Co-Kinetic Journal Issue 87 - January 2021 by Co-Kinetic

New Webinar from Tor

How to Monetise Your Therapy Skills Online l 14 strategies you can employ to generate ongoing online revenue using specifically your therapy skills l The focus is on building scalable revenue streams which don’t depend on you being physically present and which can thrive despite Covid-19 l I show you step-by-step how to monetise your online strategies and explore a couple of different revenue models l And I’ll explain how to build a marketing funnel from scratch, and then fill it specifically with people primed to want your offering l Finally we look at how you can use a blended online and offline approach, which plays to the strengths of each environment, and helps you to deliver a better overall customer experience

To survive we need to learn to diversify without losing focus on our strengths I’ve listened to 2 of Tor’s webinar’s on marketing and surviving Corvid-19 she is passionate about supporting physios and small practices in making to most of our time and providing added value for our clients. If you are looking at growing your business you wouldn’t be wasting your time listening to one of these.

Thank-you Tor.... The H.E.A.Ling...NURTURED therapist giving 80% of her time and effort creating 200% results for all therapist.. I salute you for being soooo brutally honest and genuine% Thank you Densil Cape Town South Africa

Great webinar and really informative resources which I am now using within my Subscription to get new leads for my clinic. Highly recommend!!!

To Register click here https://bit.ly/30J3dev

RATING OUT OF 101 REVIEWS

Having listened to yesterdays fab webinar I am now inspired to grow my business! I have subscribed today with the basic package free branding and having looked at what’s on offer to market my business I cannot wait to get going! Thank you, thank you, thank you Tor!

what’s inside PRACTICAL

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ENTREPRENEUR THERAPIST

Alone We Can Do So Little; Together We Can Do 21-01-COKINETIC FORMATS WEB MOBILE

So Much

o say that 2020 was an amazingly challenging time for all clinicians and clinic owners would be an understatement. During the different stages of clinical and business restrictions, the strain placed on our personal and professional lives was one I’m guessing most of us hope we never have to face again. However, like all times of adversity we find strength in the people doing good in our respective worlds and industries. Just as some friendships evolved, business relationships also changed. Like many of you I found that the support I received from those reputable and good-willed people a breath of fresh air, in what was otherwise an anxious, heart-palpitating time. I, like you, have followed and respected the work that Tor does with her business, Co-Kinetic. I love the professional language she uses, the real-life experience and value she offers in her education and webinars, and the real-world tone in which she delivers this. Her easy, non-salesy, value-add approach is an excellent example to all of us in allied health, about how we can better relate to our markets without having to be salesy. Which is why I’d like to share this story with you. I am an owner of three physiotherapy clinics in Melbourne, Australia. When Covid-19 really began to impact in Australia we had no option but to review all of our hygiene practices and the way we operated. All aspects of patient flow through the clinic was assessed and it was identified that our bed linen was a major issue. The simple fact was, we either had to have a set of linen

ALONE WE CAN DO SO LITTLE; TOGETHER WE CAN DO SO MUCH

By Darren Ross BPhysio, MPhysio and clinic owner

In 2020 the arrival of the Covid-19 pandemic has meant that physiotherapists have had to adapt to survive. These times, although tough, have also been the push to create better solutions. This article shows how, with the right mix of inspiration, advice, connections, courage and serendipity, adapting can lead not only to a business surviving but a new business being created and flourishing. Read this article online https://bit.ly/3lYto7V or environmentally and aesthetically nasty paper sheets replaced after every patient, or we had to explore alternatives. We decided to remove our terry towelling bed covers and cotton pillow covers and use the vinyl bed and increase use of paper covers on the pillows. The issue was that in one of our clinics with 15 treatment rooms, every couch was a different colour, the beds were all in different states of age, and the materials did not hold up to the increased use of cleaning products. They started cracking and perishing, so we began re-upholstering them. When the first few beds cost us around AUD $600 (approximately £340), we realised this was going to be an expensive exercise and one we would need to do regularly as a result of the cleaning products constantly breaking down the material. So, we began to explore options. Back in 2019, I had a vision of reducing the carbon footprint of each of our clinics by reducing the use of single-use paper covers and laundering. Our commercial laundry was running 80% of the time. I had in

mind the concept of wipe down covers and pillows – it was one of several design ideas my brain all too often comes up with! The more I reviewed the needs of our clinics and the lack of suitable high-grade products, the more this idea took shape. Very quickly I had sourced the highest grade of medical material, one that is antimicrobial, MRSA-resistant, wipe down, and can even be autoclaved for surgical environments … also most importantly, tactile and aesthetically pleasing in a clinical setting. We created beta samples and they worked brilliantly, and so we fitted out our clinics and our problem was solved. But, if we were facing this issue, what

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JOURNAL WATCH

THE 10 MOST DISCUSSED PIECES OF RESEARCH IN PHYSICAL & MANUAL THERAPY (OCT - DEC 2020)

THE 12 MOS PIECES OF T DISCUSSED RESEARCH IN HEALTH & WELLBEING (OCT - DEC 2020)

STANDARDIZED MASSAGE INTERVENTIONS AS PROTOCOLS FOR THE INDUCTION OF PSYCHOPHYSIOLOGICAL RELAXATION IN THE LABORATORY: A BLOCK RANDOMIZED, CONTROLLED TRIAL

THERE IS MORE TO PAIN THAN TISSUE DAMAGE: EIGHT PRINCIPLES TO GUIDE CARE OF ACUTE NON-TRAUMATIC PAIN IN SPORT

WORLD HEALTH ORGANIZATI GUIDELINES ON 2020 ON PHYSICAL ACTIVITY AND SEDENTARY British Journal BEHAVIOUR of Sports

Medicine

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EFFECT OF EXERCISE ON ALL CAUSE TRAINING FOR FIVE YEARS MORTALITY - THE GENERATION IN OLDER ADULTS 100 STUDY: RANDOMISE D CONTROLLE D TRIAL British

Scientific Reports

Medical

Journal

British Journal of Sports Medicine

INSIGHTS FROM A GENERAL SUPPORTING PRACTICE SERVICE A LOWER CARBOHYDR TYPE 2 DIABETES ATE DIET IN EVALUATION MELLITUS ANALYSIS OF PATIENTS WITH ROUTINE CLINICAND PREDIABETES: DATA INCLUDING A SECONDARY AND PRESCRIBIN HbA1c, WEIGHT G OVER 6 YEARS BMJ Nutrition, Prevention

HOW MUCH? HOW FAST? HOW SOON? THREE SIMPLE CONCEPTS FOR PROGRESSING TRAINING LOADS TO MINIMIZE INJURY RISK AND ENHANCE PERFORMANCE

EFFECTIVENESS OF PROGRESSIVE TENDON-LOADING EXERCISE THERAPY IN PATIENTS WITH PATELLAR TENDINOPATHY: A RANDOMISED CLINICAL TRIAL

British Journal of Sports Medicine

& Health

EFFECTS OF MEMORY ANDA SINGLE EXERCISE WORKOUT LEARNING ON FUNCTIONS ADULTS – A IN SYSTEMATIC YOUNG REVIEW Translationa

Journal of Orthopaedic & Sports Physical Therapy

l Sports

FOOT CORE TRAINING TO PREVENT RUNNING-RELATED INJURIES: A SURVIVAL ANALYSIS OF A SINGLE-BLIND, RANDOMIZED CONTROLLED TRIAL

Association

WHO’S AFRAID OF THE BIG BAD WOLF? OPEN-CHAIN EXERCISES AFTER ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION

ASSOCIATIO

British Journal of Sports Medicine

Internal

TAPING FOR CONDITIONS OF THE MUSCULOSKELETAL SYSTEM: AN EVIDENCE MAP REVIEW

Journal of Pain

EFFECTIVENESS OF MANUAL THERAPY IN PATIENTS WITH TENSION-TYPE HEADACHE. A SYSTEMATIC REVIEW AND METAANALYSIS Disability & Rehabilitation

The PDF version of this infographic includes hyperlinks to the individual pieces of research. Click here to access https://spxj.nl/36CShBB

Medicine

FROZEN SHOULDER: STUCK AND STUBBORN

HEALTH AND WELLBEING

Positive Pregnancy:

BUILDING A MEDITATION PRODUCTIVE ROUTINE , CREATIVE AND HAPPIER FOR A MORE SCIENTIFIC LIFE Nature

Chiropractic & Manual Therapies

CUPPING FOR PATIENTS WITH CHRONIC PAIN: A SYSTEMATIC REVIEW AND META-ANALYSIS

Produced by:

N OF PHYSICAL ACTIVITY INTENSITY WITH MORTALITY JAMA

Journal of Orthopaedic & Sports Physical Therapy

COMPARATIVE EFFECTIVENESS OF TREATMENTS FOR PATELLOFEMORAL PAIN: A LIVING SYSTEMATIC REVIEW WITH NETWORK META-ANALYSIS

Medicine

EFFECT OF VITAMIN D ACID SUPPLEMEN SUPPLEMEN TATION, TATION, OR A STRENGTH- OMEGA-3 FATTY PROGRAM TRAINING EXERCISE ON CLINICAL JAMA: Journal OUTCOMES IN OLDER ADULTS of the American Medical

American Journal of Sports Medicine

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LAUGHING IS GOOD BODY - HERE’S FOR YOUR MIND AND WHAT THE RESEARCH YOUR SHOWS

hen someone considers the ‘medical team’ required to facilitate a women through pregnancy and childbirth, physical therapist may not be the first name on the list. Obstetrician, doctor, midwife, nurse, ultrasound technician are the more common list of professional in the top line-up. Typically with our historic reputation of ‘man-handling’ joints and muscles, turning people into pretzels, military-style rehabilitation routines, it’s no surprise a ‘fragile’ pregnant lady wouldn’t make us her first port of call. And yet, if we play our cards right with the patients of our practice, their extended families, friends and members of our community, we can have a huge role in encouraging a healthy and happy pregnancy experience. We often have the most one-on-one time with a patient (compared to many medical professionals), developing trust and deeper relationships. We have a key responsibility during those 9 months, and postpartum, to: l educate and build confidence in pregnant women that being physically active is safe and actually good for them and their baby; l not neglect injured or painful areas on their body just because they are pregnant – physical therapy treatment can be safe if done cautiously; l reassure that massage is safe and can relieve pain, and also that reducing stress and inducing relaxation is a much needed experience when pregnant; l educate that pregnancy back pain can be treated and relieved; and l educate that urinary incontinence can be managed through exercise during both pregnancy and postpartum phases.

The Conversatio n

The PDF version of this infographic include s hyperlinks to the individ pieces ual of researc h. Click here to https://spxj.nl/access 39GENGR

Produced by: TIME-SAVING

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RESOURCES

FOR PHYSICAL

A META-REVIE ROLE OF EXERCISE,W OF ‘LIFESTYLE PSYCHIATRY SMOKING, PREVENTION ’: AND TREATMENT DIET AND SLEEP THE IN THE OF MENTAL DISORDERS World Psychiatry

MINDFULNE SS-BASED STRESS THE MANAGEME NT OF CHRONIC REDUCTION IN PAIN AND ITS Journal of the American COMORBID DEPRESSION Osteopathi c Association

EXERCISE AND

THE BRAIN: ACTIVITY CHANGESTHREE WAYS PHYSICAL ITS VERY STRUCTURE

AND MANUAL

THERAPISTS

The Conversatio n

EXERCISE BENEFITS

ON ALZHEIMER’ STATE-OF-T S DISEASE: HE-SCIENCE

Ageing

Research

Reviews

PHYSICAL & MANUAL THERAPY AND HEALTH & WELLBEING INFOGRAPHICS

We know these facts but pregnant women can be very anxious, nervous and protective of their bump. They would rather suffer the pain than seek help if they fear it may hurt their baby. To ensure their trust in us, we must

PRACTITIONER UPDATE

Advice on many aspects of life, including physical activity, manual therapy and massage, nutrition and sleep, can help a woman have a happy and healthy pregnancy as well as promoting healthier outcomes postpartum for both mother and baby. We, as physical therapists, are in an ideal position to give this advice and encouragement. This article describes the current guidelines so that you can tailor your recommendations according to the unique situation and pre-pregnancy exercise levels of each of your pregnant patients, enabling them all to have the best possible experience of pregnancy. Read this article online https://spxj.nl/3fXqzCo make sure we know the exact facts and current recommendations regarding their care. This article therefore plans to summarise the key physical activity guidelines for pregnant women (including precautions, red flags and proscriptions) and the role of exercise and manual therapy in the treatment and prevention of pregnancy back pain, as well as highlighting some key dietary and sleep hygiene concerns that may impact on the pregnancy experience.

Physical Activity and Pregnancy

We all know that regular physical activity across the lifespan is associated with substantial health benefits, including improvements in physical fitness and mental health, as well as decreased risk of chronic disease and mortality. Pregnancy is a unique period of a woman’s life, where lifestyle behaviours, including physical activity, can significantly affect her health, as well as that of her foetus. Although guidelines around the world recommend women without contraindications engage in prenatal physical activity, fewer than 15% of women will actually achieve the minimum recommendation of 150 minutes per week of moderate-

By Kathryn Thomas BSc MPhil 21-01-COKINETIC FORMATS WEB MOBILE

All references marked with an asterisk are open access and links are provided in the reference list intensity physical activity during their pregnancy (1*). Unfortunately, uncertainty among some pregnant women and obstetric care providers as to whether prenatal physical activity may increase the risk of miscarriage, growth restriction, preterm birth, fatigue or harm to the foetus has created a barrier to being active (1*). Concerns over harms have not been substantiated by research and the risks of not engaging in prenatal physical activity have not been adequately emphasised. Over the last three decades, the rates of pregnancy complications, such as gestational diabetes mellitus, pre-eclampsia, gestational hypertension and

Co-Kinetic.com

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PHYSICAL THERAPY

Frozen Shoulder: Stuck and Stubborn Frozen shoulder: we’ve all heard of it but do we really understand it and know how to treat it? The answer is probably no, because it is a bit of a conundrum. It’s aetiology is unclear and there is a lack of consensus for best management. Added to which it can last for a long time (years) and patients often do not fully recover. Physical therapy, however, can speed resolution and improve outcomes. This article will help you to accurately diagnose this condition and provides you with all the information you need to tailor an individualised treatment plan for your patient based on both biomedical and psychosocial factors for optimal outcome. This article is supported by a number of useful videos and links to further information. Read this article online https://spxj.nl/3ltEbXc By Kathryn Thomas BSc MPhil

Background

Adhesive capsulitis, periarthritis, and frozen shoulder are all terms used to describe a painful and stiff glenohumeral joint. The aetiology of adhesive capsulitis is not clearly understood and a lack of consensus remains in clinical management for this condition. It can occur as a primary idiopathic condition or secondary to medical conditions or trauma. The hallmarks of frozen shoulder are pain and stiffness, caused by formation of adhesions or scar tissue in the glenohumeral joint. Management strategies vary depending on stage of presentation, patient factors and clinician preferences; treatment ranges from conservative options to surgical intervention (1,2*,3*). The incidence rate of this painful musculoskeletal disorder is 2–5% in the general population with a higher prevalence among elderly individuals and patients with diabetes. Frozen shoulder is defined by three key clinical characteristics (Video 1) (1): 1. an insidious onset of severe pain; 2. shoulder stiffness with markedly reduced external rotation (Video 2); and 3. negative radiographic findings.

21-01-COKINETIC | SHOULDER FORMATS WEB MOBILE PRINT The term ‘adhesive capsulitis’ is used synonymously, reflecting the pathophysiological features of frozen shoulder – namely inflammation, fibrosis and contracture of the glenohumeral capsule and/or adjacent bursa. Although frozen shoulder is a benign and self-limiting condition, usually extending over a period of 1–3 years, stiffness and pain are incompletely resolved in 20–50% of patients, leading to long-lasting impairment in shoulderrelated daily activities and sleep quality. A recent review regarding the natural history of frozen shoulder revealed that the theory of progressing to full recovery without any treatment was not supported in the literature. Therefore, appropriate management is necessary to accelerate symptom relief and attain optimal functional recovery (1). Even in patients that receive therapy, only 59% have a near normal shoulder after 4 years. However, patients with persistent symptoms seem to cope or accept this, as the longstanding symptoms (beyond 3–4 years) are commonly mild (4). Non-surgical therapies are the mainstay treatments for frozen shoulder. Surgical management is considered only after failure of conservative

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

Video 1: How to diagnose Frozen Shoulder (Courtesy of YouTube user Physiotutors) https://youtu.be/5zpXbvEf9j0

Video 2: True or Pseudo Frozen Shoulder? | Adhesive Capsulitis Diagnosis (Courtesy of YouTube user Physiotutors) https://youtu.be/rqCBa2zqASo

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POSITIVE PREGNANCY: PRACTITIONER UPDATE

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RETURN TO COMPETITION FOLLLOWING COVID-19

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

BIOTENSEGRITY AND HUMAN MOVEMENT: THE IMPORTANCE OF CLOSED KINETIC CHAINS

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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

OPEN

= OPEN ACCESS

RISK OF INJURIES ASSOCIATED WITH SPORT SPECIALIZATION AND INTENSE TRAINING PATTERNS IN YOUNG ATHLETES: A LONGITUDINAL CLINICAL CASE-CONTROL STUDY. Jayanthi N, Kleithermes S, Dugas L et al. Orthopaedic journal of sports medicine 2020;8(6):2325967120922764 A total of 579 young athletes aged between 7 and 18 years (mean age, 14.1±2.3 years; 53% female), presenting for sportsrelated injuries or sports physical examinations were recruited from either sports medicine clinics or paediatric/family medicine offices and completed a baseline survey and first follow-up survey at 6 months. Of this sample, 27% (158/579) of participants were uninjured and 73% (421/579) were injured, with 29% (121/421) of injuries classified as reinjuries. Consistent with previous studies, over the 3-year study period the degree of sport specialisation had an effect such

that more specialised athletes were significantly more likely to be injured or have an overuse injury compared with less specialised athletes after adjusting for potential confounders. Additionally, female athletes were more at risk for all injuries and overuse injuries after adjusting for covariates. Finally, young athletes who trained in weekly hours in excess of their age or who trained twice as many hours as their free play were significantly more likely to be injured on univariate analysis.

Co-Kinetic comment There are lots of similar studies and yet still coaches and sadly parents push and push to get little Janet and John to be the next sporting superstar. One

RISK FACTORS FOR OVERUSE INJURIES IN SHORT- AND LONG-DISTANCE RUNNING: A SYSTEMATIC REVIEW. van Poppel D, van der Worp M, Slakkbekoorn A et al. Journal of Sport and Health Science 2020;doi:https://doi. org/10.1016/j.jshs.2020.06.006

OPEN

For the purposes of this study, short-distance running is a mean of ≤20km/week and ≤10km/session and long-distance running a mean running distance >20km/ week and >10km/session. Data came from electronic databases and the GRADE approach was used to assess the quality of the evidence. A total of 29 studies were included; 17 studies focused on short-distance runners, 11 studies focused on long-distance runners, and 1 study focused on both types of runners. A previous running-related injury was the strongest risk factor for an injury for long-distance runners, with moderate-quality evidence. Previous injuries not attributed to running was the strongest risk factor for an injury for short-distance runners, with high-quality evidence. Higher BMI, higher age, sex (male), having no previous running experience, and lower running volume were strong risk factors, with moderate-quality evidence, for short-distance runners. Low-quality evidence was found for all risk models as predictors of running-related injuries among shortand long-distance runners.

Co-Kinetic comment This supports lots of previous papers that give previous injury as the main risk factor in the next injury. You can only conclude that these injuries are not being rehabilitated properly in the first place. 4

OPEN

or two might make it but the majority get broken on the journey and never make it to the top. The USA National Athletic Trainers’ Association has issued an official statement recommending that adolescent and young athletes delay specialising in one sport as long as possible, participate only in one organised sport per season, not play a single sport for more than 8 months of the year, not participate in organised sport or activity for more weekly hours than their age, have a minimum of 2 days a week without activity for rest and recovery, and a rest at the end of each session. You can find the statement and references to the research that supports it here https://bit.ly/2JcMREE.

Injury occurs because of these factors. l Preparatory activity factors: such as warm-ups, which are often neglected or sometimes not done at all. l Poor physical condition of the participants: sessions need to be tailored to the participants who may only be taking part because they have been told to or they are trying to make an impression on teachers, coaches or their peers. l Poor basic physical mobility: studies of exercise physiology show that the nerve excitability of teenagers is higher than that of other age groups, and their inhibition ability is relatively poor. This contributes to an inability to resist the impact or twist caused by high-intensity activities during exercise.

Co-Kinetic Journal 2021;87(January):4-11

RESEARCH INTO PRACTICE

Journal Watch KNEE INJURIES IN NORMAL-WEIGHT, OVERWEIGHT, AND OBESE RUNNERS: DOES BODY MASS INDEX MATTER? Juhler C, Andersen KB, Nielsen RO et al. Journal of Orthopaedic & Sports Physical Therapy 2020;50(7):397–401

This report compiled data from four independent prospective studies (2612 participants). The proportion of runningrelated knee injuries out of the total number of runningrelated injuries was calculated for normal-weight (BMI, less than 25kg/m²), overweight (BMI, 25kg/m² to less than 30kg/m²), and obese runners (BMI, 30kg/m² or greater). The measure of association was absolute difference in proportion of running-related knee injuries with normal-weight runners as the reference group. A total of 571 runners sustained a runningrelated injury (181 running-related knee injuries and 390 running-related injuries in other anatomical locations). The proportion of running-related knee injuries was 13% lower among overweight runners compared with normal-weight runners. Similarly, the proportion of running-related knee injuries was 12% lower among obese runners compared with normal-weight runners.

Co-Kinetic comment Size isn’t everything. If you are a pound or two over the handicap, fear of injury is no reason not to pound the streets. The speculated reasons for this are that the larger individuals run slower and that this changes the way that the load for each stride is distributed.

SPORTS INJURY AND PREVENTIVE MEASURES IN PHYSICAL EDUCATION AND TRAINING. Qian B. Presented at the International Conference on Economic Development and Education Innovation 2020 (EDEI 2020), Kunming, China l Technical problems: this is an area for coaches. There is a need to ensure that the participants can perform movements required for the particular sport correctly. l Venues, equipment and clothing: the playing surface is important. Full contact sports on a hard surface are a recipe for disaster. Uneven or damaged surfaces encourage twisted ankles. Is unused equipment being left on the ground as a trip hazard? Are helmets, pads, mouth guards, etc, being worn when required?

Co-Kinetic comment This is a conference presentation about training physical education students

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OPEN

but it serves as an injury prevention checklist for all sports training sessions. It may all seem a bit obvious but injuries still happen because of these factors so someone isn’t taking notice. If you do not think this is true check out how many elite footballers are shown on TV training without shin pads or how many adult players wear kids’ shin pads in games. Think also about Aussie fast bowler Glen McGrath who famously tripped over a loose ball and missed a couple of vital test matches resulting in his side losing the Ashes. The paper concludes, however, that despite all your best efforts injuries will occur so have an on-site first aid treatment plan.

MESENCHYMAL STEM CELL THERAPY FOR SPORTS INJURIES – FROM RESEARCH TO CLINICAL PRACTICE. Looi QH, Eng OPEN SP, Liau LL et al. Sains Malaysiana 2020;49(4):825–838 This review paper discusses the treatment of sports injuries with mesenchymal stem cells (MSCs) using data from preclinical and clinical studies. Stem cells are natural biological cells which are capable of self-regeneration and differentiate into other cell types. Although there are multiple types of stem cells, MSCs seem to be the most promising for use in injury recovery because they can differentiate into bone, cartilage, nerve, tendon and ligament cells and they can be harvested from many tissues including bone marrow, fat, peripheral blood and umbilical cord. They are safe to use because they do not produce an inflammatory response and have a very low risk of tumour formation after transplantation owing to their limited replication lifespan. They are capable of modulating the cell– cell signalling pathways through the secretion of various cytokines and growth factors. The evidence comes mainly from animal and in vitro studies although there have been some human trials using allogenic cells. MSCs appear to improve regeneration of articular cartilage, meniscus plus ligament osteointegration, and biomechanical strength. There is, to date, no clinical data reported on ligament repair. A few studies have reported improved biomechanical properties and collagen organisation of damaged Achilles tendons and in the repair of elbow extensor and rotator cuff tendons. Similar studies have reported acceleration of the muscle healing process and a decrease in the formation of scar tissue that affects normal muscle function. Faster bone fracture healing has also been reported, along with claims of nerve regeneration.

Co-Kinetic comment This is a very optimistic paper. It contains references to numerous studies which give the dosage and application method if you would like more information on the subject. It reports that so far the results from most of the human trials showed that MSC therapy is safe and effective in treating sports injuries. It could be the future!

HIGH INTENSITY LASER THERAPY OPEN EFFECT ON PAIN IN PATIENTS WITH MYOFASCIAL TRIGGER POINTS. Ahmed HM, Taleb EA, Eldesoky MT et al. Egyptian Journal of Physical Therapy 2020;3:1–8 Fifty patients suffering from myofascial trigger points in the upper trapezius muscle (32F, 18M; age range 20–40 years; BMI <25kg/ m²), were randomly assigned into two equal groups. Group A received traditional treatment only (transcutaneous electrical nerve stimulation, ultrasound, passive stretch and isometric exercise), group B received the same treatment plus high-intensity laser therapy for 2 sessions/week for 4 weeks. Measurement of the visual analogue scale was recorded before and after the intervention. The results showed that there was significant difference between the two groups in the outcome measures in the post-treatment assessment, with the intervention administered by group B being more significant than the control group.

Co-Kinetic comment The device used was a ‘Hilt Zimmer Opton pro’ and, judging by this study, it works but the machine costs thousands or at least it does from the sales sites that give prices. Sadly, not all do; they want your details to give you a quote. Why? Are they trying to judge how much your organisation can pay? If so, ignore them and buy from the people who are up front. Meanwhile if you are interested in the ‘traditional’ treatments mentioned in this paper it is very good at giving dosage for the manual therapy and electrotherapy used.

THE USE OF RECOVERY STRATEGIES BY SPANISH FIRST DIVISION SOCCER TEAMS: A CROSS-SECTIONAL SURVEY. Altarriba-Bartes A, Peña J, Vicens-Bordas J et al. The Physician and Sportsmedicine 2020;doi:10.1080/00913847.2020.1819150 The data for this study came from an online survey designed to explore the recovery strategies used by all the professional football teams who played in the Spanish first division (LaLiga), during the season 2018– 2019 (n=20) and the ones promoted for the season 2019–2020 (n=3). The recovery strategies were grouped as follows: l Natural strategies: active field- or gym-based, active pool-based, active or passive stretching, sleep/ nap, food or fluid replacement and supplement use. l Physical strategies: cryotherapy or cooling methods (cold/ice bath/shower/immersion and ice pack/vest application), contrast temperature therapy (contrast bath/shower/immersion and sauna), heat methods (heat pack application), compression garments, massage, foam

rolling and liniment or gel/cream application. l Psychological strategies: progressive muscle relaxation and imagery/ prayer/music. l Complementary/alternative strategies: reflexology or acupuncture and medication use.

Do you think that aspects of sports are truly evil? If so, this essay on ethical philosophy is for you. The highlights are that there are two kinds of evil. ‘Natural evils’ are bad states of affairs which do not result from the intentions or negligence of a person who has the ability to discern right from wrong and to be held accountable for his or her own actions. In the philosophy world such beings are called ‘moral agents’. Hurricanes and toothaches are examples of natural evils. By contrast, ‘moral evils’ do result from the intentions or negligence of moral agents. Murder and lying are examples of moral evils. Sport is an activity performed by moral agents. The application of rules in sports presupposes that participants have a capacity to distinguish rights from wrongs. Yet, in the world of sports, rules are frequently violated, thus

occasioning evil. Cheating has a long history in sports. Some philosophers (and many players) have considered that cheating is not necessarily a moral wrong. That people may cheat is part of the structure of the sport and is taken into consideration in the rules, so that cheating in a sport can be built into audience and player perceptions of the game. If it is true that cheating is recognised as an option that both sides may morally take up, then in general the principles of equality and justice are not affected. It may be that player A is a better cheater than player B, yet if cheating is recognised as part of the skill and strategy of the game, then A’s advantage is merely an aspect of his being a better player than B. Cheaters expect that they are entitled to make exceptions to the rules for their own advantage and, ultimately, aspire to win by not meeting the rules agreed to in the first place. However, it does harm the losers who in the absence of

It was found that teams used different recovery protocols and combinations, although natural and physical strategies such as sleep/nap, food/fluid replacement, cold/ice bath/shower/ immersion and massage were always present. There is no agreement in the protocols and timings employed. Three physical strategies showed a higher presence in the recovery protocols after competition: cold/ice bath/shower/ immersion, massage and foam rolling; always used by seventeen teams (74%), sixteen (70%) and thirteen (57%), respectively. The design and supervision

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of recovery are multidisciplinary tasks in 87% of the teams. The findings demonstrate that although there is a body of scientific evidence on recovery, a gap between theory and practice exists with 13% of the teams acknowledging that insufficient logistics and economic resources limit the use of some strategies, and two teams (9%) not periodising or individualising recovery.

Co-Kinetic comment Neither the diversity of recovery methods nor the fact that medical departments cite a lack of resources that limit their options is a surprise because there is no simple ‘one size fits all’ approach. Sadly, too many clubs worldwide are happy to pay millions for and to players but penny pinch in how to look after them. What is a shock is that two clubs (9%) do not tailor their strategies to the individuals and one team reported not using any recovery strategy after training, either in preseason or in season.

EFFECT OF FASCIAL MANIPULATION ON GLENOHUMERAL INTERNAL ROTATION DEFICIT IN OVERHEAD ATHLETES – A RANDOMIZED CONTROLLED TRIAL. Mathew NP, Raja G P, Davis F. Muscles, Ligaments & Tendons Journal 2020;10(1):17–23 Forty-three asymptomatic overhead athletes with a glenohumeral internal rotation deficit (GIRD) of more than 20° when compared with the non-dominant shoulder were randomly assigned to two groups. The experimental group received 3 sessions of fascial manipulation (FM) treatment in 2 weeks. The FM was applied to densified centre of coordination (CC) points located on the myofascial sequences for 5 to 8 minutes at each CC point. The control group received 3 sessions of posterior shoulder capsule release using a tennis ball under supervision. Along with the ball release, the therapist taught the control group home-based, unsupervised sleeper and cross-body adduction stretches. A universal goniometer was used to measure the internal rotation range of motion (IRROM) before and after all 3 treatment sessions in both groups. The results showed that there was no statistically significant differences between the control and experimental groups.

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However, immediate improvement in the IRROM following FM was more substantial in the experimental group following each session.

Co-Kinetic comment The authors state that GIRD is usually managed by stretching and soft tissue release of the posterior shoulder capsule. That might be part of a treatment plan but posture and scapula rhythm need to be addressed as well. The fact that they were not may explain why there seems to be little difference in the groups post-intervention. In addition, the FM in the intervention group involved using a finger joint or elbow to push into the CC point. There is not that much difference between that and the self-massage the participants did with a tennis ball. The CC points refer to a FM protocol designed by Stecco (2004 & 2009). They are small areas on the deep fascia where tensional vectors coincide located in myofascial units in each of the six body planes. The best analogy for this is to think of four horses in a line pulling a chariot. The reins from the four horses come together at a CC in the hand of the driver. For more information on this protocol see Stecco L. Fascial manipulation for musculoskeletal pain. Piccin 2004. ISBN 978-8829916979. Buy from Amazon £30.00 https://amzn.to/3lqAVvV and Stecco L, Stecco C. Fascial manipulation: practical part. Piccin 2009. ISBN 978-8829919789. Buy from Amazon https://amzn.to/3lso1NO.

THE PROBLEM OF EVIL IN SPORTS: APPLICATIONS AND ARGUMENTS. Andrade G. Sport, Ethics and Philosophy 2020;doi:10.1080/17511321.2020.1788629 cheating may have been the winners. Those who unfairly profit from cheating in sport are taking away from honest athletes what is duly theirs. But, apart from losers, cheating harms the beauty and integrity of sports itself. Cheating in turn encourages other contestants to cheat. In fact, one typical selfserving excuse provided by abusers of steroids and other illegal substances in sports is that other competitors do it and not doing actually becomes an insurmountable disadvantage. Trash talking must also be considered a moral evil. Trash talking constitutes a form of disrespect, especially if charged with race or gender bias. Trash talking harms the dignity of sports’ participants and may even leave permanent psychological damage. Retaliation may also qualify as Co-Kinetic.com

a moral evil. Even if done under the permissibility of the rules of the game, retaliation in sports is considered a moral wrong. Injuries are bound to happen in any sports activity, so occasioning them to happen in rivals is not necessarily a moral evil. However, intentionally seeking to cause them as a form of retaliation is morally deficient. Consequently, every time an athlete cheats, trash talk to opponents, or unjustly retaliates against rivals, he/she is exercising free will. In the context of sports, the presumption of free will is an important one. In athletic contests, performance is valued in as much as it is based on athletes’ efforts and discipline, and this comes from moral agents’ free will. The religious conclusion to this is that facing moral evil is character building. This might be especially

appealing in a sports context. ‘No pain, no gain’ is a very popular slogan among athletes and coaches. The phrase neatly expresses the idea that in order to succeed and grow towards excellence, athletes must suffer the rigors of training.

Co-Kinetic comment This is a thought-provoking piece. Morally, when does acceptable cheating become unacceptable cheating? If you like a religious debate, there is much in this essay for you to enjoy. It cites the Maradona ‘hand of God’ goal, when the Argentinian handballed to score a goal against England, to be either divine providence or an argument that God does not exist because to watch and let this moral evil pass when it could have been prevented is promoting evil. Whether or not you agree with that may have a lot to do with your nationality. 7

STANDARDIZED MASSAGE INTERVENTIONS AS PROTOCOLS FOR THE INDUCTION OF PSYCHOPHYSIOLOGICAL RELAXATION IN THE LABORATORY: A BLOCK RANDOMIZED, CONTROLLED TRIAL. Meier M, Unternaehrer E, Dimitroff SJ et al. Scientific Reports 2020;10:14774 The aim of this paper was to investigate whether standardised massages are capable of reliably inducing physiological and psychological states of relaxation. Relaxation was indicated by changes in high frequency heart rate variability (HF-HRV), a vagally-mediated heart rate variability component, and repeated ratings of subjective relaxation and stress levels. Sixty healthy women were randomly assigned to a vagus nerve massage (n=19), a soft shoulder massage (n=22), or a resting control group (n=19). The protocol was that base line measurements were taken followed by a 10-minute massage intervention. For the vagus group this was a standardised head/neck massage that was applied with moderate pressure. The stimulation included stroking and twisting the trapezius muscle by gripping between the trapezius and sternocleidomastoid muscle, below which the main strand of the vagus nerve runs, to reach deeper regions plus stroking the muscles below the base of the skull from the spine to the back of the ears. The shoulder massage group protocol was to stroke and softly touch the neck and shoulder. The resting group were seated with no physical contact. During the intervention, HF-HRV and subjective relaxation increased, whereas subjective stress decreased significantly in

In a nutshell this review says that there is some low-level evidence to suggest the use of Kinesio tape for athletes with acute shoulder symptoms and acupuncture for carpal tunnel syndrome and as an adjunct treatment for low back pain. For sports massage it quotes a comprehensive meta-analysis by researchers at the University of Illinois, Illinois, USA, that evaluated several variables and factors from 37 studies which included gate control theory of pain reduction, promotion of parasympathetic activity, influence of body chemistry, mechanical effects, promotion of restorative sleep, and interpersonal attention. The authors concluded that the current body of evidence “supports the general conclusion that massage therapy is effective”. An additional meta-analysis consisting of 12 RCTs evaluating the impact of massage therapy on neck and shoulder pain suggests immediate positive effects of massage therapy on both shoulder and neck pain, with shortterm positive effects for shoulder pain only. However, functional status of the shoulder was not found to be markedly affected by massage therapy. 8

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all groups. Both massage interventions elicited significantly higher HF-HRV compared to the control group. Therefore, both massage protocols increased psychophysiological relaxation and may serve as useful tools in future research.

Co-Kinetic comment Sadly, for a paper with the word ‘standardised’ in its title it does not provide much detail about the massage protocol.

THE EVIDENCE FOR COMMON NONSURGICAL MODALITIES IN SPORTS MEDICINE, PART 1: KINESIO TAPE, SPORTS MASSAGE THERAPY, AND ACUPUNCTURE. Trofa DP, Obana KK, Herndon CL et al. OPEN Journal of the American Academy of Orthopaedic Surgeons. Global Research & Reviews 2020;4(1):e19.00104 In yet another systematic review of 26 studies consisting of 2565 patients, the authors concluded that therapeutic massage reduced pain and improved function compared with no treatment for some musculoskeletal conditions. Part 2 of this series evaluates cupping and blood flow restriction (BFR) training (Trofa et al. The evidence for common nonsurgical modalities in sports medicine, part 2: cupping and blood flow restriction. Journal of the American Academy of Orthopaedic Surgeons. Global Research & Reviews 2020;4(1):e19.00105 https://spxj. nl/2KXIzkX). This paper concludes that although the body of recent evidence is limited, the current literature suggests that low-load BFR training can increase muscle strength, endurance, cross-sectional area, and potentially sport-specific performance. In addition, low-load BFR training holds promise for enhanced recovery from injury. Finally, for the elite athlete,

maximal strength benefits may be achieved by supplementing traditional high-load training with low-load BFR training. For cupping there is a paucity of recent research, guidance and regulation, particularly regarding its efficacy for improving athletic performance. However, there is support for the use of cupping in treating musculoskeletal pain associated with nonspecific neck, back and shoulder pain.

Co-Kinetic comment As is often the case, there is a caveat: the evidence for these modalities may be positive but the quality of the studies is low. However, there is a key sentence in this paper, “Nonsurgical modalities are low-cost treatment strategies with very few reported adverse outcomes”. In fact the adverse reaction incidence is reported as being as low as adverse outcomes, which is reported to be as low as 0.008%. The worst of these was a male ice hockey player who developed rhabdomyolysis following BFR. The bottom line is that these modalities are worth trying even if the so-called high-quality studies are not available at present. Co-Kinetic Journal 2021;87(January):4-11

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EFFECTS OF MANUAL CORRECTION OF PELVIC TILT ON THE COURSE OF ONYCHOCRYPTOSIS. Frank S, Frank M, Frank G. World OPEN Science 2020;7(59):doi:10.31435/rsglobal_ ws/30092020/7200 (in Russian) This study started with the premise that pelvic tilt is one of the root causes of onychocryptosis (ingrowing toenails). Recovering the correct position of pelvic bones via manual methods restores the symmetrical position of the nail edge in the lateral nail fold of a toe and thus preventing any damage to the soft tissues of the lateral nail fold, which is what causes onychocryptosis in the first place. By correcting pelvic bone imbalance via manual methods, we can therefore eliminate onychocryptosis without even touching the affected toe.

Co-Kinetic comment Sadly we could only access the English translation of the abstract not the full paper. This is a pity because the idea of a toe problem being caused by a postural issue further up the kinetic chain is worth exploring.

PREVALENCE OF MUSCULOSKELETAL PROBLEMS IN PHYSIOTHERAPY STUDENTS. Desai M, Jain S. International Journal of Health Sciences and Research 2020;10(4):59–64

This was a cross-sectional survey carried out among 250 physiotherapy students aged 18–24 years both males and females who are first- to fourth-year undergraduate physiotherapy students and interns at the School of Physiotherapy, Nerul, Navi Mumbai, India. They were given a questionnaire aimed at getting information regarding the various musculoskeletal problems they faced. The results showed that 70.1% of the physiotherapy students had musculoskeletal pain after joining the physical therapy profession and the most common sites of pain were low back (177), neck (167), shoulders (114) and upper back (102).

Co-Kinetic comment In a similar study of qualified Australian physios, West & Gardner (2001) found that 55% of respondents had experienced a work-related injury and 40% had experienced injury in the previous year and that injured physiotherapists modified their techniques to continue working. So why weren’t they taught not to get injured in the first place? (West DJ, Gardner D. Occupational Injuries of physiotherapists in North and Central Queensland. Australian Journal of Physiotherapy 2001;47:179–186 https://bit.ly/2JmreBx)

THE eSPORTS CONUNDRUM: IS THE SPORTS SCIENCES COMMUNITY READY TO FACE THEM? A PERSPECTIVE. Fiore R, Zampaglione D, Murazzi E et al. The Journal of Sports Medicine and Physical Fitness 2020;60(12):1591–1602 According to the authors there are several characteristics that eSports have in common with traditional sports: from the spirit of competition, to the structural composition of the teams, to the increase in performance with training and practice, up to the injuries and physical and psychological stress of the athlete. Emphasising the similarities between electronic and non-electronic sports is essential in order to make people, and the scientific community in particular, understand how they should be considered equal to the ‘traditional’ vision of sports especially in the need for professional medical support. The number of professional and

amateur eSports players increases every day, as does the birth of professional organisations and national teams, whereas medical monitoring seems to have fallen behind. The hope is that the scientific community and in particular the medical disciplines will be able to closely support the world of eSports to guarantee the correct assistance to all professional and non-professional athletes. An increase in the number of scientific works and specific studies will certainly bring benefits in countering physical attrition, reducing the risk of injury, in psychological support to athletes and in the fight against doping reality.

Co-Kinetic comment There are lots of papers asking if eSports are equal to the traditional blood and sweat versions. No one has an answer yet, but the global lockdowns and curtailment of ‘real’ sport is pushing those with a competitive edge towards the consoles. Maybe it is time the scientific community stopped the arguments about whether or not eSports are equal or not and just got on with making sure the players are fit for the task and the injuries are treated.

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OPEN EFFECTIVENESS OF UPPER EXTREMITY PROPRIOCEPTIVE TRAINING ON REACTION TIME IN TABLE TENNIS PLAYERS. Bokil C, Bisen R, Kalra K. International Journal of Health Sciences and Research 2020;10(5):34–39

Thirty-four novice table tennis players, both males and females aged 7–15, were divided into two groups: a control group (n=17) who underwent conventional training for 6 weeks consisting of lower limb strengthening exercises, core strengthening exercises and agility training exercises and an experimental group (n=17) who underwent the same training plus upper limb proprioception training. This included hands on a wobble board: 30s hold, 1min hold, 2min hold; hands on a Bosu ball: 30s hold, 1min hold, 2min hold; elbows on gym ball: 1min hold, 2min hold; hands on a gym ball for a 1min hold and other similar exercises. The reaction time of all the players was measured using the ruler drop test at base line and at 6 weeks. Within-group comparisons showed no significant statistical difference in reaction time in the control group whereas the reaction time significantly decreased in the experimental group. Between-group comparisons showed a significant statistical reduction in reaction time for the experimental group.

Co-Kinetic comment We have said this before when presenting similar studies. The question is: Why is proprioception training not ‘conventional’ in all sports? 9

ACCURACY OF CLINICAL EXAMINATION AND MRI FOR MENISCAL INJURIES OF KNEE JOINT TAKING ARTHROSCOPY AS THE GOLD STANDARD. Naqvi MA, OPEN Sair-ur-Rehman M, Shafiq Z et al. Medical Forum 2020;31(9):199–202 A total of 178 patients of both genders, aged 18–45 years and presenting with a history of sports or accidental knee injury were enrolled in the study. All the patients had clinical as well as MRI evaluation which was then compared to findings during arthroscopy. Clinical examination included history and examination, namely suggestive symptoms (including pain, swelling, limited motion, locking and clicking) and the McMurray test. Meniscal injury was detected by MRI in 117 (65.3%) cases and was undetected in 61 (34.7%) of cases. Meniscal injury was detected by clinical examination in 115 (64.1%) cases and undetected in 63 (35.9%) cases. Arthroscopy detected meniscal injury in 113 (63%) cases, whereas it remained undetected in 65 (37%) cases. This meant that clinical examination has a sensitivity of 77%, specificity of 54% and diagnostic accuracy of 78%. MRI had sensitivity of 86%, specificity of 69% and diagnostic accuracy of 81%.

Co-Kinetic comment There is no significant difference between the diagnostic accuracy of MRI and clinical evaluation for meniscus tears and this only used history and one special test. Chuck in a couple more meniscus tests and the clinical examination should be even more accurate. Skip the MRI and save your money.

“ACL SURGERY: WHEN TO DO IT?”. Musahl V, Diermeier T, de SA D, et al. Knee Surgery, Sports Traumatology, Arthroscopy 2020;28:2023–2026 This starts by discussing patient responses following ACL injury. A ‘coper’ can return to the preinjury levels without surgery and subjective instability; an ‘adapter’ reduces their level of activity to avoid subjective instability; and a ‘noncoper’ cannot return to preinjury activity levels owing to subjective instability and episodes of giving way. Overall, only 65% of patients return to their preinjury sports level after surgical ACL reconstruction, with 55% returning to competitive sports. However, a sub-analysis of return to sports rates after ACL reconstruction in top-level athletes (ie. football, soccer, basketball) varies between 78 and 90%. The ideal timing of ACL reconstruction remains controversial and is influenced, in part, by the interplay between concomitant injuries such as meniscal tears, incidence of arthrofibrosis, return to full activity, as well as economic factors. Traditional dogma has suggested delaying surgery at least 6 weeks to allow for the knee to ‘rest’, decrease swelling, and regain ROM; with early surgery claimed to

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increase risks of arthrofibrosis. A recent RCT by Eriksson et al. is quoted in which 70 patients with high recreational activity level were compared for ROM and patient-reported outcomes after 3- and 6-month followup, with a focus on timing of the ACL reconstruction. ‘Early’ was defined as within 8 days after trauma and ‘delayed’ after 6–10 weeks. At the 3-month follow-up, no significant differences in ROM between groups were evident; yet at 6 months postoperatively, the ‘early’ reconstruction group had less muscular hypotrophy of the thigh muscles. Additionally, at later follow-up, patient-reported outcomes were similar. Moreover, with regard to economic burden, a delayed ACL reconstruction resulted in significantly more sick-leave days (89 vs 57 days) within the first year compared with ‘early’ reconstruction, resulting in higher indirect costs.

Co-Kinetic comment The authors of this paper strongly believe that ‘early’ is better than ‘late’.

EXERCISE: THE ULTIMATE TREATMENT TO ALL AILMENTS? Kasiakogias A, Sharma S. Clinical Cardiology 2020;43:817–826

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In 600BC, Susruta, an Indian physician was the first healer who prescribed exercise and advised that the regimen should be performed daily and be of half the extent of the patient’s capacity. Hippocrates (460–370BC) identified the joined importance of food and exercise and was the first physician to prescribe exercise in written form for a patient ‘suffering from consumption’. Since the 1950s, a burgeoning amount of evidence has accumulated supporting exercise as a highly cost-effective measure for the prevention and treatment of disease. Currently, exercise has been shown to be capable of preventing over 35 chronic conditions, many of which are within the cardiovascular (CV) spectrum, as well as of reducing CV and all-cause mortality. Physical inactivity is a principal contributor to the global burden of disease. Calculations of population-attributable fractions have shown that physical activity not meeting current recommendations is the cause of 6% of coronary artery disease, 7% of type 2 diabetes mellitus,

and 9% of premature deaths. Exercise may protect against certain cancers such as breast, colon, prostate and pancreatic cancer. It also reduces rates of osteoporosis and hip fractures, dementia, anxiety and depression. The importance of exercise for CV protection is supported by epidemiological data in the setting of primary prevention and randomised clinical study data in the setting of secondary prevention. Although the clinical guidelines of most countries recommend a minimum of 150min/week of moderate intensity (1000kcal/week) or 75min/week of vigorous intensity aerobic exercise, a little exercise is better than none and even simple standing exhibits a dose-response relationship with lower rates of mortality. Similarly, moderate or vigorous exercise that is below the recommended volume by current guidelines is still associated with lower rates of CV and all-cause mortality.

Co-Kinetic comment In highlighting this paper to our readers, we are preaching to the converted. Put a copy on the desk of anyone who doubts the efficacy of exercise. Not sure why the title needs a question mark.

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ADDING MOBILISATION WITH MOVEMENT TO EXERCISE AND ADVICE HASTENS THE IMPROVEMENT IN RANGE, PAIN AND FUNCTION AFTER NON-OPERATIVE CAST IMMOBILISATION FOR DISTAL RADIUS FRACTURE: A MULTICENTRE, RANDOMISED TRIAL. Reid SA, Andersen JM, Vicenzino B. Journal of Physiotherapy 2020;66(2):105–112

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Sixty-seven adults (76% female, mean age 60 years) were treated with casting after distal radius fracture. The control group received exercises and advice. The experimental group received the same exercises and advice, plus supination and wrist extension mobilisation with movement (MWM). The primary outcome was forearm supination at 4 weeks (immediately postintervention). Secondary outcomes included wrist extension, flexion, pronation, grip strength, QuickDASH (disabilities of arm, shoulder and hand), patient-rated wrist evaluation (PRWE) and global rating of change. Follow-up time points were 4 and 12 weeks, with patient-rated measures at 26 and 52 weeks. The results showed that compared with the control group, supination was greater in the experimental group by 12° at 4 weeks and 8° at 12 weeks. Various secondary outcomes were better in the experimental group at 4 weeks: extension 14°, flexion 9°, QuickDASH and PRWE. Benefits were still evident at 12 weeks for supination, extension, flexion and QuickDASH. Patients in the experimental group were more likely to rate their global change as ‘improved’. There were no clear benefits in any of the participant-rated measures at 26 and 52 weeks and no adverse effects.

Co-Kinetic comment This paper asked a simple question: Does adding mobilisation with movement to usual care (ie. exercises plus advice) improve outcomes after immobilisation for a distal radius fracture? The answer is yes. If you want to repeat it the mobs are well described. Given the measurements were taken with a handheld goniometer (which is not the most accurate tool in the measuring box) perhaps the most valid outcome is that the patients state their symptoms as ‘improved’.

The data for this study was obtained from responses to a questionnaire from 187 USA athletic trainers (ATs) in 40 states who had been certified for between 1 and 47 years. Respondents represented most major practice settings with 48% practising in colleges and 36% in high schools. In the immediate care of injuries, 97% of ATs are using compression, 83% use elevation, 79% are using some form of cryotherapy, 49% use electrical stimulation, and 28% use some form of manual therapy. Before therapeutic exercise, 73% of ATs are using manual therapy, 57% use electrical stimulation, 51% use ultrasound, and 49% specifically use instrument assisted soft tissue mobilisation (IASTM). After therapeutic exercise, 67% of ATs use an ice bag, 65% use some form of manual therapy, 58% use

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INTRA-EXAMINER AND INTER-EXAMINER RELIABILITY IN THE DETERMINATION OF ANGULAR MEASUREMENTS OF OPEN THE WRIST USING A SMARTPHONE APPLICATION. Wassmuth T, Sakata M, de Paula A et al. Manual Therapy, Posturology & Rehabilitation Journal 2020;18:1–6 The aim of the study was to determine the intra-examiner and inter-examiner reliability of the Goniometer PRO© smartphone application for measuring the ROM of the wrist. A correlational, blind, cross-sectional study was conducted involving 43 healthy women (mean age, 20±2.3 years) with no upper limb injuries. Both wrists were examined in each participant (n=86). Active wrist flexion and extension were measured by three previously trained examiners using the smartphone application for the determination of inter-examiner reliability and a second evaluation was performed after 48 hours for the determination of intra-examiner reliability. There was excellent intra-examiner and inter-examiner reliability for both wrists. A very good correlation was found for the intra-examiner evaluation of the left wrist and good correlations were found for the right wrist and for the inter-examiner evaluations of both wrists.

Co-Kinetic comment According to this paper the app works, at least on the wrist, but if you go to your app store of choice the reviews are mixed. The main downside seems to be that the app lets you do a set number of measurements then it wants you to pay for more, which is fair enough because you are buying a product; however, there are also lots of free apps so can someone do a validity study on them, please?

CURRENT PRACTICES IN ACUTE MUSCULOSKELETAL INJURY CARE: A NATIONAL SURVEY OF ATHLETIC TRAINERS. Beauregard T, Merrick M. Journal of Sports Medicine and Allied Health Sciences: Official Journal of the Ohio Athletic Trainers Association 2000;6(1):3 OPEN

a cold and compression device, 53% use ice massage, and 44% use elevation. During the maturation/ remodelling phase, 73% of ATs are treating their patients with some form of manual therapy, 61% use IASTM specifically, and 44% use some form of electrical stimulation. The most common forms of cryotherapy are, in order, ice bags, ice massage, cold and compression devices, cold whirlpool, and ice bucket. The most common forms of manual therapy are, in order, IASTM, massage, active release therapy, muscle energy technique, proprioceptive neuromuscular facilitation, and joint mobilisation.

Co-Kinetic comment A decent range of treatment modalities and probably very similar to those used by sports physical therapists in the UK. The most amazing thing is that one of the respondents has been a certified athletic trainer for 47 years. Can we hear more about him or her, please?

THE 10 MOST DISCUSSED PIECES OF RESEARCH IN PHYSICAL & MANUAL THERAPY (OCT - DEC 2020)

STANDARDIZED MASSAGE INTERVENTIONS AS PROTOCOLS FOR THE INDUCTION OF PSYCHOPHYSIOLOGICAL RELAXATION IN THE LABORATORY: A BLOCK RANDOMIZED, CONTROLLED TRIAL

THERE IS MORE TO PAIN THAN TISSUE DAMAGE: EIGHT PRINCIPLES TO GUIDE CARE OF ACUTE NON-TRAUMATIC PAIN IN SPORT

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HOW MUCH? HOW FAST? HOW SOON? THREE SIMPLE CONCEPTS FOR PROGRESSING TRAINING LOADS TO MINIMIZE INJURY RISK AND ENHANCE PERFORMANCE

EFFECTIVENESS OF PROGRESSIVE TENDON-LOADING EXERCISE THERAPY IN PATIENTS WITH PATELLAR TENDINOPATHY: A RANDOMISED CLINICAL TRIAL

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FOOT CORE TRAINING TO PREVENT RUNNING-RELATED INJURIES: A SURVIVAL ANALYSIS OF A SINGLE-BLIND, RANDOMIZED CONTROLLED TRIAL American Journal of Sports Medicine

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EFFECTIVENESS OF MANUAL THERAPY IN PATIENTS WITH TENSION-TYPE HEADACHE. A SYSTEMATIC REVIEW AND METAANALYSIS Disability & Rehabilitation

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EFFECT OF EXERCISE TRAINING FOR FIVE YEARS ON ALL CAUSE MORTALITY IN OLDER ADULTS - THE GENERATION 100 STUDY: RANDOMISED CONTROLLED TRIAL

INSIGHTS FROM A GENERAL PRACTICE SERVICE EVALUATION SUPPORTING A LOWER CARBOHYDRATE DIET IN PATIENTS WITH TYPE 2 DIABETES MELLITUS AND PREDIABETES: A SECONDARY ANALYSIS OF ROUTINE CLINIC DATA INCLUDING HbA1c, WEIGHT AND PRESCRIBING OVER 6 YEARS

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EFFECT OF VITAMIN D SUPPLEMENTATION, OMEGA-3 FATTY ACID SUPPLEMENTATION, OR A STRENGTH-TRAINING EXERCISE PROGRAM ON CLINICAL OUTCOMES IN OLDER ADULTS JAMA: Journal of the American Medical Association

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BUILDING A MEDITATION ROUTINE FOR A MORE PRODUCTIVE, CREATIVE AND HAPPIER SCIENTIFIC LIFE Nature

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The PDF version of this infographic includes hyperlinks to the individual pieces of research. Click here to access https://spxj.nl/39GENGR

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Return to Competition Following Covid-19 By Kathryn Thomas BSc MPhil

n what is now hopefully the wake of the coronavirus disease (Covid-19) pandemic, the focus of healthcare may be shifting to managing the long-term ramifications of the disease: what are they and what will they entail? Current ideas and suggestions have been published previously in Parts 1 and 2 of ‘Rehabilitation Following Covid-19’ (https://bit.ly/379wArx and https://bit.ly/2YcNjWT); the focus being on restoring respiratory capacity and optimising physical function and activity. These principles will apply to everyone regardless of age or previous fitness level. However, there may be a need for a deeper focus on competitive athletes, particularly concerning cardiac health, and a more structured return to play (RTP) at their higher level than the general sporting population. Some professional teams and leagues have already resumed their competitive schedules, whereas other sports persons are continuing to train and prepare for events hoping competition will soon return. With lockdown levels easing worldwide even the semi-professional or competitive social athlete will be pushing themselves to get back into their weekly sporting leagues, matches, marathons, etc. You may be involved with a sports team or treat individual athletes – either way it may be relevant to consider some of these pre-participation 14

Covid-19 infection is known to cause cardiovascular injury. However, the incidence of silent cardiac injury after recovery from Covid-19 is unknown. If any potential cardiac damage in athletes is left unidentified and return to play happens too quickly, cardiac dysfunction or sudden cardiac death could result. This article provides details of the tests and monitoring necessary to evaluate any potential cardiac injury in athletes after Covid-19 infection, as well as details of how to support their safe return to sport with a graduated return-to-play programme. Read this article online https://spxj.nl/33yAIAH screening tools and RTP protocols for athletes recovering from Covid-19.

Cardiovascular Involvement with Covid-19

The clinical manifestations of Covid-19 include cardiac involvement and complications, among which are myocarditis (including fulminant cases), arrhythmias and rapid-onset heart failure (1*). In a metaanalysis including six studies with a total of 1527 patients with Covid-19, 8% suffered acute cardiac injury with an incidence about 13-fold higher in critically ill patients admitted in intensive care units (2*,3*). The mechanisms responsible for acute myocardial injury in patients with Covid-19 are not fully understood, but inflammatory reaction with cytokine storm, immunological factors, ACE2-related signalling pathways, hypoxia and direct myocardial damage by viral invasion may be involved (1*). Covid-19 may directly infect myocardial cells, leading to myocarditis with lymphocyte-

rich inflammatory histology, acute impairment of cardiac muscle function and potentially residual chronic scar with increased vulnerability to malignant ventricular arrhythmias. Although Covid-19 myocardial injury, as defined by increases in circulating cardiac troponin levels, has been described in up to 28% of the sickest of patients (2*,3*), its prevalence and clinical implications among infected people who experience mild illness or who remain asymptomatic remains completely unknown. Further, the incidence of silent myocardial inflammation that lingers long after the resolution of typical Covid-19 symptoms – a form of disease that may uniquely affect athletes during resumption of training and

COVID-19 | 21-01-COKINETIC FORMATS WEB MOBILE PRINT All references marked with an asterisk are open access and links are provided in the reference list

CLINICAL MANIFESTATIONS OF COVID-19 INCLUDE CARDIAC INVOLVEMENT AND COMPLICATIONS Co-Kinetic Journal 2021;87(January):14-18

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competition – is also completely unknown (4*). In some cases, cardiac involvement occurred even in patients without symptoms and signs of interstitial pneumonia, reinforcing the importance of subclinical cardiological investigation and measurement of cardiac biomarkers (5*).

RETURN TO PLAY SHOULD FOLLOW A GRADUATED PROTOCOL WITH CONTINUED MONITORING AND MEDICAL ASSESSMENT AS NECESSARY

Table 1: Cardiac evaluation in athletes with prior COVID-19 infection Baggish A, Drezner JA, Kim J et al. Resurgence of sport in the wake of COVID-19: cardiac considerations in competitive athletes. British Journal of Sports Medicine 2020;doi:10.1136/bjsports-2020-102516 (4*) Clinical scenario

Recommended assessment

Comments

Athletes with prior asymptomatic infection as confirmed by antibody to severe acute respiratory syndrome coronavirus 2

Focused medical history and physical examination to screen for findings newly emergent in the COVID-19 era

lM yopericarditis related to COVID-19 should be considered in patients with a history of new-onset chest pain/pressure (even in the absence of fever and respiratory symptoms), palpitations or exercise intolerance lC omprehensive clinical evaluation, regardless of ECG findings, is indicated in athletes with new-onset cardiovascular symptoms or exercise intolerance

Athletes with a history of mild illness (nonhospitalised) related to confirmed or suspected COVID-19

Focused medical history and physical examination to screen for persistent or new postinfectious findings following COVID-19 infection l I f ECG is abnormal or shows new repolarisation changes compared with a prior ECG, then additional individualised evaluation is warranted, including at minimum echocardiography and exercise testing, in conjunction with a sports cardiologist

lC omprehensive clinical evaluation, regardless of ECG findings, is indicated in athletes with new-onset cardiovascular symptoms or exercise intolerance

Athletes with a history of moderate to severe illness (hospitalised) related to confirmed or suspected COVID-19

Comprehensive evaluation prior to return to sport, in conjunction with a sports cardiologist, to include blood biomarker assessment (ie. hs-Tn and NP), 12-lead ECG, echocardiography, exercise testing and ambulatory rhythm monitoring

lM yocardial injury is more likely in patients with a more severe disease course, and normal cardiac function and exercise tolerance should be established prior to a return to exercise lC ardiac MRI may be considered based on clinical suspicion of myocardial injury†

Athletes with a history of Covid-19 infection (regardless of severity) and documented myocardial injury as indicated by one or more of the following: inhospital ECG changes, hs-Tn or NP elevation, arrhythmia or impaired cardiac function

lR eturn to training should be gradual and under the supervision of a cardiologist l L ongitudinal follow-up, including serial cardiac imaging, may be required in athletes with initially abnormal cardiac function

Consider 12-lead ECG* l I f ECG is abnormal or shows new repolarisation changes compared with a prior ECG, then additional evaluation with minimum ECG and exercise test is warranted in conjunction with a sports cardiologist

Perform 12-lead ECG*

lE CG findings that may indicate viral-induced myocardial injury include pathological Q waves, ST segment depression, (new) diffuse ST segment elevation and T-wave inversion

Echocardiogram (ECG) as a screening test to exclude myocarditis is limited. ECG in patients with myocarditis may be normal or may show non-specific abnormalities. Additional evaluation may be warranted based on clinical suspicion. † Cardiac MRI should be performed with gadolinium to assess for myocardial scar and LGE. The presence of LGE is associated with a higher risk of major adverse cardiovascular events. hs-Tn, high-sensitivity cardiac troponin; LGE, late gadolinium enhancement; NP, natriuretic peptide. *

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IN ATHLETES CLINICALLY RECOVERED FROM A PROVEN COVID-19 INFECTION (EVEN THOSE WITH MILD DISEASE, WITHOUT CARDIAC SYMPTOMS OR HOSPITAL ADMISSION), A SUBCLINICAL MYOCARDIAL INJURY MAY BE PRESENT Cardiac Testing in Athletes with Covid-19

Figure 1: Covid-19 graduated return to play for performance athletes: guidance for medical professionals [Infographic] Download from Elliott N, Martin R, Heron N et al. Infographic. Graduated return to play guidance following COVID-19 infection. British Journal of Sports Medicine 2020;doi:10.1136/ bjsports-2020-102637 (7*) 16

Specialists preach that in athletes clinically recovered from a proven infection (even those with mild disease, without cardiac symptoms or hospital admission), a subclinical myocardial injury may be present (6*). They recommend a medical evaluation before the athlete resumes training, ultimately with examinations such as transthoracic echocardiogram, maximal exercise testing and 24-hour Holter monitoring to exclude subclinical disease (6*). However, owing to the risk of disease transmission, these exams should be performed with caution and following all the recommended protective measures, specifically regarding exercise testing, as it may be difficult to find facilities willing to perform these tests (6*). In order to identify a very low-risk group, who can be cleared without the need for supervised exercise testing, the evidence of recovery and risk stratification should be based on additional information, such as (6*): 1. clear exclusion of symptoms suggestive of myocarditis or myopericarditis; 2. deep knowledge of the infection ‘status’ (repetition of viral tests when

appropriate or immunological tests if available); 3. exclusion of ongoing myocardial injury (normal troponin measurements); and 4. exclusion of significant arrhythmias (normal 24/48-hour Holter monitoring). In the absence of positive findings the athletes can resume exercise training (6*). In the presence of any positive findings and in those with serious Covid-19 infection, the management should be similar to other cases of myocarditis, with a further work-up (eg. cardiac magnetic resonance and implantable looping recorders, among others). If the diagnosis of myocarditis or myopericarditis is established, a period of disqualification (3–6 months) is needed, according to the clinical severity and duration of the illness (6*). After this period, it is reasonable to resume training and competition if left ventricular systolic function has returned to the normal range, serum biomarkers of myocardial injury have normalised and clinically significant arrhythmias (such as frequent or complex repetitive forms of ventricular or supraventricular arrhythmias) are absent on 24-hour Holter monitoring and exercise test. Specialists highlight that myocarditis is a cause of malignant arrhythmias, left ventricular dysfunction and sudden cardiac death in athletes (6*). Evidence is limited, and conclusive recommendations regarding the above issues will require ongoing research and monitoring of athletes afflicted with Covid-19. However, some more detailed initial guidance for the cardiac evaluation of athletes with prior Covid-19 infection is provided in Table 1 (4*).

Controlled RTP for Athletes following Covid-19 With the risk of cardiac, renal,

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respiratory and haematological complications, it is best practice to follow steady resumption of training, paying attention to physical and psychological factors following Covid-19 infection. A graduated RTP (GRTP) protocol is a progressive programme that introduces physical activity and sport in a stepwise fashion. This is well illustrated in the infographic shown in Figure 1 (7*). Key considerations include (7*): lB efore GRTP, the athlete must be able to complete activities of daily living and walk 500m on the flat without excessive fatigue or breathlessness. lT he athlete should have at least 10 days’ rest and be symptom free for 7 days before starting. lA thletes of less aerobically intense sports like golf may progress quicker. Experience suggests that some athletes take over 3 weeks to recover. Some monitoring may add value, which could include (7*): l r esting heart rate; l r ate of perceived exertion; l s leep, stress, fatigue and muscle soreness; and l i njury-psychological readiness to return to sport. If any symptoms occur (including excessive fatigue) while going through GRTP, the athlete must return to the previous stage and progress again after a minimum period of 24 hours’ rest without symptoms (7*). Athletes diagnosed with Covid-19 and who have medical conditions such as diabetes, cardiovascular disease or renal disease should have a medical assessment before commencing GRTP (7*). Athletes who have a complicated or prolonged Covid-19 illness may need further investigations, as discussed above, including (4*): lb lood testing for markers of inflammation (high-sensitivity troponin, brain natriuretic peptide and C reactive protein); l c ardiac monitoring (12-lead ECG, echocardiogram, exercise tolerance Co-Kinetic.com

test and cardiac MRI); l r espiratory function assessment (spirometry); and l r enal and haematological monitoring.

Conclusion

Cardiac evaluation is of utmost importance owing to the direct complications of the disease and the potential adverse effects of some medications used for the treatment of Covid-19 (eg. steroids; antibiotics; and anti-malaria, antiviral, anti-inflammatory or immunosuppressant drugs), with implications for exercise training (6*). From the perspective of heart health, PPE (pre-participation evaluation – not, in this case, personal protective equipment!) is traditionally viewed as a tool to screen for occult cardiovascular diseases that predispose the athlete to sudden death (4*). In the wake of Covid-19, it will be prudent to adopt a broader view of cardiovascular PPE. In addition to using the PPE tool to search for rare genetic and congenital conditions, it will be best positioned to facilitate safe returnto-sport screening for cardiovascular sequelae of Covid-19 (4*). Despite the many aspects and doubts that remain to be clarified regarding Covid-19 disease implications in the various medical and scientific societies, there is high pressure to resume sports competitions because of economic and competitive factors. However, from the clinical point of view, it may seem premature to restart exercise before clear control of this virus is achieved (8*). A better clarification of the disease evolution and the potential long-term cardiorespiratory complications is also needed. Additionally, it is important to underline that, as described in other topics of sports cardiology, exercise training may contribute to the development of some cardiovascular conditions, even in apparently healthy individuals (9*). References

1. Madjid M, Safavi-Naeini P, Solomon SD et al. Potential effects of coronaviruses on the cardiovascular system: a review. JAMA Cardiology 2020;5(7):831–840 Open access https://bit.ly/3kYobfK 2. Shi S, Qin M, Shen B et al. Association

of cardiac injury with mortality in hospitalized patients with Covid-19 in Wuhan, China. JAMA Cardiol. 2020 Jul 1;5(7):802–810 Open access https://bit.ly/2J85Ak7 3. Shi S, Qin M, Cai Y et al. Characteristics and clinical significance of myocardial injury in patients with severe coronavirus disease 2019. European Heart Journal 2020;41(22):2070–2079 Open access https://bit. ly/3nU9k7V 4. Baggish A, Drezner JA, Kim J et al. Resurgence of sport in the wake of Covid-19: cardiac considerations in competitive athletes. British Journal of Sports Medicine 2020;doi:10.1136/ bjsports-2020-102516 Open access https://bit.ly/2J7bnqy 5. Inciardi RM, Lupi L, Zaccone G et al. Cardiac involvement in a patient with coronavirus disease 2019 (Covid-19). JAMA Cardiology 2020;5(7):819–824 Open access https://bit.ly/3m3W0NH 6. Dores H, Cardim N. Return to play after Covid-19: a sport cardiologist’s view. British Journal of Sports Medicine 2020;doi:10.1136/ bjsports-2020-102482 Open access https:// bit.ly/3l4n4ey 7. Elliott N, Martin R, Heron N et al. Infographic. Graduated return to play guidance following Covid-19 infection. British Journal of Sports Medicine 2020;doi:10.1136/ bjsports-2020-102637 Open access https://bit.ly/2UWTgpw 8. Corsini A, Bisciotti GN, Eirale C et al. Football cannot restart soon during the Covid-19 emergency! A critical perspective from the Italian experience and a call for action. British Journal of Sports Medicine 2020;doi:10.1136/bjsports-2020-102306 Open access https://bit.ly/360I9ST 9. Dores H, de Araújo Gonçalves P, Cardim N et al. Coronary artery disease in athletes: an adverse effect of intense exercise? Revista Portuguesa Cardiologia 2018;37(1):77–85 Open access https://bit.ly/3fvQbWS.

MANAGEMENT OF ATHLETES WITH POSITIVE FINDINGS SHOULD BE SIMILAR TO THAT OF MYOCARDITIS 17

KEY POINTS

lR ehabilitation for any person following Covid-19 infection should focus on restoring respiratory capacity and optimising physical function and activity. lC linical manifestations of Covid-19 include cardiac involvement and complications, among which are myocarditis, arrhythmias and rapid-onset heart failure. l I n athletes clinically recovered from a proven infection (even those with mild disease, without cardiac symptoms or hospital admission), a subclinical myocardial injury may be present. l I t is recommended that a medical evaluation is performed before the athlete resumes training. lE xams can include transthoracic echocardiogram, maximal exercise testing and 24-hour Holter monitoring to exclude subclinical disease. l I n the absence of any positive findings (from the exams above) the athlete can resume exercise. l I n the presence of any positive findings (from the exams above), the athlete should be managed as with cases of myocarditis – including further examinations and 3–6 months’ disqualification from training. lA controlled, graduated return to play (GRTP) is recommended for all athletes, ensuring they have had at least 10 days’ rest and be symptom free for 7 days before starting any training. lC areful monitoring of heart rate, perceived exertion, sleep, stress, anxiety, muscle soreness and psychological readiness for sport must be performed during GRTP. l E xaminations must be performed with caution owing to the risk of transmission and/ or re-infection.

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RELATED CONTENT

lR ehabilitation Following COVID-19 Part 1: Theoretical Considerations [Article] https://bit.ly/379wArx l Rehabilitation Following Covid-19 Part 2: Practical Applications [Article] https://bit.ly/2YcNjWT l Covid-19 Patient Rehabilitation and Recovery Resources https://bit.ly/2CYgDJP

DISCUSSIONS

l What are your long-term concerns, both physically and psychologically, for athletes during this pandemic? l Have you witnessed or experienced prolonged return to training in athletes following Covid-19 infection compared to ‘normal’ flu/viral infections? l Apart from cardiac complications what else would you want to monitor when facilitating a GRTP with an athlete?

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 Masters 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 2021;87(January):14-18

PHYSICAL THERAPY

Background

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

Video 1: How to diagnose Frozen Shoulder (Courtesy of YouTube user Physiotutors) https://youtu.be/5zpXbvEf9j0

Video 2: True or Pseudo Frozen Shoulder? | Adhesive Capsulitis Diagnosis (Courtesy of YouTube user Physiotutors) https://youtu.be/rqCBa2zqASo 19

ADHESIVE CAPSULITIS, PERIARTHRITIS, AND FROZEN SHOULDER ARE ALL TERMS USED TO DESCRIBE A PAINFUL AND STIFF GLENOHUMERAL JOINT treatment, and the surgical procedures are heterogeneous, with inconsistent benefits and iatrogenic risks (1). Physical therapy should, however, follow (early) after surgery for complete rehabilitation of the shoulder (5). The current evidence for consensus concerning the most effective nonsurgical treatment for frozen shoulder is insufficient (1). The disease has specific characteristics and demographic factors; the correct recognition of moderating factors, such as the disease stage and comorbid conditions, is critical for tailoring patient-specific treatment options (1). Three phases with varying clinical characteristics are described in frozen shoulder: the painful freezing phase, the frozen or adhesive phase, and the thawing or regression phase. Individual studies and clinical experience indicate that each phase requires different treatment (relating to the most pronounced symptom) for best results, but there is no strong evidence and no meta-analyses determining their effectiveness (1,4). Given the higher prevalence of diabetes

mellitus, obesity and hypothyroidism in patients with frozen shoulder, knowing the association between systemic comorbidities and therapeutic responses is helpful for tailoring treatment plans. No therapeutic intervention is currently universally accepted as most effective for restoring motion and diminishing pain in patients with frozen shoulder (4). The aim of this article is to highlight the most current thinking regarding conservative management and treatment techniques of frozen shoulder.

Pathophysiology and Clinical Presentation

Frozen shoulder can be either primary or secondary; secondary causes include trauma, previous shoulder surgery, prolonged immobilisation, diabetes, thyroid disease, Dupuytren disease and other autoimmune disorders (2*). Primary idiopathic frozen shoulder occurs in patients presenting with painful, restricted shoulder movements where no underlying cause is found. The pathophysiology of primary adhesive capsulitis is still not fully understood, but histological studies have shown that frozen shoulder is characterised by a thickened, tight capsule, with chronic inflammatory cells and fibroblasts found in the joint capsule (6*). Furthermore, fibroblasts in frozen shoulder have an activated phenotype associated with cytokine dysregulation, suggesting an autoimmune aetiology (6*).

Traditionally three stages are recognised but some studies identify a fourth stage which is actually the first starting point – a type of ‘pre-freezing’ (Table 1) (2*,7*). The condition starts with a painful phase, including severe pain and progressive restriction of movement. This phase is characterised by hypertrophic synovitis with hypervascularity, but a normal appearance of the capsular tissue. This is followed by a ‘freezing’ stage where symptoms gradually worsen over 9 months; histologically, there is perivascular synovitis and collagen deposition. (Where descriptions are based on three phases only – the painful and freezing stages would be combined). Over the subsequent 1–4 months, the ‘frozen’ phase occurs, characterised by stiffness as a predominating symptom. The ‘thawing’ phase, in which symptoms resolve, has the greatest variability in duration and can last for up to 2 years. The latter two stages involve the formation of dense collagenous tissue in the capsule, associated with scar formation (2*). There is significant variation in clinical practice and the disease course may not follow such a stepwise progression. The diagnosis is usually made clinically, with pain and stiffness as the hallmark of the condition.

Clinical Features for Diagnosis

The following clinical features are included in the diagnosis of frozen shoulder: l The onset of pain is often gradual

Table 1: Clinical stages of adhesive capsulitis and histological findings From Date A, Rahman L. Frozen shoulder: overview of clinical presentation and review of the current evidence base for management strategies. Future Science OA 2020;https://doi.org/10.2144/fsoa-2020-0145 (2*). Reproduction by Creative Commons Attribution 4.0 International licence (CC BY 4.0: https://creativecommons.org/licenses/by/4.0/).

Stage

Symptoms

Duration of symptoms (months)

Histology

1 Painful stage

Moderate pain and reduction of movement

Hypertrophic synovitis with hypervascularity Normal capsular tissue

2 Freezing stage

Severe pain and reduction of movement

3–9

Perivascular synovitis and disorganised collagen deposition and scarring

3 Frozen stage

Pain may be present but stiffness predominates

10–14

Dense and hypercellular collagenous tissue of the capsule

4 Thawing stage

Minimal pain and gradual improvement in movement

14–24

Fully developed scar tissue Pathophysiology remains unclear

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over a period of months, with night pain being a common feature. l The pain may be poorly localised and described as a deep ache, or sometimes presents as a pain referred to the deltoid origin, radiating to the biceps area. l Examination findings are often non-specific without any point tenderness and with normal rotator cuff strength. l Both passive and active range of motion (ROM) are globally reduced; this is best assessed through passive external rotation with the arm by the side. The results of laboratory tests are usually normal but may be useful in identifying underlying conditions, such as diabetes or thyroid disease. Plain radiographs of the shoulder are also usually normal but can help diagnose or exclude other conditions, such as calcific tendinopathy of the rotator cuff, glenohumeral arthritis, acromioclavicular arthritis or even a shoulder dislocation. In calcific tendinopathy, disuse osteopenia may be demonstrated on the plain radiographs. Imaging modalities such as arthrography, technetium bone scans and magnetic resonance imaging are not routinely indicated or helpful in evaluation of adhesive capsulitis but can be used to exclude other shoulder pathology (2*).

Conservative Management

The goal of treatment in frozen shoulder is to restore function and manage symptoms. The choice of treatment can vary with patient factors, stage at presentation, clinician preferences and local policies or funding. Non-surgical or conservative management is the preferred choice of treatment, with most patients usually improving in 6â&#x20AC;&#x201C;18 months. Conservative treatment options include analgesics, oral steroids, physical therapies, hydrodilatation, suprascapular nerve block and intraarticular steroid or sodium hyaluronate injections. Surgical treatment is offered to patients with persistent symptoms despite conservative management; strategies include manipulation under anaesthesia, arthroscopic release Co-Kinetic.com

and open release. There remains no consensus or high-level evidence to definitively support one treatment modality over another (1). Physical therapy has traditionally been the initial treatment modality for frozen shoulder and it is often used alongside other adjuncts, including steroid injections, transcutaneous electrical nerve stimulation, analgesics and warm or cold pads. There remains variation of physical therapy regimen in both clinical practice and in the literature; however, the principles revolve around reducing pain, mobilising the joint, and a supervised stretching and strength maintenance programme (2*,8*,9*,10*,11*). Randomised controlled trials (RCTs) may not have shown significantly better outcomes in patients receiving physical therapy compared to those receiving no treatment (12*,13*). Further research is clearly needed to determine the role of physical therapy and adjuncts to treatment in frozen shoulder management. Although there may be a lack of high-level evidence to support physical therapy over observation or medical therapy alone (2*), the clinical relevance of physical therapy in treating frozen shoulder still remains. Patients require assistance in managing their pain, which can heavily impact on their daily life and emotional wellbeing. At the same time, any improvement in pain and mobility may facilitate a better quality of life, aid in independence, better function and improvements in their work or physical activity ability. In the early freezing stage, gentle stretching exercises of short duration are recommended, including pendulum exercises and passive external rotation and passive forward elevation in supine (8*). Strengthening exercises such as isometric shoulder external rotation and posterior capsular stretching can be introduced in the later frozen stage (8*). In the thawing stages, both strengthening and stretching exercises can be combined and increased in frequency, or combined with Maitland grade 3â&#x20AC;&#x201C;4 mobilisation (Video 3), to improve ROM (8*,9*). Vermeulen et al. showed that high-grade mobilisation (working through the pain barrier)

NO THERAPEUTIC INTERVENTION IS CURRENTLY UNIVERSALLY ACCEPTED AS MOST EFFECTIVE FOR RESTORING MOTION AND DIMINISHING PAIN was marginally better than low-grade mobilisation (working within pain limits) (14*).This is discussed further below. Griggs et al. in a prospective nonrandomised study of 75 patients, showed that a supervised four-directional shoulder stretching programme resulted in a satisfactory outcome in 90% of patients at 22 months (Link 1) (15). A recent network meta-analysis and systematic review showed the following points (1): 1. A s compared with placebo, intra-articular injection (steroid injection and capsular distension) provided benefits for pain relief and improved shoulder function and increased the passive range of external rotation, which is the hallmark clinical sign of frozen shoulder. Of these two injections, capsular distension is the highestranked treatment for pain relief. 2. N ew interventions including extracorporeal shockwave therapy (ESWT) and laser therapy, showed high probabilities of achieving pain relief and functional improvement. 3. S tretching showed a significant effect only in improving shoulder function. 4. U se of non-steroidal anti-inflammatory drugs provided a specific advantage for pain management. 5. T reatment outcomes were moderated by patientspecific factors (disease stage, female sex, and diabetes) and the use of adjunctive therapies. 6. N on-diabetic populations and groups with smaller proportions of female patients respond better to steroid injection and adjunctive therapies, such as self-exercise.

Video 3: Maitland Mobilization Grades (Courtesy of YouTube user Physiotutors) https://youtu.be/G_QI7bVrHN0 21

Studies have shown that capsular distension is the highest-ranked treatment for pain relief. Capsular distension, also named hydrodilatation, is an intra-articular injection technique to treat the adhesive joint by expansion of the capsule. There is retrospective evidence indicating the use of capsular distension as a first-line treatment regardless of the underlying cause, supporting its prominent role in improving symptoms of frozen shoulder (1,4). It is also a widely adopted alternative option to surgical treatment in patients with diabetes and frozen shoulder. However, the reported duration of efficacy is inconsistent: some evidence supported the short-term benefits of pain relief and increasing ROM, whereas other studies reported good long-term effects of capsular distension (1). There is also a lack of highquality RCT data for new treatment options such as laser therapy and ESWT. Some evidence suggests that low-level laser therapy is strongly recommended as treatment for pain

Video 4: Kaltenborn Concave-Convex Rule (Courtesy of YouTube user Physiotutors) https://youtu.be/8YVZFCm7qJ0

Video 5: Kaltenborn/Convex–Concave Rule – Flawed or Misinterpreted? (Courtesy of YouTube user Physiotutors) https://youtu.be/eB1IPxgIT2Q 22

relief and is moderately recommended therefore for improving function (1). Regarding ESWT, there is no highranking evidence for meta-analysis or systematic review to evaluate its effectiveness, but currently available data shows satisfactory improvement from multiple aspects (1). The underlying mechanism may be inferred as the ability of ESWT to increase regional blood flow and flexibility of collagen fibres and reduce inflammatory cytokines (1). Studies report on the prevalence and importance of steroid injection for managing frozen shoulder; however, on closer inspection it seems the benefits may be specific to the painful freezing phase and not to the adhesive phase of frozen shoulder. It is thought that steroid injection should be routine to control inflammation in the painful freezing phase (1). Zhang et al. have used forest plots to show the mean and median surface under the cumulative rankings (which demonstrate the probability of being in the highest rank) with 95% credible intervals for outcomes of pain and shoulder function for a list of 24 treatments [Figure 1 in Zhang J, Zhong S, Tan T, et al. Comparative efficacy and patient- specific moderating factors of nonsurgical treatment strategies for frozen shoulder: an updated systematic review and network metaanalysis. The American Journal of Sports Medicine 2020;https://doi. org/10.1177/0363546520956293 (1)].

Mobilisation Techniques for Frozen Shoulder

Goals of treatment for frozen shoulder are pain relief, maintenance of range, and restoration of function. Physiotherapy treatment consists of stretching and strengthening exercises, electrotherapy modalities or mobilisation, which may be applied side by side. Joint mobilisation is a form of passive movement in a broad spectrum of exercise used to treat painful and stiff synovial joints. Several forms of mobilisation exist and terminology varies among the authorities. The oscillatory movements will be in the direction of the joint’s accessory motions, which are small spinning, gliding, rolling or distractive

motions that occur between joint surfaces and are essential for normal mobility (3*). An example of an accessory motion at the shoulder would be movement of the humeral head inferiorly as it moves on the glenoid fossa during normal abduction. This gliding motion is necessary for the greater tuberosity of the humerus to pass under the coracoacromial arch and thereby allow full elevation of the arm. Accessory motions can be demonstrated in normal, synovial joints when an examiner passively moves one articular surface while the other is stabilised (3*). The recent review by Almureef and colleagues showed that in terms of improving shoulder mobility, the evidence suggests that patients receiving manual therapy interventions for shoulder pain will demonstrate improvements in ROM either passive or active or both (3*). Maitland mobilisation was superior to ultrasound in improving symptoms of frozen shoulder. However, combining Maitland mobilisations with ultrasound was more effective in also reducing pain. Maitland mobilisations combined with exercises was proven effective in relieving pain and improving ROM and shoulder function (3*). Maitland mobilisation with kinesiology taping along with conventional therapy has also been shown to improve the pain and disability in patients with frozen shoulder (16*). It has been shown that end-range joint mobilisation (caudal and anterior glides) along with conventional treatment (pendulum exercise, finger walk, towel stretch, wand exercise) is more effective in reducing pain with improvement in the joint range and functional performance than conventional physiotherapy alone (17). As mentioned earlier, research by Vermeulen et al. showed statistically significant greater scores in ROM and shoulder disability scores using high-grade mobilisation techniques (15). These were done twice a week for 12 weeks. Inferior glides, posterior glides, anterior and medial glides were performed as well as distraction of the humeral head with respect with the glenoid; 10–15 repetitions per glide position were performed. If fixation

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of the scapular during distraction of the humeral head proved difficult, then reverse distraction can be used (Link 2) (18*). If the glenohumeral joint ROM increases during treatment, then mobilisation techniques can be performed at greater elevation and abduction angles. In these new positions, the changed position of the humeral head and glenoid required an individual adjustment of the direction of the accessory movements in accordance with the concave-convex rules stated by Kaltenborn (19). Greater detail on the high-grade (grade 3–4) Maitland mobilisation done in this study can be found in Appendix 2 of Vermeulen et al. (14*) (Link 3). Mulligan techniques are superior to ultrasound in improving symptoms of frozen shoulder (3*). Also, Mulligan mobilisation along with supervised exercise is more effective than Maitland mobilisation in reducing pain and improving shoulder functional ability in subjects with adhesive capsulitis of shoulder (20*). Mulligan mobilisation [also called mobilisation with movement (MWM)] can be performed: l in a pain-free manner, 6–10 repetitions in 3–5 sets; l for shoulder flexion, abduction and elevation; l for mid-range mobilisation using postero-lateral glides in sitting; l to restore a loss of internal rotation (hand behind back) using inferior glides; l to improve end-range shoulder elevation using posterior and inferior glides in supine; and l to improve shoulder external rotation using posterior joint mobilisation. A study has shown that MWM combined with conventional physiotherapy was superior to diclofenac phonophoresis with conventional physiotherapy in improving pain and shoulder ROM (21*). Do Moon et al. compared the Maitland and Kaltenborn mobilisation techniques (Videos 4–8) and found significant differences in pain and the ROM of both internal and external shoulder rotation pre-and postCo-Kinetic.com

intervention using both techniques (22*). However, there were no significant differences between the groups when comparing outcome measures, and therefore from this one can’t say one technique is superior to the other (22*). Sengpya Phukon et al. conducted a study showing that both Maitland mobilisation and muscle energy techniques are effective in improving the ROM and decreasing pain in patients with adhesive capsulitis (23*). Research by Jung et al. (24*) showed that the combination of MWM with hold–relax (HR) proprioceptive neuromuscular facilitation (PNF) technique had significantly greater effects on shoulder flexion ROM, shoulder flexor muscle strength, and pain and function compared to MWM alone. Their MWM–HR combination was performed as follows (24*): lM WM Flexion: Subject was seated in a comfortable sitting position with a belt on the head of the humerus, and the therapist’s hand was wrapped around an appropriate area of the humeral head to perform a glide. Counterpressure was applied onto the scapula by the other hand of the therapist. A glide was applied over the pain-free range during slow active shoulder movements and was released after returning to the starting position. This process was repeated 15 times in 3 sets, and a 1-minute rest period was provided between each set (Link 4). l MWM External Rotation: Subject had a folded towel under the scapula while lying in a comfortable position, and the elbow flexed to 90°. The subject held the stick with both hands, and then pushed the stick with the opposite hand to produce shoulder external rotation. In the meantime, the therapist stood on the other side and held the subject’s humeral head and applied the slide within pain-free range, back and outwards based on the joint concavity. This process was repeated 15 times in 3 sets, and a 30-second rest period was provided between each set. A pressure gauge (hand dynamometer) was used to apply a uniform pressure (5N) to the slide that was applied to the subject (Link 5). l PNF HR: With the patient in supine

position and the shoulder joint was slightly relaxed at the end of the flexion range up to where the patient felt pain, the therapist slowly provided resistance in the direction of flexion, abduction, or external rotation, and (without the subject intending to move) the subject tried to go against the resistance towards extension, adduction, and internal rotation, with particular emphasis on trying to resist external rotation. The

Video 6: Caudal Shoulder Capsule | Roll Glide Assessment & Mobilization (Courtesy of YouTube user Physiotutors) https://youtu.be/8jpw78Kt4Xs

Video 7: Ventral Shoulder Capsule | Roll Glide Assessment & Mobilization (Courtesy of YouTube user Physiotutors) https://youtu.be/bUIx4mQl7UE

Video 8: Dorsal Shoulder Capsule | Roll Glide Assessment & Mobilization (Courtesy of YouTube user Physiotutors) https://youtu.be/ECi9gFoKpEM 23

THE HALLMARKS OF FROZEN SHOULDER ARE PAIN AND STIFFNESS, CAUSED BY FORMATION OF ADHESIONS OR SCAR TISSUE IN THE GLENOHUMERAL JOINT therapist’s bare hand was placed in contact onto the antagonist muscle area to apply resistance and gradually increased the resistance by isometric contraction to reach the maximum resistance. When relaxation was achieved by inducing relaxation, this procedure was repeated 6 times. Then, after securing the newly obtained range, it was repeatedly attempted again at the limit point and carried out for a total of 15 minutes (Link 6, Link 7) (24*). Moderate evidence therefore exists in favour of mobilisation techniques in the short and long term, for the effectiveness of arthrographic distension alone and as an addition to active physiotherapy in the short term (4).

Exercise Therapy for Frozen Shoulder

ROM exercises can contribute to improving joint and soft tissue mobility and decreases the risk of adhesion and contracture formation. Exercise therapy has already been touched on through this article, including the use of isometric exercises and mobility exercises such as pendulum, finger walk, towel stretch and wand exercises. Stretching exercises given as home programmes are also helpful in breaking the collagen bonds and realigning the fibres for permanent elongation or increased flexibility and mobility of the soft tissues that have adaptively shortened and become hypomobile over time in the frozen shoulder (3*). The home exercise programme should not focus on stretching alone. Although the standard exercises (including pendulum, finger walking on the wall, and using a stick to passively 24

mobilise the joint) are beneficial, these are not performed as static stretches but rather dynamic movements. A lot of posterior shoulder tightness that limits ROM, can be due to muscle fatigue. Therefore including strengthening exercises and facilitating the shoulder muscles (both scapular and rotator cuff) to work through the range (whatever range the patient has) can be beneficial. A recent study showed that rotator cuff strengthening (combined with manual therapy) had significant impact on shoulder pain, ROM, function and disability in patients with adhesive capsulitis compared to those patients receiving manual therapy alone (25*). The strengthening routine can be progressed from basic isometric internal and external rotation and abduction, to dynamic strengthening using a thera-band and scapular stabilisation exercises (25*). Group exercise classes produced significantly greater improvements in shoulder symptoms compared to individual physiotherapy and home exercise performed alone (26). The study by Russel et al. showed improvement in shoulder ROM was significantly better in both physiotherapy groups (individual and group classes) compared to home exercise therapy performed alone (26). Interestingly the improvement in HADS (hospital anxiety and depression scale) score was significantly greater in both physiotherapy intervention groups than in home exercises performed alone. Therefore a group exercise class may facilitate a more rapid improvement in patients’ symptoms (26). There are many options when considering physiotherapy for a patient with frozen shoulder. Initially, this may be based on what stage they present with – their primary complaint may be pain and therefore treatment may have a different focus to someone who presents at stage 3 with minimal pain but significant loss of function owing to limited ROM. Whether you choose manual therapy, massage, stretching, a mobilisation technique (with the grade or range depending on pain tolerance), PNF and exercise therapy, or a combination of any of these, doing something – anything – seems

to be beneficial (11*). As shown in the forest plot in Figure 1 in Zhang et al., it seems that doing most things will help to a greater or lesser extent, rather than doing nothing at all (1). But this is a very slow and frustrating recovery for patients, and their therapist! So what else could make the difference? Are you missing a key component to really helping these patients improve?

Biopsychosocial Component to Shoulder Pain

Clinicians are often faced with challenging questions from patients, insurance or compensation providers, administrators and policy makers about the outcome of soft tissue disorders of the shoulder. Frequent questions include “What will the extent of recovery be?” and “Are there any factors that could delay recovery?” The literature on prognosis and potential prognostic factors in shoulder disorders, however, is limited. Reviews have identified a series of indicators that seem to be prognostic for outcome including initial baseline pain or disability, age, sex, general physical health, physical therapist’s predictions, duration of symptoms before starting therapy, being post-surgery, and being involved in a worker’s compensation claim (27*). The predictors mentioned above and the impact of chronic pain on the patient as a ‘whole’ – their mental and emotional wellbeing combined with their physical health – are not always under our control and care. Psychological distress, fear of movement, catastrophic thinking and decreased self-efficacy are all associated with greater shoulder pain and disability (28). We are unable to treat many of these variables through standard physical therapy modalities. However, being aware of them, helping guide a patient to other healthcare providers, listening carefully, and educating the patient may be the one ‘modality’ that turns the corner for a person suffering with frozen shoulder. Even a focus on ‘what can you do’ rather than ‘what can’t you do’ could be beneficial. Focus on positive reinforcement, even suggesting that patients not engaging in leisure time physical activity or hobbies are

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encouraged to do so and those taking part are encouraged to remain doing so, in whatever capacity they are able (27*,29*). Prognostic factors associated with the outcome of physiotherapy for shoulder pain are unclear, and currently cannot fully support clinical decision-making (30*). A recent analysis identified five such predictive factors that were measured with disabilities of the arm, shoulder and hand questionnaire (DASH) at discharge or the amount of change in DASH score over treatment time (27*). DASH reflects the effect of the disorder in terms of physical function and symptoms, which are the primary reasons patients seek care for musculoskeletal disorders. Factors that predict persisting disability include (27*): 1. higher initial disability; 2. therapist prediction of restrictive activities (watch what you say about what they can’t do!); 3. workers compensation claim; 4. older age; and 5. being female. Chester et al. made the following conclusions (29*): l Higher patient expectation of recovery as a result of physiotherapy, higher pain self-efficacy, lower pain severity at rest, and for patients not retired, being in employment or education were associated with a better outcome. l Clinical examination findings suggestive of a structural diagnosis were inconsistently associated with outcome. l Physiotherapists’ predictions of how well a patient will respond to treatment cannot be relied on. l Psychosocial in addition to biomedical information should be formally assessed and feed into decision-making about management options. l Physicians referring patients to physiotherapy should reinforce a positive expectation of recovery as a result of physiotherapy treatment. l Patients with resting pain and/or pain arising from other comorbidities may be provided with and guided on appropriate pain medication Co-Kinetic.com

or other pain-relieving treatments before or at the same time as referral to physiotherapy. l A multidisciplinary approach should be considered for patients with more extreme psychological responses associated with a poorer outcome, resting shoulder pain not responding to medication provided by their physician, and patients not currently employed or in education but of working age.

mobilisation techniques with conventional physiotherapy, including exercise therapy, may be beneficial. Considering the psychological health of the patient may be critical in moving forward and making progress during treatment. The optimal intervention should be individualised, depending on disease stage, primary symptom or complaint, adjunctive therapies, sex, and complex comorbid conditions such as diabetes.

High levels of pain and disability at baseline are associated with high levels of pain and disability at 6-month follow-up. However, this ‘predicted’ poor outcome is modified to a predicted better outcome if the patient has high pain self-efficacy and a greater expectation of treatment. Pain self-efficacy is the extent or strength of the patient’s belief in their ability to complete tasks and reach a desired outcome despite their shoulder pain. Low levels of baseline pain and disability are associated with low levels of follow-up pain and disability. This predicted better outcome is modified to a predicted poor outcome if the patient has low pain self-efficacy. Examples of questions regarding patient beliefs, experience and expectations – which are the foundation of self-efficacy – can be found in Supplementary File 1 (Link 8) from Chester et al. (29*). Therefore it is strongly suggested that pain selfefficacy and patient expectation should be formally assessed and discussed at the first physiotherapy appointment (31).

References Owing to space limitations in the printed journal, the full reference list can be accessed by clicking the link below, logging into your Co-Kinetic account and downloading the full article PDF from the Media Contents box. https://spxj.nl/3ltEbXc

Conclusion

Frozen shoulder is a common condition that causes significant and prolonged morbidity for patients and carries wider economic implications. The last two decades have seen significant progress in understanding of the pathophysiology behind frozen shoulder, which has complemented developments in current management strategies. However, there remains variation in clinical practice with no consensus in treatment for this condition. Non-operative interventions remain the first-line approach. Studies appear to show that combining

KEY POINTS

lA dhesive capsulitis or frozen shoulder is a relatively common condition characterised by pain and stiffness of the shoulder joint. lT he pathophysiology of frozen shoulder is still not fully understood; however, histological studies have shown that the condition is characterised by a thickened, tight capsule, with chronic inflammatory cells and fibroblasts found in the joint capsule. lC linically, the presentation can be classified into four stages: painful, freezing, frozen and thawing. lT he goal of treatment is to restore patient function and manage symptoms, with myriad non-operative and operative treatment strategies used in clinical practice. lP hysical therapy, often with adjuncts, is the preferred first-line treatment, although there remains a lack of high-level evidence in the literature to support this approach. lP hysical therapy can include end-of-range mobilisations, grade 3–4 Maitland mobilisations, Mulligan/muscle energy techniques and Kaltenborn techniques. lE xercise therapy may involve stretching and strengthening of the rotator cuff and scapular musculature. lA ddressing the biopsychosocial component of chronic pain, and specifically shoulder pain, will be a large component of treatment success. lP redicators of success may include duration of pain and disability, intensity of pain, age, sex, compensation, and self-efficacy. lA team approach to managing a patient with frozen shoulder will be needed in order to address the many factors that may be in play.

DISCUSSIONS

l What are your key strategies or treatment techniques when managing a patient with frozen shoulder? lH ave you even ‘discharged’ a patient or ‘lost’ a patient (patient discontinued therapy) who still had residual symptoms? lC onsider the psychological component of chronic shoulder pain and its impact on treatment success – what additional questions or considerations for self-efficacy will you use during assessment and management?

RELATED CONTENT

lM anaging the Pinch: A Review of Shoulder Impingement Care [Article] http://spxj.nl/2h8S3L6 lS houlder Impingement: Diagnosis, Treatment and Rehabilitation for Physical Therapists [Article] http://spxj.nl/2w3mxQI lS houlder Pain Patient Information Resources https://bit.ly/365z3nP LINK 1: Figures 1–4 from Griggs SM, Ahn A, Green A. Idiopathic adhesive capsulitis. A prospective functional outcome study of nonoperative treatment. Journal of Bone and Joint Surgery (Am.) 2000;82(10):1398–1407 (15). https://bit.ly/39JiAYK LINK 2: Figure 1: Reversed distraction technique of the glenohumeral joint when patient lies on the nonaffected side. Vermeulen HM, et al. End-range mobilization techniques in adhesive capsulitis of the shoulder joint: A multiple-subject case report. Physical Therapy 2000;80(12):1204– 1213 (18). https://bit.ly/33LEkzn LINK 3: Appendix 2: Treatment scheme for application of high-grade mobilization techniques (HGMT) and low-grade mobilization techniques (LGMT). Vermeulen HM, et al. Comparison of high-grade and low-grade mobilization techniques in the management of adhesive capsulitis of the shoulder: randomized controlled trial. Physical Therapy 2006;86(3):355–368 (14). https://bit.ly/2KZe2mC LINK 4: Figure 2: MWM for shoulder flexion. MWM: mobilization with movement. Jung J, Chung Y. Effects of combining both mobilization and hold-relax. technique on the function of post-surgical patients with shoulder adhesive capsulitis. Physical Therapy Rehabilitation Science 2020;9(2):90–97 (24). https://bit.ly/2IcwxTN LINK 5: Figure 3: MWM for shoulder external rotation. MWM: mobilization with movement. Jung J, Chung Y. Effects of combining both mobilization and hold-relax. technique on the function of post-surgical patients with shoulder adhesive capsulitis. Physical Therapy Rehabilitation Science 2020;9(2):90–97 (24). https://bit.ly/36KO3YR LINK 6: Figure 4: HR PNF stretching for shoulder flexion. Jung J, Chung Y. Effects of combining both mobilization and hold-relax. technique on the function of post-surgical patients with shoulder adhesive capsulitis. Physical Therapy Rehabilitation Science 2020;9(2):90–97 (24). https://bit.ly/2VC3sEh LINK 7: Figure 5: HR PNF stretching for shoulder external rotation. Jung J, Chung Y. Effects of combining both mobilization and hold-relax. technique on the function of post-surgical patients with shoulder adhesive capsulitis. Physical Therapy Rehabilitation Science 2020;9(2):90– 97 (24). https://bit.ly/2L9zHZB LINK 8: See Supplementary File 1 in “Psychological factors are associated with the outcome of physiotherapy for people with shoulder pain: a multicentre longitudinal cohort study” by Chester, et al. British Journal of Sports Medicine 2018 Feb;52(4):269–275 (29). https://bit.ly/39LOpQD

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Tweet this: Frozen shoulder occurs in 4 stages: painful, freezing, frozen and thawing https://spxj.nl/3ltEbXc Tweet this: Frozen shoulder needs good management to optimise outcomes on resolution https://spxj.nl/3ltEbXc Tweet this: Treatment goals for frozen shoulder are pain relief, maintaining range and restoring function https://spxj.nl/3ltEbXc Tweet this: There are many therapies for frozen shoulder, all of which seem to be better than doing nothing https://spxj.nl/3ltEbXc Tweet this: Outcomes from frozen shoulder also depend on a psychosocial element and an MDT may be needed https://spxj.nl/3ltEbXc THE AUTHOR Kathryn Thomas BSc Physio, MPhil Sports Physiotherapy is a physiotherapist with a master’s degree in Sports Physiotherapy from the Institute of Sports Science and University of Cape Town, South Africa. She graduated both her honours and master’s degrees Cum Laude, and with Deans awards. After graduating in 2000 Kathryn worked in sports practices focusing on musculoskeletal injuries and rehabilitation. She was contracted to work with the Dolphins Cricket team (county/provincial team) and The Sharks rugby teams (Super rugby). Kathryn has also worked and supervised physios at the annual Comrades Marathon and Amashova cycle races for many years. She has worked with elite athletes from different sporting disciplines such as hockey, athletics, swimming and tennis. She was a competitive athlete holding national and provincial colours for swimming, biathlon, athletics, and surf lifesaving, and has a passion for sports and exercise physiology. She has presented research at the annual American College of Sports Medicine congress in Baltimore, and at South African Sports Medicine Association in 2000 and 2011. She is Co-Kinetic’s technical editor and has taken on responsibility for writing our new clinical review updates for practitioners. Email: kittyjoythomas@gmail.com

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References

1. Zhang J, Zhong S, Tan T et al. Comparative efficacy and patient-specific moderating factors of nonsurgical treatment strategies for frozen shoulder: an updated systematic review and network meta-analysis. The American Journal of Sports Medicine 2020;doi;https://doi. org/10.1177/0363546520956293 2. Date A, Rahman L. Frozen shoulder: overview of clinical presentation and review of the current evidence base for management strategies. Future Science OA 2020;doi:https://doi.org/10.2144/ fsoa-2020-0145 Open access https://bit.ly/33jxReK 3. Almureef S, Ali WM, Shamsi S et al. Effectiveness of mobilization with conventional physiotherapy in frozen shoulder: a systematic review. International Journal of Recent Innovations in Medicine and Clinical Research 2020;2(4):22–29 Open access https://bit.ly/39lE7q3 4. Favejee MM, Huisstede BMA, Koes BW. Frozen shoulder: the effectiveness of conservative and surgical interventions – systematic review. British Journal of Sports Medicine 2011;45:49–56 5. Redler LH, Dennis ER. Treatment of adhesive capsulitis of the shoulder. Journal of the American Academy of Orthopaedic Surgeons 2019;27(12):e544–e554 6. Hand GC, Athanasou NA, Matthews T et al. The pathology of frozen shoulder. Journal of Bone and Joint Surgery (Br) 2007;89(7):928–932 Open access https://bit.ly/36fNgil 7. Hannafin JA, Chiaia TA. Adhesive capsulitis: a treatment approach. Clinical Orthopaedics and Related Research 2000;372:95–109 Open access https://bit.ly/3qduBf1 8. Chan HBY, Pua PY, How CH. Physical therapy in the management of frozen shoulder. Singapore Medical Journal 2017;58(12):685–689 Open access https://bit.ly/2VkYawZ 9. van de Laar S, van der Zwaal P. Management of the frozen shoulder. Orthopedic Research and Reviews 2014;6:81–90 Open access https://bit.ly/36926qw 10. Cho CH, Bae KC, Kim DH. Treatment strategy for frozen shoulder. Clinics in Orthopedic Surgery 2019;11(3):249–257 Open access https://bit.ly/39eUZ1U 11. Cavalleri E, Servadio A, Berardi A et al. The effectiveness of physiotherapy in idiopathic or primary frozen shoulder: a systematic review and meta-analysis. Muscles, Ligaments and Tendons Journal 2020;10(1) Open access https://bit.ly/2VkYPhX 12. Bulgen DY, Binder AI, Hazleman BL, et al. Frozen shoulder: prospective clinical study with an evaluation of three treatment regimens. Annals of the Rheumatic Diseases 1984;43(3):353–360 Open access https://bit.ly/2V5bULR 13. Carette S, Moffet H, Tardif J et al. Intraarticular corticosteroids, supervised physiotherapy, or a combination of the two in the treatment of adhesive capsulitis of the shoulder: a placebo-controlled trial. Arthritis and Rheumatism 2003;48(3):829–838 Open access https://bit.ly/3fD6nG5 14. Vermeulen HM, Rozing PM, Obermann WR et al. Comparison of high-grade and low-grade mobilization techniques in the management of adhesive capsulitis of the shoulder: randomized controlled trial. Physical Therapy 2006;86(3):355–

Co-Kinetic.com

Frozen Shoulder: Stuck and Stubborn 368 Open access https://bit.ly/36bjV8v 15. Griggs SM, Ahn A, Green A. Idiopathic adhesive capsulitis. A prospective functional outcome study of nonoperative treatment. Journal of Bone and Joint Surgery (Am) 2000;82(10):1398–1407 16. Kanase SB, Shanmugam S. Effect of Kinesiotaping with Maitland mobilization and Maitland mobilization in management of frozen shoulder. International Journal of Science and Research 2014;3(9):1817–1821 Open access https://bit.ly/3q7fvHC 17. Anitha A, Sridevi J, Anusuya S et al. Effectiveness of end range mobilisation along with conventional therapy in patients with periarthritis of the shoulder. Research Journal of Pharmacy and Technology 2020;13(3):1271–1276 18. Vermeulen HM, Obermann WR, Burger BJ et al. End-range mobilization techniques in adhesive capsulitis of the shoulder joint: a multiple-subject case report. Physical Therapy 2000;80(12):1204– 1213 Open access https://bit.ly/33o0rvH 19. Mangus BC, Hoffman LA, Hoffman MA et al. Basic principles of extremity joint mobilization using a Kaltenborn approach. Journal of Sport Rehabilitation 2002;11:235–250 20. Minerva RK, Alagingi NK, Patchava A et al. To compare the effectiveness of Maitland versus Mulligan mobilisation in idiopathic adhesive capsulitis of shoulder. International Journal of Health Sciences and Research 2016;6(2):236–244 Open access https://bit.ly/33odu01 21. Sayed El Sawabey MF, Elsayed WH, Moharram AN et al. Effect of mobilization with movement versus diclofenac phonophoresis on shoulder adhesive capsulitis. Medical Journal of Cairo University 2020;88(1):45–50 Open access https://bit.ly/3fDm7ZD 22. Do Moon G, Lim JY, Da YK, Kim TH. Comparison of Maitland and Kaltenborn mobilization techniques for improving shoulder pain and range of motion in frozen shoulders. Journal of Physical Therapy Science 2015;27(5):1391–1395 Open access https://bit.ly/3pZKZzz 23. Phukon S, Sowmya MV, Sujata B et al. A comparative study between the efficacy of Maitland mobilization and muscle energy techniques in stage ii shoulder adhesive capsulitis. International Journal of Medical and Health Research 2017;3(5):39–42 Open access https://bit.ly/3o5rMe1 24. Jung J, Chung Y. Effects of combining both mobilization and hold-relax technique on the function of post-surgical patients with shoulder adhesive capsulitis. Physical Therapy Rehabilitation Science 2020;9(2):90–97 Open access https://bit.ly/37g2Bi3 25. Oh B-h, Kim S-y. The effect of home exercise programs for rotator cuff strengthening on pain, range of motion, disability level, and quality of life in patients with adhesive capsulitis. Physical Therapy Korea 2020;27(1):19–29 (in Korean) Open access https://bit.ly/3fCfo26

26. Russell S, Jariwala A, Conlon R et al. A blinded, randomized, controlled trial assessing conservative management strategies for frozen shoulder. Journal of Shoulder and Elbow Surgery 2014;23(4):500–507 27. Kennedy CA, Manno M, Hogg-Johnson S et al. Prognosis in soft tissue disorders of the shoulder: predicting both change in disability and level of disability after treatment. Physical Therapy 2006;86(7):1013–1032 Open access https://bit.ly/2V4ihiN 28. Menendez ME, Baker DK, Oladeji LO, Fryberger CT, McGwin G, Ponce BA. Psychological Distress Is Associated with Greater Perceived Disability and Pain in Patients Presenting to a Shoulder Clinic. The Journal of Bone and Joint Surgery (Am) 2015;97(24):1999–2003 29. Chester R, Jerosch-Herold C, Lewis J et al. Psychological factors are associated with the outcome of physiotherapy for people with shoulder pain: a multicentre longitudinal cohort study. British Journal of Sports Medicine 2018;52:269–275 Open access https://bit.ly/3fMHMyE 30. Chester R, Shepstone L, Daniell H et al. Predicting response to physiotherapy treatment for musculoskeletal shoulder pain: a systematic review. BMC Musculoskelet Disord 2013;14:203 Open access https://bit.ly/2JhIlUO 31. Chester R, Khondoker M, Shepstone L et al. Self-efficacy and risk of persistent shoulder pain: results of a Classification and Regression Tree (CART) analysis. British Journal of Sports Medicine 2019;53:825–834. 26i

HEALTH AND WELLBEING

Positive Pregnancy W

hen someone considers the ‘medical team’ required to facilitate a woman through pregnancy and childbirth, a physical therapist may not be the first name on the list. Obstetrician, doctor, midwife, nurse and ultrasound technician are the more common list of professionals in the top line-up. Typically with our historic reputation of ‘man-handling’ joints and muscles and ‘no pain, no gain’ rehabilitation routines, it’s no surprise a pregnant lady wouldn’t make us her first port of call. And yet, if we offer a truly holistic service to the patients of our practice, their extended families, friends and members of our community, we can play a significant role in encouraging a healthy and happy pregnancy experience. We often have the most one-on-one time with a patient (compared to many medical professionals), developing trust and deeper relationships. We have a key responsibility during those 9 months, and postpartum, to: l educate and build confidence in pregnant women that being physically active is not only safe, but is good for them and their baby; l not neglect injured or painful areas on their body just because they are pregnant – physical therapy treatment can be safe if done cautiously; l reassure that massage is safe and can relieve pain, and also that reducing stress and inducing relaxation is a much needed experience when pregnant; l educate that pregnancy back pain can be treated and relieved; and l educate that urinary incontinence can be managed through exercise during both pregnancy and postpartum phases. We know these facts but pregnant women can be very anxious, nervous and protective of their bump. They would rather suffer the pain than seek help if they fear it may hurt their baby. To ensure their trust in us, we must make sure we know the Co-Kinetic.com

PRACTITIONER UPDATE

Advice on many aspects of life, including physical activity, manual therapy and massage, nutrition and sleep, can help a woman have a happy and healthy pregnancy as well as promoting healthier outcomes postpartum for both mother and baby. We, as physical therapists, are in an ideal position to give this advice and encouragement. This article describes the current guidelines so that you can tailor your recommendations according to the unique situation and pre-pregnancy exercise levels of each of your pregnant patients, enabling them all to have the best possible experience of pregnancy. Read this article online https://spxj.nl/3fXqzCo facts and current recommendations regarding their care. This article therefore summarises the key physical activity guidelines for pregnant women (including precautions, red flags and proscriptions) and the role of exercise and manual therapy in the treatment and prevention of pregnancy back pain, as well as highlighting some key dietary and sleep hygiene concerns that may impact on the pregnancy experience.

Physical Activity and Pregnancy

By Kathryn Thomas BSc MPhil 21-01-COKINETIC FORMATS WEB MOBILE

All references marked with an asterisk are open access and links are provided in the reference list pregnancy (1*). Unfortunately, uncertainty among some pregnant women and obstetric care providers as to whether prenatal physical activity may increase the risk of miscarriage, growth restriction, preterm birth, fatigue or harm to the foetus has created a barrier to being active (1*). Concerns over harms have not been substantiated by research and the risks of not engaging in prenatal physical activity have not been adequately emphasised. Over the last three decades, the rates of pregnancy complications, such as gestational diabetes mellitus, preeclampsia, gestational hypertension and new-born macrosomia,

Table 1: Absolute and relative contraindications to physical activity during pregnancy Mottola MF et al. 2019 Canadian guideline for physical activity throughout pregnancy. British Journal of Sports Medicine 2018;52:1339–1346 (1*)

Absolute contraindications l Ruptured membranes, premature labour l Unexplained persistent vaginal bleeding l Placenta praevia after 28 weeks’ gestation l Pre-eclampsia l Incompetent cervix l Intrauterine growth restriction l High-order multiple pregnancy (eg. triplets) l Uncontrolled type 1 diabetes, uncontrolled hypertension or uncontrolled thyroid disease l Other serious cardiovascular, respiratory or systemic disorder

Relative contraindications l Recurrent pregnancy loss l History of spontaneous preterm birth l Gestational hypertension l Symptomatic anaemia l Malnutrition l Eating disorder l Twin pregnancy after 28th week l Mild/moderate cardiovascular or respiratory disease l Other significant medical conditions

have risen dramatically, most likely as a consequence of rising rates of maternal obesity (1*). Physical activity has been proposed as a preventive or therapeutic measure to reduce pregnancy complications and optimise maternal– foetal health (1*). The specific recommendations in the 2019 Canadian Guideline for Physical Activity throughout Pregnancy (1*) are provided below (See also Related Content for relevant patient information leaflets): 1. All women without contraindication

Table 2: Heart rate ranges for pregnant women Mottola MF et al. 2019 Canadian guideline for physical activity throughout pregnancy. British Journal of Sports Medicine 2018;52:1339–1346 (1*) Maternal age

Intensity

<29

Light Moderate Vigorous

Heart rate range (beats/min) 102–124 125–146 147–169†

30+

Light Moderate Vigorous

101–120 121–141 142–162†

l Moderate-intensity physical activity [40–59% heart rate reserve (HRR)]; vigorous-intensity physical activity (60–80% HRR) (1). l Target heart rate ranges were derived from peak exercise tests in medically screened, low-risk pregnant women (1). † As there is minimal information regarding the impact of physical activity at the upper end of the vigorousintensity heart rate ranges, women wishing to be active at this intensity (or beyond) are encouraged to consult their obstetric care provider (1).

should be physically active throughout pregnancy. (Strong recommendation, moderate-quality evidence.) Specific subgroups were examined: l Women who were previously inactive. (Strong recommendation, moderate-quality evidence.) l Women diagnosed with gestational diabetes mellitus. (Weak recommendation, lowquality evidence.) l Women categorised as overweight or obese [prepregnancy body mass index (BMI) ≥25kg/m2]. (Strong recommendation, low-quality evidence.) 2. Pregnant women should accumulate at least 150 minutes of moderateintensity physical activity each week to achieve clinically meaningful health benefits and reductions in pregnancy complications. (Strong recommendation, moderate-quality evidence.) 3. Physical activity should be accumulated over a minimum of 3 days per week; however, being active every day is encouraged. (Strong recommendation, moderatequality evidence.) 4. Pregnant women should incorporate a variety of aerobic and resistance training activities to achieve greater benefits. Adding yoga and/or gentle stretching may also be beneficial. (Strong recommendation, highquality evidence.) 5. Pelvic floor muscle training (PFMT) (eg. Kegel exercises) may be

performed on a daily basis to reduce the risk of urinary incontinence (See Related Content for relevant patient information leaflet). PFMT is recommended to prevent urinary incontinence even though it was not rated as a ‘critical’ outcome and was based on low-quality evidence. Prenatal PFMT is associated with a 50% reduction in prenatal and 35% reduction in postnatal urinary incontinence. The Guidelines Consensus Panel recommended instruction on proper technique to obtain optimal benefits. (Weak recommendation, low-quality evidence.) 6. Pregnant women who experience light-headedness, nausea or feel unwell when they exercise flat on their back should modify their exercise position to avoid the supine position. (Weak recommendation, very-low-quality evidence.) Studies have shown that, compared with no physical activity, accumulating at least 150 minutes of moderate-intensity physical activity over 3 or more days per week was associated with clinically meaningful reductions in the odds of developing gestational diabetes mellitus, pre-eclampsia and gestational hypertension (1*). Accumulating more physical activity (frequency, duration or volume) over the week was associated with greater benefits; however, physical activity below the recommendations also incurred some benefits. So anything is better than nothing!

Contraindications to Physical Activity

All pregnant women can participate in physical activity throughout pregnancy with the exception of those who have contraindications (Table 1). Women with absolute contraindications may continue their usual activities of daily living but should not participate in more strenuous activities. Women with relative contraindications should discuss the advantages and disadvantages of moderate-to-vigorous intensity physical activity with their obstetric care provider before participation. When considering exercise intensity, maternal heart rate is an accurate measure. Pregnancy-specific heart rate

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zones can be used for women wishing to monitor their exercise intensity (Table 2) (1*). However, this may not be for all – some women may be fearful of exceeding certain zones and causing harm to the baby. Other measures of physical activity intensity include the talk test. As the term ‘talk test’ implies, the woman is at a comfortable intensity if she is able to maintain a conversation during physical activity and should reduce the intensity if this is not possible (1*). The talk test is a simple ‘tool’ and potentially less scary for some women.

General Safety Precautions

Some general safety precautions for women who are pregnant and physically active include the following (1*): l Avoid activities that involve physical contact or danger of falling, which may increase the risk of foetal trauma. These activities include, but are not limited to, horse riding, downhill skiing, ice hockey, gymnastics or Olympic lifts (1*). l Pregnant women are recommended to avoid non-stationary cycling as this activity may carry a higher risk of falling owing to changes in body mechanics and the ability to respond to the environment (eg. traffic, unsteady surfaces) as pregnancy progresses. As an alternative, brisk walking, stationary cycling, swimming or aquafit are aerobic activities that are associated with less risk of falling or physical contact (1*). l Women should not scuba-dive in pregnancy, as the foetus is not protected from decompression sickness and gas embolism (1*). l Lowlander women (ie. living below 2500m) should avoid physical activity at high altitude (>2500m). Those considering physical activity above those altitudes should seek supervision from an obstetric care provider with knowledge of the impact of high altitude on maternal and foetal outcomes (1*). l With appropriate acclimatisation, moderate-intensity physical activity at altitudes up to 1800–2500m (6000–8250 feet) does not appear to significantly alter maternal or Co-Kinetic.com

PHYSICAL ACTIVITY HAS BEEN PROPOSED AS A MEASURE TO REDUCE PREGNANCY COMPLICATIONS THAT ARE LIKELY TO BE CAUSED BY MATERNAL OBESITY foetal wellbeing (1*). However, women should be wary of hiking in a location where they might fall (1*). l It is also important that women stay hydrated and avoid vigorous physical activity in excessive heat, especially with high humidity, to avoid dehydration (eg. hot yoga) (1*). l Those considering athletic competition or exercising significantly above the recommended guidelines should seek supervision from an obstetric care provider with knowledge of the impact of high-intensity physical activity on maternal and foetal outcomes (1*). l Maintain adequate nutrition and hydration – drink water before, during and after physical activity (1*). l Know the reasons to stop physical activity (listed below) and consult a qualified healthcare provider immediately if they occur (1*). During pregnancy, some women will experience a visible separation of their abdominal muscles, called diastasis recti. Those women are counselled to seek physiotherapy advice and avoid abdominal strengthening exercises (eg. abdominal curls) as this may worsen the condition, increasing the likelihood of requiring postnatal repair (1*). However, continuing aerobic exercise such as walking is associated with decreased odds of developing diastasis recti (1*). Although there has been less research on resistance exercises compared with aerobic exercises in pregnancy, available evidence regarding resistance exercise in pregnancy has not identified adverse impacts on the mother, the foetus or the neonate. Therefore, resistance training that adheres to the safety considerations discussed above is encouraged (1*). Studies have shown that ‘mixed’ interventions combining aerobic and resistance training activities demonstrated

greater improvements in pregnancy outcomes than aerobic activity alone. (1*). Previously inactive women are encouraged to start physical activity in pregnancy but may need to begin gradually, at lower intensity and increase the duration and intensity as their pregnancy progresses (1*). Remember, as with any exercise regimen, a warm-up and cooldown period should be included. Ligaments become relaxed during pregnancy because of increasing hormone levels and may impact on the range of movement, thereby increasing the risk of injury (1*). All women should STOP ACTIVITY and seek medical attention if they experience any of the symptoms below (1*): l persistent excessive shortness of breath that does not resolve on rest; l severe chest pain; l regular and painful uterine contractions; l vaginal bleeding; l persistent loss of fluid from the vagina indicating rupture of the membranes; or l persistent dizziness or faintness that does not resolve on rest. The 2019 Canadian Guideline for Physical Activity throughout Pregnancy (1*) are the latest recommendations and should represent a foundational shift in the view of prenatal physical activity from a recommended behaviour to improve quality of life, to a specific prescription for physical activity to reduce pregnancy complications and optimise health across the lifespan of two generations. It is critical that these guidelines be implemented into clinical practice to achieve the significant and potentially lifelong health benefits for both the mother and the child. 29

COMBINING AEROBIC AND RESISTANCE TRAINING ACTIVITIES DEMONSTRATED GREATER IMPROVEMENTS IN PREGNANCY OUTCOMES THAN AEROBIC ACTIVITY ALONE Managing Back Pain Through Pregnancy

Approximately 50% of women experience low back pain (LBP) or pelvic girdle pain (PGP) during pregnancy; 25% continue to experience pain 1 year after delivery. A 10-year follow-up study reported that 1 in 10 women with PGP in pregnancy has severe consequences up to 11 years postpartum (2*). LBP is pain or discomfort located between the 12th rib and the gluteal fold, and PGP has been defined as ‘pain experienced between the posterior iliac crest and the gluteal fold, particularly in the vicinity of the sacroiliac joints’. Despite the fact that both conditions are considered distinct entities, both place a great burden on pregnant women regarding health quality and daily functioning. With repercussions such as disruption of sleep, social and sexual life, work capacity and increased psychological stress, it is not surprising that pregnant women experiencing either LBP or PGP have also been reported to be less likely to exercise regularly during pregnancy (2*). In the general population, ‘moderate’ quality evidence suggests exercise has a small positive effect on the severity of LBP compared with usual care, which is comparable with the effectiveness of other non-pharmacological approaches recommended for the management of acute or chronic LBP (3). Compared with other nonpharmacological treatments, such as interdisciplinary rehabilitation, acupuncture,

spinal manipulation or cognitive behavioural therapy, exercise is a cost-effective option as part of a self-management strategy, requiring minimal equipment and can be performed at home (2*,3). Previous national and international guidelines of exercise during pregnancy in terms of fitness, overall wellbeing and decreased risk of developing pregnancy-related complications (4*,5*,6*). However, in these guidelines, exercise was not discussed within its role of managing pregnancy-related pain. The European guidelines for the diagnosis and treatment of PGP, published in 2008 (7*), were the first to mention that exercise should be recommended for pregnant women, with a focus on activities of daily living and avoidance of maladaptive movement patterns (7*). The Cochrane Review published in 2015 by Liddle et al. supports this recommendation, concluding that “exercise may reduce pregnancyrelated low-back pain” (8*). However, research gaps still remain with a limited number of randomised controlled trials containing ‘low’ quality evidence. Similar to non-specific LBP in the general population, risk factors for pregnancy-related LBP and PGP are believed to be multifactorial (eg. increased joint laxity, displacement of gravity centre and increased axial loading, and vascular changes) and the exact pathogenesis remains unclear (2*). Evidence suggests that a variety of types of prenatal exercise (ie. aerobic exercise, yoga, specific strengthening exercise, general strengthening exercise or a combination of different types of exercise) did not reduce the odds of LBP or PGP occurring during pregnancy or in the early postpartum period (2*). However, there is some evidence showing that prenatal exercise was an effective treatment to decrease the severity of LBP and PGP during pregnancy (2*); additionally,

‘low’ quality evidence from one randomised controlled trial indicated that exercise during pregnancy decreased the severity of LBP in the postpartum period (8*). As mentioned in addition to pain, women with LBP or PGP commonly report disturbed sleep, difficulties attending normal daily activities, significant absenteeism from work, and residual symptoms postpartum. Some women also suffer considerable stress, with many worrying that their pain is a sign of problems with their developing baby. Despite this, women may receive little or no treatment to manage their condition (9*). Studies of complementary therapies (therapies including craniosacral therapy, chiropractic neuro-emotional techniques, osteopathic manipulative treatment, and massage) have indicated a moderate treatment effect for decreasing pain intensity compared to usual care and relaxation, and a moderate effect on pain disability compared to usual care (9*). Specifically, positive effects have been shown for pain intensity after osteopathy and partner-delivered massage. Partnerdelivered massage had a positive effect on pain intensity experienced by depressed pregnant women when compared to relaxation, and there was an overall positive effect when the therapies (massage and relaxation techniques) were combined (10). Despite some concerns regarding the use of manual therapies by pregnant women, Oswald et al. assert that very few adverse effects have been reported in the literature (11*). Findings from the few studies included in the current review that reported safety are consistent and suggest complementary manual therapies as a safe and effective option during pregnancy compared to no treatment at all (9*).

Nutrition During Pregnancy

Diet can play a vital role in the care of your pregnant patients: including having sufficient energy to be physically active, ensuring a balanced energy intake to expenditure for weight control during pregnancy, and the effects of certain foods on mood and sleep. Food selections should emphasise choosing a variety of nutrient-dense foods from

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a daily multivitamin or if they are at all four food groups, as opposed to high risk for bearing offspring with energy-dense, nutrient-poor foods. A neural tube defects, a 4.0mg folic nutrient-rich, energy-appropriate diet acid supplement 12 weeks before will help to ensure a woman’s own and after conception followed by nutritional requirements are met and 0.4–1mg until weaning. Caution facilitate healthy development of her women not to take more than one foetus throughout the pregnancy (12*). daily dose of their multivitamin (14*). The amount of energy required 5. R ecommend a supplement to support pregnancy (for women containing 16–20mg of elemental with a pre-pregnancy BMI of 18.5 to iron to pregnant women who are in 25) is modest, with no recommended good health (12*). increase in calorie intake during the first a night to day one post-labour! The 6. E merging evidence suggests that trimester and an increase of only 340 shock would be too much to bare. choline, omega-3 fatty acids and and 450kcal/day in the second and third But is there something else more iodine are important nutrients that trimesters, respectively. This generally serious about inadequate sleep during may be limited in the diets that equates to only two to three additional pregnancy? pregnant women consume. Discuss servings per day from any of the four Disrupted and/or poor quality foods rich in these nutrients (eg. food groups in the second and third sleep during pregnancy can be eggs for choline; fatty fish and nuts/ trimesters. Energy requirements for attributed to a combination of seeds for omega-3 fatty acids; women with a pre-pregnancy BMI above mechanical and physiological changes saltwater fish low in methylmercury 25kg/m are not well established (12*). including (15*): and iodized salt for iodine) with l changing hormones; women as the pregnancy progresses l increased metabolic requirements Recommendations for weight and (12*). of pregnancy due to foetal nutrition during pregnancy 7. E mphasise the importance of organogenesis, which may place 1. Measure and discuss weight gain for limiting or avoiding certain foods burden on maternal energy stores pregnancy with all women as early during pregnancy (eg. avoid foods and, thus, increased sleep time in pregnancy and as regularly as is potentially contaminated with may be a potential mechanism to feasible. Recommendations for the bacteria and fish with high levels of conserve energy; range of pregnancy-related weight methylmercury) (12*). l nocturia, resulting from bladder gain should be based on the woman’s 8. F ollow guidelines for alcohol compression due to increased pre-pregnancy BMI (Table 3) (13*). use during pregnancy. There is uterine size; Gaining weight within recommended evidence that alcohol consumption l heartburn; ranges will help to optimise maternal, in pregnancy can cause foetal l increased foetal movements; infant, and child health outcomes. harm. There is insufficient evidence l sleep-disordered breathing due 2. Women who have not met the regarding foetal safety or harm at to hormonal fluctuations and/ minimum or have exceeded the low levels of alcohol consumption in or overweight and obesity where maximum amount of weight pregnancy (12*). excess weight further compresses gain recommended for a specific the thorax and hinders respiratory gestational age require additional capacity leading to altered follow-up and assessment. They Sleep Hygiene respiration; and should be encouraged to increase or During Pregnancy l pregnancy-related discomfort, joint slow their rate of weight gain to fall We joke about the lack of sleep during pain, cramping, nausea and an within the recommended ranges of pregnancy as ‘essential’ preparation for enlarged abdomen may limit sleep weekly rate of gain until delivery (12*). what is to come. Imagine going from positions. 3. Support women in understanding a solid undisturbed 9 hours of sleep how to meet recommendations for specific nutrients of concern during Table 3: Range of pregnancy-related weight gain should be pregnancy, which include folate, iron, based on pre-pregnancy body mass index (BMI) Vanstone M et choline, omega-3 fatty acids, and al. Pregnant women's perceptions of gestational weight gain: a systematic iodine (12*). review and meta-synthesis of qualitative research. Maternal & Child Nutrition 4. Follow the 2015 Society of 2017;13(4):e12374 (13*) Obstetricians and Gynaecologists of Canada guideline for the Pre-pregnancy BMI BMI (kg/m2) Total weight gain range (kg) supplementary use of folic acid by Underweight <18.5 12.7–18.0 pregnant women (14*). Pregnant Normal weight 18.5–24.9 11.3–15.9 women at low or moderate risk for Overweight 25.0–29.9 6.8–11.3 bearing an offspring with a neural tube defect should consume 0.4mg Obese (all classes) >30 5–9 and 1.0mg folic acid, respectively, in

EVIDENCE SUGGESTS THAT PRENATAL EXERCISE IS AN EFFECTIVE TREATMENT TO DECREASE THE SEVERITY OF LOW BACK PAIN DURING PREGNANCY

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ENCOURAGING GOOD SLEEP HYGIENE IN PREGNANCY MAY IMPROVE MATERNAL– FOETAL OUTCOMES

There is an inadequacy of information concerning the role of adequate sleep hygiene during pregnancy and how it relates to maternal–foetal outcomes. However, Chang et al. noted that prenatal sleep deprivation was associated with longer labour, increased labour pain perception and discomfort, higher caesarean rates, preterm births and postpartum depression (16*). No study to date has extensively examined the mechanisms by which short sleep impairs glycemia as related to gestational diabetes mellitus, a prevalent pregnancy-related comorbidity. This is important because the quality of the intrauterine environment influences maternal–foetal health and also offspring predisposition to obesity and cardiometabolic disease later in life. Several determinants, including but not limited to pre-gravid obesity and excessive gestational weight gain, alter the developmental milieu, foetal growth and child obesity risk. Given the host of psychosocial and physiological complications associated with childhood obesity, targeting the gestational period is purported to be an opportune time for preventive intervention (15*). A lack of sleep promotes positive energy balance, weight gain and central adiposity through increased calorie consumption; restoration of adequate sleep in identified short sleepers protects against further weight gain. It seems reasonable to hypothesise that the same principle runs true during pregnancy and, therefore, adequate sleep may be a health benefit during pregnancy (15*). Impaired sleep can create a vicious cycle of fatigue, lack of 32

energy to exercise or be active, weight gain, health concerns, stress, anxiety, depression, impaired sleep and so on. It has been theorized that a consequence of better sleep may be greater engagement in healthy lifestyles, being more physical than sedentary, further balance energy consumption with energy expenditure during pregnancy, and yield optimal glycaemic control and potentially gestational weight gain at term (15*). Thus encouraging sleep early in pregnancy and/or behaviour which facilitates improved sleep (eg. regular physical activity, massage and physical therapy to relieve back pain that may be impacting on sleep) may help attenuate pregnancy-associated deterioration in sleep hygiene and improve maternal–foetal outcomes. Evidence links insufficient sleep with adiposity gains over time, suggesting the need to inform all patients about the value of sleep hygiene as a preventive measure. These recommendations should not be limited to the non-pregnant population but extended to expecting mothers as well. Given the complex nature of body weight regulation and the poor maternal–foetal outcomes associated with impaired glycaemic and excessive gestational weight gain, sleep may be another talking point for practitioners to assess and advise on during prenatal counselling (15*).

Final Comments

In closing, physical therapists can play a key role in pregnancy health and wellness. Knowledge about the benefits of physical activity during pregnancy, both physical and mental wellbeing, should be shared

with patients in your practice and community. Physical activity can help prevent or relieve back pain during pregnancy. It can help improve mood and reduce stress and anxiety in the expecting mother. Being physically active will help regulate weight gain during pregnancy which may have huge effects in preventing glycaemic complications in both the mother and foetus which could have longterm negative effects. Hands-on physical therapy can reduce pain, stress, anxiety and discomfort being experienced. All of this, combined with a healthy diet, should facilitate better sleep patterns during pregnancy, which again should positively impact the mother’s physical and mental wellness. Let’s make a meaningful impact with our pregnant patients during a time which should be filled with optimism, excitement and joy. References

1. Mottola MF, Davenport MH, Ruchat S et al. 2019 Canadian guideline for physical activity throughout pregnancy. British Journal of Sports Medicine 2018;52:1339–1346 Open access https://bit.ly/3q4gc4K 2. Davenport MH, Marchand A, Mottola MF et al. Exercise for the prevention and treatment of low back, pelvic girdle and lumbopelvic pain during pregnancy: a systematic review and meta-analysis. British Journal of Sports Medicine 2019;53:90– 98 Open access https://bit.ly/2V0Ua4l 3. Chou R, Deyo R, Friedly J et al. Nonpharmacologic therapies for low back pain: a systematic review for an American College of Physicians clinical practice guideline. Annals of Internal Medicine 2017;166:493–505 4. Evenson KR, Barakat R, Brown WJ et al. Guidelines for physical activity during pregnancy: comparisons from around the world. American Journal of Lifestyle Medicine 2014;8:102–121 Open access https://bit.ly/2JbuDDl 5. Physical activity and exercise during pregnancy and the postpartum period: ACOG Committee Opinion, number 804. Obstetrics and Gynecology 2020;135(4):e178-e188 Open access https://bit.ly/33cTRIc 6. Davies GA, Wolfe LA, Mottola MF et al. Joint SOGC/CSEP clinical practice guideline: exercise in pregnancy and the postpartum period. Canadian Journal of Applied Physiology 2003;28:329–341 Open access https://bit.ly/39gFGWf 7. Vleeming A, Albert HB, Ostgaard HC et al. European guidelines for the diagnosis and treatment of pelvic girdle pain.

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European Spine Journal 2008;17:794–819 Open access https://bit.ly/364RwB6 8. Liddle SD, Pennick V. Interventions for preventing and treating low-back and pelvic pain during pregnancy. Cochrane Database of Systematic Reviews 2015;2015(9):CD001139 Open access https://bit.ly/3nVKUeb 9. Hall H, Cramer H, Sundberg T et al. The effectiveness of complementary manual therapies for pregnancy-related back and pelvic pain: A systematic review with metaanalysis. Medicine 2016;95(38):e4723 Open access https://bit.ly/2Jc7oc0 10. Field T, Diego M, Hernandez-Reif M et al. Massage therapy effects on depressed pregnant women. Journal of Psychosomatic Obstetrics and Gynaecology 2004;25:115–122 11. Oswald C, Higgins CC, Assimakopoulos D. Optimizing pain relief during pregnancy using manual therapy. Canadian Family Physician 2013; 59:841–842 Open access https://bit.ly/361xPtL 12. Nutrition Working Group, O’Connor DL, Blake J et al. Canadian consensus on female

nutrition: adolescence, reproduction, menopause, and beyond. Journal of Obstetrics and Gynaecology Canada 2016;38(6):508–554.e18 Open access https://bit.ly/2KA1pOF 13. Vanstone M, Kandasamy S, Giacomini M et al. Pregnant women’s perceptions of gestational weight gain: a systematic review and meta-synthesis of qualitative research. Maternal & Child Nutrition 2017;13(4):e12374 Open access https://bit.ly/3pZPGsW 14. Genetics Committee, Wilson RD, Audibert F et al. Pre-conception folic acid and multivitamin supplementation for the primary and secondary prevention of neural tube defects and other folic acidsensitive congenital anomalies. Journal of Obstetrics and Gynaecol Canada 2015;37(6):534–552 Open access https://bit.ly/364R4mf 15. Ferraro ZM, Chaput JP, Gruslin A et al. The potential value of sleep hygiene for a healthy pregnancy: a brief review. ISRN Family Medicine 2014;2014:928293 Open access https://bit.ly/3650f65

KEY POINTS

l Pregnant women should accumulate at least 150 minutes of moderate-intensity physical activity each week to achieve meaningful physical and mental benefits and reductions in pregnancy complications. l All women without contraindication should be physically active throughout pregnancy. l Pregnant women should incorporate a variety of aerobic and resistance training activities to achieve greater benefits. l Fewer than 15% of women will actually achieve the minimum recommendation of physical activity per week. l Absolute and relative contraindications to exercise should be adhered to. l Approximately 50% of women experience low back or pelvic girdle pain during pregnancy; 25% continue to experience pain 1 year after delivery. l Low back or pelvic girdle pain is associated with a decrease in regular physical activity during pregnancy. l Physical activity and exercise performed during pregnancy decreases the severity of low back, pelvic and lumbopelvic pain. l Complementary therapies (including craniosacral therapy, chiropractic, osteopathic manipulative treatment, and massage) can decrease pain intensity and are safe during pregnancy. l A healthy diet and supplements will help regulate gestational weight gain, promote physical activity and glucose control, which may affect the health of the mother and baby long term. l New evolving theories suggest sleep hygiene is critical for the long-term health of the mother and foetus.

RELATED CONTENT

l Pregnancy Patient Information Leaflets https://bit.ly/2VTqsyS l Patient Information Leaflet: Under Pressure - Strategies for Reducing and Preventing Stress Incontinence [Printable leaflet] https://bit.ly/364CLOF l Low Back Pain During Pregnancy: Physiological versus Pathological Back Pain [Article] http://spxj.nl/2umiDCI

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16. Chang JJ, Pien GW, Duntley SP et al. Sleep deprivation during pregnancy and maternal and fetal outcomes: is there a relationship? Sleep Medicine Reviews 2010;14(2):107–114 Open access https://bit.ly/3nVQ8H4.

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Tweet this: Physical therapists are in an ideal position to encourage a healthy and happy pregnancy https://spxj.nl/3fXqzCo Tweet this: Physical activity can help combat pregnancy complications linked to rising maternal obesity https://spxj.nl/3fXqzCo Tweet this: Inactive women are encouraged to start physical activity in pregnancy but should begin gradually https://spxj.nl/3fXqzCo

DISCUSSIONS

l What physical activities or exercises do you promote to pregnant women most often, knowing they may enjoy it and be more compliant? (For example, yoga, aquacise, walking, resistance exercises…) l Are there any specific exercises or treatment techniques/modalities that you choose to avoid when managing a pregnant patient with back pain? l What tips, treatments or routines do you advise to promote relaxation and better sleep during pregnancy? 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 Masters 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 33

HEALTH AND WELLBEING

Positive Pregnancy W

PRACTITIONER UPDATE

Advice on many aspects of life, including physical activity, manual therapy and massage, nutrition and sleep, can help a woman have a happy and healthy pregnancy as well as promoting healthier outcomes postpartum for both mother and baby. We, as physical therapists, are in an ideal position to give this advice and encouragement. This article describes the current guidelines so that you can tailor your recommendations according to the unique situation and pre-pregnancy exercise levels of each of your pregnant patients, enabling them all to have the best possible experience of pregnancy. Read this article online https://spxj.nl/3fXqzCo facts and current recommendations regarding their care. This article therefore summarises the key physical activity guidelines for pregnant women (including precautions, red flags and proscriptions) and the role of exercise and manual therapy in the treatment and prevention of pregnancy back pain, as well as highlighting some key dietary and sleep hygiene concerns that may impact on the pregnancy experience.

Physical Activity and Pregnancy

By Kathryn Thomas BSc MPhil 21-01-COKINETIC FORMATS WEB MOBILE

Intensity

<29

Light Moderate Vigorous

Heart rate range (beats/min) 102–124 125–146 147–169†

30+

Light Moderate Vigorous

101–120 121–141 142–162†

Contraindications to Physical Activity

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General Safety Precautions

COMBINING AEROBIC AND RESISTANCE TRAINING ACTIVITIES DEMONSTRATED GREATER IMPROVEMENTS IN PREGNANCY OUTCOMES THAN AEROBIC ACTIVITY ALONE Managing Back Pain Through Pregnancy

Nutrition During Pregnancy

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EVIDENCE SUGGESTS THAT PRENATAL EXERCISE IS AN EFFECTIVE TREATMENT TO DECREASE THE SEVERITY OF LOW BACK PAIN DURING PREGNANCY

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ENCOURAGING GOOD SLEEP HYGIENE IN PREGNANCY MAY IMPROVE MATERNAL– FOETAL OUTCOMES

Final Comments

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HEALTH AND WELLBEING

KEY POINTS

RELATED CONTENT

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DISCUSSIONS

BIOTENSEGRITY AND HUMAN MOVEMENT:

Introduction

The theory of biotensegrity posits that tensegrity force management strategies are used by all living biological organisms; hence to understand the term ‘biotensegrity’, we first need to understand the concept of ‘tensegrity’. Tensegrity structures are systems of hard components (bars or struts) that are islanded within a sea of tension cables, and their struts may seem to float in mid-air – giving rise to tensegrity’s other name ‘floating compression’. This illusion is created because the parts are arranged to mutually act on each other, with the bars compressed by the cables as the cables are tensioned by the struts, creating a volumetric structure which functions as a unified whole. Structures built using tensegrity principles are remarkably strong and light for their mass and have highly unusual, nonlinear physical properties. Biotensegrity is a structural principle that describes the tensegral relationship among and between all parts of living organisms, and at multiple scale levels from the molecular to the cellular to the musculoskeletal. Within the body’s transmutable soft matter system, the roles of tensioned cables may be fulfilled by structures such as integrins, the extracellular matrix, fascia, ligaments, tendons or muscle, and the role of the compressed bars may be played by elements from the cytoskeleton to the skeleton. For example, the human spine, if it were simply a ‘column’ of vertebrae, would fail as soon as we moved away from vertical. The fact that it doesn’t and that it can function and successfully manage 34

Human bodies are biotensegrity structures. This is what allows us to achieve our very special combination of stability, movement, adaptability and resilience. As we better understand biotensegrity, we can better understand how our physical structure functions, and we can use this knowledge to help our clients and patients discover more optimal movement. This article is extracted from Chapter 15 “Reconfiguring” of the author’s book Everything Moves: How biotensegrity informs human movement and ties together many topics previously introduced, including how the body’s closed kinematic chains emerge as part of its tensegral structure. As in the rest of the book, it contains a number of exercises to help you to learn through practical experience. Read this article online https://bit.ly/2JD4spj By Susan Lowell de Solórzano MA and transfer forces while in many positions is because it is a tensegrity structure. Concepts mentioned above, such as force management, systems, nonlinearity, and soft matter, are explored more thoroughly in earlier chapters of my book Everything Moves: How biotensegrity informs human movement. This article is extracted from Chapter 15, “Reconfiguring,” which integrates these various ideas and discusses how alliances of closed kinematic chains in the body’s transmutable tensegrity system simultaneously allow movement and force management, including attenuation and amplification.

Three Birds

When I was a girl, in the living room at my friend’s house there stood an extraordinary sculpture that her grandmother had made of two lifesized great blue herons. They were over a metre tall, with a graceful posture and long, lovely lines from their feet up their long stick-like legs, continuing on to their nearly upright bodies, and on through their long necks, to the top of their crested heads. This is the first I remember learning about these magnificent birds, and subsequently I became able to identify them in the wild. This led me to wonder about the identity of other

BIOTENSEGRITY | 21-01-COKINETIC FORMATS WEB MOBILE PRINT All references marked with an asterisk are open access and links are provided in the reference list

I DON’T BEND MY ELBOW, I RECONFIGURE MY ARM (STEVEN LEVIN) Co-Kinetic Journal 2021;87(January):34-43

MANUAL THERAPY

(a)

(b)

(c)

Figure 1: Three birds, all of which are great blue herons (a) flying, (b) upright, (c) hunched. (a) photo by CheepShot (CC by S-A 2.0); (b) photo by Tomo Ueda on Unsplash; (c) photo by Julie Marsh on Unsplash.

birds, and one in particular that caught my attention was another large grey water bird, also with long legs, long bill and a feathered crest draped down the back of its head but, unlike the great blue heron, it seemed to have no neck at all, and instead had a hunched stance. What was this bird called? I was also curious about yet another good-sized bird I would often see flying over stretches of water, such as down the path of a river or low across the surface of a lake. This bird had an angular body, including an unusual zig-zag of a neck, as if its chin were pulled straight back, so that it flew with its head back and up, with its long legs stretched out straight behind it as it flew. I remember thinking how difficult it must be for this unfortunate creature to fly with this crooked neck and upright head, unable to extend its head forward more aerodynamically like a swan or goose. Added to that was this strenuous task of having to hold its legs straight out behind it as it flew. It looked uncomfortable and exhausting. I now know that all three of these birds were one and the same species. They are all the different functional, necessary and optimal shapes of the great blue heron. Surely many other shapes and configurations are necessary for herons, shapes they create for themselves, then relinquish in favour of the next in order to lead a healthy heron life (Fig. 1).

Prison Break

A few years ago in New Zealand, in the middle of the night, ‘Inky’, a battlescarred captive who had been living in his enclosure for two years, somehow managed to squeeze his way out through a small hole. Silently, he slipped across the floor to a nearby drainage Co-Kinetic.com

pipe, then slithered 50 metres through the pipe until he reached the open ocean, and freedom. Although it sounds like a scene from a movie, this was the real-life adventure of Inky the octopus, whose escape from New Zealand’s National Aquarium in 2016 went viral on social media, surprising the scientists who had been charged with his care. Having no bones, this remarkable cephalopod reconfigures its smaller parts to morph itself from one shape into the next, as needed, and can fit through surprisingly small spaces. National Geographic’s media division, Nat Geo, features a film of a 272kg octopus passing through a lucite tube whose diameter is less than 25mm. Through all the kingdoms of biological life, an ability to reconfigure is found.

I Don’t Bend My Elbow…

We have discussed how language and conceptual frameworks influence our perception of our bodies. To this point, Steve Levin often says, “I don’t bend my elbow, I reconfigure my arm”. We have the ability (within certain limits of course) to transform ourselves and reconfigure in amazing ways. This may bring to mind contortionists but, as in the case of Inky and the heron, biology in general offers many examples indicating that an ability to reconfigure is common to all of us. Human reconfiguring can readily be seen, for example, in images of therapeutic cupping treatments, where surprising amounts of flesh are suctioned upwards into glass cups, and then instantly return to their normal position upon release of the suction (Fig. 2). Slow motion images of a person being hit in the head with a soccer ball reveal astonishing

movement response patterns that we might not easily imagine our heads would be able to create. The study of biotensegrity provides us with a conceptual and structural framework for how we reconfigure, how we can do so responsively and at multiple scale levels simultaneously, for how we can be structurally functional at every moment while we are in the process of reconfiguring, and for how we can do all this with optimal energy and material efficiency. This magic happens through the geometry of our myriad closed kinematic chains (CKCs), “…because kinematics is all about the geometry of motion” (1). CKCs are a component of the six-strut tensegrity vector icosahedron as well. This article (from Chapter 15 “Reconfiguring” of Everything Moves: How biotensegrity informs human movement) focuses on the need for, and use of, CKCs to reconfigure and to create the biomotional, in-out-andaround movement of living things.

Reviewing CKCs

CKCs (introduced in Chapter 6 “Triangles” of the book Everything Moves) are loops of linked mechanical elements, the most minimal of which is the triangle, which is stable and immoveable. We have seen that CKC loops of over four linkages are highly moveable, but difficult to control on their own. The four-bar CKC is: “The simplest geometric arrangement that enables the structure itself to control motion … where the length and position of

Figure 2: Distortion of the body by cupping. Cupping techniques use suction to pull the body’s tissues upward and outward for therapeutic effect. When the cup is removed, the body instantly regains its original shape. Photo courtesy of quatro.sinko; CC BY-SA 2.0.

THE STUDY OF BIOTENSEGRITY PROVIDES US WITH A CONCEPTUAL AND STRUCTURAL FRAMEWORK FOR HOW WE RECONFIGURE each bar (linkage) determines the behaviour of all the others in the system, and the angular relationships between them define its mechanical properties” (2).

Figure 3: A pantograph. This is a mechanical CKC which allows the user to trace an image at one end to create a duplicate image of a larger or smaller size at the other.

We humans have, to some extent, this ability to change our shapes to meet the demands of the moment, and our biologically constituted CKCs can produce behaviours which are governed by the structures themselves, the result being energetically and materially efficient movements of functional, immediate, on-site responsivity which can magnify or attenuate, as well as transfer, forces. It is no wonder that CKCs are “ubiquitous, mechanically-efficient and evolutionaryconserved structural arrangements” (1).

Box 1: Revisiting CKCs

Figure 4: CKCs and auxeticity. This CKC model designed by Junichi Yananose demonstrates the characteristic of auxeticity, and from its expanded state can condense in either a left or right spiral pattern. Because of its linkages, it can be controlled and transformed by changing any one angle. Photos © Ana Teresa Ortega.

Figure 5: Correlating a CKC movement in the body. (a) With the arm resting palm up, the radius and ulna bones in the forearm are parallel, just as the longer sides of the stick CKC next to it are. (b) When the palm turns over, the radius and ulna become crossed; in a similar way, one of the shorter ends of the stick CKC can be flipped over, which results in the longer sticks crossing. Photos © Ana Teresa Ortega. 36

(a)

(b)

As you move, see if you can sense where and how your body might be manifesting CKC mechanisms; share your experiences with a colleague.

The Power of CKCs

In 1603, Swabian Jesuit polymath priest Christoph Scheiner invented the pantograph, a mechanical device using CKC linkages and two pens. Since

the pens were connected through the linkage system, a person could draw with one pen and simultaneously create a duplicate drawing with the other. The device could also be configured such that drawing a small image with one pen could result in a duplicate image at a much larger-scale level being created, or the reverse (Fig. 3). The movement energy transferred through a CKC system that produces these changes in size also produces changes in speed and distance. The pen that creates the larger picture through the pantograph moves a longer distance across the paper in any given period of time, and thereby must move at a faster speed than the pen that makes the smaller image. Conversely, if a hand is drawing the larger image, that effort concentrates through the CKCs of the pantograph to create the smaller image, and this offers a viable model, showing how energy generated by a movement of a larger muscle in the torso could be transferred and concentrated outward to create a smaller but more powerful move in the more distal fingertips. Thus, a system of multiple interlinked and coordinated CKCs can be configured to trigger stored energy which, when released through a very small internal movement, can result in almost explosive behaviours. This helps to explain how a mantis shrimp can catch its prey in three milliseconds and with the force of 1500 Newtons (3*). It also presents a mechanism for understanding the otherwise

Box 2: A CKC in your forearm Build a four-bar CKC using toothpicks and connectors, as you have done before, but this time with bars of different lengths, such that two parallel toothpicks are full length, and the other two parallel bars are much shorter (skewers can be used for the longer lengths). Link the bars together and play with this CKC a bit to get a sense of how it can move. In your forearm, two parallel bones, the radius and the ulna, provide much of the structural support. At the wrist end and at the elbow end of these bones, imagine the components of bone, muscle, ligament, and tendon which can coalesce into stiff short units as needed to provide additional linkages to join the radius and ulna, creating a four-bar CKC. Wrap your hand around the opposite forearm, and while holding it there and feeling into what is happening internally as you move, rotate the forearm that is being held and feel the changing four-bar configuration within. Return to your new toothpick CKC and see if you can generate a similar movement with your model (Fig. 5).

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inexplicable actions of trap jaw ants, who ‘jump’ by releasing their springloaded mandibles against a surface, thereby propelling themselves into the air at distances more than 20 times the length of their own bodies. Multiple interlinked CKCs can generate simultaneous movement throughout an interlinked network no matter where the movement is initiated. An example of this can be seen in the movement of a CKC model which exhibits auxetic qualities as it expands and contracts. Although it is easier to generate the movement by turning the centre piece, in truth the same movement can be generated by moving any part of the model (Fig. 4).

Where are the CKCs in the Body?

Where are the CKCs in the body? In short, they are everywhere, just as force vector tensegrities are. On macro scale levels, there are linkages among combinations of bone, cartilage, muscle, tendon and ligament. The four-bar configuration requires a relative stiffness in the four elements, and relative compliance at the joints. We are used to thinking of the stiffness of bone and cartilage, but tendons, ligaments and muscles can stiffen as needed, and can become part of a CKC system in this way. To feel this in your body at a macro level, try the activity in Box 2. In Chapter 13 “Systems” in the book, we explored pushing into a wall and feeling the increased pressure on the bottoms of the feet. In doing this, one creates a CKC linkage system at a scale level larger than the body by recruiting the wall and the floor, a hybrid CKC system involving the body and its environment. We create such larger-scale level external CKCs all the time, though we may not be used to thinking of them this way. Once we become aware of the concept, however, we can be more mindful about how we might use it to our advantage, as the activity in Box 3 illustrates. Can you imagine what smallerscale level CKCs might be found throughout the body? Zooming in to the level of the fascia, the endoscopic work of Jean-Claude Guimberteau shows us a rich internal world of fascial Co-Kinetic.com

tissue CKCs transmuting before our eyes in response to changing forces, revealing how we truly are dynamic, living force vector management systems. Without an understanding of the multiple scale level, scaffolded and interconnected biomechanics of biotensegrity and CKCs, it would be difficult to explain structurally what we are seeing in Guimberteau’s moving images or in the stunningly beautiful biological reconfiguring revealed by Rafael Martín-Ledo in his microscopy videos of plankton from the Bay of Santander, Spain displayed on his Twitter account, Rafael Marine Microfauna.

Equilibrium: Stable, Low-Energy Shape Change

When we move with optimal efficiency, we reconfigure our inner tensegrities and CKCs to move from one equilibrium to another through a continuum of equilibriums, constantly changing at multiple scale levels simultaneously in order to maintain our optimal lowenergy state. We accomplish this by constantly establishing and relinquishing an incalculable number of CKCs, and the ability to regulate these changes is embedded in the geometry of our bodies. Michael Turvey demonstrates this dynamic as he moves about during a presentation: “As I am engaged in behaviours like this, I am distributing forces, distributing stresses I should say, so as to ensure balances of forces on the body … every time I move, all of these are me distributing stresses on the tissues of the body in a way that sets up a balance of the forces. Otherwise, I’m in trouble. Some of us are getting a little older … as you get a little older you’re a bit more aware of these things, this preserving of the balance. And, every time I change shape, I have to reorganise the body so that the forces provide an appropriate compensation: they have to be right. So I have to, as it were, have a way of protecting myself to the distortions brought about by changing shape, to keep stable. Every time I change shape, I am confronted by a stability problem.” (4*)

For an engineering perspective on the same principle, we can look to Robert E. Skelton, an engineer who specialises in tensegrity structures, and who expresses the concept this way: “If I want to change the shape of the structure but keep the stiffness constant, there is some path along the equilibrium that would do that ... or if I want to change the stiffness without changing the shape, then there is another path I must follow … every point on this line is an equilibrium, so the control energy I require (the energy I have to put in the structure to change the shape) is theoretically zero. I’m moving from one equilibrium to another ... so I’m redesigning the structure constantly to get the equilibrium I want.” (5*)

Box 3: Pick up something heavy Visualising multiple scale levels of CKCs, both internally and between us and our environment, can help distribute forces throughout the body when accomplishing a task such as lifting. If we want to lift a heavy object, we know we must be mindful to avoid injury. How do we prepare? Levin suggests the trick is to “suck it in to the body,” to make it seem like a part of us and integrate with it before we try to lift. With our awareness, we reorient our structure to invite this external object to become part of our body’s system. Try this with a chair. What happens if you move to lift it without thinking? You most likely will not have organised your body optimally for the task (this is how injury can happen). Take a few moments to organise your body mindfully, and imagine integrating this extra weight with your structure, as if you were to lift a child. Thinking about this before we do it triggers our natural habit of organising our structure according to the desired task. Even if we are not able to feel these internal structural changes in a specific way, being mindful of them can lead to increased sensitivity to feeling internal changes. Before lifting the chair, the weight of it is going directly down into the centre of the Earth through its four legs, but once we lift it, the weight of the chair will be going into the ground through our feet. We can reconfigure our own body to account for this in advance of starting to lift, and use the CKCs of our fascial network and other systems to prepare a path for distributing the weight of the chair throughout our system, so that no one part bears the weight of the chair more than any other. When we lift the chair, our total system weight will increase by the weight of the chair, but so will the ground reaction force pushing upwards against us. What can we harness? If we focus on integrating and distributing the incoming added weight, as well as the incoming increased ground reaction force, the chair may feel lighter than expected.

Skelton is talking about a tensegrity model here, and not a living biological organism. For us to change ourselves but maintain equilibrium does require more energy than zero, but this points to the possibility that our reconfiguring can be done with a relatively small energy cost, which would make it optimally sustainable, and developmentally and evolutionarily advantageous.

Redundancy and Degeneracy

Additionally, developmental and evolutionary advantages of CKCs include the fact that the same energetic outcomes (called kinematic transmissions) can be produced by multiple and different CKCs, and this constitutes a many-to-one mapping system. The many-to-one concept recognises that different CKC shape configurations can produce equivalent functions, an emergent and nonlinear property of complex systems (6*,7*). Many-to-one mapping further links with how multiple structural configuration possibilities can present themselves in response to the needs

of the organism, called redundancy, and this is the necessary condition for the characteristic called degeneracy. In biology, degeneracy is the ability of different sets of structural components to perform the same task or produce the same results, which becomes possible when varieties of different components and configurations can perform similar functions. This (we theorise) is what allows a developing organism to change its shape while transitioning through its developmental continuum without needing to sacrifice functional ability, and it is also what allows a variety of functional variations to arise as needed when organisms are transitioning along an evolutionary continuum. Kinematic transmission, manyto-one mapping, redundancy and degeneracy are each complex concepts, but we can get a broad idea of their interrelationships through a few simple activities (Box 4). We can now begin to see how it is possible for a structure to reconfigure while its equilibrium, though never static, remains generally balanced, and

Figure 6: Different handmade CKCs made with straws and string, toothpicks and marshmallows, and cardboard with brass fasteners. Photos © Ana Teresa Ortega.

Box 4: Working with a variety of CKCs CKCs of straws and string can be made very quickly and with little effort, and are valuable selfteaching tools. Using four straws, cut each into four sections of varying lengths and connect each set of four pieces with a loop of string (Fig. 6). With each of the CKCs, hold one bar as fixed on a flat surface and note the movement possibilities of the other bars in the chain. Then choose a different bar in the CKC to immobilise, and note the different movement possibilities that arise in the same CKC when a different bar is fixed. Follow this same process with your other CKCs, and you may begin to imagine the many combinations and movement patterns that become possible among transmutable structures which can instantly form different combinations of CKC alliances as needed, and relinquish them instantly when no longer optimal to the system or organism. Imagine this happening in multiple locations within an organism and at multiple scale levels simultaneously. You may begin to glean how, for any given point or needed event in the organism, a wide variety of CKC alliances could be involved (many-to-one mapping of kinematic transmission). You may further be able to imagine how, if a certain specific CKC combination was not an option at any given moment, it could be possible, within this highly transmutable structural landscape, for another to quickly materialise to take up the task (degeneracy and redundancy) (Fig. 6).

how its mechanical output can change (or stay the same, as needed) while its shape changes. These changes in shape may be in response to forces that need to be managed successfully and/or to take action as the organism needs to survive and thrive (Box 5). And, in addition to the advantages of low-energy shape change with stable equilibrium, degeneracy and redundancy, CKCs provide (again by virtue of simple geometry) on-site, non-neural, moment-tomoment responsivity as needed – an intelligently adjustable equilibrium – without sacrificing function, stability or ability to resist deformation. Our internal CKCs are reconfiguring constantly, and we have the ability to organise ourselves in many different ways to accomplish the same task. This provides a developmental and evolutionary advantage, providing a way to retain function at all times as we grow and change.

Flexible Force Management

We have seen how CKCs allow forces applied in one location to result in actions far removed from the site of the original force. This – when combined with the above characteristics of lowenergy, cost-stable equilibrium even during changes in shape, redundancy, and degeneracy – allows for flexible force management in the body. When we respond to incoming forces or endeavour to create an action, we have the structure (and through this, the ability) to use as little internal potential (caloric) energy as possible to recruit external potential and kinetic energy sources and forces (whatever is out there), and the body is the algorithmic structure that organises the energy transformation from potential to kinetic in service of the task (Box 6). Knowing that shape affects function, we can imagine how our internal CKCs may provide the mechanism, through generation of internal shape changes, for structure-based and shape-based therapeutic applications. A wide variety of therapeutic movement and treatments including physical medicine, yoga, tai chi ch’uan, Pilates, gyrotonics, FlexAware, kinesiology tape application, matrix repatterning,

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Rolfing, acupuncture and massage may be operational through the CKCs within our tensegral structure to achieve the success of their effectiveness.

Do Our Parts Wear Out?

CKCs are operational as we change, instantly and on the fly, which parts of us are doing what, and they give us the ability to change repeatedly – yet each time in a slightly different way. Consider the advantage this could provide when seeking optimal movement patterns for a given task.

With machines, precise tooling insures that the movements of unvarying components are repeated almost exactly over time, but this same repetition of applied forces leads to parts wearing out and eventually needing to be re-tooled or replaced. The shadow side of perceiving a similar machine-like tooling in the body (which might seem to ensure repeated, identical movement patterns) may lead us to the concept of our parts ‘wearing out’, or practices which result in repetitive motion injuries. With our bodies, instead of being

Box 5: Bubbles in your beer: observing responses to changing force vectors You can observe instant reconfiguring in response to changing force vectors by watching bubbles in a glass of beer or a bubble bath. Prick a larger bubble or wait until a bubble pops. The sudden disappearance of a bubble immediately changes the force vectors affecting the entire group of bubbles around it, and we can observe the surrounding bubbles instantly reconfiguring to rebalance the system and find a new equilibrium. Introduce energy into the system by blowing on it or swirling it around, and new bubbles will appear in response, offering up new chances to observe the popping and rebalancing.

locked in to attempting to repeat a movement exactly the same way every time, our transmutable CKCs give us the option of accomplishing a given task repeatedly in slightly different ways. Instead of one ‘correct’ or ‘perfect’ motion that is done repetitively in exactly the same way as much as possible, a strategy informed by our understanding of our inner CKCs may allow for the creation of a series of motions that, even if they look externally much the same, and even if all have the same purpose, arise in slightly different ways each time, with slightly different constellations of CKCs manifesting in response to the subtle changes of each moment and the specific situation. There may be thousands (if not multiple thousands) of factors that contribute to the emergence of the different arrays of patterns. They can make what may externally appear to look like one specific physical configuration that is happening over and over again actually very different events. And this is what we want, because we are not

Box 6: Push and wiggle: managing incoming force through distribution and reconfiguring CKCs This is a two-person activity. One person who will push, the other who will wiggle, reconfiguring while comfortably distributing the incoming force. Have a friend stand next to you and slowly push on your upper arm with their palm. What are your choices for a response? For many, the only two possibilities will be ‘fight’ or ‘flight’: either to actively resist the incoming force or to move away from it. However, our tensegral structural configuration and our internal transmutable CKCs allow us to have another option. As the force comes in, stay relaxed and imagine yourself as a water balloon filling up in all directions. Do not move your feet. Your goal is to neither resist the force by pushing back against it, nor to allow yourself to be moved by it. Instead, you concentrate on being that full water balloon and remain indifferent to the incoming force. When you begin to do this

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successfully, you will feel an increase of pressure on the bottom of one of your feet, because your body becomes an open conduit which transfers the force of the push to the ground. As the force is transferred through you, it is being distributed throughout your system’s incalculable number of scaffolded tensegral structures, and in a similar way to how you integrated the weight of the chair in the activity above: the incoming force feels much reduced. This is why your partner must add pressure slowly – it is important that the push does not take you outside of your ability to comfortably integrate the pressure fully throughout your body so that it has an unencumbered path to ground. After you have had success with this, you will be ready for the next step. As your partner is pushing on you, and while remaining comfortable and relaxed in the face of it, start to wiggle your body a bit here and there. Keep your arm where it is, so that the point of contact with your partner does

not change, and do not move your feet, but allow the other parts of your body to loosen up and to start moving around. You will find that it is possible to make many shapes and to be constantly changing those shapes while simultaneously managing the incoming force with almost no effort. Your body can reconfigure internally in a similar way to how the bubbles in beer adjust to the changes in force vectors among them. If you make yourself stiff or become too soupy, you will find that your ability to effortlessly manage the incoming force will be severely compromised. However, it is possible to manifest an optimal integrated structure with a stable but changeable equilibrium which can manage incoming forces through the structural continuum of nested, transmutable tensegrities and their endogenous CKCs. Biotensegrity is the only science that explains how this is possible.

Figure 7: Transformational objects. Geometric configurations featuring closed kinematic chains can result in oscillations and transformational behaviours in a variety of objects. In front, interlinked wires can be bent to create structures such as the Kuboid ‘invertible cube’, invented by mathematician Paul Schatz (left), and a traditional flexible sphere ring toy (centre). Front right, a Jacob’s Ladder toy. In back, Hoberman® Switch Pitch™ toys in two different colour pairs. When thrown, the balls expand auxetically and may flip to change which colour appears on the outside once the ball condenses again. Photos © Ana Teresa Ortega.

like machines. We benefit from those differences and we benefit from the variety of internal changes that help us generate all those different ways of creating an action and managing the forces that are related to it. A movement teacher was once concerned about repeatedly moving from a more open and outwardly rotated position in the hip and leg area to a more inwardly rotated and closed position when there was full body weight on the leg. The perception was that this action was ‘driving the bone’ (the femoral head) into and out of the hip socket, which, it was felt, was effectively ‘scooping out’ the joint, and which would eventually wear down or wear out. It was then pointed out that in tai chi and in other patterned movement activities, such as dancing

the twist, this sort of action is done without causing harm and may even be part of cultivating health in the joints. The teacher could not recall where this idea of ‘scooping out’ the hip joint had originally come from, but the story is indicative of common ideas about how ‘wear and tear’ can damage our bodies. In 2017, researchers published the results of a study investigating the bones of human knee joints from prehistoric, early industrial (1800s– early 1900s) and post-industrial (1900s–2000s) times. They discovered that in our post-industrial times, knee joint osteoarthritis had more than doubled. More research needs to be done, but at least one of the authors of the study, Daniel E. Lieberman, felt that the results could be due to our

Table 1: Effects of excision of one or more well-defined hip and/or thigh muscles

From Markhede G, Stener B. Function after removal of various hip and thigh muscles for extirpation of tumors. Acta Orthopaedica Scandinavica 1981;52:373–395 (9*) Muscle(s) excised

Limb operation

Impairment/loss of function

Iliopsoas

Hip flexion

Slight

All three prime adductors (longus, brevis, magnus)

Hip adduction

Slight to moderate

Gluteus maximus

Hip extension

None or slight

One, two and three of Knee extension the quadriceps muscles

Slight to somewhat more than slight

One of the hamstrings

Knee flexion

None

All three hamstrings

Knee flexion

Moderate

Of 46 patients tested

Number of muscles lost

Impairment/Loss of function

11 1–3 None 17 1–4.5 Slight 16 3–7 Moderate

more sedentary lifestyle: “Arthritis is a disease that becomes more common as you age, but it’s not caused by ‘wear and tear’; if anything, it might be caused by the absence of physical activity, so a major way to prevent arthritis could be moving more, not less” (8*). Perhaps balance is needed here. Rough treatment of the body which takes us into pain repeatedly can invite damage, but not enough movement may be just as detrimental. Although death is another necessary constraint of biology, and inevitably the system transitions to it, it would be unfortunate if the concept of wearing down and wearing out in the machine sense were keeping us from healthy patterns and healthy doses of movement.

Boston Marathon

The 2018 Boston Marathon was, by many counts, the most brutal in the race’s 122-year history. A Nor’Easter (a notoriously violent type of New England storm which blows in from the atypical direction of the northeast) brought unexpected cold and rain, and created strong headwinds for runners on the west-toeast course. Many competitors from warmer climates dropped out, and the eventual winner of the women’s race, Desiree Davila Linden, had planned to drop out almost from the beginning, but kept running in part to accompany her friend Shalane Flanagan, who came in fifth. In the women’s race, 14th place went to Sarena Burla, a professional runner who had experience running the Boston and other marathons. What Burla did not have was about half of her right hamstring. The biceps portion had been removed in 2010 due to a rare form of soft tissue cancer. At the time of her surgery, Burla’s doctor thought she may never be able to run again, let alone compete.

CKCs Provide Options for Compensating and Accommodation

A 1981 survey of people with missing hip and thigh muscles and their related functional compensations revealed that “Loss of one of the hamstrings usually caused no impairment of function whereas loss of all three resulted in Co-Kinetic Journal 2021;87(January):34-43

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moderate impairment of function” (9*). Indeed, it is surprising to see how much soft tissue one can lose while still retaining a significant amount of functional ability (Table 1). What allows the body to compensate so successfully for a lost or missing muscle? Our transmutable, reconfigurable CKCs once again provide a credible explanation. If one wants to take a walk, but the right ankle is hurting a bit (assuming no tissue pathology for this example), we know that the process of walking involves constant management and transfer by the whole body system of forces that are generated through walking. Regarding the ankle as a fixed mechanical unit that has only one possible way of managing and transferring these forces, the only option may be to walk in pain. On the other hand, understanding the body’s internal structure, including the area of the ankle, as a comprehensive system of innumerable and transmutable interlinked CKCs that can self-organise and reconfigure on the fly as needed according to the changing demands that arise in the process of taking a walk, one can imagine and envision the possibility that structurally speaking there may be a number of possible configurations which could result in pain-free walking options. This view sees the body as having a built-in work-around where the part of the system that needs to recover can rest and be free to heal, even as the areas adjacent to it are doing the work of walking, because the forces can be routed around the problem area that is experiencing the pain. Thus, our understanding of our body’s functional systems may help us to solve movement problems as they arise, and to optimise whatever the job is we are trying to do.

Models and Critical Thinking

As I was writing this last chapter of the book, I revisited the paper, “The significance of closed kinematic chains to biological movement and dynamic stability,” which I had the privilege of coauthoring with Steve Levin and Graham Scarr in 2017 (1). In it, we cite Mees Muller’s 1996 paper on CKCs (10). Co-Kinetic.com

Box 7: Comparing the movements of two different CKC models Build a planar CKC model using strips of cardboard. Punch holes at both ends of each cardboard bar, and connect the four bars using brass fasteners or bent pins (Fig. 6). You will find that you have choices for how the bars line up relative to each other. At each joint, the fastener will have to pass through one bar or the other first. Since this is not an exhaustive study, simply choose which bar the pin goes through first and build the CKC. Once assembled, move the bars of the CKC and get a feel for the movement pattern that arises. Notice also, any instances in which the cardboard bars are able to slip past one another. Next, change one of the joints such that the positions of the bars are reversed by removing the fastener, and before replacing it, reversing which bar the fastener goes through first. Again, move the bars of the CKC and notice if there is a change in the movement pattern. Muller devised a brilliant and simple yet comprehensive way of categorising the nearly infinite variety of different four-bar shapes. In doing so, Muller demonstrated how there are multiple ways to create the same action and effects with different configurations of components, which was taken up by Alfaro et al. (6*) and Wainwright et al. (7*) in developing their concept of many-to-one mapping. In re-enacting Muller’s systematic method for plotting CKCs, I constructed several models using lengths of straw looped together with string, put the models on a flat surface and, keeping one bar fixed, changed the shape bit-by-bit and used a compass to measure the same two key angles that Muller had used in creating his maps. This process creates a series of measures that can be used as x- and y-axis coordinates for plotting on a graph. My problem was that the shapes of the lines I was getting in my graphs only partially matched Muller’s. I could not figure out what was wrong, and frequently pushed the project aside to clear my head so I could go back to the puzzle with fresh eyes later on. I eventually tried using a different kind of model and found that CKCs made of flat cardboard bars connected by fasteners (pin-joints) can be configured to more closely match Muller’s ranges of motion, with the bars now moving in slightly different but parallel planes that allow them to slip past each other at the points where those in the straw models bumped into one other (Fig. 6). Muller was revealing the mechanics and underlying theory of four-bar

RECONFIGURING HAPPENS THROUGH THE GEOMETRY OF OUR MYRIAD CLOSED KINEMATIC CHAINS CKCs, where the bars rotate around fixed points within a plane, while my physical straw and cardboard models helped in better understanding the basic principles and extending them into a biological context (Box 7). Even though there was some trial and error in the process, what this demonstrates for our purposes of moving forward together as researchers in the science of biotensegrity is the importance of building and using physical models (Fig. 7), being aware of any assumptions we are making about their validity and applications, and remembering that every model, no matter how valuable, has limitations [recall Box’s “All models are wrong…” (11)].

Functional Structure is Not Arbitrary

We have seen again and again how shape matters. We have seen how we are configuring and reconfiguring all the time, continually and continuously, and on many different levels at once. Our ability to be completely and always moving and moveable is the key to our biological success. This includes our ability to rigidify ourselves when we need to, then soften so we can change and then take a different firm position, or to prevent ourselves from being rigid, or (and this is what is 41

mostly actually happening) to combine the two abilities optimally and simultaneously in a variety of different areas, in a variety of different ways, and on a multitude of different scale levels within our systems. We are, each of us, patterns. But we are conscious patterns and thus we can endlessly reconfigure. However, we are constrained to do so only within the realm of viable functional structure. What constitutes functional structure is not arbitrary or abstract, but is founded in the fundamentals of energy efficiency and what can build upon that. Functional structure must be sustainable and adaptable in order to succeed biologically.

Further Resources

Chapter 15 “Reconfiguring” in the book Everything Moves: How Biotensegrity Informs Human Movement also contains links to a number of videos that demonstrate points described in the chapter. References

1. Levin S M, Lowell de Solórzano S and Scarr G. The significance of closed kinematic chains to biological movement and dynamic stability. Journal of Bodywork and Movement Therapies 2017;21(3):664–672 2. Scarr G. Biotensegrity: the structural basis of life, 2nd edn. Handspring Publishing 2018. ISBN 978-1909141841 View on Handspring https://bit.ly/3gxMlNm 3. Patek SN, Caldwell RL. Extreme impact and cavitation forces of a biological hammer: strike forces of the peacock mantis shrimp Odontodactylus scyllarus. Journal of Experimental Biology 2005;208:3655– 3664 Open access https://spxj.nl/2JBcWgh 4. Turvey M. UConn Talks - Michael Turvey [video online]. University of Connecticut 2014 Open access https://spxj.nl/3oi0zVj 5. Skelton RE. On the analysis and design of tensegrity structures [video online]. UnipegasoChannel YouTube 2015 Open access https://spxj.nl/37yQdKb 6. Alfaro ME, Bolnick DI, Wainwright PC. Evolutionary consequences of many-to-one mapping of jaw morphology to mechanics in labrid fishes. The American Naturalist 2005;165(6):E140–154 Open access https://spxj.nl/3ogzQIQ 7. Wainwright PC et al. Many-toone mapping of form to function: a general principle in organismal design? Integrative and Comparative Biology 2005;45(2):256–262 Open access https://spxj.nl/3ojsAvJ 8. Goldberg C. Harvard study of skeletons 42

suggests much age-related arthritis may be preventable. Common Health, WBUR 2017 Open access https://wbur.fm/2IrAWSO; Original study: Wallace IJ, Worthington S, Felson DT et al. Knee osteoarthritis has doubled in prevalence since the mid-20th century. Proceedings of the National Academy of Sciences of the United States of America 2017;114(35):9332–9336 Open access https://spxj.nl/36xLgBU 9. Markhede G, Stener B. Function after removal of various hip and thigh muscles for extirpation of tumors. Acta Orthopaedica Scandinavica 1981;52:373–395 Open

access https://spxj.nl/37u6DDE 10. Muller M. A novel classification of planar four-bar linkages and its application to the mechanical analysis of animal systems. Philosophical Transactions of the Royal Society of London. Series B, Biological Sciences 1996;351(1340):689–720 11. Box GEP, Draper NR. Empirical modelbuilding and response surface. Wiley-Blackwell 1986. ISBN 978-0471810339 (Print £21.93) Buy from Amazon https://amzn.to/36wnoia

RELATED CONTENT

lB iotensegrity’s Tipping Point - Has it Finally Arrived? New Concepts in Movement Science and Manual Therapies [Article] http://spxj.nl/2ExwjDN l Tensegrity and Biotensegrity: Will it Change Our Understanding of Human Anatomy? [Article] http://spxj.nl/2ExdOz9 lB iotensegrity Part 1: An Introduction to Biotensegrity and its Importance to Massage Therapists [Article] https://spxj.nl/2KiKZZ7 lB iotensegrity Part 2: The Role of the Fascia in the Science of Body Architecture [Article] https://spxj.nl/3lxy6cA l Biotensegrity Part 3: Levers and Pendulums in Human Anatomy Are So Yesterday! [Article] http://spxj.nl/2Cr5FGG

KEY POINTS

lT ensegrity is a structural principle based on a system of isolated components (struts) that are under compression inside a network of continuous tension cables. lB eing able to change shape (or ‘reconfigure’) is a necessary part of life. lB iotensegrity allows us to understand how we can successfully manage forces, and can remain stable and balanced while moving and changing shape. lW e can be structurally functional throughout movement because of the geometry of tensegrity and of our multitude of possible closed kinematic chains (CKCs). lO ur biologically constituted CKCs can produce behaviours which are governed by the structures themselves, resulting in energetically efficient movements of immediate, on-site responsivity which can magnify or attenuate, as well as transfer, forces, and which may do so independent of the nervous system. lC KCs manifest everywhere in the body, from the micro to macro levels. lT hat the same energetic outcomes (or kinematic transmissions) can be produced by many different CKCs creates redundancy and degeneracy in our bodies, which allows us to adapt to changing external conditions and to compensate for injured or missing muscles. lO ur parts do not ‘wear out’ like those in machines; our bodies are made for endless variations of healthy, energy efficient movement. lB uilding and using physical models is essential to our study of biotensegrity, yet all models have limitations. lF unctional structure is not arbitrary; it is energy efficient and must be sustainable and adaptable.

Co-Kinetic Journal 2021;87(January):34-43

MANUAL THERAPY

Want to share on Twitter? Here are some suggestions

Tweet this: The human spine is a tensegrity structure https://bit.ly/2JD4spj Tweet this: Our ability to function structurally while moving is because of the geometry of our myriad CKCs https://bit.ly/2JD4spj Tweet this: CKCs allow low-energy changes of shape with stable equilibrium https://bit.ly/2JD4spj Tweet this: Studies have shown that arthritis becomes more common with an increase in sedentary behaviour https://bit.ly/2JD4spj Tweet this: Our reconfigurable CKCs allow the body to compensate successfully for a lost or missing muscle https://bit.ly/2JD4spj

DISCUSSIONS

l Discuss with a colleague what tensegrity is and how you see it in the human body. l How has this article affected how you think of the concept of assigning specific muscles to specific actions, or the idea of ‘wear and tear’ of the joints? l How might a better understanding of biotensegrity influence your practice?

THE AUTHOR Susan Lowell de Solórzano, MA Human Development & Education with a focus on kinesthetic learning, is certified as a Level III tai chi instructor by the American Tai Chi and Qigong Association, and is a certified FlexAware teacher. Susan has been an associate of Dr Stephen M. Levin, originator of the theory of biotensegrity. She is a co-founder and board member of the Stephen M. Levin Biotensegrity Archive (BiotensegrityArchive.org), and since March 2020, Susan and fellow archive board members Graham Scarr and Chris Clancy have co-produced and hosted the Archive’s weekly online BiotensegriTea Party events (https://bit.ly/2VUx5ks). Susan is a co-founder and head organizer, DC BIG (Washington, DC Biotensegrity Interest Group; est. 2012) and she authored the Biotensegrity Archive’s BX 101 self-study guide to biotensegrity. Email: susan@biotensegrity101.com Twitter: @1Biotensegrity Website: http://www.biotensegrity101.com YouTube: https://spxj.nl/3lJ9MVj

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ENTREPRENEUR THERAPIST

Alone We Can Do So Little; Together We Can Do 21-01-COKINETIC FORMATS WEB MOBILE

So Much

By Darren Ross BPhysio, MPhysio and clinic owner

In 2020 the arrival of the Covid-19 pandemic has meant that physical therapists have had to adapt to survive. These times, although tough, have also been the push to create better solutions. This article shows how, with the right mix of inspiration, advice, connections, courage and serendipity, adapting can lead not only to a business surviving but a new business being created and flourishing. Read this article online https://bit.ly/3lYto7V or environmentally and aesthetically nasty paper sheets replaced after every patient, or we had to explore alternatives. We decided to remove our terry towelling bed covers and cotton pillow covers and use the vinyl bed and increase use of paper covers on the pillows. The issue was that in one of our clinics with 15 treatment rooms, every couch was a different colour, the beds were all in different states of age, and the materials did not hold up to the increased use of cleaning products. They started cracking and perishing, so we began re-upholstering them. When the first few beds cost us around AUD $600 (approximately £340), we realised this was going to be an expensive exercise and one we would need to do regularly as a result of the cleaning products constantly breaking down the material. So, we began to explore options. Back in 2019, I had a vision of reducing the carbon footprint of each of our clinics by reducing the use of single-use paper covers and laundering. Our commercial laundry was running 80% of the time. I had in

were other clinics doing? On speaking with other clinic owners, it turns out everyone was in the same boat. This brought me to the idea of creating a product that was of the highest grade of material, which could be quickly and easily wiped down between clients, to maximise the protection of both patients and our own staff. Trust me when I say that venturing from clinical operations to manufacturing is not a natural transition!

How to Monetise your Therapy Skills Online and Build New Covid-Resistant Online Recurring Revenue Streams

At this exact time I attended a webinar with Tor. It was entitled ‘How to Monetise your Therapy Skills Online, and Build New Covid-Resistant Online Recurring Revenue Streams’, in which she discussed a whole host of ways of creating alternate revenue streams, to tap into networks and ideas that can leverage your clinical scope in other ways. It was so timely. During the entire session my brain was bouncing between the concepts she was delivering and my product. I had already created a business plan, but this evolved after her session. It proved to me that not only was I on the right track, but her session filled me with the confidence to tackle the steps needed. This coincided with my wife’s work disappearing; she worked part-time in the marketing and administration of a National Orchestra and parttime organising corporate travel for her brother’s business, both of which disintegrated overnight. Then comes possibly the most amazing coincidence or crazy act of Karma reimbursement. One of my patients, whom I have treated for over 15 years (along with most of his family), just happens to be one of the leading manufacturers of 46

hospital bed systems. And that week, after 2 years of absence, his name appears in my diary. He lies on one of our test covers – and the rest as they say is history! Immediately we start working together on improving product design and creating a production line, and Clinic Armour was born. Our concept of a single bed and pillow cover was quickly scrapped, because 25 years of bed shapes crossing all sorts of health sectors doesn’t lend itself to one-size-fits-all. Not only do we now cater for physical therapy clinics, but we have fitted out most types of allied health clinics as well as general practice surgeries, and even created custom surgical table covers. The growth of Clinic Armour has been amazing, we have seen week-onweek exponential growth and this has delivered everything Tor mentioned in her webinar: l non-exertional income; l diversification from patient fees; l an online business model which hopefully enables us one day to have a significant lifestyle change; and l new markets – we started out just shipping within Australia and we are now selling globally. There have been endless challenges, new ones arriving every time you think things are under control, but we have

worked through these. One of the unforeseen bonuses is that this new revenue source has taken pressure off our traditional patient-based business which has in turn given me the space to enjoy that aspect of my business even more. We have also had some great feel-good moments: we have not only helped save several jobs in the Australian manufacturing facility, but they have had to increase staffing by employing four new people just for our product line. The feedback and support from clinics has been amazing. In summary, I come back to my earliest point, in times of adversity if you have surrounded yourself with good people and solid networks, you will get through. Tor has been one such person for me. She didn’t know it until just a few weeks ago when she was kind enough to take a call from me. We spoke for some time and I shared this journey with her, one that she was a part of. Clinic Armour is an affordable medical barrier linen system of examination covers and pillow covers aimed at reducing risks of infection and improving clinic hygiene across patient contact surfaces. For more information about Clinic Armour please visit www.clinicarmour.com. We are now also shipping to the UK and you can get a 5% DISCOUNT using the code COKINETIC at checkout

THE AUTHOR Darren Ross completed a Bachelor of Physiotherapy (La Trobe University, Melbourne, Australia) in 1998 and a Masters of Manipulative Physiotherapy in 2000. Between 2001 and 2005 he was the chairman of the Australian Physiotherapy Association (APA) Musculoskeletal Physiotherapy Victorian Chapter. He has lectured for both the APA on the APA Spinal courses, La Trobe University and the University of Melbourne as a guest lecturer. He currently sits on the Physiotherapy Business Victoria committee of the APA. Darren is a Senior Musculoskeletal Physiotherapist and director of Physica, with three physiotherapy clinics in Melbourne. He has a particular clinical interest in spinal and shoulder rehabilitation and is professionally passionate about improving patient healthcare experiences. He is also the product designer and clinical manager in Clinic Armour, a business that offers premium wiped down hygiene solutions for allied health and medical clinics. Email: darren@physica.com.au Website: https://www.clinicarmour.com/ and www.physica.com.au LinkedIn: www.linkedin.com/in/darren-ross-physio Facebook: https://www.facebook.com/Clinicarmour Co-Kinetic Journal 2021;87(January):45-46

ENTREPRENEUR THERAPIST

The Power of Giving Gift Vouchers W

e learn early on that it is better to give than to receive. We are taught to give and that it feels good to help someone in need. But is there a deeper current to giving? There is a growing body of evidence that shows we are evolving to become more compassionate and collaborative in our quest to survive and thrive. Today, scientific research provides compelling data to support the notion that giving is a powerful pathway to finding purpose, getting through difficult times, and finding fulfilment and meaning in life. Which is why offering people the opportunity to have positive experiences, such as increased relaxation, reduced anxiety and even pain relief, through the services you provide, is a powerful offer. Not only is it a very thoughtful gift, it can also be uniquely tailored to suit your clientele and the services you provide. Most of you will know that since Covid-19 struck, I’ve been working hard throughout the year to find ways to help you generate income in these difficult circumstances. One of the best ways of generating cash is to sell gift vouchers, which is why I built this into the Co-Kinetic system and launched it just a few weeks ago. As always my system combines technology (gift sales and management) with pre-created content, such as voucher sign-up pages, ready-made social media and great looking health-focused gift certificates, to help you take orders and promote your campaigns. The goal of this article is to give you some ideas of the sorts of things you can do with a voucher system – not just the Co-Kinetic one, but any voucher system. The difference with the Co-Kinetic system is that it’s built with health professionals in mind. Co-Kinetic.com

Last year, Covid-19 and the associated lockdowns and movement restrictions left many businesses reeling from massive interruptions of cashflow. Selling gift vouchers for your business is a brilliant way to improve cashflow and grow your business in any circumstances, particularly now when the trend for gifting experiences rather than goods is on the increase. Tor has been working hard creating a system to make selling gift vouchers easy for you to do. This article explains the many benefits and shows you how simple it can be. Read this article online https://bit.ly/375FXu1 By Tor Davies, Co-Kinetic Founder The social media is sensitive to our healthcare climate and the pre-written sales pages (which can be fully edited) have been written specifically to focus on adding value and highlighting benefits, while not being over-salesy. The goal of this article is to give you ideas of ways in which you can harness the power of selling gift vouchers and certificates. On the face of it, selling vouchers is simple and straightforward, but there are some less widely known ways you can also harness the power of vouchers to help your business.

Reasons Why Selling Gift Vouchers is Great for Your Business

Gift vouchers: help grow sales – to start with the most obvious; boost cashflow – generates revenue in advance of delivering the service; are a great way to re-engage past customers; allow your business to participate in a whole range of special events and holidays; increase customer engagement – gift givers become

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ambassadors of your brand (and will be more likely to spend more with you) and the gift recipients benefit from the gift itself and an opportunity for you to build on this opportunity; can incentivise people to take actions that further benefit your business, like give reviews or engage in social media posts; . help raise awareness of your business; can be sold easily using your website and your social networks; can be purchased instantly and conveniently, making them excellent last-minute gifts (vouchers can be posted or sent as an email within minutes); can be purchased from the comfort (and safety) of home;

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generate revenue even if 11 still they’re not used (approximately 20% are never redeemed); help introduce new customers who may not have used your service previously; can lead to larger purchases or upsell opportunities; are simple to manage and distribute; can be sold at any time (including during lockdown) to help plug shortcomings in cashflow; and appeal to all genders, both young and old.

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How to Sell Gift linic C Vouchers in Your ility to showcase and s the flexib

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Ideas for Selling Gift Vouchers

Offer an Incentive or Added-Value to Buy a Gift Voucher

Examples could include the following suggestions: lB uy a gift voucher today and be entered into our draw to win a prize, eg. – £X of massage sessions/ treatments – a massage a week for X months – a free running injury consultation consisting of… – a 1-hour bike fit/gait analysis/ movement screen, etc. lA lternatively create a prize draw with different levels of prizes and each gift voucher qualifies the purchaser for an entry into the prize draw. Obviously the bigger and better the prize draw is, the greater the likely response. Again, an ideal opportunity to collaborate with other local partners. lO ffer an additional bonus or valueadd to the gift voucher, like a free glass of champagne, or again team up with local partners to offer a free coffee and cake at a local café (more ideas below). lA dd additional benefits or services to the appointment, book a

30-minute massage, and get an extra 15 minutes free or add in an extra service that doesn’t cost you much to offer – maybe a gait assessment or a free bike fit – each element gives you the opportunity to build a stronger relationship. lO ffer greater value than the gift voucher actually costs to purchase, so for example, you could offer a voucher value of £100 for the actual physical cost of £50. Or £50 value for the cost of £25, which gives clients the chance to get double the value – remember you still get money upfront. To have greater impact here, you could choose to only make this offer to a specific group of people, such as your premium, most committed and loyal customers, thereby building further loyalty in the offer itself.

Collaborate with Local Partners

This is a win–win because all local businesses will be super-grateful for any offers of help, which makes this an ideal time to team up with other businesses to enhance your offer. This also helps you build collaborations for the future, as well as work out what works and what doesn’t.

Co-Kinetic Journal 2021;87(January):47-50

ENTREPRENEUR THERAPIST

Use Cross-Promotions Building on the idea of adding value to your voucher recipients or your gift givers, you could offer extras from local businesses to add to your gift voucher offer. For example, you could team up with: l a local restaurant to offer money off a meal; l a local coffee shop, to offer a free cake and coffee; l a local pub to offer free round of drinks or a bottle of wine with any meal; l a local shop to offer a money-off coupon; l a non-competitive beauty therapist to offer for example xx% off a pedicure/manicure; l a yoga or Pilates instructor to offer money off an exercise session which could complement your treatment; or l a local farm shop to offer a moneyoff coupon. Your local collaborators would give you the necessary vouchers which you could distribute as you choose. Create Product and Services Packages The package would include services you offer, and it could just be limited to your own services, such as a Running/ Skiing/Cycling Injury Prevention Package which could combine several different elements from treatments to special assessments or fitness training. However, it could also include other complementary services from other providers, combined to form a unique offering. For example, if you wanted to go with a ‘stress reduction’ theme you might combine a set of massage treatments with complementary yoga or meditation sessions, or even discounts on stressreducing products like candles and oils. Think as far out of the box here as you like, to create a unique and desirable offer/package. Have you got friends or clients who run small businesses that you could team up with? Do you know your pub landlord well? Why not get on a call and talk through some ideas? You never know Co-Kinetic.com

where it might lead you. Or have you got some lovely local businesses creating unique products that you could team up with either to offer coupons or ways to turn your offering into that extra special gift?

Use Vouchers or Coupons To Get People To Take Action

You can use coupons to encourage or thank people taking actions that help you and your business. Ideas might include: l s haring, tagging or engaging in a social media post or on your page in general (maybe offer a voucher each month to the most active person on your page); l r eferring a friend; lb uying a gift voucher; lw riting a review (although I would avoid offering it as an inducement, instead use it as an unexpected thank you); and l s igning up to your email newsletter – what a great way to encourage that first visit.

Reasons to Promote a Voucher Offer

The great thing about voucher offers is that you’re very rarely short of a reason to create a campaign. The most obvious reasons to create a voucher campaign are holiday sales or sales that tie in with traditional annual events, but you can also create voucher offers for occasions that are unique to you, your local community, your clinic or dates or events that are important to you personally.

Public Holidays, Seasonal or Special Event Suggestions

1. January Sales 2. Winter Blues/Blue Monday (3rd Monday in Jan) – most depressing day, apparently 3. Valentine’s Day 4. Nirvana Day

5. Mother’s Day 6. Father’s Day 7. Easter Holiday 8. Vesak Day (Buddha’s birthday) – good if you have a yoga offering 9. Summer Holiday 10. Harvest Festival 11. Halloween 12. Black Friday/Cyber Monday 13. Thanksgiving 14. Christmas 15. Divali/Ramadam/ Chinese New Year

Ideas ‘Unique to You’

l f irst visit discount; l c linic opening anniversary; l a s part of a VIP clinic membership; l a special offer in honour of a significant date to you; lg ive a gift for a client’s birthday – great for re-engaging lapsed clients and boosting loyalty with current clients; lu se them to raise money for a charity (donate a percentage of takings); lu se them to offer special packages, eg. 5 sessions for the price of 4; or l a s part of a local event or raffle prize.

How to Increase Uptake

Doing the following will help to increase your sales of gift vouchers: lM ake sure there’s a clearly stated deadline. lA dd incentives (or offer extras) to make the sale more compelling. lM ake the campaign bespoke/ targeted, ie. they have a theme (such as those in the list above) rather than a generic sales campaign. lA dd urgency, eg. limit the number of vouchers available. lT o increase conversions customise your offer to appeal to certain target groups such as by interests, gender or age groups. lU se data targeting, like location, along with something like Facebook ads to make sure only relevant people see your ad promotions. lT he better your level of engagement with your customer base and particularly your email list, the greater the uptake will be. lW here possible add something of additional perceived benefit – maybe a free glass of champagne, a fruit smoothie, some chocolates – something small that doesn’t cost much but adds that extra touch.

Implementation Tips

The following are good tips for putting your gift voucher plan into action: lD on’t overcomplicate it – stick with what people understand and make it an easy transaction to both purchase but also redeem. lM ake sure the terms are reasonable and you don’t impose overly restrictive redemption terms (especially while Covid continues to be a concern) but do make sure there’s some sort of redemption deadline. lG ive them something they can physically print out as it will serve to remind them of the voucher’s existence.

Key Features of the Co-Kinetic system

lW e have produced ready-made social media promoting your gift voucher campaigns which you can post straight from within Co-Kinetic. lW e’ve created the voucher signup pages (using professional copywriters to increase conversions) – everything is editable to suit your needs. lS et whatever cost, value and terms you want and sell whatever you want. Offer Ideas ings you th l O n sign-up, your gift purchaser of es pl am ex Here are some is taken to a bespoke designed d: rte sta u yo t can offer to ge , ns downloadable/printable gift voucher io ss se on s nt ffer discou lo st showing redemption details and fir ur yo f of % eg. here’s 50 terms (and also sent an email t; appointmen – confirmation containing the code e free (BOGOF) uy one, get on lb with any additional information you ; e’s in nt le great for Va s; wish to supply). aw dr e riz /p ns l c ompetitio age of l S hare the link on your social ck pa ’ ng lvi so l a ‘problem networks, in your email newsletter, services; on your website, even in your clinic les/5 for 4 (cash l t reatment bund window if you have one. upfront); 0 £5 l T he system uses the currency that r fe of 5, £2 r fo uy a gift lb get the your Stripe account is set to use so it ain (ag e lu va n redemptio can be used by anyone, anywhere in ); nt cash upfro add a d ul the world. (co Y y bu u l f ree X, if yo lY ou can take payments of any size deadline); r/sample but equally you can offer a coupon ste ta y/ bu u yo l t ry before massage, e ut at zero cost which can be redeemed in -m 30 e fre sessions – , etc; fit as a discount against a booking – ke bi , sis aly an free gait k you gifts; an great way to build your email list. th d an s rd wa l r andom re t/done X, how l D ownload the CSV file of voucher/ go ve u’ yo – s pgrade lu r a discount; fo coupon bookings so you can Y to g in ad gr about up prompt those who have credit and an against their accounts, by email, to in exchange for l f ree coupons make a booking. s. es dr email ad 50

To Summarise

rs is lling gift vouche The beauty of se rs, te whatever offe that you can crea , nt wa u yo ons for whatever reas way, the in the world. In a e ar u yo er wherev the offer will be. the more unique e, ar u yo rs e tiv ea more cr u can use vouche range of ways yo a ne tli ou o to als t ed I’ve tri ur business, bu build not only yo and coupons to unity. your local comm ly build networks in booster, particular a great cashflow be n ca , ey up th g s Ye w needs toppin , or when cashflo ild at difficult times other ways to bu used in so many be o als n s, ca er m ey but th existing custo engagement with loyalty, increase k people for ers to return, than m sto cu d ol e ag encour mers to your ing in new custo br d an , ns tio ac taking business. an add-on ucher System is The Co-Kinetic Vo ibers at a cr bs su to existing le ab ail av n tio ip subscr th). It can also £11.99 per mon st (ju nt ou sc di 50% a standalone w subscribers as ne by d 99 se ha rc be pu required) for £23. her subscription ot o (n er n ev tio er ip cr subs be used wh currency, so can tiul m ly It’s . ct th re di on e per m ses com and all the purcha rld wo e th in e ar you nk account. into your own ba 36XBlo8 visit https://bit.ly/ For more details

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lM embership Magic: How You Can Build Recurring Revenues into Your Physical Therapy Business [Article] https://bit.ly/33wJiiE lH ow to Monetise Your Therapy Skills Online [Article] https://bit.ly/39QKjXz lH ow to Mitigate the Impact of COVID-19 and Keep Your Business on Track [Article] https://bit.ly/3dXn1hC THE AUTHOR Tor Davies began her professional life training as a physiotherapist at Addenbrookes Hospital, Cambridge, UK. She went on to complete a BSc in Sport & Exercise Science at the University of Birmingham while also achieving a WTA international tennis ranking. After graduation she worked in marketing with a London agency and then moved into medical journalism where her passion for publishing was born. At 27 she established sportEX medicine, a quarterly journal for physical and manual therapists. With a passion for technology as well as publishing, Tor’s leadership grew sportEX into the Co-Kinetic journal and website which included a more collaborative, royalty-based form of publishing as well as a wider content remit. Tor’s focus is on providing resources to help therapists develop their professional authority and brand, and grow their own businesses while working more efficiently and effectively, a topic that she speaks regularly on at global conferences. Join us on Facebook: www.facebook.com/CoKinetic/ Connect with Tor: www.facebook.com/cokinetic.tor Co-Kinetic Journal 2021;87(January):47-50