into two groups according to their successful or poor response to the treatment regardless of treatment type they received. The plantar pressures of the cases were measured in static mode while standing and dynamic mode while walking.

A total of 44 subjects successfully completed the study. In group 1,

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characterised by successful responders, there were 24 subjects, whereas group 2, comprising poor responders, included 20 subjects. After treatment in group 1, the dynamic plantar pressure on the medial forefoot showed a significant increase. However, there was no significant change in plantar pressure in the poor responders. Plantar fascia thickness correlated positively with thumb dynamic pressures.

Co-Kinetic comment

The results suggest that fascial thickness and dynamic forefoot plantar pressures may be related. The authors suggest that medial forefoot plantar pressures increased as a result of gait restoration with significant pain reduction in adults. This adds to the body of knowledge about plantar fascia but it doesn’t help much clinically.

PHYSICAL THERAPISTS’ PERSPECTIVES OF PATIENT VALUES AND THEIR PLACE IN CLINICAL PRACTICE: A QUALITATIVE STUDY. Bastemeijer CM, van Ewijk JP, Hazelzet JA et al. Brazilian Journal of Physical Therapy 2023;27(5):100552

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Co-Kinetic comment

What that means in English is that physical therapists naturally take patients’ values into consideration and that treatment guidelines are at odds with the individual nature of the patients. One does wonder if by the time the responses have been compared, analysed and conceptualised there is anything left of what people actually said. Another thought is how come a study of Dutch therapists written in English ends up in the Brazilian Journal of Physical Therapy?

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CHARACTERISTICS OF SPORTS-RELATED INJURIES PRESENTING TO A PAEDIATRIC EMERGENCY DEPARTMENT. Nichols JC, Shah N, Jones A et al. Southern Medical Journal 2023;116(11):883–887 This was a retrospective review of sports injuries presenting during the course of 1 year (2019) to the Emergency Department (ED) of Benjamin Russell Hospital for Children, a large academic children’s hospital in Alabama, USA. Inclusion criteria focused on patients 18 years old and younger whose ED visit resulted from active participation in a sport. A total of 1333 injuries seen by the ED were sports injuries. Most commonly, these injuries were associated with American football (43%), basketball (36%), soccer (11%), or baseball (8%). Considering sports-related injuries, 428 (32%) patients were younger

than 12 years old and 905 (68%) were 12 years old and older. School was the most common location for sports injuries (28%). When comparing injuries by age groups (younger than 12 vs 12 and older), football and baseball injuries were more common in those younger than 12 years (53% vs 38%), whereas basketball and soccer injuries were more common in those 12 years and older (43% vs 22%).

When comparing injuries by sex, football and baseball injuries were more common in males (49% vs 6%), whereas basketball and soccer injuries were more common in females (59% vs 32%).

Co-Kinetic comment

This sort of epidemiological study is useful to point people involved in sport to where they should direct their attention to prevent injuries. The most valid point is that the authors feel that there are fewer injuries in sports that have previously been under scrutiny, especially those considered to be higher risk, particularly for concussive injuries. It means that preventive measures are working; now we need to find the time and energy to include the less-high-risk sports.

This is a case study of a 24-year-old Latin American male professional soccer player who sustained a blunt traumatic left eye injury when a soccer ball hit him during a match. He reported immediate monocular vision loss and attempted to continue to play for 30 minutes.

Because of his vision loss, however, he was unable to continue playing. He reported improvement in the superior aspect of the visual field in 1 hour, but his inferior visual field deficit did not improve for 24 hours. He was initially seen in the Emergency Department (ED) immediately after the game and evaluated by an ophthalmologist. He was diagnosed with traumatic iritis and commotio retinae. He was treated with ophthalmic prednisolone and cyclopentolate. He suffered 5 days of blurred vision. On day 6, he reported no visual symptoms or visual disturbances. He was cleared and returned to play 14 days after his injury, scoring goals in each of his first two matches post-injury.

The study goes on to discuss epidemiology. Basketball has the highest rate of sports-related ocular trauma but airsoft and paintball, baseball, boxing, hockey, lacrosse, martial arts, racquetball and softball are all classed as high risk. At the opposite end of the risk spectrum, cycling, swimming, diving, snow skiing and water skiing are low risk with gymnastics, running and track and field considered as eye safe. The American Academy of Paediatrics, the American Academy 8

IT’S IN THE GAME: A REVIEW OF NEUROLOGICAL LESIONS ASSOCIATED WITH SPORTS. Pedrosa M, Martins B, Araújo R. Journal of the Neurological Sciences 2023;455:122803 The data for this study came from a search of the PubMed and Scopus databases. Sports included had to be those recognised by the International Olympic Committee. Chronic traumatic encephalopathy and other neurodegenerative disorders were not included.

A total of 292 studies were included concerning 33 different sports. The most reported neurological injury was damage to the peripheral nervous system. Traumatic injuries were also extensively reported, including cerebral haemorrhage and arterial dissections. Non-traumatic life-threatening events are infrequent but may also occur, eg. posterior reversible encephalopathy syndrome, cerebral venous thrombosis, and arterial dissections. Some conditions were predominantly reported in specific sports, eg. yips in baseball and golf, raising the possibility of a common pathophysiology. Spinal cord infarction due to fibrocartilaginous embolism was reported in several sports associated with minor trauma.

Co-Kinetic comment

Although neurological injury in sport is uncommon (the authors cite an incidence of approximately 2.5%) and they are mostly benign and transient, some are really scary. It is these you have to be prepared for. The exclusion of chronic traumatic encephalopathy is understandable given that it only shows up in a post-mortem examination, but it is very much a current hot topic with a large number of footballers and rugby players suing their governing bodies.

BLUNT OCULAR TRAUMA IN SPORT. Daniel AD, Achar S, Parikh M. Current Sports Medicine Reports 2023;22(11):375–379

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of Ophthalmology, and the American Academy of Optometry strongly recommend the use of appropriate eye protection in sports with a high risk of ocular injury.

Pitch-side Physicians should consider having a standard ‘eye kit’ in their medical bag for evaluation and management of ocular injuries. Common components should include an ophthalmoscope, visual acuity chart, light source with cobalt blue light, cotton swabs, eye shield, sterile saline, contact lens remover, and fluorescein dye.

Injuries are commonly classified as closed-globe injuries, open-penetrating-globe injuries, and radiation injuries. Of sports-related ocular injuries, 80.1% are monocular. Blunt trauma usually results in closed-globe injuries.

Co-Kinetic comment

Basically the eye was swollen and it was treated with an anti-inflammatory and a drug that widens the pupils. It is the epidemiology section of the study that is an eye opener. There is a lot of it about. Telling us he scored in on his return to play is a nice touch.

Co-Kinetic Journal 2024;99(January):4-8

RESEARCH INTO PRACTICE

Journal Watch Manual Therapy

A total of 36 patients were divided into three groups of 12. They were between 30–50 years old, were diabetic and had symptoms that affected activities of daily living that had lasted for more than 3 months.

Group A received Maitland grade 3 or 4 mobilisations dependant on the patient’s tolerance for 3 sets of 10 repetitions, with 1 minute rest between sets, 3 times a week for 4 weeks.

Group B received similar but at grades 1 or 2 plus passive proprioceptive neuromuscular facilitation patterns in a supine position during the final 3 minutes of each treatment session while operating in

COMPARISON OF EFFECTIVENESS OF MAITLAND’S MOBILIZATIONS AT END-RANGE VERSUS WITHIN PAIN-FREE JOINT RANGE OF MOVEMENT IN TREATMENT OF PATIENTS WITH FROZEN SHOULDER RCT. Khan Z, Akmal F, Asif M et al. British Journal of Multidisciplinary and Advanced Studies 2023;4(5):100–126

the pain-free zone and 2 minutes of Codman pendulum movements. Each of these exercises was done for 3 sets of 10 reps with a minute between sets.

Group C received an exercise regimen of wand, pulley, finger ladder, and Codman’s pendulum activities, as well as active and active aided ROM exercises, isometric exercises, and pectoral stretching as a home exercise programme at least twice each day.

The results showed that the greatest improvement in post-intervention

SPORTS MASSAGE THERAPY ON THE REDUCTION OF DELAYED ONSET MUSCLE SORENESS: A SYSTEMATIC REVIEW AND META ANALYSIS. Yanitamara DL, Perdana SS, Azizah AN. Malahayati International Journal of Nursing and Health Science 2023;6(4) doi: 10.33024/minh.

OPEN v6i4.12370 The aim of this study was to determine whether sports massage can reduce delayed onset muscle soreness (DOMS) and provide recovery effects. PubMed and ScienceDirect were searched using a PICO strategy.

Population: people with DOMS. Intervention: sport massage. Comparison: control treatment. Outcome: pain reduction. Keywords in this article search were “DOMS” AND “Recovery” AND “Sport massage.” The inclusion criteria in this study were full-text articles with a randomised control trial research design. Eight articles were rereviewed.

The results showed that sports massage could not reduce DOMS effectively and significantly.

Co-Kinetic comment

Never let it be said that we only report studies that are positive towards our favourite techniques. This one isn’t. The fact that it is the opposite finding to a load of previous studies does not affect our neutral stance.

Co-Kinetic.com

ROM was in group A, the high grade mobilisation group, although the ROM of all groups improved.

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Co-Kinetic comment

Manual therapy fans can take this as a win but the study is short on important details such as the exact exercise protocol and the directions of the mobilisation describing it only as “the therapist adjusts the direction or intensity of mobilization if pain negatively affects how the procedures are carried out”, which is odd given that they devote pages to the statistical review of the data.

REVITALIZING PERFORMANCE: EXPLORING THE INFLUENCE OF SPORTS MASSAGE AND PNF STRETCHING ON LACTIC ACID RECOVERY IN FEMALES FUTSAL ATHLETES. Zubaida I, Dhani DP, Anugrah SM et al. Journal Sport Area 2023;8(3):310–317 Twenty athletes aged 18 or 19 years were OPEN divided into two groups (n=10 for each group). Both were subjected to a 30-minute anaerobic exercise session followed by either a 15-minute sports massage session or a similar length session of proprioceptive neuromuscular facilitation (PNF) stretching. Blood samples were taken before and after the exercise and the interventions. The results showed an increase in lactic acid after anaerobic exercise in both groups. The massage group experienced a significant decrease in lactic acid compared to the PNF group which did not experience a significant decrease.

Co-Kinetic comment

This paper is short on detail. There is no description of the massage or PNF protocol. The massage did remove lactic acid but this was proved years ago by earlier research. However, other studies have shown that graded exercise in the form of a cool down removes lactic acid much quicker than massage.

Perhaps the last word on this should go to Albert Moraska, one of the leading researchers in the field of massage, who stated in a 2011 paper, “from a simple practical standpoint, lactate clearance after massage does not warrant investigation.”

9

The aim of this study was to examine whether the use of the foam roller massager for lower limb muscles affects VEGF-A and FGF-2 levels in young men. A total of 60 healthy military recruits were randomly divided into an experimental group (n=40) who performed selfmassage of the lower limbs using a foam roller and a control group (n=20) who did not perform massage.

Massage was applied to lower limb muscles 4 times a week for 7 weeks using a hard irregular ridged roller 33cm in length and 14cm in diameter.

The sequence was massage of the posterior aspect of the lower leg (triceps surae muscle), massage of the posterior aspect of the thigh (biceps femoris muscle, semitendinosus muscle, semimembranosus muscle), massage of the medial aspect of the thigh (adductor longus, brevis and magnus), massage of the lateral aspect

EFFECTS OF THE FOAM MASSAGE ROLLER ON VEGF-A AND FGF-2 BLOOD LEVELS IN YOUNG MEN. Roslanowski A, Partynska A, Ratajczak-Wielgomas K et al. in vivo 2023;37(5):2057–2069 of the thigh (biceps femoris and quadriceps femoris muscles), massage of the gluteal region (gluteus maximus muscle), massage of the anterior aspect of the thigh (quadriceps femoris muscle) performed on each leg separately for 9 minutes.

Blood was collected before the experiment and after weeks 1, 3, 5 and 7.

The results showed that there was a significant increase in VEGF-A serum levels in the massage group compared to the control. No significant changes in serum FGF-2 levels were found.

A COMPARATIVE STUDY OF THE EFFICACY OF INSTRUMENT-ASSISTED SOFT TISSUE MOBILISATION AND MASSAGE TECHNIQUES IN PATIENTS WITH PATELLOFEMORAL JOINT PAIN. Liu Y, Wang Y. Frontiers in Medicine 2023;10:1305733 This study set out to compare the clinical efficacy of instrument-assisted soft tissue mobilisation (IASTM) and manipulative therapy. It is a randomised double-blind controlled intervention design whose subjects had been diagnosed with patellofemoral pain syndrome.

The intervention group (n=13) underwent IASTM treatment, while the control group (n=12) received Tui na manipulation therapy for twice a week, with a 2–3 day interval between each session, for a total of 4 weeks.

There was no significant difference in the basic information of the two intervention groups. After the first treatment and 4 weeks of treatment, the Lysholm knee function score in both groups significantly improved indicating that both interventions can improve the function of patients’ lower limbs. The score was greater in the IASTM group after 4 weeks of treatment, indicating that its improvement in functional performance is superior. Both groups 10

OPEN

Co-Kinetic comment

Although the massage protocol is well described, there is no mention of what the control group did other than to say no massage. Vascular endothelial growth factor A (VEGF-A) stimulates a range of actions that promote angiogenesis – and thus muscle regeneration – so increasing it is a good thing.

Fibroblast growth factor 2 (FGF-2) is involved in cell growth and tissue repair.

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showed significant improvement in knee joint pain after the first treatment and 4 weeks of treatment, with the IASTM group having a lower VAS pain scale and better pain improvement after 4 weeks of treatment. The strength of the two intervention groups significantly increased after the maximum isometric muscle strength test of the lower limb extensor muscles before and after four weeks of treatment. On a modified Thomas test, the extension angle, deviation angle and hip abduction angle of the tested legs in the two intervention groups were significantly reduced indicating an improvement in lower limb joint mobility.

Co-Kinetic comment

Tui na manipulation is an ancient Chinese body work system which incorporates both a philosophy of energy imbalance and manual pressure techniques using similar points to acupuncture along with rubbing and kneading of the tissue. IASTM is often used to treat musculoskeletal conditions by using tools to apply friction type techniques across the skin. In this study both interventions work, with IASTM coming out better in the short- to medium-term post-trial period. Give them a go, the paper is detailed so you can follow the treatment plan but don’t spend a fortune on tools. The things in your cutlery draw will work just as well.

Co-Kinetic Journal 2024;99(January):9-11

RESEARCH INTO PRACTICE

This was a case control study; ‘cases’ included patients with acute neurological injury who received massage therapy at least once during their admission to the University of California—San Diego (UCSD) Health Medical Center. Any adult patient (age >18 years) with acute brain or neurological injury (including ischemic stroke, intracerebral haemorrhage, spinal cord injury, subarachnoid hemorrhage, traumatic brain injury, brain abscess and status epilepticus) who did not meet exclusion criteria were offered massage therapy at no cost to the patient or family. Specific exclusion criteria included: (1) clinically suspected intracranial hypertension without intracranial pressure monitor in place; (2) cervical instability; (3) pregnancy; (4) hemodynamic instability requiring active titration of pressors; (5) patient agitation where safety of therapists could not be assured; (6) incarceration with inability to remove shackles; and (7) clinical or radiographic instability of the primary neurological process.

Treatment modalities were at the discretion of the massage therapist and included passive and active joint mobilisation, acupressure point activation, reflexology and Tui na.

Massage therapy was variable in its application and included palm circles, gentle rubbing and Swedish massage to the back, shoulders, arms, thighs, legs and feet. The passive and active joint mobilisation was used on the wrists,

MASSAGE THERAPY MAY BE SAFE AND REDUCE PAIN IN CRITICALLY ILL PATIENTS WITH ACUTE NEUROLOGICAL INJURY: A CASE CONTROL STUDY. Kazer M, Chang VA, Pietrykowski J et al. International Journal of Therapeutic Massage & Bodywork 2023;16(3):3–9 hands, fingers, ankles, feet and toes.

Reflexology included thumb walk on the spine and head reflexes of the big toes. Tui na kneading was used over the upper and lower extremities. Sessions lasted between 10 and 30 minutes and were tailored to the patient’s level of comfort and mobilisation ability. Clinical outcomes extracted included pre- and post-massage vital signs (eg. heart rate, mean arterial pressure) with pain score. These values were measured immediately before and immediately following massage therapy. Additional clinical information extracted included delirium incidence (and if delirious, longest continuous duration of delirium during hospitalisation), ICU length of stay (LOS), hospital LOS, in-hospital adverse (eg. pneumonia) and serious adverse (eg. cardiac arrest, death) events, and discharge destination (ie. home, long-term acute care, rehabilitation, skilled nursing facility, or death/hospice). In patients with intracranial pressure monitors, preand post-massage measurements of intracranial pressure were noted.

‘Control’ patients (patients admitted

to the neurocritical care service who did not receive massage therapy) were matched to the intervention group so that there were 21 pairs of patients.

The mean age of the cohort was 57 years (range, 28–85 years). Females represented 52.4%.

The results showed that there was a statistically significant reduction in pain scores among patients who received massage therapy. There was no statistical difference in hospital LOS, discharge destination, in-hospital mortality, adverse events, or incidence/ duration of delirium between patients who received massage therapy and those who did not. No adverse events were ascribed to the massage therapy when evaluated by blinded neurocritical care specialists.

OPEN

Co-Kinetic comment

This is a major finding for massage in an acute hospital setting.

It adds to other research that confirms that if nothing else, soft tissue work reduces pain in various populations. Sadly it is almost as if the medical profession doesn’t believe it, hence the “may be safe and reduce pain”. There is no “may” about it. It does reduce pain and it is safe because no adverse events were reported.

EFFECTIVENESS OF NEURO MOBILISATION ON PAIN, RANGE OF MOTION, MUSCLE ENDURANCE AND DISABILITY IN CERVICAL RADICULOPATHY: - A SYSTEMATIC REVIEW. Rafiq S, Zafar H, Gillani SA et al. Journal of the Pakistan Medical Association 2023;73(9):1857–1861 This is a systematic review of the usual medical databases for studies published between 2012 and 2022 looking for randomised controlled trials involving patients diagnosed with cervical radiculopathy. The diagnosis was based on clinical criteria, such as pain, numbness, tingling sensation, weakness, or through the Spurling’s test. Outcome measures included at least one of assessment of neural mobilisation, pain, ROM, muscle endurance and disability.

Studies comprising any diagnosis other than cervical radiculopathy and those using any treatment technique Co-Kinetic.com

not related to physiotherapy were excluded. Methodology of the studies was assessed using the PEDro scale.

The initial search revealed 1563 studies of which 8 met all the criteria and were reviewed. Of these, 4 had a good overall quality score (6 or more on the PEDro scale), 3 had a moderate score (4–5) and 1 received a low score (<4). The conclusion was that no matter the approach or dosage used, manual therapy was successful in treating cervical radiculopathy symptoms in all investigations.

However, the greatest success came

from multimodal strategies that incorporate neural mobilisation treatment in the short term.

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Co-Kinetic comment

As so often with systematic reviews, the final comment is along the lines of more research is needed and/or the variation in methodology between the studies does not allow for comparison. In this one, the authors complain about (among other things) concealment of data, intention of treatments analysis, lack of comparison with baseline values, inadequate follow-up and variability, and poor blinding. One did not even mention the age of the subjects. Come on researchers, follow the PEDro guidelines or similar scales and don’t inflict any score under 6 on us.

11

STRUGGLING WITH FIBROMYALGIA?

(or know someone who is) Fact vs Fiction

F

ibromyalgia is a term you might have come across quite a few times, especially if you or someone you know experiences unexplained pain, fatigue and other symptoms. With so much information (and misinformation) floating around, it’s easy to get confused. One of the most common misconceptions is that fibromyalgia is an autoimmune disease. In this leaflet, we’ll break down what autoimmune diseases are, what current research says about fibromyalgia, and address some of the myths that often confuse the picture.

though many aspects remain under investigation.

One of the leading theories is that fibromyalgia is related to how the brain and spinal cord process pain signals. It’s like the volume knob on pain perception is turned up too high. So, things that shouldn’t hurt much (or at all) can feel quite painful to someone with fibromyalgia.

While some early studies explored the possibility of fibromyalgia being an autoimmune condition, most current research suggests otherwise. There’s no

evidence to show that the immune system attacks the body’s tissues in fibromyalgia as it does in autoimmune diseases. Moreover, fibromyalgia doesn’t cause the joint deformities or organ damage that many autoimmune diseases do.

However, it’s worth noting that fibromyalgia can coexist with autoimmune diseases. This overlap can sometimes lead to confusion in diagnosis and understanding. But it’s crucial to remember that having one doesn’t necessarily mean you have the other.

atural Treatm ents for Fibro myalgia A Holistic Ap proach

L

iving with fibrom yalgia can be conventional challenging.

While medicine offers some solutio individuals are ns, many turning toward complement s holistic approa their treatm ches to ent plans. This current treatm isn’t about replaci ents, but about ng your exploring additio can help to offer relief. nal avenues that Holistic treatm ents consider spirit, and emotio the whole person ns. body, mind, the holistic approa By understanding how everything connec ch aims to achieve and wellnes ts, the best possib s. le health

DIETARY CHAN GES: NOUR THE BODY ISHING TO MAN

Manual an d Massage Therapy fo r Fibromya L lgia

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What is Fibromyalgia?

The Saga Continues

Fibromyalgia is a condition that has, in the past, gone by several different names. Its aetiology and pathology have been poorly understood and its very existence has been questioned. Now, however, fibromyalgia seems to be accepted as a problem of pain processing. This article discusses the different components that contribute to central sensitisation to provide a better understanding of the current knowledge of the causes of fibromyalgia.

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

14

A

fter decades of research and debate, the enigma of fibromyalgia (FM) still prevails.

Gradually, acceptance of the validity of FM is growing; however, many gaps remain in the understanding of the condition’s aetiology, pathology and prognosis, which makes developing management protocols challenging.

Underdiagnosis, overdiagnosis and misdiagnosis are common. To avoid this diagnostic conundrum, guidelines suggest a comprehensive clinical assessment. Every chronic pain patient should be screened for chronic widespread pain (CWP) (defined as pain in four of five body regions). From there, those with CWP should be screened for the presence of additional major symptoms of FM, including unrefreshing sleep and fatigue. To consolidate the diagnosis of FM (or identify features that may point to some other condition) a complete medical (including drug) history and complete physical examination is mandatory in the evaluation of a patient with CWP (1*).

Owing to the lack of laboratory and other objective tests for FM, screening to rule out other diseases can be a step towards diagnosing

By Kathryn Thomas BSc MPhil FM. Diagnosis and screening tests are discussed in detail in the accompanying article “Fibromyalgia: An Update on Diagnostic Tools and Non-Pharmacological Management”.

FM as a stand-alone diagnosis is rare.

Many patients present with other overlapping chronic pain conditions or mental disorders. Understanding the severity of the patient’s FM will help direct treatment and inform the likely outcome for an individual patient (2*).

Fibromyalgia may be part of a larger metabolic deficiency in the serotoninergic system. However, in the absence of any diagnostic markers, this ‘invisible syndrome’ has been labelled variously neurasthenia, fibrositis, fibromyositis, psychogenic rheumatism, and now fibromyalgia. It is a disease defined entirely by its symptoms, which is why doubts remain, even to this day, as to whether it is a real clinical condition (3*).

Although the aetiology is still mysterious, advances in research have shown that alterations in pain

processing within the nervous system are likely to be causative.

Brain scans have shown increased neuronal excitation and amplification of pain signals. A current line of thinking proposes that FM may be a spectrum with peripheral pain at one end and centralised pain at the other (3*). However, because pain is an experience (ie. a perception) and not a ‘thing’ that can be processed,

CHRONIC WIDESPREAD PAIN, UNREFRESHING SLEEP AND FATIGUE ARE THE MAIN SYMPTOMS OF FIBROMYALGIA

Co-Kinetic Journal 2024;99(January):14-18

CLINICAL UPDATE

scientists continue to search for answers. Pathophysiological factors of FM continue to be the focus of much research; the hope is that better understanding in this area will guide more effective treatment.

So, what is your knowledge and understanding of what is happening in your FM patients? This article briefly tries to highlight the many physiological changes that could be affecting your patient.

Pathophysiology of Pain in FM Patients

FM appears to be a pain-processing problem. Patients become hypersensitive to pain, resulting in a constant hypervigilance to pain which is often associated with psychological problems (2*). FM is more common in women than men and is believed to be related to higher levels of anxiety and depression, altered behaviour in response to pain, altered central nervous system (CNS) input and hormonal effects related to the menstrual cycle (2*). Other factors that appear to be involved in the pathophysiology of FM are neuroendocrine factors, genetic predisposition, oxidative stress, and environmental and psychosocial changes.

Research by Varol et al. suggests a FM model where clinical sensoryrelated, psychological and psychophysical variables are connected, albeit in separate clusters (4). They support the psychobiological mechanisms driving FM as a nociplastic condition with a relevant role of sensitisation.

‘Nociplastic pain’ refers to “pain that arises from altered nociception despite no clear evidence of actual or threatened tissue damage, or evidence for disease or lesion, causing the activation of peripheral nociceptors of the somatosensory pathways resulting in pain” (5*). It is likely to be provoked by changes in nociceptive processing, possibly due to CNS activity modifications. FM patients often describe their pain as dull, deep or aching (traditional descriptors of nociceptive pain) or burning and tingling (usually defining neuropathic pain) (5*). However, as a hallmark of nociplastic pain, no clear evidence of Co-Kinetic.com

primary tissue damage exists, so how does a patient’s description of their pain reference a point of origin?

It can be assumed that some FM patients may develop small fibre neuropathy. This is not a case of a first pathological event, but rather because of the same pathophysiological mechanism underlying the syndrome.

This may be secondary to the development of hyperalgesia, allodynia or the abnormal wind-up of secondary pain, where patients display enhanced sensitivity to painful and nonpainful stimuli. This presentation tends to be the consequence of functional and morphological changes in the CNS, primarily in pain-processing structures in the brain. This is referred to as central sensitisation, possibly supported by glial activation as the result of neuroinflammatory triggers.

As suggested, other systems could also play a part in the pain patterns of FM patients, including autonomic nervous system (ANS) abnormalities and hypothalamic–pituitary–adrenal (HPA) axis dysfunction (5*).

Central Sensitisation (CS)

In FM, the most common alterations include dysfunctions in monoaminergic neurotransmission, leading to elevated levels of excitatory neurotransmitters, such as glutamate and substance P, and decreased levels of serotonin and norepinephrine in the spinal cord at the level of descending anti-nociceptive pathways. Other observations include dopamine dysregulation and altered activity of endogenous cerebral opioids.

Together this phenomenon seems to explain the central pathophysiology of FM (Fig. 1) (2*).

CS may be caused by increased nociceptive tonic supply in the spinal cord, which in turn may contribute to peripheral abnormalities. Peripheral pain generators have also been identified as possible contributors of FM. These can manifest as symptoms of cognitive impairment, chronic fatigue, sleep disturbances, intestinal irritability, interstitial cystitis and mood disorders in FM patients (2*).

Potential pain pathways relating to FM are explained in much greater detail in an article by Favretti et al. (5*).

PAIN Sensitization of the nociceptive fibers cause pain perception from non-painful sensory stimuli

CNS

Descending fibers inhibition Dorsal horn of the spinal cord

Ascending fibers

Dorsal ganglia of the spinal roots

Spinal cord Peripheral nociceptors

Peripheral nerve

Figure 1: Ascending and descending pathways that influence pain sensitivity Siracusa R, Paola RD, Cuzzocrea S, Impellizzeri D. Fibromyalgia: pathogenesis, mechanisms, diagnosis and treatment options update. International Journal of Molecular Sciences 2021;22(8):3891 (2*). Published under Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).

15

FIBROMYALGIA APPEARS TO BE A PAIN-PROCESSING PROBLEM, KNOWN AS CENTRAL SENSITISATION

The main features of CS are as follows. l CS is defined as the ‘increased responsiveness of nociceptive neurons in CNS to their normal or subthreshold afferent input’. l Evidence indicates that CS is characterised by dysfunctional descending inhibitory pathways and increased facilitative activity.

Temporal summation with enlarged receptive fields, lower nociceptor thresholds, increased spontaneous neuronal activity and augmented stimulus responses results. l Changes in neurotransmitter release results in repetitive stimulation of nociceptors that activate several neuroplasticity mechanisms including reduced pain thresholds, amplification of pain responses and spread of pain sensitivity to non-injured areas, leading to the enhanced excitability of the dorsal horn neurons. l Along descending inhibitory pathways, endogenous opioid tone appears normal or increased in FM patients, whereas endogenous serotoninergic and noradrenergic activity is decreased, resulting in reduced conditioned pain modulation.

euroinflammation

Neuroinflammation is a form of localised inflammation occurring in the peripheral nervous system and CNS (5*). Vascular changes occur with increased permeability, glial cell activation, the infiltration and activation of leukocytes and the increased production of inflammatory mediators 16

including cytokines and chemokines (6*). Neuroinflammation is supposed to be implicated in the chronification and persistence of pain.

Immune cells, including mast cells (MCs), appear to play a central role in neuroinflammation development. MCs are universally located in vascularised tissue, predominantly at the interface with the external environment.

Small-calibre sensory nerve fibres in peripherally innervated tissue, endoneural lining and (small quantities) in the brain carry MCs. MCs secrete mediators which promote nociceptor activation and hypersensitisation. In addition to this there is substantial evidence that MCs can impact blood– brain barrier (BBB) permeability, disrupting its integrity. Interaction of MCs and nociceptors, in the absence of tight control, can induce nociceptive hyperactivity while lowering pain thresholds. This persistent stimulation can finally sensitise the neurons of the dorsal horn, leading to CS (5*,6*). Glial cells also seem to play a role in neuroinflammation and the chronification of pain.

Neuroendocrine and ANS Dysfunction

Known modulators of the pain system are stress stimuli, either real or perceived, arising from different life events. Exposure to a stressor elicits the rapid activation of the ANS and the HPA axis under normal physiological situations. Catecholamines and cortisol are consequently released, starting the so-called ‘fight or flight’ response. Analgesic mechanisms and the induction of anti-nociceptive reactions is a hallmark of this response.

Exaggerated or maladaptive reactions can lead to a deregulation of the stress response, resulting in altered nociception, eventually leading to chronic pain development (5*). There is evidence supporting this, where chronic stress induces functional and morphological changes in key stress regulatory regions, especially the corticolimbic system. These changes can result in numerous abnormalities, including a dysfunctional HPA axis and an unbalanced ANS, both described in various chronic pain conditions. A complex and unique interaction seems

to arise between steroid production, the HPA axis, ANS and immune system with chronic pain conditions, possibly explaining the pathophysiological and clinical discrepancies between them (2*).

It is widely described that dysregulation of the neuroendocrine axis exists in FM. Different psychological triggers and physical traumas are associated with enhanced pain in FM patients. Influences of gene expression, possibly leading to HPA axis impairment, include potential environmental triggers of which several have been identified.

These potential stressors include repeated physical or psychological stressors, adverse events in neonatal or childhood life. In genetically predisposed individuals, environmental factors are believed to promote FM – evidence suggests a strong familial aggregation among FM patients.

Gene testing and its associations with FM continues to be investigated as current reports remain contradictory in identifying any individual gene and its impact on FM (2*,4).

Biomarkers

Having a greater knowledge of the pathophysiological mechanisms underlying this heterogenous condition may enable the identification of certain pain biomarkers that could be used in diagnosis and ongoing management.

These are explained in detail in articles

by Favretti et al. (5*), Gyrofi et al. (7*) and Garcia et al. (8). The following biomarkers are commonly investigated for pain in FM patients. l Glutamate: an excitatory neurotransmitter of the nervous system, that plays a significant role in nociceptive modulation. l Substance P: a neuropeptide, expressed throughout the nervous and immune systems, integral in pain processes and numerous pathological conditions. l Nerve growth factor: growth and survival of nerve cells. l Brain-derived neurotrophic factor. l Mu opioid receptor. l MCs and cytokine production. l Pentraxin-3: an acute-phase glycoprotein, which acts as a modulator of inflammatory processes. l Neuropeptide Y: expressed by a variety of immune cells and implicated

Co-Kinetic Journal 2024;99(January):14-18

CLINICAL UPDATE

in many physiological and pathological conditions. l Free radicals: FM patients produce higher levels of harmful free radicals and have a decreased antioxidant ability compared with healthy controls. This contributes to oxidative stress. The CNS is highly susceptible to reactive oxygen species because of its high lipid content.

The association of these metabolites with the clinical evidence of pain or FM symptoms is still unclear. This, combined with large study protocol discrepancies makes it difficult to find conclusive results. Continued work in this area is not lost. It is unlikely (at this stage) that one of the metabolites mentioned above could be used as a biomarker for FM diagnosis. Research in this field remains important, contributing to clarifying at least part of the pathogenetic mechanism underlying this complex syndrome.

Identifying underlying pathophysiology and biomarkers may be useful beyond diagnostic purposes and form part of prognosis or treatment monitoring.

There is still little evidence, however, regarding the association between certain markers and patients’ clinical symptoms, especially pain. Thus, more research in this area is needed (5*,7*).

Conclusion

FM is considered a central sensitivity syndrome. This refers to a neuronal signal amplification mechanism within the CNS that leads to a greater perception of pain. Patients with FM often present with increases in their receptive field of pain, allodynia, and hyperalgesia. CS is implicated in persistent and chronic pain. But where and when did that initial nociceptive stimulus occur? Persistent peripheral nociceptive input associated with tissue damage is often not evident. If peripheral pain generators could be blocked, then the symptoms of FM should disappear or not ever develop.

Researchers focus more on CS as the mechanism of pain sensitivity because there is less evidence to support the involvement of peripheral pain, tissue abnormalities and nociceptive processes in FM. Co-Kinetic.com

Pain sensitisation is, however, not a singular phenomenon. There may be contributing components from central, peripheral and psychosocial pain triggers. Studies have observed that FM patients were selectively attentive to information regarding the body and the environment in relation to pain (9). The term ‘cognitive-emotional sensitisation’ was coined to explain this, whereby a selective attention to certain body pain can increase the perception of that pain. Pain sensitivity has also been linked to social groups.

‘Interpersonal sensitisation’ suggests a mechanism of shared neuronal representation of the experience of pain. A feed-forward effect can occur in a family for example, in an attempt to reduce painful behaviours in one of its members, it inadvertently creates a state of anxiety in the person concerned by increasing the perception of pain (9).

No doubt, FM is a complicated syndrome. Chronic pain, joint rigidity, fatigue, sleep interruption, cerebral dysfunction and depression are the most common symptoms. As a result of the impact FM has on quality of life and the economic burden on healthcare systems, research on understanding FM is becoming progressively more significant. The pathogenesis of FM is not well known, and in turn the diagnosis and management options remain mostly subjective.

To date, no objective tests or biomarkers with sufficient diagnostic accuracy have been identified, and current analyses can only indicate a predisposition to FM. Numerous studies, however, provide insights into the pathophysiology of FM. Proteomic research as well as gene expression profiling may have potential applications as novel methods for the diagnosis of FM in the future.

Pharmacological treatment alone is inadequate for most patients who suffer from FM syndrome. Given the different mechanisms of pain sensitivity, treatments will continue to involve multidisciplinary programmes that target the peripheral, central, cognitive-emotional and interpersonal

causes of the chronic pain that characterise FM pathophysiology.

More detail on clinical assessment, diagnosis and treatment options is available in the accompanying article “Fibromyalgia: An Update on Diagnostic Tools and NonPharmacological Management” .

FM can be a devastating diagnosis, often exacerbated by diagnostic delays, clinical scepticism, and patient frustrations. It is very important that the patient gets a rapid and accurate diagnosis and can move forward to treatment. Optimal treatment options seem to involve combination approaches including exercise therapy, weight loss, cognitive behavioural therapy, and drug therapy. It is imperative that the clinical team work to educate the patient about their diagnosis and treatment options, the role of combination therapy, the importance of exercise, medication, and the nature of overlapping symptoms (3*).

References

1. Häuser W, Sarzi-Puttini P, Fitzcharles MA. Fibromyalgia syndrome: under-, over- and misdiagnosis. Clinical and Experimental Rheumatology 2019;37(1)Suppl 116:90– 97 Open access https://bit.ly/3t2VcRX 2. Siracusa R, Paola RD, Cuzzocrea S, Impellizzeri D. Fibromyalgia: pathogenesis, mechanisms, diagnosis and treatment options update. International Journal of Molecular Sciences 2021;22(8):3891 Open access https://bit.ly/3N1VTBX 3. Varrassi G, Rekatsina M, Perrot S et al. Is fibromyalgia a fashionable diagnosis or a medical mystery? Cureus 2023;15(9):e44852 Open access https://bit.ly/3MYYk8s

TO DATE, NO OBJECTIVE TESTS OR BIOMARKERS WITH SUFFICIENT DIAGNOSTIC ACCURACY HAVE BEEN IDENTIFIED FOR FIBROMYALGIA

17

4. Varol U, Úbeda-D’Ocasar E, CigaránMéndez M et al. Understanding the psychophysiological and sensitization mechanisms behind fibromyalgia syndrome: a network analysis approach. Pain Medicine 2023;24(3):275–284 5. Favretti M, Iannuccelli C, Di Franco M. Pain biomarkers in fibromyalgia syndrome: current understanding and future directions.

International Journal of Molecular

Sciences 2023;24(13):10443 Open access https://bit.ly/3GkRrKU 6. Ji RR, Nackley A, Huh Y et al.

Neuroinflammation and central sensitization in chronic and widespread pain.

Anesthesiology 2018;129(2):343–366 Open access https://bit.ly/46yZwpO 7. Gyorfi M, Rupp A, Abd-Elsayed A. Fibromyalgia pathophysiology.

Biomedicines 2022;10(12):3070 Open

access https://bit.ly/46AH684 8. García Rodríguez DF, Abud Mendoza C. Physiopathology of fibromyalgia.

Reumatologia Clinica (Engl Ed) 2020;16(3):191–194 9. Brosschot JF. Cognitive-emotional sensitization and somatic health complaints.

Scandinavian Journal of Psychology 2002;43(2):113–121.

KEY POINTS

SCREENING TO RULE OUT OTHER DISEASES CAN BE A STEP TOWARDS DIAGNOSING FIBROMYALGIA

RELATED CONTENT l Fibromyalgia: An Update on Diagnostic Tools and NonPharmacological Management [Article] l Pain Does Not Always Indicate Injury [Article] l Pain: The Brain’s Interpretation of Danger [Article] l Efficacy of Manual Therapy for Chronic Musculoskeletal Pain [Article]

DISCUSSIONS

l What is your knowledge or understanding of pain pathways in FM patients? l Have you identified psychosocial pain triggers in FM patients? l Without objective biomarkers or tests, do you find diagnosis and discussion about FM with patients challenging?

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l Fibromyalgia (FM) remains an enigma, with gaps in the understanding of the condition’s aetiology, pathology and prognosis. l Due to the lack of diagnostic markers doubts remain as to whether it is a real clinical condition. l The pathophysiology of FM includes neuroendocrine factors, genetic predisposition, oxidative stress, and environmental and psychosocial changes. l FM is a pain-processing problem, the psychobiological mechanism driving FM may be nociplastic pain. l Nociplastic pain is pain that arises from altered nociception, despite no clear evidence of actual or threatened tissue damage, or evidence for disease or lesion, causing the activation of peripheral nociceptors of the somatosensory pathways resulting in pain. l Central sensitisation is the ‘increased responsiveness of nociceptive neurons in the CNS to their normal or subthreshold afferent input’. l Peripheral pain generators have also been identified as possible contributors of FM, manifesting as cognitive impairment, chronic fatigue, sleep disturbances, intestinal irritability, interstitial cystitis and mood disorders. l Other systems could play a part in the pain patterns of FM patients, including the neuroinflammation, immune system, autonomic nervous system (ANS) abnormalities and hypothalamic–pituitary–adrenal (HPA) axis dysfunction. l Pain biomarkers could be used in diagnosis and ongoing management but ongoing research is needed. l Pain sensitisation in FM is not a singular phenomenon; there may be contributing components from central, peripheral and psychosocial pain triggers.

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 2024;99(January):14 -18

CLINICAL UPDATE

Fibromyalgia

An Update on Diagnostic Tools and NonPharmacological Management Fibromyalgia is challenging to diagnose and manage as patients present with a heterogeneous array of symptoms and there is a poor understanding of the underlying causes. The decades of research and refinement summarised in this article have improved our understanding of the disease as well as the criteria for diagnosis. This allows us to tailor the diagnosis and management to the individual according to their personal experience of the condition.

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

F

ibromyalgia (FM) is a chronic musculoskeletal disease of unknown aetiology. It is a common condition affecting 2–8% of the general population. The prevalence is higher among women aged between 50 and 80 years. FM is characterised by multiple regional pain syndromes or diffuse pain throughout the body and hyperalgesia. Other symptoms can include chronic fatigue, low mood or depression, non-restorative sleep, and cognitive dysfunction. Patients with FM therefore experience both functional and emotional disorders (1*,2,3*). FM has been proven to grossly impact an individual’s quality of life (QoL) and can result in substantial healthcare costs.

In the past, individuals without any underlying pathophysiologic processes to explain their pain and symptoms were often labelled with having FM, almost as a throw-away term for these patients. However, decades of

By Kathryn Thomas BSc MPhil research into FM has clearly shown objective abnormalities in central nervous pain and sensory processing, autonomic function, and even lowgrade inflammation (4*). Knowledge of the underlying mechanisms of pain has moved away from ongoing inflammation (nociceptive pain) or nerve damage (neuropathic pain) to a prototypical condition where pain and other symptoms originate from the central nervous system and systemic factors. This third mechanism of pain has been officially adopted by the International Association for the Study of Pain and is termed nociplastic pain (5*). It is now believed that nociplastic pain mechanisms play the primary role in conditions such as FM, tension headache, irritable bowel syndrome, and many chronic overlapping pain conditions. It may even be

superimposed upon nociceptive or neuropathic pain conditions such as autoimmune disorders (5*).

Diagnosis and subsequent management of FM have historically been challenging owing to the heterogeneous presentation of symptoms. Early recognition and intervention may prevent psychological, behavioural and other comorbidities which make this condition difficult or impossible to reverse. The ‘criteria wars’ have resulted in several instruments being developed that can and should be used to screen, diagnose and treat individuals for FM (6*). It is not ideal for the field of FM to have a lack of agreement in diagnostic criteria.

This can result in the same individual being diagnosed with varying degrees of FM or no FM at all, risking FM

EARLY RECOGNITION AND INTERVENTION MAY PREVENT PSYCHOLOGICAL, BEHAVIOURAL AND OTHER COMORBIDITIES WHICH MAKE THIS CONDITION DIFFICULT OR IMPOSSIBLE TO REVERSE

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BASED ON UNANIMOUS EXPERT OPINION, OPTIMAL MANAGEMENT REQUIRES PROMPT DIAGNOSIS FOLLOWED BY PATIENT EDUCATION, INCLUDING WRITTEN MATERIAL, ABOUT THE CONDITION condition legitimacy (7*,8*). To decide whether FM is either present or absent, either the 2016 modification of the 2010/2011 American College of Rheumatology criteria for FM (ACR FM 2016) or the Analgesic, Anaesthetic, and Addiction Clinical Trial Translations Innovations Opportunities and Networks–American Pain Society pain taxonomy (AAPT) criteria would suffice. The AAPT process may be methodologically superior to the ACR process; however, the ACR may be more clinically relevant, providing a general severity measure and being scored as a continuous quantitative measure (9*). These are explained in more detail below.

Pain is the dominant symptom in FM. Symptoms including fatigue, nonrefreshing sleep, mood disturbance and cognitive impairment are common, but not universal. When combined, these symptoms have an overwhelming influence on QoL and emphasise the heterogeneous and complex nature of the condition.

Based on unanimous expert opinion, optimal management requires prompt diagnosis followed by patient education, including written material, about the condition. A comprehensive assessment of pain, function and the psychosocial status should be conducted. Non-pharmacological interventions are recommended as the first-line treatment for FM. Management should have a graduated approach, aiming at improving healthrelated QoL (HRQoL). Treatment options should consider availability, cost, safety issues and patient preference. Specific or individual treatments will be discussed in more detail below. Disease characteristics that predict response to different nonpharmacologic therapies are poorly understood. This lack of knowledge limits the ability to personalise management of FM or forecast patient

20

responses (2,10*).

This article aims to highlight assessment and diagnosis options available for clinical use. It will also discuss the non-pharmacological treatments relevant to physical and manual therapists.

Assessment and Diagnosis

In the absence of definitive pathology, the assessment, investigation and subsequent diagnosis of FM borders on subjective rather than objective findings. Evaluation relies upon the patient’s report of their symptoms and their degree of severity. The presence and experience of these symptoms consequently affects the individual’s daily functioning both physically and psychologically.

Experts have over the years developed, and continue to refine, the criteria for assessing and diagnosing FM. Until 2016, assessment of pain included 19 sites and a 4-item severity scale from which an overall FM severity score, the polysymptomatic distress (PSD) scale, could be calculated.

Historic criteria defined FM based on chronic widespread pain (CWP) and tenderness in 11 out of 18 predefined tender points (11,12*). Clinically, there were faults with this criterion, namely: l many physicians did not know how to examine for tender points or refused to do it; l evaluation of tender points was rarely performed; l tender points can overlap and consequently be interpreted as muscle (peripheral) pathology, or myofascial trigger points; and l some patients have limited access to a physician for assessment.

Another limitation was that the original criteria did not consider symptoms beyond pain, nor did it grade severity of the FM symptoms nor monitor quantitative changes (13*).

Subsequent to this, the ACR 2010 FM diagnostic criteria were based on a widespread pain index (WPI) (range 0–19) and a symptom severity scale (SSS) score (range 0–12). In 2011 the criteria were modified such that the FM survey questionnaire could be selfadministered by the patient. This FM survey diagnostic criteria were satisfied if the following three conditions were met (7*): . the W I and the SSS score , or W I is plus SSS score 2. symptoms have been present at a similar level for at least 3 months; and 3. the patient does not have a disorder that would otherwise explain the pain.

The ‘new’ criteria for diagnosis combined the concept of generalised chronic pain (such as a generalised pain index covering 19 regions) with the presence of an additional measure for fatigue, sleep, cognitive symptoms, mood symptoms, and other sources of pain. The SSS score and the combination of the generalised pain index provided a maximum score of 31. For diagnosis, patients had to score a minimum of 3 or higher on the generalised pain index, with a total score of 12 when combined with the SSS score (14).

In 2016 the criteria were evaluated to adequately serve as diagnostic criteria when used in clinical practice, but also as classification criteria when used for research. The 2016 ACR criteria are satisfied if the following three conditions are met (9*,14): . the W I and the SSS score , or W I is with SSS score 2. generalised pain, defined as pain in at least four of five regions, is present; and 3. symptoms have been present at a similar level for at least 3 months.

The previous requirement that

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CLINICAL UPDATE

the patient could not have other conditions that could explain the pain was removed. A diagnosis of FM is valid irrespective of other diagnoses and the diagnosis of FM does not exclude the presence of other clinically important illnesses (14). A fibromyalgia severity (FS) score (range 0–31) was developed as a sum of the WPI and the SSS (12*,14), as shown in the Physiopedia image (https://bit. ly/3RfPSUL) (15*).

The most recent, modified 2019 fibromyalgia assessment status (FAS) criteria (the original version was published in 2009) are detailed in ‘Figure 1. The FAS 2019 modCr’ (https://bit.ly/3N9dLee) in Salaffi et al. (16*). These criteria try to simplify the rating of chronic pain where pain in 19 body regions is merely classified as present or absent, rather than rated on a four-point numerical scale. The modified FAS criteria are similar to the AAPT criteria (17*), in that it focuses only on fatigue and sleep quality to simplify the diagnostic process.

Research comparing all six sets of criteria (ie. the 1990, 2010, 2011, and 2016 ACR criteria, as well as the FAS and AAPT criteria), found that the AAPT criteria had the lowest diagnostic accuracy. The modified FAS criteria may have similar limitations. Prioritising simplicity may reduce diagnostic accuracy (18*).

Although patients with FM frequently complain about fatigue, pain is the defining characteristic for diagnosis (19*). The variable nature of pain is one of the most challenging aspects of FM. It can be associated with morning stiffness and/ or increasing pain throughout the day.

Patients with FM may have increased pain sensitivity due to dysregulated functioning of the hypothalamus– pituitary–adrenal–cortex axis and central sensitisation. Pain is associated with greater disease severity, reduced function, and symptoms of FM. Thus, pain is a significant symptom that may affect physical functioning (20*).

As many as 80% of patients with FM report poor sleep (21). Poor sleep is strongly and dose-dependently associated with symptom severity.

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Studies have also indicated that lower sleep quality is a risk factor for FM. There are interactions between clinical symptoms present in FM and sleep disorders, neuroendocrine and immune disorders. It is possible, therefore, that sleep disturbances can be both a cause and a consequence of FM. Overall QoL of FM patients can be significantly impacted by the combination of pain and poor-quality sleep (21). Some researchers consider that pain alone does not directly produce emotional distress (20*).

Rather, the quality of sleep can be an important mediator in the relationship between pain, distress, emotional functioning, and anxiety.

Anxiety is a key symptom in FM. It is frequently associated with greater levels of pain and neuropsychological disorders in these patients. Research has shown that patients with high levels of anxiety usually present with increased risk of severe FM which can greatly impact their QoL. The prevalence of anxiety and depressive disorders in FM patients is significantly higher (20–80%) compared to the general population (13–64%) (22,23).

In patients with severe anxiety and/ or depression, compliance with non-pharmacological therapy can be affected. The interaction of chronic pain and fatigue, anxiety and depression and poor therapy compliance can become cyclical and self-perpetuating. A negative mood experienced by many FM patients, can lead to a poor perception of physical health; similarly, depression can increase a patients perception of pain, resulting in a cycle of depression/pain/ depression (3*,24).

Although continuous efforts are being made to improve the accuracy of FM diagnosis, the 2016 ACR criteria remain the most accurate; thus, these criteria should be used in clinical practice. An article by Kang J et al.

clearly details the different assessment criteria, including the 2016 ACR, if greater clarity is needed (25*).

Non-Pharmacological Management of FM

If the criteria for diagnosis with all its acronyms and updates hasn’t already confused you, then let’s hope the management protocols are easier to follow. The complexity of FM symptomatology and the heterogeneity of severity, sensitivity and response across individuals makes prescribed management procedures almost impossible. Management can be targeted by breaking down the individual’s symptoms into three main areas: 1. aspects of physical health (musculoskeletal system); 2. pain regulation mechanisms (neuroendocrine system); and 3. factors related to psychological wellbeing and mental health.

Studies have endeavoured to explore the complex relationships between symptoms and treatment modalities.

Musculoskeletal pain and sleep disorders are the main primary factors that drive patients to seek treatment.

Clinical practice guidelines (10*,26*,27*) and meta-analyses (28*) recommend non-pharmacological approaches as first-line treatment for FM. These are listed in the European Alliance of Associations for Rheumatology (EULAR) recommendations in Table 1. The treatments range from patient education, physical therapy and psychotherapy to some alternative therapies such as yoga, tai chi, or acupuncture (20*,29*). In most patients, a multidisciplinary approach, combining non-pharmacological and pharmacological treatments, is needed (3*). Physicians should encourage and support FM patients to participate in the non-pharmacological components of interventions as part of routine clinical practice.

MANAGEMENT GUIDELINES UNANIMOUSLY RECOMMEND THE USE OF EXERCISE FOR TREATING FIBROMYALGIA

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The EULAR recommendations are unanimous in providing a ‘strong for’ recommendation for the use of exercise. Exercise is the only treatment component strongly recommended across all guidelines (30*). This

recommendation is based on evidence available from clinical trials (level 1a, grade A evidence), particularly given its effect on pain, fatigue, sleep, physical function and wellbeing, availability, relatively low cost, and lack

of safety concerns. Aerobic, aquatic, resistance, and strengthening exercises are considered equally effective for relieving FM symptoms (25*). Currently available evidence does not prove superiority of one exercise therapy

Table 1: EULAR recommendations for managing patients with fibromyalgia Macfarlane GJ, Kronisch C, Dean LE et al. EULAR revised recommendations for the management of fibromyalgia. Annals of the Rheumatic Diseases 2017;76(2):318–328 (10; https://ard.bmj.com/content/76/2/318). Reproduced with permission Recommendation

Level of Grade Strength of Agreement evidence recommendation (%)*

Overarching principles Optimal management requires prompt diagnosis. Full understanding of fibromyalgia requires comprehensive assessment of pain, function and psychosocial context. It should be recognised as a complex and heterogeneous condition where there is abnormal pain processing and other secondary features. In general, the management of FM should take the form of a graduated approach.

IV

D

100

Management of fibromyalgia should aim at improving health-related quality of life balancing benefit and risk of treatment that often requires a multidisciplinary approach with a combination of non-pharmacological and pharmacological treatment modalities tailored according to pain intensity, function, associated features (such as depression), fatigue, sleep disturbance and patient preferences and comorbidities; by shared decision-making with the patient. Initial management should focus on nonpharmacological therapies.

IV

D

100

Aerobic and strengthening exercise

la

A

Strong for

100

Cognitive behavioural therapies

la

A

Weak for

100

Multicomponent therapies

la

A

Weak for

93

Defined physical therapies: acupuncture or hydrotherapy

la

A

Weak for

93

Meditative movement therapies (qigong, yoga, tai chi) and mindfulness-based stress reduction

la

A

Weak for

71– 73

Amitriptyline (at low dose)

la

A

Weak for

100

Duloxetine or milnacipran

la

A

Weak for

100

Tramadol

lb

A

Weak for

100

Pregabalin

la

A

Weak for

94

Cyclobenzaprine

la

A

Weak for

75

Specific recommendations Non-pharmacological management

Pharmacological management

*Percentage of working group scoring at least 7 on 0–10 numerical rating scale assessing agreement.

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CLINICAL UPDATE

over another or the benefits of aerobic versus strengthening type exercises (10*). Patients beginning exercise therapy should be encouraged to begin at a level of intensity immediately below their current capacity of daily activity. A gradual increase in duration and intensity can be introduced, building to 20 to 30 minutes of low-to-moderate intensity exercise 2–3 times per week.

Support from family, friends and physicians is important as one of the greatest challenges is maintenance of patient motivation; both from the beginning and adhering to long-term exercise regimens (25*).

Flexibility exercise training programmes – defined as those involving movements of a joint or a series of joints, through complete range of motion, thus targeting major muscle-tendon units – have been studied. When compared with aerobic training, a systematic review was uncertain whether flexibility improved outcomes such as HRQoL, pain intensity, fatigue, stiffness, and physical function, as the certainty of the evidence is very low. Any long-term benefits of flexibility exercise training had a low level of certainty (31*).

Improvements in the fibromyalgia impact questionnaire (FIQ) scores were seen with exercise, psychological treatments, multidisciplinary modality, balneotherapy, and massage. An example of the FIQ is shown in ‘Table 1 Revised fibromyalgia impact questionnaire (FIQ)’ (https://bit.ly/47HPROO) in Bennett RM et al. (32*). Research has shown that all forms of exercise improve pain and depression except for flexibility exercise alone. Fatigue was improved through mind–body and strengthening exercises, whereas aerobic and strengthening exercises improved sleep to a greater degree.

Pain, sleep, FIQ score and depression (but not fatigue) were improved with psychological treatments including cognitive behavioural therapy (CBT) and mindfulness (2). This information is collated in a useful infographic by Andrade et al. (Fig. 1) (33).

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Although the strength of the recommendation varies, CBT is recommended by most guidelines (10*,26*,27*,30*). CBT, both traditional and acceptance-based, is effective for reducing negative mood, disability and pain. This in turn makes it effective for improving HRQoL (34*). Likewise, internet-based CBT (ICBT) has been proven to be effective: it reduces negative mood and disability and improves HRQoL (35*). Pain reduction of at least 50% was not documented when using ICBT. Thus, guided ICBT or traditional CBT may be superior to unguided interventions for reducing symptom severity and improving outcomes. Thus, ICBT may be useful for FM patients with mild-to-moderate symptoms, or those with logistical restrictions to attending clinics.

Individuals with more severe FM should be managed in a specialised setting through traditional and acceptance-based CBT (35*).

Complementary and alternative therapies vary greatly in terms of both the quality of relevant clinical trials and the level of evidence. The EULAR guidelines are the first to tentatively (‘weak for’) recommend various nonconventional therapies. Such therapies include meditative movement therapies (which improved sleep, fatigue and QoL) or mindfulnessbased stress reduction (which improved pain and QoL) as well as the physical therapies of acupuncture or hydrotherapy (for which there was evidence that they improved pain/ fatigue and pain/QoL, respectively) (10*). Examples of meditative movement therapies include qigong, yoga, and tai chi. Owing to their ambiguous mechanisms of action, methodological flaws, and inabilities to elicit sustained responses most guidelines are reluctant to recommend these therapies (25*). Sadly there is a clear gap between patient enthusiasm for these therapies and the necessary supporting scientific research regarding their efficacy and safety.

There are some nonpharmacological therapies that are not recommend because of a lack

of effectiveness and/or low study quality, these include biofeedback, capsaicin, hypnotherapy, massage, S-adenosyl-L-methionine (SAMe) and other complementary and alternative therapies. Interestingly, the EULAR guidelines provided a ‘strong against’ evaluation for chiropractic therapy based on safety concerns (10*).

Manual therapy has been defined in different ways, one of them as the “manipulation of soft tissues and joints using the hands” and another as the “systematic mapping of soft tissue with rhythmic pressure to prevent, develop, maintain, rehabilitate, or increase physical function or relieve pain” (36). In physical therapy practice, manual therapy is frequently used

Figure 1: The effects of exercise in patients with fibromyalgia: an umbrella review Andrade A, Dominski FH. Infographic.

Effects of exercise in patients with fibromyalgia: an umbrella review.

British Journal of Sports Medicine 2021;55:279–280 (33 https://bit.ly/3Rf7vUH). Reproduced with permission

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COMPLEMENTARY AND ALTERNATIVE THERAPIES VARY GREATLY IN TERMS OF BOTH THE QUALITY OF RELEVANT CLINICAL TRIALS AND THE LEVEL OF EVIDENCE History and physical examination

If needed to exclude treatable comorbidities: l Laboratory and/or radiological exams l Referral to other specialists

Diagnosis of fibromyalgia

in the treatment of patients with musculoskeletal disorders. Likewise manual therapy has been shown to have positive effects on chronic back pain, migraines, anxiety, hypertension, depression, and many other physical and psychological conditions (3*).

Massage is an important element in manual therapy but very few clinical trials have been conducted reporting the effects in FM patients.

Despite the lack of supporting literature, research has shown that therapeutic massage is used by 75% of patients with FM (37*).

The intensity or type of massage technique may require some consideration (38).

1. Myofascial release 1.1. Moderate evidence of beneficial effects on pain, fatigue, stiffness, anxiety, depression and HRQoL. 1.2. A large effect on pain after treatment, which reduces progressively over the shortand medium-term follow-ups.

1.3. Insufficient information on pain-pressure-threshold (PPT) and sleep have been reported.

1.4. It has been hypothesised that widespread pain and central sensitisation experienced with FM is due to fascial

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Patient education and information sheet If insufficient effect

Physical therapy with individualised graded physical exercise (can be combined with other recommended non-pharmacological therapies such as hydrotherapy, acupuncture) If insufficient effect Reassessment of patient to tailor individualised treatment

Additional individualised treatment

Pain-related depression, anxiety, catastrophizing, overly passive or active coping

Severe pain/sleep disturbance

Severe disability/sick leave

Psychological therapies

Pharmacotherapy

Multimodal rehabilitation programs

l Mainly cognitive behavioural therapy l For more severe depression/anxiety consider pharmacological treatment

Severe pain l Duloxetine l Pregabalin l Tramadol (or in combination with paracetamol) Severe sleep problems l Low dose amitriptyline l Cyclobenzaprine or l Pregabalin at night

Figure 2: Management recommendations flow chart Macfarlane GJ, Kronisch C, Dean LE et al. EULAR revised recommendations for the management of fibromyalgia. Annals of the Rheumatic Diseases 2017;76(2):318–328 (10; https://ard.bmj.com/content/76/2/318). Reproduced with permission. EULAR, European Alliance of Associations for Rheumatology

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CLINICAL UPDATE

dysfunction. Massage aimed at releasing fascial restriction can treat myofascial fibrotic changes by breaking up excessive collagen adhesions.

These in turn can reduce excess tension in the fascial system and promote tissue healing, thereby contributing to pain improvement.

This theory is based on a physiological point of view.

2. Connective tissue massage 2.1. The evidence is limited but suggests that connective tissue massage has beneficial, immediate effects on depression and HRQoL in FM patients.

2.2. Connective tissue massage produces an autonomic response via cutaneovisceral reflexes by applying a specialised stroke to connective tissue reflex zones, specifically in the bony attachments of fascia or where fascia is superficial.

2.3. Although connective tissue massage differs from that of myofascial release, improvement in some outcomes might be explained by manipulation of the fascia in both styles.

3. Swedish massage 3.1. No positive effect was seen on outcomes at any assessment time point when compared to standard care, with and without phone calls, or guided progressive relaxation.

4. Lymphatic drainage 4.1. Manual lymphatic drainage was superior to connective tissue massage in terms of stiffness, depression and HRQoL. 4.2. It is hypothesised that shorter sessions or the more intense pressure of connective tissue massage might have been responsible for this difference.

5. Shiatsu 5.1. There is limited evidence of the beneficial, immediate

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effects of shiatsu on pain, PPT, fatigue, sleep and HRQoL. 6. Other styles of massage 6.1. There is limited or no evidence of effectiveness in specific outcome.

Research suggests that every style of massage, except for Swedish massage, might display positive effects on FM symptoms. The commonly practised Swedish massage cannot be recommended at present. Currently, myofascial release has the best evidence of effectiveness for multiple outcomes and could be preferred over other styles (38).

For FM patients, manual therapy should be painless, progressive, and the intensity should gradually increase from session to session depending on the patient’s symptoms and response to previous sessions. The benefits of manual therapy for FM patients includes promotion of restful sleep, decreased anxiety and depression, and reduced pain (both immediate and delayed perception of pain). It has been suggested that manual therapy should be done at least 1–2 times per week, although the reason for this number of sessions is unclear (3*).

Studies have shown that manual therapy can be carried out on the sensitive diagnostic points, producing positive results in reduced pain perception. Vibration manual therapy carried out with the fingertips, and moderate digital pressure on the sensitive diagnostic points performed for 15 minutes, twice a week for 4 weeks resulted in improvements in patient outcomes. Moderate pressure stimulates pressure receptors, which in turn increases vagal activity – a theory behind the benefits seen with manual therapy (3*,38).

As with any patient and condition, management should be individualised according to their needs. In the case of a lack of effect from any of the above suggested therapies, other options should be explored. For those with mood disorder or unhelpful coping strategies psychological therapies (‘weak for’) should be considered.

Pharmacological therapies (all ‘weak for’) should be considered for those with sleep disturbance (amitriptyline, cyclobenzaprine, pregabalin) or severe pain (duloxetine, pregabalin, tramadol). Some pharmacotherapies are not recommended owing to lack of efficacy, whereas others are specifically given a ‘strong against’ evaluation (for example, growth hormone, sodium oxybate, strong opioids and corticosteroids) based on lack of efficacy and high risk of side effects.

Multimodal rehabilitation (‘weak for’) programmes may be necessary for patients with severe disability (10*).

Figure 2 is a flow chart of the EULAR FM management recommendations.

Conclusion

FM is a complex, multidimensional disease that involves various pathophysiologies. Research suggests a superiority of multicomponent therapies over individual therapies in providing positive outcomes for the patient. Multicomponent therapy has been shown to be effective for reducing key FM symptoms such as pain, fatigue and depressed mood; it is also effective for improving selfefficacy and physical fitness (39*). It should be noted that the effects of multicomponent therapy, as well as individual therapy can be short lived.

Extra effort is needed to ensure that the benefits persist after treatment.

Education, booster sessions, and self-

FOR FIBROMYALGIA PATIENTS, MANUAL THERAPY SHOULD BE PAINLESS, PROGRESSIVE, AND THE INTENSITY SHOULD GRADUALLY INCREASE FROM SESSION TO SESSION

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help groups can all enhance patient motivation and compliance to therapy.

Even with high-quality reviews and meta-analyses, the size of effect for most treatments is relatively modest. Further research is proposed to clarify who will benefit from specific interventions, their effect in combination and organisation of healthcare systems to optimise outcome.

There are now several instruments that can and should be used to

screen, diagnose, and treat individuals for FM. The earlier the diagnosis and intervention the better the outcome, before psychological, behavioural, and other comorbidities make this condition difficult or impossible to reverse (40*).

References Owing to space limitations in the print version, the references that accompany this article are available online.

RELATED CONTENT l Pain Does Not Always Indicate Injury [Article] l Pain: The Brain’s Interpretation of Danger [Article] l Efficacy of Manual Therapy for Chronic Musculoskeletal Pain [Article] l What is Fibromyalgia? The Saga Continues [Article] URL needed

KEY POINTS

l Fibromyalgia (FM) is a heterogeneous disorder in terms of symptoms and severity, as well as the response to treatment; treatment plans should be individualised based on each patient’s characteristics. l Although continued efforts have been made to improve the accuracy of FM diagnosis, the 2016 ACR criteria remain the most accurate. l Despite advances in pharmacological and non-pharmacological treatments, there is considerable room for improvement in the treatment of FM. l Treatment should be based on availability, cost, safety issues and patient preference. l Non-pharmacological management is based on patient education, exercise, and cognitive behavioural therapy. l Exercise and strength training have been shown to be most effective and are strongly recommended. l Exercise therapy should be administered gradually, with intensity and duration being increased in a progressive manner. l The most effective strategy is to combine various treatment modalities to reduce symptoms and promote optimal functioning.

DISCUSSIONS

l Do you have any challenges around diagnosing fibromyalgia (FM)? l Which type of exercise therapy do you find most effective – aerobic or strength training? l Do you use manual therapy and massage with your FM patients? And if so, what is your massage technique and pressure, and their response to treatment?

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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 2024;99(January):19-26

CLINICAL UPDATE

Fibromyalgia: An Update on Diagnostic Tools and Non-Pharmacological Management References 1. White HD, Robinson TD. A novel use for testosterone to treat central sensitization of chronic pain in fibromyalgia patients. International Immunopharmacology 2015;27:244–248 Open access https://bit.ly/3GkSZ7I 2. Kundakci B, Kaur J, Goh SL et al. Efficacy of nonpharmacological interventions for individual features of fibromyalgia: a systematic review and meta-analysis of randomised controlled trials. Pain 2022;163:1432– 1445 3. Nadal-Nicolás Y, Rubio-Arias JÁ, Martínez-Olcina M et al. Effects of manual therapy on fatigue, pain, and psychological aspects in women with fibromyalgia.

International Journal of Environmental Research and Public Health 2020;17:4611 Open access https://bit.ly/49TPeU2 4. Sluka KA, Clauw DJ. Neurobiology of fibromyalgia and chronic widespread pain. Neuroscience 2020;338:114–129 Open access https://bit.ly/414m80s 5. Kosek E, Cohen M, Baron R et al. Do we need a third mechanistic descriptor for chronic pain states?

Pain 2016;157:1382–1386 Open access https://bit.ly/3RhayLX 6. Häuser W, Perrot S, Clauw DJ, Fitzcharles M-A. Unravelling fibromyalgia—steps toward individualized management. The Journal of Pain 2018;19:125–134 Open access https://bit.ly/3GjDNYn 7. Wolfe F, Fitzcharles M, Goldenberg DL et al.

Comparison of physician-based and patient-based criteria for the diagnosis of fibromyalgia. Arthritis Care & Research (Hoboken) 2016;68:652–659 Open access https://bit.ly/46xpudw 8. Walitt B, Katz RS, Bergman MJ, Wolfe F. Threequarters of persons in the US population reporting a clinical diagnosis of fibromyalgia do not satisfy fibromyalgia criteria: the 2012 National Health Interview Survey. PLoS One 2016;11:e0157235 Open access https://bit.ly/47LUfgh 9. Häuser W, Brähler E, Ablin J, Wolfe F. Modified 2016 American College of Rheumatology fibromyalgia criteria, the analgesic, anesthetic, and addiction clinical trial translations innovations opportunities and networks – American Pain Society pain taxonomy, and the prevalence of fibromyalgia. Arthritis Care & Research (Hoboken) 2021;73:617–625 Open access https://bit.ly/3N1AZCN 10. Macfarlane GJ, Kronisch C, Dean LE et al. EULAR revised recommendations for the management of fibromyalgia. Annals of the Rheumatic Diseases 2017;76:318–328 Open access https://bit.ly/3sRe5r6 11. Wolfe F, Smythe HA, Yunus MB et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis and Rheumatism 1990;33:160–172 12. Wolfe F, Clauw DJ, Fitzcharles M et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity.

Arthritis Care & Research (Hoboken) 2010;62:600– 610 Open access https://bit.ly/3T2h7Ds 13. Fors EA, Wensaas KA, Eide H et al. Fibromyalgia 2016 criteria and assessments: comprehensive validation in a Norwegian population. Scandinavian Journal of

Co-Kinetic.com

Pain 2020;20:663–672 Open access https://bit.ly/49TQvui 14. Wolfe F, Clauw DJ, Fitzcharles M-A et al. 2016 Revisions to the 2010/2011 fibromyalgia diagnostic criteria. Seminars in Arthritis and Rheumatism 2016;46:319–329 15. The American College of Rheumatology 2010 preliminary diagnostic criteria for fibromyalgia.

Physiopedia 2023 Open access https://bit.ly/3RfPSUL 16. Salaffi F, Di Carlo M, Farah S et al. Diagnosis of fibromyalgia: comparison of the 2011/2016 ACR and AAPT criteria and validation of the modified fibromyalgia assessment status. Rheumatology 2020;59:3042–3049 Open access https://bit.ly/3QVLj0l 17. Arnold LM, Bennett RM, Crofford LJ et al. AAPT diagnostic criteria for fibromyalgia. The Journal of Pain 2019;20:611–628 Open access https://bit.ly/3N4dSYl 18. Kang JH, Choi SE, Xu H et al. Comparison of the AAPT fibromyalgia diagnostic criteria and modified FAS criteria with existing ACR criteria for fibromyalgia in Korean patients. Rheumatology and Therapy 2021;8:1003–1014 Open access https://bit.ly/47RcRuF 19. Dailey DL, Frey Law LA, Vance CGT et al. Perceived function and physical performance are associated with pain and fatigue in women with fibromyalgia. Arthritis Research & Therapy 2016;18:68 Open access https://bit.ly/47SIzYm 20. Écija C, Luque-Reca O, Suso-Ribera C et al. Associations of cognitive fusion and pain catastrophizing with fibromyalgia impact through fatigue, pain severity, and depression: an exploratory study using structural equation modeling. Journal of Clinical Medicine 2020;9:1763 Open access https://bit.ly/46AjD7h 21. Wu YL, Chang LY, Lee HC et al. Sleep disturbances in fibromyalgia: a meta-analysis of case-control studies.

Journal of Psychosomatic Research 2017;96:89–97 22. Choy EH. Current treatments to counter sleep dysfunction as a pathogenic stimulus of fibromyalgia.

Pain Management 2016;6:339–346 23. Segura-Jiménez V, Álvarez-Gallardo IC, CarbonellBaeza A et al. Fibromyalgia has a larger impact on physical health than on psychological health, yet both are markedly affected: the al-Ándalus project. Seminars in Arthritis and Rheumatism 2015;44:563–570 24. Mercieca C, Borg AA. EULAR recommendations underplay importance of severe anxiety and depression in fibromyalgia treatment. Annals of the Rheumatic Diseases 2017;76:e53 25. Kang JH, Choi SE, Park DJ, Lee SS. Disentangling diagnosis and management of fibromyalgia. Journal of Rheumatic Diseases 2022;29:4–13 Open access https://bit.ly/47SYdmJ 26. Ariani A, Bazzichi L, Sarzi Puttini P et al. The Italian Society for Rheumatology clinical practice guidelines for the diagnosis and management of fibromyalgia.

Best practices based on current scientific evidence.

Reumatismo 2021;73:89–105 Open access https://bit.ly/46HGIVG 27. Fitzcharles MA, Ste-Marie PA, Goldenberg DL et al. 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome: executive summary. Pain Research & Management

2013;18:119–126 Open access https://bit.ly/415c73a 28. Mascarenhas RO, Souza MB, Oliveira MX et al. Association of therapies with reduced pain and improved quality of life in patients with fibromyalgia.

JAMA Internal Medicine 2021;181:104 Open access https://bit.ly/47xjN0p 29. Pulido-Martos M, Luque-Reca O, Segura-Jiménez V et al. Physical and psychological paths toward less severe fibromyalgia: a structural equation model. Annals of Physical and Rehabilitation Medicine 2020;63:46– 52 Open access https://bit.ly/3Rii0GN 30. Thieme K, Mathys M, Turk DC. Evidenced-based guidelines on the treatment of fibromyalgia patients: are they consistent and if not, why not? Have effective psychological treatments been overlooked? The Journal of Pain 2017;18:747–756 Open access https://bit.ly/3uAEKsK 31. Kim SY, Busch AJ, Overend TJ et al. Flexibility exercise training for adults with fibromyalgia. Cochrane Database of Systematic Reviews 2019;9:CD013419 Open access https://bit.ly/47N8oZS 32. Bennett RM, Friend R, Jones KD et al. The Revised Fibromyalgia Impact Questionnaire (FIQR): validation and psychometric properties. Arthritis Research & Therapy 2009;11:415 Open access https://bit.ly/3N7MVTF 33. Andrade A, Dominski FH. Infographic. Effects of exercise in patients with fibromyalgia: an umbrella review. British Journal of Sports Medicine 2021;55:279–280 34. Bernardy K, Klose P, Welsch P, Häuser W. Efficacy, acceptability and safety of cognitive behavioural therapies in fibromyalgia syndrome – a systematic review and meta-analysis of randomized controlled trials.

European Journal of Pain 2018;22:242–260 Open access https://bit.ly/3N4fH7w 35. Bernardy K, Klose P, Welsch P, Häuser W. Efficacy, acceptability and safety of Internet-delivered psychological therapies for fibromyalgia syndrome: a systematic review and meta-analysis of randomized controlled trials. European Journal of Pain 2019;23:3– 14 Open access https://bit.ly/40ZUCRt 36. Kalichman L. Massage therapy for fibromyalgia symptoms. Rheumatology International 2010;30:1151–1157 37. Bervoets DC, Luijsterburg PA, Alessie JJ et al.

Massage therapy has short-term benefits for people with common musculoskeletal disorders compared to no treatment: a systematic review. Journal of Physiotherapy 2015;61:106–116 Open access https://bit.ly/46CscON 38. Yuan SLK, Matsutani LA, Marques AP. Effectiveness of different styles of massage therapy in fibromyalgia: A systematic review and meta-analysis. Manual Therapy 2015;20:257–264 39. Häuser W, Bernardy K, Arnold B et al. Efficacy of multicomponent treatment in fibromyalgia syndrome: a meta-analysis of randomized controlled clinical trials.

Arthritis Care & Research (Hoboken) 2009;61:216– 224 Open access https://bit.ly/3GjW9Zd 40. Clauw D. Time to stop the fibromyalgia criteria wars and refocus on identifying and treating individuals with this type of pain earlier in their illness. Arthritis Care & Research (Hoboken) 2021;73:613–616 Open access https://bit.ly/3R1j5kO.

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ENTREPRENEUR THERAPIST

From One Physiotherapist to Another:

Rethinking Marketing for Our Profession

By Tor Davies, physiotherapist-turned Co-Kinetic founder

A

s a former physiotherapist, I understand the unique challenges and joys of our profession. When I began my journey in creating a marketing platform seven years ago, it was with a clear purpose: to support physical therapists like us in growing their practices in a way that feels right. I’m not just another marketer; I’m someone who knows what it’s like to treat patients and who understands the delicate balance between patient care and running a business.

Over the years, I’ve had the privilege of speaking with many of you. These conversations have been more than just enlightening; they’ve formed the cornerstone of my mission. You’ve shared how traditional marketing doesn’t sit well with you, how the ‘salesy’ approach feels out of place in our world of care and healing, how the myriad of marketing strategies and solutions can feel overwhelming, especially

IT’S ABOUT MAKING MARKETING FEEL LESS LIKE A CHORE AND MORE LIKE AN EXTENSION OF THE CARE WE’RE SO PASSIONATE ABOUT Co-Kinetic.com

for a small business, and how the technology barrier feels insurmountable.

So, I set out to create something different – a platform that’s not about pushing sales, but about continuing the care and support we provide to our patients, just through a different medium. It’s about making marketing feel less like a chore and more like an extension of the care we’re so passionate about. It’s designed to be as hands-off as possible, respecting the value of your time and energy, and making the most of every minute you invest in growing your practice.

As I write this (mid-December), we are literally days away from going live with this new marketing resource, as a first priority for my existing subscribers, so let me share with you how I’m transforming the approach to marketing in our field, one step at a time, making it more in tune with who we are as therapists and as people who care deeply about helping others.

Tackling the Pain Points Head On

As a community of therapists, we face a common set of challenges when it comes to marketing our services. The confusion that comes with figuring out not just digital marketing but marketing full stop, the steep learning curve, 27

concerns over costs, the scarcity of time, and limited resources – these are real barriers that can make marketing feel more like a brick wall than a helpful tool.

Recognising these pain points, I set out to find a solution that addresses each one, a solution that simplifies marketing without compromising on effectiveness.

A Unique Solution for Physical Therapists

This journey led to the creation of the platform I’ve dubbed “Co-Kinetic 2.0” (the front cover being a direct nod to it) – a unique blend of technology and content, built specifically for physical therapists. It’s not just another marketing tool; it’s a comprehensive solution designed to cut through the confusion, save time and be costeffective while requiring minimal resources from your end (I’ve even taken on a team to offer a done-for-you version too).

Our platform stands out because of its simplicity and its focus on both digital and local outreach. You won’t need to spend hours trying to understand the ins and outs of digital marketing or invest in expensive resources. We provide ready-to-use, interconnected content that resonates with your clients, whether you’re connecting with them online or in your local community.

By using this platform, the time you used to spend feeling overwhelmed by marketing can now be redirected towards what you do best – caring for your patients. The focus shifts from scattered efforts to a coherent, strategic approach that fits into the busy schedule of clinic owners. It’s not about doing more; it’s about doing what’s effective.

Next, I’ll share a bit more about how this platform can fit into your daily routine, helping you manage your marketing without it feeling like a burden.

Simplifying Your Marketing, Month by Month

Let’s face it, most (if any) of us in the physical therapy field didn’t get into this profession to become marketers! On a weekly basis I hear the words “if I’d realised how important marketing would be to running a small business, I might have thought twice about doing it”. That’s why I wanted to create something that takes the complexity out of marketing and fits into your day without any hassle. Think of our platform as your marketing consultant and marketing assistant all in one – it’s a mix of user-friendly software and high quality content that’s been created specifically for physical therapists running their own business.

Each month, subscribers to the Clinic Growth Hub will receive a brand new campaign that aligns with international health awareness months, health discoveries and key sporting events. This means you’re always talking about things that are timely and relevant, without having to do the research yourself.

And here’s the really cool part: you don’t need to decide what to post or email every day. Once you set the dates for when you want each campaign to start and finish, the platform takes care of everything else. It handles your social media posts, sends out emails to nurture relationships with 28

your clients, and in early 2024 we’ll even have it updating your blog for you. You’re not just getting a library of content to choose from; you’re getting a pre-organised schedule that runs itself.

This approach is all about making marketing as hassle-free as possible.

You can be involved as much or as little as you like. If you want to add a personal touch, rewrite an email or tweak something, you can. If you’d rather pick a different campaign from our existing library, you can do that, but if you’re happy to let it run on its own, that’s completely fine too. Either way, you’re staying connected with your community and keeping your clinic’s digital presence active and engaging, with minimal effort on your part.

What Makes Our Solution a Game-Changer

I know full well there are a lot of marketing tools and solutions out there, so what really sets our platform apart?

Well, firstly there is nothing else out there like it, full stop.

But here are a few other key points: Profession-Specific Content That Hits the Mark: We don’t just give you generic marketing material.

Our content is written by physical therapists, for physical therapists, ensuring it’s always relevant and authentic. Plus, you have the freedom to personalise it, adapting it for your professional discipline and keeping your clinic’s unique voice.

Stay Ahead with Monthly Campaigns: Our platform ensures your marketing is always fresh and timely.

Each month, we roll out a new campaign that syncs with global health trends and sporting events, keeping you in step with what’s happening in the world.

Efficiency Meets Effectiveness: We know only too well how both time and money are precious when you run a small business. Our platform is built to make the best use of your resources, delivering top-tier, peer-reviewed, marketing materials without the hefty price tag of hiring a marketing agency, or the time investment of creating the content from scratch.

Set and Forget – Or Get Involved – Or Let Us Handle It All: Flexibility is key with our platform. You have the freedom to be as hands-on or hands-off as you prefer. Feel like setting it up and letting it run on its own? Perfect. Want to dive in and tweak things to precisely fit your clinic’s style? Go for it. And if you really want to be totally hands-off, we’ve got you covered. For a little extra, our team can manage everything for you. It’s all about making it work for you, in the way that suits you best.

Scalable to Your Needs: Whether you’re flying solo or part of a larger team, our platform grows with you.

It’s designed to provide value that scales with your practice, ensuring you always have the right tools at your disposal.

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ENTREPRENEUR THERAPIST

Licence Release and Pricing Strategy

We’re rolling out our licences in carefully planned stages. Why? For two main reasons: So we can onboard you thoroughly and not be spread too thin (we are still a small business!)

To maintain geographical exclusivity which we’re currently mapping manually. The article on page 31 goes into more detail.

Looking Ahead: Practical Upgrades On the Horizon

There are so many things we can do with this platform to help make your day-to-day marketing tasks as painless, as automated and as effective as possible.

Here’s what we’ll be working on in the first half of 2024: l Straightforward Analytics: A metrics dashboard that’s all about clarity and action. It’s going to give you a simple, no-nonsense view of how your content is performing, and how many lives it’s impacting, so you can make informed decisions without wading through data overload. l Blog Posting Made Easy: In the first part of 2024, we’ll introduce an automated blog posting tool to help you keep your website full of fresh insights and SEO-optimised without spending hours writing or wrestling with technology. l Personal Touch with AI: We’ll also be expanding our use of AI to basically everywhere that features text-based content, helping you to further streamline the marketing process. l Actionable Marketing Advice: As all the content we produce connects together, we have access to much more detailed metrics than most platforms ever would. This means we can crunch the data behind the scenes to provide you with practical suggestions on how to fine-tune your marketing. l Campaigns Created by You: And looking further down the road, we will be looking to build a tool that will help you to generate complete marketing campaigns from scratch on any niche that you choose, so that you can refine and enhance the service you offer to fit your unique target audiences.

We’re focused on adding features that genuinely add real practical value to your clinic. So, as the digital world grows, so will the tools at your disposal.

In the next article I’ll explain more specifically what the content looks like and how it connects to create a holistic marketing approach, an approach that’s generally missing in most people’s marketing strategies.

WE’RE FOCUSED ON ADDING FEATURES THAT ADD REAL PRACTICAL VALUE TO YOUR CLINIC Co-Kinetic.com

The Missing Link in Your Marketing: Creating a Holistic Marketing Ecosystem for Your Physical Therapy Clinic

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n physical therapy, we understand the critical role of fascia – a connective tissue that envelopes and integrates every part of the body.

Just like fascia, a holistic marketing ecosystem interconnects every aspect of your clinic’s outreach (marketing), ensuring that each element not only functions well on its own but also contributes to the strength and health of the whole.

In this interconnected marketing world, your patient resources, blog posts, social media interactions, and every other marketing activity are like different parts of the body, with your website acting as the core. This ecosystem works in harmony to create a seamless patient journey, much like how fascia maintains the structural integrity and coordinated movement of the body.

Let’s delve into how each component of your marketing strategy works together, echoing the interconnectedness of fascia in our bodies, to build a strong, cohesive, and thriving presence for your clinic.

Here’s How the Dots Connect

Each component of your digital marketing strategy works in concert to create a cohesive patient journey, with trust as the underlying theme. Here’s how they connect and interact: Patient Resources: Advice leaflets serve as the foundation of your content marketing strategy and are invaluable assets in your marketing toolkit.

They offer help and showcase your commitment to patient education. By incorporating these into your website, sharing them through social media, linking to them in blog posts, and distributing via email, you provide consistent value to your patients. This reinforces your role as a trusted advisor but also encourages sharing, further extending your reach and impact.

Blog Posts: Your blog posts demonstrate your expertise, address common patient concerns and questions, and improve your SEO, by acting as authority-building content which helps to draw visitors to your website. By linking to more detailed patient resources, this increases engagement and interaction on your website and can be used to help you build your email list by offering some resources through email lead collection pages.

Social Media: Social media channels are your engagement amplifiers.

They take the helpful content from your blog and patient leaflets and spread it further, engaging current and potential patients in conversation and linking back to your website, increasing traffic and boosting SEO. Testimonials: Testimonials act as trust signals to both Google as well as prospective patients. When featured on your website and shared on social media, they provide social proof, giving potential patients confidence in your clinic’s ability to deliver quality care and encouraging Google to share more of that allimportant organic website traffic with you.

Website: Your website is the hub of your online presence.

It capitalises on the interest generated by your blog and social media content, showcases your testimonials, and provides clear paths to conversion, whether that’s booking an appointment, signing up for a webinar, or downloading helpful resources. In other words, your website should be primed for converting the traffic you’re generating through your other marketing efforts (this is something that often gets neglected).

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Customer Nurture Emails: Once a visitor takes an action on your website, nurture emails come into play. They are firmly rooted in providing value (you must leave the salesy stuff out), and keep the conversation going, provide additional value, and encourage repeat visits to your website or direct conversations, further strengthening the relationship and building trust over time.

Educational Events: These are the engagement deepeners in your marketing funnel. After establishing a connection through informative content and nurturing relationships via email, events such as webinars, workshops, presentations or Q&A sessions provide a live platform for potential and existing patients to interact with you and your clinic in real-time.

They offer a dynamic way to showcase your expertise, answer direct questions and further solidify trust. These events, promoted through your website, social media and in collaboration with other local partnerships, not only educate but also humanise your brand, making your clinic’s presence more tangible and relatable. The opportunity for direct engagement and the value provided through these events can significantly enhance the patient’s journey towards choosing your services.

In this interconnected marketing ecosystem, each piece of content reinforces the others, ensuring that patients receive a consistent message and experience at every touchpoint. This integrated approach not only builds trust but also guides potential patients through each stage of the marketing funnel, from awareness to consideration, and ultimately to the decision to choose your clinic for their care.

Content marketing and its relationship to sales

Strengthening Your Clinic’s resence with a nified Approach

By intertwining patient resources, blog content, social media interactions and other marketing activities, your strategy becomes more than the sum of its parts – it becomes a cohesive force that effectively communicates

your clinic’s values, expertise and commitment to patient care.

This will help you to build a marketing strategy that resonates, engages, and grows your practice in ways you probably never thought was possible.

Next I’ll explain how the licencing model works and why it’s necessary.

Here’s how it works in the Co-Kinetic marketing ecosystem

IN THIS INTERCONNECTED MARKETING ECOSYSTEM, EACH PIECE OF CONTENT REINFORCES THE OTHERS 30

Co-Kinetic Journal 2023;99(January):27-34

ENTREPRENEUR THERAPIST

A Thank You in Tiers: The Philosophy Behind Our New Licencing Approach

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December we launched our completely redesigned and rebuilt physical therapy marketing platform, informed by the lessons learned from its predecessor (now fondly referred to as Co-Kinetic 1.0), and I wanted to explain the thinking behind the tiered licencing model that I’m introducing.

Since I started this business way back in 1999, I’ve always taken an approach that I know is unusual for many companies, and that’s to genuinely reward early supporters.

People who signed up to my journal then, are still paying the same price 25 years later! Why? Because most, if not all of you, will know just how fundamental those early customers are. It’s the difference between making or breaking your business.

I’m grateful every day that I work in the most amazing industry where my customers are (for the most part at least), unbelievably kind, supportive, motivational and empathetic.

And it has become arguably even more important for me, as I’ve travelled through the last 25 years of my business journey, to continue building on that ethos of rewarding the people who support me from the start. And this licence model is intended to do just this.

Why Tiered Licences?

The concept of tiered licence releases is simple. The earlier you join me, the more you stand to gain — not just in savings, but in access to an ever-improving platform and set of tools designed to make your marketing not just easier but also more effective.

I’ve structured the pricing to respect the early investment and early commitment. As the features of the platform develop and the content library continues to grow, the price of the licences will increase.

But there are two other reasons why this approach is important, the first is the need to maintain regional exclusivity as licences are taken up and the second is to help my small team to manage the onboarding process and ensure that everyone can get the help as and where needed (that said the platform makes things so simple, we hope that help will be barely needed at all!).

Here are some of the main licencing features: l Scaled Pricing: Our initial licence fees are set at an very accessible rate (£99 a month at launch), rewarding those who commit early. As licences are purchased, the cost for new members will increase, which means your early commitment gives you more for less. l Equal Access to Expanding Features: Everyone, regardless of when you join, will have access to the Co-Kinetic.com

complete and growing set of tools but those who commit early, gain the advantage of receiving all the future updates and additional content without any increases in price. l Batched Releases for One-to-One Support: Rolling out licences in phases allows us to manage the hands-on support process so that we can ensure you get the best use out of both the content and our platform without feeling rushed or overwhelmed. l Exclusive Regional Presence: To keep your marketing impactful, we are going to carefully control the number of licences available in each area (there will be approximately one licence available for every 50,000 population in your area) and this will be managed internationally, irrespective of where you live in the world. At the outset we will manage this process by mapping each new licence manually, which means we need to control the number of people applying at any one time.

Content and Technology: The Heart of Our Platform

When you choose one of our licences, you’re not just getting a marketing tool; you’re getting a comprehensive suite of content and technology which has been designed specifically to streamline your marketing efforts and enhance your clinic’s online (and offline) presence.

Content Designed to Engage and Educate:

l Monthly Content Campaigns: Stay relevant with fresh campaigns each month, focused on health, sport, wellbeing and musculoskeletal care. l Editable Blog Posts: Two SEO-optimised articles per month to boost your website’s visibility and provide valuable information to both current and potential patients and increase your website traffic. The blog posts are fully customisable. l Customer Nurture Emails: Regular, professionally written emails to keep your audience engaged and informed, fostering trust and encouraging repeat visits.

Every email is editable. You can choose how many to activate each month. l Social Media Posts: A range of ready-to-go posts to maintain a consistent, informative presence on your social channels. The text in these posts is also editable. l Patient Advice Leaflets: Branded materials that are great online but also serve as hands-on takeaways for local outreach, interlinking with your digital content (social 31

posts, blogs and emails) to deliver a genuinely holistic strategy. l Lead-Generating Ads: Pre-written ad copy and imagery to help you build your email list of prospective customers using the social media platforms.

Technology Designed to Simplify and Amplify:

l Social Media Scheduling Tool: A user-friendly scheduler pre-loaded with content, ready for publishing, saving you time and keeping your profiles active. At launch it will connect by default to Facebook, Twitter/X, Instagram, LinkedIn and Google Business. In February 2024 we’ll be adding TikTok. l Automated Email Workflows: Set-and-forget email sequences that nurture customer relationships with minimal input required from you after initial setup. l Automated Blog Posting Tool: Keep your blog updated without manual effort; at launch we’ll provide you with copy and paste text and images and later in 2024 we will be adding an auto-posting function that will do everything for you. l Lead Collection Pages: Conversion-optimised email lead collection pages for each new campaign, to help grow your email list. l List Upload Capability: Easily import your existing client list into the platform for immediate use in your marketing campaigns (coming in late Dec/early Jan 2024). l Engagement Analytics: Understand the reach and effectiveness of your content with straightforward analytics for your social media, website, and emails (coming in Feb 2024).

THIS COMBINATION OF CONTENT AND TECHNOLOGY IS WHAT MAKES OUR PLATFORM UNIQUE

This combination of content and technology is what makes our platform unique and ensures that you have everything you need to pull-off a powerful and structured marketing strategy that really resonates with your audience and builds trust around your services.

Basically my goal is to deliver the marketing system you’ve been asking for — which is as close as possible to an automated marketing ecosystem that’s efficient and handsoff. I’m aiming to significantly reduce the time you spend on marketing each month, without sacrificing your effectiveness.

Licence Tiers and Pricing

Below is a transparent breakdown of tiers, along with the number of licences available in each and their estimated release dates.

TIER

1 2 3 4 5 6

LY MONTH PRICE

ES LICENC NO. OF E L B AVAILA

TED ESTIMA E RELEAS

99 ££99 129 ££129 149 ££149 179 ££179 199 ££199 249 ££249

24

December 2023

18

January 2024

32

February 2024

40

TBD

48

TBD

48

TBD

Why Does Pricing Differ Between Tiers?

l Early Commitment Advantage: The earlier you secure your licence, the more cost-effective it is. Early tiers benefit from a lower price point as a thank you for joining us at the start of our journey. l Increasing Value Over Time: As we release new features and more content becomes available, the price of new licences reflects this added value. l Regional Exclusivity: We increase prices to maintain the exclusivity and impact of the content in your area.

Basically, by getting in early, you’ll get the best pricing available.

What Should You Do Next?

Join the Waitlist Here’s how the waitlist works and why it matters: l No Commitment Necessary: Joining the waitlist doesn’t tie you to a purchase. It’s a way to express your interest and stay informed with developments. l Be the First to Know: As a member of the waitlist, you’ll get the first notifications of licence availability before they’re released publicly. This means you get the chance to secure your licence at the best possible rate before anyone else. l Secure Your Advantage: Early waitlist members have the opportunity to access the lowest pricing tiers and are the first to benefit from our platform’s latest features and content.

32

ERE TLIST H I A W E H N JOIN T YOU CA https://bit.ly/48wwj0n

Tell Your Mates to Join the Waitlist!

If you have physical therapy colleagues running businesses (preferably outside your own regional area ) give them the heads up so that they get the first shout to claim a licence for their own territory.

Remember, joining the waitlist doesn’t tie you into anything, it just ensures that you get first ‘dibs’ on new licences as they are released. Just send them the following link https://bit.ly/48wwj0n.

Co-Kinetic Journal 2023;99(January):27-34

ENTREPRENEUR THERAPIST

The

Clinic Growth Hub

Your Questions Answered is the Clinic Growth Hub, and how does it work?

Q What The Clinic Growth Hub is a comprehensive marketing platform

designed specifically for physical therapy clinics. It provides a range of tools and resources, including content, social media management, email nurture and list building, SEO-optimised blog content and patient engagement strategies, all integrated into a user-friendly platform.

How do I sign up or join the waitlist?

Q To join our platform, start by entering our waitlist here

https://bit.ly/48wwj0n. We release licences in batches to ensure quality and exclusivity. By being on the waitlist, you'll be the first to know when new licences become available.

I need to be tech-savvy or have marketing Q Do expertise to use the Clinic Growth Hub?

Not at all! We've designed the Clinic Growth Hub specifically to be super user-friendly, so you don't need any technical skills or marketing knowledge to get started. Our pre-structured campaigns make it easy for anyone to jump right in. You're guided step by step through the process. And if you're more experienced, you'll find plenty of flexibility to use the platform in sophisticated ways to suit your advanced needs.

Will you help me get started?

Q Absolutely. We know starting with something new can be a

bit daunting, which is why we've made getting started super-easy – please refer to the Support and Training section below for more info.

I don't have the time or inclination, could you Q Ifmanage my marketing for me?

Yes, we can! If you'd prefer us to handle your marketing, we offer this service for a small additional fee. Please email us at support@co-kinetic.com for more details.

Billing and Plans

does the tiered pricing model work?

Q How Please read our previous article. does the regional mapping work?

Q How We allow for one licence per every 50,000 of the population,

broken down by postcode areas (or equivalent) worldwide.

I tied into a contract?

Q Am Our subscriptions are by default monthly rolling subscriptions, Co-Kinetic.com

meaning you're not tied into any long-term contract. You can cancel your subscription at any time and it will expire at the end of the term.

I change my plan later on?

Q Can Absolutely! You can upgrade or downgrade to an another

subscription at any time.

The Content

I see the content before I buy?

Q Can Yes. All our subscriptions come with full 7 day trials. If you decide

the content is not for you, just cancel within that period and you won't be billed a single penny.

profession is your content best suited to?

Q Which Our content is specifically geared towards: physiotherapists;

osteopaths; chiropractors; sports therapists; massage practitioners and any other similarly related professionals.

the content still relevant if I live outside the UK? Q IsAbsolutely, clinical content travels internationally and everything

is editable so that you can make regional adjustments as required.

often is new content released?

Q How Each month, we launch a new campaign that is timely and

globally relevant. The campaigns link to international health awareness dates, sports events, or the latest health and wellbeing discoveries.

an I customise the content to fit my clinic s brand Q Yes, absolutely. While our content comes ready to use, we've

made all the text (emails, social posts and blog posts) fully editable giving you the flexibility to tailor the messaging to reflect your specific professional discipline.

do I know the content quality is going to be good Q How enough?

Since our inception in 1999 as a physical therapy journal publisher, we've been committed to upholding the highest standards of content quality. Just as we meticulously peer-review our quarterly journal, we apply the same rigorous scrutiny to our marketing content.

types of media are included in the campaigns?

Q What We use a variety of media formats including videos, animations,

infographics, memes and animated infographics. In February we will be introducing short form video.

33

Technology

What technical skills do I need to use your platform?

Q None! We've built our platform to be intuitive and user-

friendly. No matter your level of technical expertise, you'll find it straightforward to navigate and use.

re there any specific hardware or software Q requirements?

Nope. Our platform is completely web-based, so all you need is an internet connection and a modern web browser.

inbuilt tools does your technology platform Q What include?

Our platform is equipped with a suite of inbuilt tools designed for ease and effectiveness: l Email Lead Collection Pages: To grow your email list with targeted campaigns. l Social Media Scheduler: With pre-loaded content for automating your social media presence. l Email Workflow Sender: To keep your customer nurture emails running on autopilot. l Automated Blog Poster: (coming in Feb 2024).

Q

Which social networks does your inbuilt social scheduling tool connect to?

At launch we'll be integrating with: Facebook, Instagram, X (Twitter), LinkedIn and Google Business. We’ll be adding short form video and TikTok in Feb 2024.

Can I run more than one campaign at a time or is Q there a limit to how much I can post?

Yes, you can run as many campaigns as you want, whenever you want. And no, we don't believe in imposing limits. Your marketing success, is our business success.

I have your solution, can I just leave my social Q Once media alone?

Our solution is designed to ensure your social media pages are always fresh with high quality, authority-building content, taking the heavy lifting off your shoulders. This allows you to maintain a consistent online presence without the stress of constantly generating content. However, personal posts often resonate more deeply with audiences, leading to higher engagement so we do recommend you sprinkle in the odd one or two each week where possible.

Compliance and Privacy

do you ensure GDPR compliance?

Q How We prioritise data protection and privacy. Our platform

is designed to be fully compliant with GDPR regulations, implementing strict data handling and processing protocols and we regularly review and update our practices to stay aligned with the latest guidelines.

What is your data privacy policy regarding customer

Q data?

We firmly believe that your customer data is just that – yours. We do not use, access, or leverage your customer data; it remains exclusively within your control.

34

Results and ROI

can I measure the success of my marketing efforts Q How using your platform?

At launch we'll be collecting essential metrics like engagement and reach on all your pieces of content. Detailed analytics and dashboards are on our roadmap and will be introduced in early 2024.

What kind of ROI can I expect?

Q The true ROI of our platform lies in the significant time savings and

efficiency it offers. Imagine setting up an entire month's campaign in less than an hour – our pre-created content and automated technology make this possible.

Support and Training

there training materials or tutorials available?

Q Are Yes, we provide a range of training materials, including step-by-

step tutorials, help posts, and an introductory video to get you started.

These resources are designed to make your experience as smooth as possible.

you just do my marketing for me?

Q Can't Yes, we can take the reins of your marketing if that's what you

need. For a small additional fee, we offer a service where we handle everything for you. Contact us by raising a ticket using the chat tool in the bottom right hand corner on any page of our website, and we'll discuss your specific needs and provide a menu of services you can choose from to tailor our involvement.

Got more questions?

If you’ve got more questions, are questioning your current strategy, or just need a sanity check on your marketing approach, I'm here to chat.

No strings attached, just honest advice tailored to your clinic. You can book a chat with me here https://bit.ly/3NqKiN7

THE AUTHOR Tor Davies, a former physiotherapist with a degree in Sport & Exercise Science, transitioned into publishing after a two-year stint as a medical journalist. She founded sportEX medicine in 1999, which evolved into Co-Kinetic, a respected professional education journal in physical therapy.

In 2016, feeling there was more to be done for her industry, she consulted more than 1500 physical and manual therapists worldwide to discover their burning need: help getting clients, which meant help with marketing and sales. This led her to create an innovative marketing solution combining high-quality content with a technophobe-friendly web platform designed to put that content into action, helping physical therapists build their businesses authentically.

Recognised for her expertise, Tor contributes to trade journals, speaks at conferences, delivers to international mastermind groups and recently has taken up a post as a guest lecturer to sports therapy undergraduates. Her latest project, ‘Built on Trust: A 9 Step Roadmap for Attracting Your Ideal Physical Therapy Clients’ offers a practical course for therapists seeking effective marketing strategies, while staying true to themselves.

Join us on Facebook: www.facebook.com/CoKinetic/ Connect with Tor: www.facebook.com/cokinetic.tor Co-Kinetic Journal 2023;99(January):27-34

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