Co-Kinetic Journal Issue 83 - January 2020

1999

2019

ISSUE 83 JANUARY 2020 ISSN 2397-138X

We’ve gone GREEN!

BTEC LEVEL 6 PROFESSIONAL DIPLOMA IN ADVANCED CLINICAL AND SPORTS MASSAGE For the first time ever, UK therapists can achieve a degree level qualification in clinical and sports massage with Jing’s two-three year part-time course. This part time BTEC level 6 professional diploma will enable you to become an unparalleled expert in the arena of injury and pain management. You will learn: • Direct and indirect myofascial techniques • Physio and exercise based rehabilitation • Sports massage • Soft tissue release • Anatomy and physiology

• Musculoskeletal and systemic pathologies • Orthopaedic assessment skills • Trigger point therapy • Sports event massage • AIS, PNF and passive stretching techniques

Pearson/Edexcel accredited. Contact us to apply for a place on this life changing course: info@jingmassage.com • www.jingmassage.com

01273 628 942

what’s inside 47-51

PRACTICAL

PATIENT RESOURCES

20-01-COKINETIC FORMATS WEB MOBILE

ER

age is

only a

feelcan

are Adren level. aside human sugar nes which Brush part of indulge you take the three mainnce blood hormo were any way to tool to help rate and never ns that al heart good outlines there’s tific evide rful physic toric reactio article good scien prehis However, when manifest in ch, be a poweeing. This l. stoma it can or surviva cularly upset a joint ches, from stress, pain, and wellbthere is parti massage. around heada relief , chest h of oms like pressure, l abuse of motion sympt alcoho in whic g the role se range ed blood drug and n l Increa a muscle elevat few. functio g supportin nia, anger, to name a within soft tissue or more insom in trainin G ssion ve that 90% levels of fatigue e THIN tant role l Impro rt recovery and depre s estimate ss and . High stiffne 3. BREAplays an imporand help improv Expert stress-related been linked l Suppo ge d by high relax ase muscle g e is Massa line have es and how to e be affecte l Decre such of diseas adrena lly and swellin e, diabet the body which can issues, and l and after exercis mation mance atory a ing, cortiso vascular diseas faster, interna e inflam perfor you breath stress. Respir ms, asthm While l Reduc ce athletic ions that g ages to cardio of ther stress. proble condit levels . Nothin then high re altoge t a es, sinus group of l Enhan t injuries cancer y. Plus, ally, as allergi are one and pressucan, withou on now ge therap s system l Preven itis, and extern anxiety comm because ge massa bronch ating t from etic nervou ing rate s are more ago, not istic, massa elimin benefi ge, mpath injurie unreal se we’re stress. can breath years e massa r.

Muscle were 50 may be the parasy ge your manag n during a tend but becau when massa and regula , help happe than they ds to ing harder age our jointsof sed, and doubt es deep respon we exercis Two thingsnes are decrea hormones, range r we’re and becom tary. As s the Regula good’ endorphins, slows seden hormo reduce joints. more in stress the ‘feel which of your fluid and less phins, The increase in a feeling to tighten flexibility a endor sed. and been tal c as well ine, results your joints cal always loskele motion can keep are increa and dopam makes chroni me. ge Get Physitherapy has ent for muscu nin massa ion that to overcovitality seroto ge . relaxat easier Massa prone of treatm ions, post- s. It injury stone of calm stress much improve your t r condit injurie corner amoun uscula can sports nity as acute the area alone ry and line nes Immu is under a large and neurom relief tion to it also adrena hormo Boost ive recove Stress of mind. cortisol and up g but of stress , leaving the body operat improves circula place, state build healin take When excess sing and and that and can the e system on ial not only By decrea recovery health profile infecti of stress, the immun ting repair in the muscle y is essent s mme able to sses promo rest and ing your ge progra ion, ge therap suppre more vulner r. Clinical studiese out toxins levels, flushes injury. Massa tissue format to r massa which can tially improv the body sh to recove ge can increa res scar poten ing re, A regula and boost risk. structu having follow pressu e of pain, level, tissue and sluggi regular massa you don’t diseas se blood ng the odds stroke. to reduce stretch soft However, ge. ’s activity that cells and show as ity. , or a can decrea to loweri a massa e blood e system in t of failure flexibil have as well ute the immun (your white T-cells, which improv n r good an injury to the benefing pain contrib , kidney r of attack recove ocytes rly, can shown for e functio ry. lymph numbe a heart s have to wait immun d regula recove ts in reduci as se the have t studie body’s patien treatment, receive and speed , if you decrea Recen ge, if es the cancer pation mance Massa ge to ated with state. turn improv massa c perfor level of partici massage associ nal adding athleti l. your t from t from overal and nausea ing emotio and matter benefi benefi No improv can ioning and can e you well as condit and how you your health your local exercis necks ing body n to ting Find out therapy to relatio for sore TURE contac by improv injury. ge ge that in massa regimen by ting massa 2. POS r one culpritWhen you huncha shown ss preven pation e. have numbe s ist. driving wellne postur a desk, The Studie athletic partici ctly ge therap at is poor massa e and backs g it sitting body is incorremuscles spasm exercis d, be n and for plannin forwar ter your forces some get tone tensio can: e compu as a basis r muscle e muscle others upon car, or Poor postur monito while ge s relied 2017 n Reduc d. inetic . Massa athlete not be ibly hard aligne s, should case. ©Co-K incred n Help te relaxation muscle n in length ual to work only and shorte loosen tight its individ ation n Promo r and itself in inform in each weake pain and to position ce and l advice l guidan medica e. can relieveyour body genera specialist postur g ed as allowin pain free ute for is intend l and article or as a substit natura in this ation

The inform

2

Tweets

Facebook posts

3

Mendely readers

EXERCISE GUIDELINES FOR CANCER SURVIVORS

4 CAN MARATHON RUNNING IMPROVE KNEE DAMAGE OF MIDDLE-AGED ADULTS? A PROSPECTIVE COHORT STUDY BMJ Open Sport & Exercise Medicine

0 14 533 0

10 AN UPDATE OF SYSTEMATIC REVIEWS EXAMINING THE EFFECTIVENESS OF CONSERVATIVE PHYSIOTHERAPY INTERVENTIONS FOR SUBACROMIAL SHOULDER PAIN Journal of Orthopaedic & Sports Physical Therapy

0 3 423 0

5

AMERICAN COLLEGE OF SPORTS MEDICINE ROUNDTABLE REPORT ON PHYSICAL ACTIVITY, SEDENTARY BEHAVIOR, AND CANCER PREVENTION AND CONTROL Medicine and Science in Sports & Exercise

4 4 373 1

9 COGNITIVE FUNCTIONAL THERAPY COMPARED WITH A GROUP-BASED EXERCISE AND EDUCATION INTERVENTION FOR CHRONIC LOW BACK PAIN: A MULTICENTRE RANDOMISED CONTROLLED TRIAL (RCT) British Journal of Sports Medicine

2 3 339 0

6

MANUAL THERAPY

NECK | LOWER BACK | SACRUM | 20-01-COKINETIC FORMATS WEB MOBILE PRINT All references marked with an asterisk are open access and links are provided in the reference list

ED PIECES OF (OCT - DEC RESEARCH IN MANUAL 2019) THERAPY

2

3

0 3

55 0

23 0

16 1 216 2

7

Chiropra

ctic & Manual

Orthopaedic Journal of Sports Medicine

0 0 2 0

9

0 0 COMPARIN G THERAPIES THE RANGE

11 0

OF MUSCULOS WITH POSTGRADAPPLIED BY PHYSICAL KELETAL UATE THERAPIST THERAPY S IN PATIENTSQUALIFICATIONS IN WITH NON-SPEC MANUAL PAIN WITH IFIC RECOMMEN INTERNATIONAL GUIDELINE NECK Musculo DATIONS: AN OBSERVATI S AND skeletal ONAL STUDY Science and Practice

Produced by: News stories Facebook posts

Tweets

TIME-SAVING RESOURCES FOR PHYSICAL AND MANUAL THERAPISTS

Mendely readers

The PDF version of this infogra hyperlinks phic includ to Click here the individual es pieces to acces of resear s https:/ ch. /spxj.n l/2DQf1Pc

MANUAL THERAPY & PHYSICAL THERAPY INFOGRAPHICS

0 1

18 0

PROMOTIN IN PATIENTSG THE USE OF SELF-MAN AGEMENT CHIROPRAC WITH SPINE PAIN MANAGED BARRIERS TORS AND CHIROPRAC BY TIC INTERNS: KNOWLEDGAND DESIGN OF A THEORY-BA

Chiropra E TRANSLATION INTERVENT SED ctic & Manual ION Therapie s

Therapie

s

ASSOCIATION OF ADOLESCENT SPORT PARTICIPATION WITH COGNITION AND DEPRESSIVE SYMPTOMS IN EARLY ADULTHOOD

34 6

of ative Therapy

6

PLoS ONE

0 13 1 0 ASSOCIATE 4KNOWLEDG E OF PSYCHOSO 0 D WITH LOW CIAL BACK PAIN FACTORS AMONGST 0 STUDENTS: 410HEALTH SCIENCE A SCOPING REVIEW

British Journal of Sports Medicine

8

5 3

HEADACHE RELEVANC SYMPTOM MODIFICAT ASSESSMEE OF APPROPRIATE ION: THE NT AND MANAGEM MANUAL THERAPY WITH FEATURES OF MIGRAINE ENT OF A PATIENT HEADACHE AND CERVICOGE Manual - A CASE REPORT NIC Journal & Manipul

THE NORDIC MAINTENA DOES PSYCHOLO NCE CARE PROGRAM: GICAL PROFILE IT IS TIME TO MOVE TREATMENT EFFECT BEYOND ‘BODY REGION THERAPY OF A PREVENTIVMODIFY THE E MANUAL SILOS’ TO MANAGE ANALYSIS INTERVENTION? A SECONDAR OF A PRAGMATIC MUSCULOSKELETAL PAIN: RANDOMIZ Y FIVE ACTIONS TO CHANGE ED CONTROLL ED TRIAL CLINICAL PRACTICE

British Journal of Sports Medicine

69 17

A STUDY EXPLORING EXTREMITY THE PREVALEN

4

tation

5

0 1

0 10

CE Journal PAIN OF SPINAL SOURCE OF of Therapy Manual & Manipul(EXPOSS) ative

IS A COMBINED PROGRAMM THERAPY E THAN USUALAND EXERCISE MOREOF MANUAL CARE IN PATIENTS EFFECTIVE SPECIFIC WITH NONCONTROLL CHRONIC NECK PAIN? ED TRIAL Clinical A RANDOMIZED Rehabili

7

PHYSICALLY ACTIVE LESSONS IN SCHOOLS AND THEIR IMPACT ON PHYSICAL ACTIVITY, EDUCATIONAL, HEALTH AND COGNITION OUTCOMES: A SYSTEMATIC REVIEW AND META-ANALYSIS

41

AL

T DISCUSS

1

304 52

THE EFFECTIVE NESS OF INSTRUME SOFT PARTICIPAN TISSUE MOBILIZAT NT-ASSISTED ION TS CONDITION WITHOUT EXTREMITYIN ATHLETES, EXTREMITY S, AND INDIVIDUAL OR SPINAL CONDITION , LOWER EXTREMITYS WITH UPPER

S: A SYSTEMATI , AND SPINAL of Physical Medicin C REVIEW Archives e & Rehabili tation

THE 10 MOST DISCUSSED PIECES OF RESEARCH IN PHYSICAL THERAPY (OCT - DEC 2019)

l They’re great for building relationships - specifically designed for human interaction, engagement and sharing l Great networking potential

O

0 11

158 17 2951 9

29 8 222 5

What Are The Strengths of Social Networks?

8

8 2

8 22

EFFECTS OF INSTRUME TISSUE MOBILIZAT NT-ASSIST ED SOFT ION PROPERTIE S MedicinON MUSCULOSKELETAL Sports e and & Exercise

10

0 4

Science

THE BLUEPRINT FOR RUNNING A SUCCESSFUL OPEN CLINIC EVENT: Part 5 ON SCORES S THE DOORLESSONS LEARNT

And Where to Start With Your Event

By Vicki Marsh, Massage Therapist, Owner of the HeadStart Clinic 20-01-COKINETIC FORMATS WEB MOBILE

Overview

PRINT

These results are taken from the past two years of the Open Clinic event that I run at my Headstart Sports Injury and Performance Clinic, based in Cambridge, UK. In 2018, we focused on offering only 1-to-1 appointments with the aim of testing a range of follow-up offers to convert these taster appointments into paying clients. We also worked with some fellow therapists to offer a range of additional appointments such as nutrition and gait analysis. This helped all those of us involved to build our email list and expose ourselves to more prospective customers. We had 287 appointments available in total (145 of which were non-massage and 142 of which were specifically massage).

In the results below, we’ve focused on the massage-only appointments so

If you’ve been following along with this series, then this is the article you’ve probably been waiting for. This is where we give you the numbers behind our Open Clinic event, show you just how effectively events like this can help to build your business, offer you some lessons we continue to learn every time we run these events, and, most importantly, where to start when it comes to organising your own Open Clinic event.

There are four articles that precede this one, which take you through the full planning, organisation and marketing of your event, you can find links to those articles in the Related Content box at the end of the article. Read this article online https://spxj.nl/2RETdyo we can compare like with like across 2018 and 2019, but it was a great experience to team up with fellow therapists and I’d definitely do this again in future events.

In 2019, we had one less room available to run the event, so we had less availability, and I had a 2-monthold baby – so the aim for 2019 was to make the week EASY, rather than overcomplicate it with additional therapists as we did in 2018.

In 2019, we had 145 free

30-minute trial massage appointments available, which we sold out.

ON THE SCORES

DOORS

Email sign-ups

2018 463

Attendees (for massage appointments)

142

2019 516 145

Immediate sales l Pre-event new clients sales l New clients sales

£300

£375

£1026

£927

l Membership sales × 6 (annual value) £3960 £4320 TOTAL INCREASED REVENUE

£5286 £5622

in

9 0

EFFECTIVE IMPROVINGNESS OF DRY NEEDLING TENSION-T PAIN AND DISABILITY FOR HEADACHE YPE, CERVICOGENIC, IN ADULTS WITH S: PROTOCOL OR MIGRAINE

REVIEW Chiropra FOR A SYSTEMATI Manual ctic C Therapie & s

Co-Kinetic.com

37

Produced by:

ur posture should flow with ease through dynamically changing positions as we move, and so is constantly adapting. In healthy movement we select from a range of stabilising possibilities, calibrating our neuromuscular pattern according to the task we are performing (1). However, if our postural control is compromised in response to our emotional, behavioural, functional or neurosensory landscape, our choices can narrow to adopt a habitual specific stabilising strategy.

This becomes a lock – the stereotypical immobilising response in a part of the body that is used for stabilisation regardless of the task’s demands.

Locks can be classified as being either foundation or functional. A foundation lock is one that is present in the person’s posture whether they are in motion or at rest. It is a consistent postural feature and does not vary greatly in response to movement demands.

A functional lock appears in response to the impulse to move. Chapter 3 of my book The Power and the Grace discussed the process by which our bodies prepare for movement: the feedforward response. This response ensures that our support musculature establishes the initial groundwork for our bodies to be able to accept load and generate force before the movement actually begins. We have many possibilities for this, and muscles like transversus abdominis, multifidus and the vastus medialis of the quadriceps have all been identified as behaving in this preparatory way (2,3,4*). However, in the presence of pain, a history of injury, or any one of the other postural influences that were discussed in Chapter 5 of the book, alternative feedforward responses can appear and become the primary preparatory strategy for the body. In Chapter 3 we also talked about looking for where a movement starts – the point of preparation.

37-40

THE BLUEPRINT FOR RUNNING A SUCCESFUL OPEN CLINIC EVENT: PART 5: SCORES ON THE DOORS, LESSONS LEARNT AND WHERE TO START WITH YOUR EVENT

SHOULD I USE SOCIAL MEDIA FOR MY PHYSICAL THERAPY BUSINESS? IF SO WHY, AND HOW?

l You can do it all from the comfort of your living room l You have access to a huge, highlytargetable group of people l Reviews and testimonials, which feature highly, at least on Facebook, are very influential sales converters l Social networks are widely used - 67% of the UK population are on Facebook, 72% of Australians, 60% of New Zealanders, 77% of Canadians and 69% of Americans l All the major social networks are free (until you utilise paid ads) l People are on social networks, primarily to socialise, so they encourage a more personal, valueadd approach, than a sales approach which suits healthcare practitioners.

By Joanne Elphinston

THE 10 MOS

British Journal of Sports Medicine

Journal of Orthopaedic & Sports Physical Therapy

4 16 538 00 538

PHY SIC

D l AN journa

ENTREPRENEUR THERAPIST

IS RUNNING ASSOCIATED WITH A LOWER RISK OF ALL-CAUSE, CARDIOVASCULAR AND CANCER MORTALITY, AND IS THE MORE THE BETTER? A SYSTEMATIC REVIEW AND META-ANALYSIS

Medicine and Science in Sports & Exercise

PATELLOFEMORAL PAIN

FO R RC ES RES OU PIS TS AV ING THE RA AL TIM E-S MA NU

ed l care contain ual medica individ

S

ocial media has become a vast and wide open canvas, and taking full advantage of it requires careful strategic planning. A good social media strategy, not just should, but WILL, have a positive and demonstrable influence on sales.

Let’s jump right in and look at some of the strengths of social networks and what you can achieve with a social media presence.

Co-Kinetic.com

1

The PDF version of this infographic includes hyperlinks to the individual pieces of research. Click here to access https://spxj.nl/38b3WWU News stories

Social media. Some people love it, some people hate it and the rest of us tolerate it, mostly begrudgingly. However, as a small business owner you’d be a little bit mad to ‘diss’ it. Yes, it’s unlikely that you’ll ever hit on something that will go ‘viral’, despite your best efforts and yes, you can get yourself in hot water if you’re very outspoken. Perhaps more importantly, you can waste a huge amount of time on social media, and never get any kind of return on that investment. But in reality, that will only happen if you post without having a solid strategy. In this article, I’ll outline the strengths of having active social network pages but more importantly review what you can achieve for your business by having a good social media presence.

I will look at the key objectives for healthcare-based businesses and explain what you should be prioritising and why.

Lastly, I’ll answer some frequently asked questions such as which platforms should you be using, how many times a day should you be posting and whether or not you should you be spending time on more than one platform. We also cover some social media trends for 2020. Hold onto your horses….! Read this article online https://spxj.nl/2rst0bG

age that mass self, mass health Get in any thoughts of your per your areas charge or pam

UCED PROD BY:

PRINT

BY TOR DAVIES, CO-KINETIC FOUNDER

AGEits: many benefits MASS with touch

BETT Relaxation stress and l are both boost your d to 1. Stress and cortiso are release aline These

41-46

If So Why, and How?

T NDOU E HA ADVIC

LIVE

ENTREPRENEUR THERAPIST

Should I Use Social Media For My Physical Therapy Business?

29-36

HOW TO UNPICK POSTURAL LOCKS

HOW TO UNPICK POSTURAL LOCKS Many people, most of the time, move without thinking about what they are doing. The right muscles fire at the right time to prepare, support and execute the desired moment. Sometimes, though, perhaps in response to pain or injury, we change the way we move, using some muscles too much as a stabilising strategy, which can become a ‘lock’ and create knock-on imbalances in the kinetic chain.

This article looks at some of the locks that you are likely to see in your patients and how you can treat them. This article has been extracted from chapter 6 of the author’s book The Power and the Grace.

Read this article online https://spxj.nl/2YyEdDx Persistent, habitual points of preparation that are used regardless of the movement challenge are in fact functional locks.

Distinguishing between foundation and functional locks helps us to identify how to address them. In the case of a foundation lock, there may be structural joint stiffening and soft tissue restriction that can benefit from direct treatment, mobilising or stretching.

These techniques create movement potential, which must then be integrated using active movement to make the brain aware of how to access and use the new motion in

the area.

Functional locks appear in response to movement, but subside at rest. Although a person will complain of tightness and stiffness in the lock area, this is the result of active

A ‘LOCK’ IS AN IMMOBILISING RESPONSE IN A PART OF THE BODY THAT IS USED FOR STABILISATION REGARDLESS OF THE TASK DEMAND

Co-Kinetic.com

29

MANUAL THERAPY

TREATING HEADACHES Can be a Pain in the Neck There are many types of headache but the two that commonly occur with neck pain are tension-type headache and cervicogenic headache. This article will enable you to make a differential diagnosis and to treat your patient appropriately, as well as helping you to recognise the red flag signs for serious pathologies that require further investigation and referral to the appropriate professionals. Read this article online https://spxj.nl/34UeuYq

TIME-SAVING RESOURCES

FOR PHYSICAL

AND

MANUAL

THERAPISTS

14-20

12-13

SYNDESMOSIS INJURY PART 2: TREATMENT AND REHABILITATION

4-11

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

TECHNICAL

1999

is published by

2019

ISSUE 83 JANUARY 2020 ISSN 2397-138X

We’ve gone GREEN!

Centor Publishing Ltd 88 Nelson Road Wimbledon, SW19 1HX, UK

1. primary headache disorders a. migraine

b. TTH with pericranial tenderness 2. secondary headache disorders a. headache associated with craniocervical dystonia b. headache attributed to chiari malformation c. headache attributed to cervical carotid or vertebral artery dissection d. headache attributed to whiplash e. CGH. The problem with headache and neck pain is complicated when more than one condition from the above list is present. The differential diagnosis in this setting raises the questions: could the neck symptoms be part of the primary headache disorder or are the neck symptoms actually the source of the headache, or does the patient have two distinct conditions such as a primary headache disorder complicated by a secondary headache?

(For example a patient who has traditionally suffered from migraines, but now presents with headaches following a recent motor vehicle accident). The emphasis on treatment may depend on your understanding of headache definition as well as your preference of treatment approach.

To lump all headache and neck pain under the heading of CGH will lead to an oversimplification of headache pathology and potentially inadequate or inappropriate treatment (5).

The updated headache classification of the International

By Kathryn Thomas BSc MPhil HEAD | NECK | 20-01-COKINETIC FORMATS WEB MOBILE PRINT All references marked with an asterisk are open access and links are provided in the reference list

MEDIA CONTENTS Co-Kinetic Headache Content Marketing Campaign https://spxj.nl/35e5WMa Co-Kinetic Chronic Pain Patient Information Resources https://spxj.nl/2v5TptP Co-Kinetic Poster: Good Versus Bad Desk Posture https://spxj.nl/2HNLe9H

THE INTERNATIONAL CLASSIFICATION OF HEADACHE DISORDERS SUGGESTS THAT TWO TYPES OF HEADACHES ARE LINKED TO THE CERVICAL SPINE: TENSION-TYPE HEADACHE (TTH) AND CERVICOGENIC HEADACHE (CGH)

Co-Kinetic.com

21

21-28

TREATING HEADACHES CAN BE A APAIN IN THE NECK

JOURNAL WATCH

SHORT

Neck pain and headaches are common co-morbidities. Individuals with disabling neck pain are 10 times more likely to suffer from headaches than those without neck pain (1).

The International Classification of Headache Disorders (ICHD-3) (2*) suggests that two types of headaches are linked to the cervical spine: tension-type headache (TTH) and cervicogenic headache (CGH). It is estimated that 2.33 billion of the world’s population experienced TTHs in 2017 (3*). CGHs are also common in the general population with a prevalence of up to 20%, and as high as 53% in patients suffering headache following a whiplash injury (4*). People who suffer from CGHs commonly report at least five headache days per month (1). So there is a strong possibility you are seeing patients in your practice be it daily or weekly that present with headache and neck pain or neck pain with headache. Which one is it?

This is where the challenge comes in. Do all patients who present with headache and neck pain have CGH? What needs to be considered is that primary headache patients (including migraine and TTH) have a fairly high prevalence of neck pain (68%) (5).

Traditionally the differential diagnosis of headache with neck pain has been subdivided into two categories (5):

LONG JANUARY 2020 ISSUE 83 ISSN 2397-138X

https://Co-Kinetic.com Facebook

www.facebook.com/CoKinetic

YouTube

www.co-kinetic.com/youtube

Twitter

www.twitter.com/sportexjournals

LinkedIn

www.linkedin.com/company/sportex-net

Our Green Credentials

Journal Cover and Inside Pages = 100% FSC Recycled Offset Paper Mailing Wrap = Biodegradable polymers, fully compostable - why not cut open at one end and re-use for your kitchen compost bin Plant-Based Ink Used in Printing Process

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

Database searches were made for randomised controlled trials or quasiexperimental studies of functional treatments being applied to treat acute ankle sprains. The treatments were: a. elastic bandage, stocking or all external assistance with elastic socklike material to support the ankle joint b. a ll types of adhesive and elastic tapes to support the ankle joint c. lace-up ankle support or other external assistances made up of soft canvas-like or nylon materials d. s emi-rigid ankle support, posterior rigid support or other external assistances made up of firm

4

= OPEN ACCESS

A SYSTEMATIC REVIEW ON THE EFFECTIVENESS OF DIFFERENT FUNCTIONAL TREATMENTS FOR ACUTE ANKLE SPRAINS. Kyaw SL, Moone IS, Oo ML. Journal of Sports Medicine and Doping Studies 2019;9(1):1000213 thermoplastic elements.

Ten studies met the inclusion criteria.

From the pooled data, the results showed that the stocking was more effective at improving pain, swelling, functional outcomes, range of motion, and return to sport/work, and had higher patient satisfaction than the bandage. There was no evidence that the taping and lace-up brace were more effective than other functional interventions in the treatment of acute ankle sprains. Furthermore, the prevalence of complications was greatest for the taping and lace-up brace interventions. The semi-rigid

WHAT IS THE QUALITY OF CLINICAL PRACTICE GUIDELINES FOR THE TREATMENT OF ACUTE LATERAL ANKLE LIGAMENT SPRAINS IN ADULTS? A SYSTEMATIC REVIEW. Green T, Wilson G, Martin D et al.

BMC Musculoskeletal Disorders 2019;20(1):394 The medical databases were searched for clinical practice guidelines (CPGs) aimed at aiding clinical decision making and the application of evidence-based treatment for acute lateral ankle ligament sprains. CPGs were found for physicians and physical therapists (Netherlands), physical therapists, athletic trainers, physicians and nurses (USA), and nurses (Canada and Australia). The content of each CPG was critically appraised independently, by three authors, using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument, online version called My AGREE PLUS. This consists of 23 key items organised into six domains: Scope and

OPEN

OPEN

Purpose, Stakeholder Involvement, Rigour of Development, Clarity of Presentation, Applicability, and Editorial Independence.

None of the CPGs scored highly in all domains. The lowest domain score was for applicability, which achieved an exceptionally low joint total score of 9% for all CPGs. The applicability domain pertains to likely barriers and facilitators to implementation, strategies to improve uptake, and resource implications of applying the guideline. The five most recent CPGs scored a zero for applicability.

Other areas of weakness were in rigour of development and editorial independence.

Co-Kinetic comment If this result applies to CPGs for other conditions and in other countries, what hope do we have?

or posterior rigid support group had a better functional recovery and higher patient satisfaction, but some complications were present.

Co-Kinetic comment Putting compression onto an ankle sprain is a bit of a stretch of the term ‘functional treatment’; maybe ‘functional support’ would have been better.

As a comparison of initial post-injury support this study does what it says, the problem is that stockings (or Tubigrip®) should only be part of the intervention. ‘optimum loading’ is the mantra these days.

A cross-sectional retrospective survey was used with an invitation letter sent to all British Rowingaffiliated clubs in England (n=353) that participated in slide-seat rowing. They were asked to provide participant characteristics and injury information in the previous 12 months from those training/ competing until March/April 2018. Participants from the age of 19 years who had rowed for at least 1 year and were considered amateur. Descriptive information, training patterns and injury history for the participants over the past 12 months was collected via the survey. An injury was defined as a musculoskeletal issue which led to adaption/missing two or more training sessions and/or at least one visit to a healthcare professional (Wilson et al, 2010). A reinjury was identified when a participant indicated injury to the same body part more than once within the 12 months and was not necessarily a recurrence of the same injury

Co-Kinetic Journal 2020;83(January):4-7

RESEARCH INTO PRACTICE

Journal Watch Physical Therapy

This essay in foot problems starts with the anatomy and the pathology behind some of the issues, such as the fact that the metatarsal heads are weight-bearing structures and any toe contracture will place retrograde pressure on them causing calluses, capsulitis and metatarsalgia. It has brief explanations of some of the more common conditions. Hyperkeratoses or calluses are abnormal thickening and hardening of the skin from excessive pressure or friction on an area of the epidermis, specifically the stratum corneum. Verrucas are warts caused by the human papillomavirus. They are the most common viral infection of the skin affecting 7–10% of the general population. Various fungal infections and their presentation and treatment are discussed. Other conditions include

COMMON FOOT PROBLEMS. Sunshein KF, Samouilov A. Emergency Medicine Reports 2019;40(15)

onychocryptosis (ingrown toenails), heel pain due to plantar fasciitis, hallux limitus (a condition in which there is limited dorsiflexion of the first metatarsal phalangeal joint), hallux rigidus (the end stage of hallux limitus when the joint undergoes degenerative changes), hammer toes and stress fractures.

OPEN

Co-Kinetic comment The abstract of this excellent paper starts by saying, “the foot does not get much respect: the hand has it beat in the prestige department”, which, given that it forms our base of support and can lead to problems all along the kinetic chain, is strange. It’s a free article so put your best foot forward and seek it out.

THE EPIDEMIOLOGY OF INJURIES IN ADULT AMATEUR ROWERS: A CROSS-SECTIONAL STUDY. Finlay C, Dobbin N, Jones G. Physical Therapy in Sport 2020;41:29–33 or a duplicate. Injury to multiple sites was recorded when a participant reported injury to more than one body part within the 12 months. Training volume was calculated as the absolute number of training sessions completed per week during a ‘typical week’, which was multiplied by the number of weeks participants estimated they trained.

Other information gathered looked at when the injury occurred to help identify at what point in the season rowers may be at higher risk, if the injury occurred during water- or landbased training, what body part(s) was/ were impacted and whether time loss or medical support was experienced.

Participants were categorised as open-weight (OW) and lightweight (LW). Only 29 of the 353 clubs took part (160 athletes). A total of 101 (65%) amateur rowers experienced at least one injury. In total, 198 injuries were reported in the previous 12-month period, with a mean injury incidence

Co-Kinetic.com

of 5.7±10.2 per 1000 sessions. Injury incidence for males and females were 6.7±13.2 and 4.9±6.6 injuries per 1000 sessions. The majority of injuries reported were classed as either overuse (n=141) or traumatic injuries (n=43), with a small proportion (7.1%) of responses not classified. There was no significant difference between sexes for overuse (men, 73.5%; women, 79.2%) or traumatic (men, 26.5%; women, 20.8%). Further, there was no significant difference between OW and LW for overuse (OW, 74.5%; LW, 85.7%) or traumatic (OW, 25.5%; LW, 14.3%). The lower back, knee and shoulder were the most commonly injured body sites.

The total number of injuries reported was higher in the head season (against the clock races) with majority of injuries being in January (n=20), February (n=24) and March (n=21). Fewer total number of injuries were reported in the regatta season, although were high in March, which represents a

OPEN

transition period between seasons.

Water-based activities resulted in 58 injuries, whereas ergometer training, non-rowing cardiovascular training, resistance training and Pilates/yoga accounted for 84 injuries and 6 injuries were unclassified. In all, 82% of rowers that reported an injury sought medical advice from at least one person/ professional, with the most commonly used profession being physiotherapist.

A large proportion of amateur rowers sought advice from other rowers who may have experienced a similar injury rather than medical professionals.

Co-Kinetic comment Come on rowing, get your act together! Overuse and on-thewater injuries suggest a training load and technique issue in the amateur ranks. Seeking advice from fellow rowers rather than medical professionals does not bode well for proper recovery and rehabilitation, and only 8% of clubs returning the information suggests a lack of interest in the welfare of your athletes.

5

RUNNING PROPENSITIES OF ATHLETES WITH HAMSTRING INJURIES. Sugimoto D, Kelly BD, Mandel DL et al. Sports 2019;7(9):210 A retrospective case-control video analysis was used on 35 (12 male and 23 female) videos of runners with hamstring injuries who were matched for sex, age, mass and height with healthy control runners. The runners with hamstring injuries had forwardtrunk posture angles of 1.6° less than the healthy control runners. The injured group showed a 4.9° larger overstride angle than the healthy runners. The injured runners also showed a tendency to rearfoot strike, compared to the more forefoot strike pattern of the healthy runners.

Co-Kinetic comment The runners with hamstring injuries demonstrated different running mechanical propensities compared with the healthy runners but there is a big methodological hole in this paper. The injured participants were examined and

Data for this study came from medical staff of the football clubs participating in the UEFA Elite Club Injury Study. Duration of absence due to an injury was defined by the number of days that passed between the date of the injury occurrence and the date when the medical team allowed the player to return to full participation. In total, 22,942 injuries registered during 494 team-seasons were included in the study. The 31 most common injury diagnoses constituted a total of 78% of all reported injuries.

Most of these injuries were either mild [leading to a median absence of 7 days or less, 6440 cases (42%)] or moderate [median absence: 7–28 days, 8518 cases (56%)], while only few were severe [median absence of >28 days, 311 cases (2%)]. The mean duration of absence from training and competition was significantly different between index injuries and reinjuries for six diagnoses (Achilles tendon pain, calf muscle injury, groin adductor pain, 6

OPEN

videoed on presenting themselves to a sports injury centre. Hamstring injury was diagnosed but there is no mention of the time scale from injury nor the severity, which may make a huge difference to the data. Plus, the measurements were taken at a fairly slow running speed. However, they may have hit on an important consideration to injury prevention.

Can someone please do a bigger study on a group of uninjured athletes who are videoed at varying speeds and then videoed again when in a postinjury recovery process and on return to sport? Who knows what that might throw up in terms of injury prevention and/or reinjury rates. It’s a great opportunity for someone with access to team-sport players.

THE INFLUENCE OF PSYCHOLOGICAL OPEN FACTORS ON THE INCIDENCE AND SEVERITY OF SPORTS-RELATED CONCUSSIONS: A SYSTEMATIC REVIEW. Trinh LN, Brown SM, Mulcahey MK. American Journal of Sports Medicine 2019;363546519882626 A systematic literature search of multiple major medical reference databases was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and MetaAnalyses) guidelines. Studies were included that evaluated the effect of pre-existing psychological factors on the incidence and severity of sports-related concussions (SRCs) in male and female athletes participating in all sports. Ten studies met the inclusion criteria and were included in the analysis.

Factors such as meanness, aggression and psychoticism were associated with an increased incidence of SRCs. Baseline traits of irritability, sadness, nervousness and depressive symptoms were associated with worse symptomatology after SRCs. In young athletes, pre-existing psychiatric illnesses, family history of psychiatric illness, and significant life stressors were associated with an increased risk of developing postconcussion syndrome after SRCs.

Co-Kinetic comment This is an interesting study that’s worth a read.

TIME BEFORE RETURN TO PLAY FOR THE MOST COMMON INJURIES IN PROFESSIONAL FOOTBALL: A 16-YEAR FOLLOW-UP OF THE UEFA ELITE CLUB INJURY STUDY. Ekstrand J, Krutsch W, Spreco A et al. British Journal of Sports Medicine 2019;pii:bjsports-2019-100666 hamstring muscle injuries and quadriceps muscle injury) with longer absence following reinjuries for all six diagnoses.

The most common injuries were as follows (median absence in brackets): l Achilles tendon pain (6) l ankle joint: capsular injury (4), medial ligament (7), lateral ligament (8), synovitis (5) l calf muscle injury: functional (4), structural (13) l concussion (4) l contusions: ankle, calf, foot, knee, lower leg, thigh (all 4) l groin: adductor (8), other muscle or tendon pain (7) l hamstring muscle injury: functional (5), structural (13) l hip flexor pain (8) l knee joint: cartilage (22), capsular injury (6), ligaments; ACL (205), MCL (16), LCL (13), lateral meniscus (36),

patellar tendinopathy (7), synovitis (6) l low back pain (4) l quadriceps muscle injury: functional (4), structural (13).

OPEN

Co-Kinetic comment This is a ‘must read’ for those of you involved in football if for no other reason than to indicate which injuries you need to be good at fixing. The author’s intentions are that it will provide guidelines for expected time away from training and competition for the most common injury types. Great plan, but there are a lot of variables in return to play times. This is apparent in the difference between the mean and median and percentile figures quoted. Let’s hope that this doesn’t get used by managers as yet another excuse for not winning games.

“They said our new Pelé would be back in 4 weeks and it took 8. It’s the medical team’s fault we have lost 6 games in those extra 4 weeks.” At least it will make a change from blaming the ref! The difference between a functional and structural injury is that the latter shows macroscopic evidence of fibre tear on MRI. They are usually located in the musculotendinous junction as these areas have biomechanical weak points.

Co-Kinetic Journal 2020;83(January):4-7

RESEARCH INTO PRACTICE

IMPORTANCE OF SCREENING IN PHYSICAL THERAPY: VERTEBRAL FRACTURE OF THORACOLUMBAR JUNCTION IN A RECREATIONAL RUNNER. Maselli F, Rossettini G, Viceconti A et al. BMJ Case Reports 2019;12:e229987 A 37-year-old male dentist complained of a stabbing low back pain (LBP), rated 8/10 on a numeric pain rating scale.

He also reported a concomitant, more superficial pain in his lower posterior back (3/10) that began after he fell backwards to the ground during a middle-distance uphill running training session (10km), 24h earlier. Pain was continuous during the day, gradually worsening throughout the night.

He was having difficulty walking. He had reduced active thoracic range of motion and all spinal movement produced high pain levels around the T12–L1 area. Many movements were impossible because of the pain. The physical therapist doing the exam hypothesised a possible fracture at the thoracolumbar junction caused by the fall and confirmed this with other tests including a tuning fork test, percussion test (bone vibration test) and percussion to the affected vertebrae. No loss of function was observed on neurological

examination.

Referral to an emergency department and subsequent radiographs confirmed a closed fracture of the first lumbar vertebra without involvement of the spinal cord. Treatment was immobilisation in a corset, pain killers and anti-inflammatory drugs.

A short time later the patient again attended the initial clinic complaining of increased pain and bilateral tingling and numbness in his feet. The physical therapist performed another neurological exam and which displayed a reduction in osteotendinous reflexes (the patellar reflex was non-evocable bilaterally, and the Achilles tendon reflex was slightly evocable, especially on the left leg). Because of the pain muscle tests were not conducted. A subsequent CT scan revealed a burst fracture of the first lumbar vertebra with a spinal cord compression. Treatment this time was surgery and support given

EFFICIENCY OF KNEE ULTRASOUND FOR DIAGNOSING ANTERIOR CRUCIATE LIGAMENT AND POSTERIOR CRUCIATE LIGAMENT INJURIES: A SYSTEMATIC REVIEW AND META-ANALYSIS. Lee SH, Yun SL. Skeletal Radiology 2019;48:1599 PubMed and EMBASE databases were searched for diagnostic accuracy studies that used ultrasound for diagnosing anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) injuries. Eleven studies were found for ACL injuries (938 ultrasound/878 patients) and six articles (281 ultrasound/237 patients) for PCL. The summary sensitivity and specificity were 0.88 and 0.99 for ACL injuries, and 0.99 and 0.97 for PCL injuries. Among the various potential covariates patient enrolment, patient position and ultrasound performer were associated with heterogeneity in terms of sensitivity, and proportion of the ACL injury was associated with heterogeneity in terms of specificity.

Co-Kinetic comment What all that means in plain English is that when performed by experienced musculoskeletal radiologists there is a very good chance that ultrasound can detect ACL and PCL injury.

Co-Kinetic.com

to the vertebra with pedicle bars and screws.

Co-Kinetic comment This is an excellent, well-written case study. It contains a lot of information on the patient’s rehab over the following 12 months. It is a great example of the fact that physical therapists in all their forms never know who is going to walk into their clinic. Previous studies have reported that 11–85% of recreational runners have at least one runningrelated injury each year and in many cases their first point of contact is going to be a physical therapist. LBP is considered to be a musculoskeletal disorder with a positive prognosis and it is commonly treated using education, manual therapy and exercises. However, LBP can also be caused by malignancy, infection, cauda equina syndrome and, as in this case, fracture. In fact, spinal fracture is reported in 1– 4% of all patients presenting with LBP to primary care clinics. So, as this paper points out, screening for the more serious conditions is important. The good news is that the patient eventually returned to running.

APPETITE CONTROL AND EXERCISE: DOES THE TIMING OF EXERCISE PLAY A ROLE? Fillon A, Mathieu ME, Boirie Y et al.

Physiology & Behavior 2019;112733 This is an essay which seeks to answer the question in the title. Although evidence is limited it seems to indicate that regularly exercising during the morning would have beneficial effects on subsequent energy intake when compared to afternoon interventions. Available results suggest that the closer to lunch the exercise is, the greater the impact might be on overall energy balance through reduced subsequent energy intake, without leading to compensatory intakes at the following meals. The timing of exercise to optimise energy balance (and affect energy intake and appetite) does not only require consideration of time during the day (morning vs afternoon or evening), but also the order/position (before vs after) and delay regarding meals.

Co-Kinetic comment According to the authors the answer to the question in the title seems to be ‘yes’, although there is very little evidence to go on. There is a PhD in this topic for someone. Get in quick and it might end up as the diet book of the century and a solution to the obesity crisis.

7

CLICK ON RESEARCH TITLES TO GO TO ABSTRACT Outdoor climbing occurs across a vast range of environments and can be further categorised based on the technique and equipment used to scale a route. Traditional climbing involves ascending a route with a rope secured by removable anchors by the lead climber. Ice climbing uses ice axes and crampons either with a rope fixed at the top of the route or secured along the way as in traditional climbing. The term ‘mountaineering’ is generally applied to situations involving climbing with ropes and sometimes crampons or ice axes with summiting a peak as the objective. In ‘free’ or ‘solo’ climbing, the climber does not use a rope while still scaling long routes. Falling during this type of climbing can result in serious injury or death.

Indoor climbing uses artificial surfaces that attempt to mimic an outdoor environment. There are National and International competitions and in 2020 it will be an Olympic sport

MUSCULOSKELETAL INJURIES IN CLIMBERS. Mugleston B, McMullen C. Current Physical Medicine and Rehabilitation Reports 2019;7(3):179–185 for the first time. Completions include lead climbing, when a rope is advanced along a route of already placed anchors; bouldering, which is climbing without a rope over a short distance, usually not much higher than 6m (20ft); and speed climbing, which involves scaling a preset route as fast as possible with safety provided by a rope secured at the top of the route.

Injury rates and types vary among climbing sub-disciplines. Outdoor climbing has a higher injury incidence than indoor climbing and acute injuries tend to be more severe. Compared to lead climbing, mountaineering may have a lower incidence of injury.

However, when they occur, injuries can be devastating involving multiple body systems and death. By comparison, at least in terms of acute injuries, indoor climbing is relatively safe.

Acute climbing injuries most commonly involve the lower extremity and are very often the result of a fall, particularly in the outdoor setting.

Indoors, bouldering has the highest injury rate. Most chronic climbing injuries occur in the upper extremities, especially the hands (principally the fingers), and are due to overuse.

Co-Kinetic comment There are a lot of people going up in the world.

Twenty-five million climbers worldwide according to the International Federation of Sport Climbing. Sadly some of them come down quicker than they hoped.

Needless to say indoor climbing with a safety rope minimises risk but for many climbers that may take away some of the fun. This excellent paper is a must for therapists likely to treat climbers. It goes into detail about finger, wrist and elbow anatomy, injury treatment and even suggests timescales for some injury recovery.

A META-ANALYSIS OF THE EFFECTS OF FOAM ROLLING ON PERFORMANCE AND RECOVERY. Wiewelhove T, Döweling A, Schneider C et al. Frontiers in Physiology 2019;10:376 The objective of this study was to compare the effects of foam rolling applied before and after exercise on sprint, jump and strength performance as well as on flexibility and muscle pain outcomes. It also sought OPEN

to identify whether self-massage with a foam roller or a roller massager is more effective. A search of the ‘usual suspect’ databases found 14 studies that used pre-rolling and 7 for postrolling. Pre-rolling resulted in a small improvement in sprint performance and flexibility, whereas the effect on jump and strength performance was negligible. Post-rolling slightly attenuated exercise-induced decreases in sprint and strength performance plus it reduced muscle

pain perception. Of the 21 studies, 14 used foam rollers, whereas the other 7 used roller massage bars/sticks. A tendency was found for foam rollers to offer larger effects on the recovery of strength performance than roller massagers. The differences in the effects between foam rolling devices in terms of pre-rolling did not seem to be of practical relevance.

Co-Kinetic comment Not much of an improvement but an improvement never the less.

Previous studies endorse the use of rollers for alleviating post-exercise muscle soreness, so get rolling.

8

Co-Kinetic Journal 2020;83(January):8-11

RESEARCH INTO PRACTICE

Journal Watch Manual Therapy

SEDENTARY BEHAVIOUR AT WORK INCREASES MUSCLE STIFFNESS OF THE BACK: WHY ROLLER MASSAGE HAS POTENTIAL AS AN ACTIVE BREAK INTERVENTION. Kett AR, Sichting F. Applied Ergonomics 2020;82:102947

Sitting for long periods creates musculoskeletal discomfort and back pain. The underlying mechanism and effective prevention strategies are still largely unknown. In this study, muscle stiffness of the back was measured in 59 office workers who followed their usual desk work regime for 4.5h in a sitting posture. The period was chosen to reflect the maximum non-stop driving time of truck drivers. Short periods of interruption (<10min) were allowed, eg. to go to the restroom. All participants used an adjustable chair that was adjusted to the individual workplace needs. Sitting posture was not

monitored.

The sitting period was either followed by an 8min roller massage intervention or a controlled standing task. The massage roller was placed between the back and a wall, and the participants had to lean against the wall to apply pressure. They were instructed to move up and down to massage their back muscles. Each area (lumbar and thoracic spine) was treated alternating for 60s. The control group also had to stand up and lean against a wall for 8min, but without the roller. Muscle stiffness was measured using resistance against deformation, using a custom-built

OPEN

indentometer device.

Results showed that muscle stiffness increased significantly after the 4.5h sitting period. When the sitting period was followed by roller massage, the stiffness values dropped slightly below baseline stiffness. In contrast, the stiffness values remained increased when the sitting period was followed by controlled standing.

Co-Kinetic comment Isn’t there a song called ‘Roll with it’? They could play it in the office while the staff are rolling along. Seriously though, this is a great idea and it seems to work. The indentometer sounds like a promising tool for similar research. More of this please.

POOR SLEEP QUALITY’S ASSOCIATION WITH SOCCER INJURIES: PRELIMINARY DATA. Silva A, Narciso FV, Soalheiro I et al.

International Journal of Sports Physiology and Performance 2019;doi:10.1123/ijspp.2019-0185

EFFECTS OF USING CONVERGENCE SPORTS MASSAGE ON SSIREUM PLAYERS’ RECOVERY HEART RATE, OXYGEN UPTAKE AND BLOOD LACTATE AFTER MAXIMAL EXERCISE. Jang HY, Lee M. Journal of the Korean Society for Convergence 2019;10(6):317–324

This was a prospective cohort study of 23 elite male soccer players competing for two teams over a 6-month period in the highest-level Brazilian competition. The players’ sleep behaviour was monitored for 10 days in the preseason using self-reporting sleep diaries and wrist activity monitors to determine sleep duration and quality. Injuries were recorded by the clubs’ medical teams. Details of injuries recorded included the type, location and severity of each injury. The results were expressed as descriptive statistics, and the significance level was set at 5%. The results indicated a moderate negative correlation between sleep efficiency and particular injury characteristics, including absence time, injury severity, and amount of injuries. The linear-regression analysis indicated that 44% of the total variance in the number of injuries can be explained by sleep efficiency, 24% of the total variance in the absence time after injury (days) can be explained by sleep efficiency, and 47% of the total variance in the injury severity can be explained by sleep efficiency. In summary. Soccer players who exhibit lower sleep quality or nonrestorative sleep show associations with increased number and severity of musculoskeletal injuries.

The purpose of this study was to investigate the effects of sports massage in the recovery period after maximal exercise on heart rate (HR), oxygen uptake (OU) and blood lactate (BL) of ssireum players. The participants of this study consisted of 24 ssireum players in a university team (UT) and a business team (BT). The first group took a rest recovery period for 20min after the maximal exercise, and the second were given a sports massage on the abdominal area, waist and lower legs in a prone position for 20min. The interaction effects of massage treatment and recovery period in HR showed a higher recovery ability in both the UT and BT when the massage treatment was given 10min after recovery than when it was not given. The main effects of the recovery period showed in all variables of HR, OU and BL. The main effects of BL on massage treatment was significantly low in both the UT and BT when the massage was given. And, the

Co-Kinetic comment Fans of unsuccessful teams often suggest that their players are dozy. It seems they might be onto something.

Co-Kinetic.com

main effects of OU was significantly lower only in the BT. In conclusion, compared sports massage treatment on ssireum players after maximal exercise positively affected the recovery mechanism of HR, OU, and BL than the rest recovery method.

Co-Kinetic comment Sadly, we only have the abstract of this paper (unless you can read Korean) and that might have lost a degree of clarity in the translation. What it is indicating is that sports massage helps with recovery. This journal has the distinction of being the 300th we have brought you articles from over the last 10 years.

Yes that’s 300 journal titles. Happy reading. Oh and ‘ssireum’ is traditional Korean wrestling.

9

The data for this study came from a narrative review of the information available on neuromuscular electrical stimulation (NMES), blood flow restriction (BFR) and vibration intervention. The problem for which the authors are seeking a solution is that disuse periods as short as 5 days can have negative consequences in young subjects, including a substantial loss of muscle mass (3.5%) and strength (9%), with activation of catabolic signalling pathways. In addition, disuse periods are accompanied by a loss of bone mineral density and an impaired cardiovascular capacity, with a loss in maximal oxygen consumption (VO2max) and cardiac output of 0.99% and 1.6% per day, respectively, during the first 2 weeks of bed rest.

BFR is a strategy to induce metabolic stress that is thought to lead to hypertrophy. It is usually accomplished by inflating a cuff around the proximal part of the target limb to a pressure that blocks venous blood return without concomitantly blocking arterial inflow into the muscle. This

Following a search of the ‘usual suspect’ databases, 47 randomised controlled trials covering 9,211 participants were identified.

Although the search criteria was for adults over 18 years old most of the people in the study were between 35 and 40 years old. Most trials compared spinal manipulative therapy (SMT) with recommended therapies. These included non-drug (eg. exercise) and drug treatments (eg. non-steroidal anti-inflammatory drugs, analgesics), whereas non-recommended interventions included noneffective (eg. light soft tissue massage, no treatment, waiting list control) or potentially even harmful treatments (eg. electrotherapies).

Moderate quality evidence suggested that SMT has similar effects to other recommended therapies for short-term pain relief and a small, clinically better improvement in function. High

10

PASSIVE STRATEGIES FOR THE PREVENTION OF MUSCLE WASTING DURING RECOVERY FROM SPORTS INJURIES. Valenzuela PL, Morales JS, Lucia A. Journal of Science in Sport and Exercise 2019;1(1):13–19 induces an increased release in growth hormone and insulin-like growth factor as a consequence of metabolite and H+ ion accumulation thereby facilitating anabolic processes. In addition, BFR elicits an increase in heat shock protein-72 which can protect proteins from stress-induced injury. The authors concluded that the concomitant application of BFR and low-intensity exercise has shown promising results in the prevention of disuse-induced muscle atrophy. Some benefits might also be obtained with BFR alone (ie. with no exercise), but evidence is still inconclusive.

NMES is the transcutaneous application of electrical currents to a muscle group thereby depolarising motor neurons and resulting in actual muscle contraction. Because this modality can generate involuntary muscle tension, it is frequently used as a passive surrogate of active training

in several populations. Effectively it acts as an ‘exercise simulator’. It can be applied both passively and synchronously with exercise, and thus attenuate most of the negative changes associated with disuse periods.

The mechanical stimulus elicited by vibration, whether applied locally or to the whole body using a platform, seems effective to reduce the loss of bone mineral density that accompanies muscle disuse and could also provide some benefits at the muscle tissue level.

Co-Kinetic comment BFR is being used in body building gyms to build muscle so its application to prevent muscle wastage post-injury is logical. Whether or not messing with the blood supply to the actual injured limb is beneficial needs a bit more research.

BENEFITS AND HARMS OF SPINAL MANIPULATIVE THERAPY FOR THE TREATMENT OF CHRONIC LOW BACK PAIN: SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMISED CONTROLLED TRIALS. Rubinstein SM, de Zoete A, van Middelkoop M et al. BMJ 2019;364 quality evidence suggested that, compared with nonrecommended therapies, SMT resulted in small, not clinically better effects for short-term pain relief and small-to-moderate clinically better functional improvement.

In general, these results were similar for the intermediate and long-term outcomes, as were the effects of SMT as an adjuvant therapy. Evidence for sham SMT was low to very low quality; therefore these effects should be considered uncertain. About half of the studies examined adverse and serious adverse events, but in most of these it was unclear how and whether these events were registered systematically. Most of the observed adverse events

OPEN

OPEN

were musculoskeletal related, transient in nature, and of mild-to-moderate severity. In one study, the Data Safety Monitoring Board judged one serious adverse event to be possibly related to SMT.

Co-Kinetic comment A study in 2011 (Petering et al. Treatment options for low back pain in athletes. Sports Health 2011;3(6):550–555), gave the prevalence rates of low back pain in athletes as ranging from 1 to 40%, with back injuries in the young athlete occurring in 10 to 15% of participants, and in golf 90% of injuries to the professionals involve the neck or back. So, there is a lot of it about and Petering’s conclusion was that there are also a lot of different treatments about: few of which have any evidence of efficacy. This latest paper adds a few positives for SMT, at least in the short term, but it balances this by noting that there can be adverse effects and that patients should be warned about this beforehand. Legally that is probably difficult to argue against, especially in these increasingly litigious times, but does it break the spell? How much of any treatment is a placebo effect?

Co-Kinetic Journal 2020;83(January):8-11

RESEARCH INTO PRACTICE

PLANTAR FASCIITIS MANAGEMENT: A COMPARATIVE STUDY BETWEEN PLANTAR FASCIA STRETCHING EXERCISES VERSUS LOCAL CORTICOSTEROID INJECTION. Ethiraj P, Venkataraman S, Arun HS et al.

Journal of Karnataka Orthopaedic Association 2019;7(2):17–21 This study divided 60 patients diagnosed with plantar fasciitis into group 1 (n=30), treated with stretching exercises, non-steroidal anti-inflammatory medications and microcellular (MCR) footwear, and group 2 (n=30), treated with analgesics, microcellular (MCR) footwear and local corticosteroid injected at the site of maximal tenderness. Patients were assessed after 2 weeks, 4 weeks, 8 weeks and 12 weeks from the start of treatment for pain and function. Pain was assessed using a 0–10 visual analogue scale. The stretching regimen was stair heel raises, knee-to-wall calf stretches and seated gastrocnemius stretches done three times a day with the stretch

held for 10s and repeated 20 times.

Pain severity in group 2 was significantly reduced after the 2nd week and 4th week from the start of the treatment when compared to group 1. However, on subsequent follow-up at the 8th week and 12th week, pain severity was reduced in both groups and was almost similar.

Co-Kinetic comment According to this study, injections in the short term seem to be good for 4 weeks. And, over 3 months both the injections and stretching have a similar effect. This is, in fact, the opposite of previous studies that suggest the injection is better. One reason may be that in the stretching regimen there was an awful lot of stretching. Microcellular rubber footwear (MCR) absorbs shocks from external forces.

DEEP FRICTION MASSAGE IN THE MANAGEMENT OF PATELLAR TENDINOPATHY IN ATHLETES: SHORT-TERM CLINICAL OUTCOMES. Chaves P, Simões D, Paço M et al.

Journal of Sport Rehabilitation 2019;doi:10.1123/jsr.2019-0046 This was a randomised, controlled cross-over trial. Ten athletes (average age 28 years) with diagnosis of unilateral patellar tendinopathy attended four sessions. Three treatment sessions with deep friction massage applied with different pressures (the mean pressure – previously determined for each participant – and the mean pressure ± 25%) and a control session, each of which was separated by 48h.

Pain (intensity upon palpation and time to onset of analgesia) and muscle strength of the knee extensors were assessed before and immediately after each session. The pain intensity changed significantly over time and among sessions.

The knee extensor strength did not change significantly over time. Regardless of the pressure applied, the time to onset of analgesia was not significantly different.

Co-Kinetic comment Deep transverse friction massage appears to have an analgesic effect but, as the authors themselves point out, this was a very small sample group.

Co-Kinetic.com

HIP PAIN IS REDUCED FOLLOWING MODERATE PRESSURE MASSAGE THERAPY. Field T, Sauvageau N, Gonzalez G et al. Chronic Pain & Management 2019;2:117 Fifty-four medical school staff and faculty at the University of Miami who had hip pain were randomly assigned to a moderate pressure massage therapy or a waiting list control group.

This reduced following attrition to 40 (n=23 in the massage group and 17 in the control). The massage group were massaged by a licensed massage therapist once per week for a 4-week period. The 20min massages consisted of moderate pressure stroking (defined as observably moving the skin) focused on the quadriceps, the hamstrings and the tendons and ligaments surrounding the hip and the knee. Self-reports including the WOMAC (pain, stiffness and function) and the PROMIS (scales on mood, sleep and daily functioning) given on the first and last days of the treatment period and at a follow-up day 1 month later. Pain was assessed for external rotation, internal rotation, sitting, standing and bending before and after the first and last day massage sessions. The massage group experienced an

OPEN

immediate post-massage decrease in pain on all measures. On the last versus the first day of the study, the massage group reported greater decreases in pain on all measures as well as less self-reported sleep disturbances than the waiting list control group. The effects were sustained at the 1 month follow-up.

Co-Kinetic comment This is yet another positive massage paper produced by the Touch Research Institute at the University of Miami.

We have plugged them many times before. If you are looking for evidence on massage for almost any condition you can think of, check them out. The participants’ characteristics were listed not just by the usual age and sex but by racial grouping and education. Is that a heterogeneous base/level playing field too far or is it the future?

11

1

The PDF version of this infographic includes hyperlinks to the individual pieces of research. Click here to access https://spxj.nl/38b3WWU News stories

2

Tweets

Facebook posts

3

Mendely readers

IS RUNNING ASSOCIATED WITH A LOWER RISK OF ALL-CAUSE, CARDIOVASCULAR AND CANCER MORTALITY, AND IS THE MORE THE BETTER? A SYSTEMATIC REVIEW AND META-ANALYSIS

EXERCISE GUIDELINES FOR CANCER SURVIVORS

British Journal of Sports Medicine

Medicine and Science in Sports & Exercise

PATELLOFEMORAL PAIN

158 17 2951 9

Journal of Orthopaedic & Sports Physical Therapy

29 8 222 5

THE 10 MOST DISCUSSED PIECES OF RESEARCH IN PHYSICAL THERAPY (OCT - DEC 2019)

4 16 538 00 538

4 CAN MARATHON RUNNING IMPROVE KNEE DAMAGE OF MIDDLE-AGED ADULTS? A PROSPECTIVE COHORT STUDY BMJ Open Sport & Exercise Medicine

0 14 533 0

10 AN UPDATE OF SYSTEMATIC REVIEWS EXAMINING THE EFFECTIVENESS OF CONSERVATIVE PHYSIOTHERAPY INTERVENTIONS FOR SUBACROMIAL SHOULDER PAIN Journal of Orthopaedic & Sports Physical Therapy

0 3 423 0

5

AMERICAN COLLEGE OF SPORTS MEDICINE ROUNDTABLE REPORT ON PHYSICAL ACTIVITY, SEDENTARY BEHAVIOR, AND CANCER PREVENTION AND CONTROL Medicine and Science in Sports & Exercise

4 4 373 1

9 COGNITIVE FUNCTIONAL THERAPY COMPARED WITH A GROUP-BASED EXERCISE AND EDUCATION INTERVENTION FOR CHRONIC LOW BACK PAIN: A MULTICENTRE RANDOMISED CONTROLLED TRIAL (RCT) British Journal of Sports Medicine

2 3 339 0

6

7

PHYSICALLY ACTIVE LESSONS IN SCHOOLS AND THEIR IMPACT ON PHYSICAL ACTIVITY, EDUCATIONAL, HEALTH AND COGNITION OUTCOMES: A SYSTEMATIC REVIEW AND META-ANALYSIS

IT IS TIME TO MOVE BEYOND ‘BODY REGION SILOS’ TO MANAGE MUSCULOSKELETAL PAIN: FIVE ACTIONS TO CHANGE CLINICAL PRACTICE

British Journal of Sports Medicine

16 1 216 2

British Journal of Sports Medicine

0 4 410 0

8 ASSOCIATION OF ADOLESCENT SPORT PARTICIPATION WITH COGNITION AND DEPRESSIVE SYMPTOMS IN EARLY ADULTHOOD Orthopaedic Journal of Sports Medicine

0 0 2 0 Produced by: TIME-SAVING RESOURCES FOR PHYSICAL AND MANUAL THERAPISTS

THE 10 MOST DISCUSSED PIECES OF RESEARCH IN MANUAL THERAPY (OCT - DEC 2019) 0 304 11

52

1

THE EFFECTIVENESS OF INSTRUMENT-ASSISTED SOFT TISSUE MOBILIZATION IN ATHLETES, PARTICIPANTS WITHOUT EXTREMITY OR SPINAL CONDITIONS, AND INDIVIDUALS WITH UPPER EXTREMITY, LOWER EXTREMITY, AND SPINAL CONDITIONS: A SYSTEMATIC REVIEW Archives

of Physical Medicine & Rehabilitation

0 3

55 0

3

IS A COMBINED PROGRAMME OF MANUAL THERAPY AND EXERCISE MORE EFFECTIVE THAN USUAL CARE IN PATIENTS WITH NONSPECIFIC CHRONIC NECK PAIN? A RANDOMIZED CONTROLLED TRIAL Clinical Rehabilitation

0 1

23 0

5

THE NORDIC MAINTENANCE CARE PROGRAM: DOES PSYCHOLOGICAL PROFILE MODIFY THE TREATMENT EFFECT OF A PREVENTIVE MANUAL THERAPY INTERVENTION? A SECONDARY ANALYSIS OF A PRAGMATIC RANDOMIZED CONTROLLED TRIAL PLoS ONE

0 1

13 0

7

KNOWLEDGE OF PSYCHOSOCIAL FACTORS ASSOCIATED WITH LOW BACK PAIN AMONGST HEALTH SCIENCE STUDENTS: A SCOPING REVIEW Chiropractic & Manual Therapies

0 0

11 0

9

COMPARING THE RANGE OF MUSCULOSKELETAL THERAPIES APPLIED BY PHYSICAL THERAPISTS WITH POSTGRADUATE QUALIFICATIONS IN MANUAL THERAPY IN PATIENTS WITH NON-SPECIFIC NECK PAIN WITH INTERNATIONAL GUIDELINES AND RECOMMENDATIONS: AN OBSERVATIONAL STUDY Musculoskeletal Science and Practice

2

0 69 10 17

A STUDY EXPLORING THE PREVALENCE OF EXTREMITY PAIN OF SPINAL SOURCE (EXPOSS) Journal of Manual & Manipulative Therapy

4

5 3

34 6

HEADACHE SYMPTOM MODIFICATION: THE RELEVANCE OF APPROPRIATE MANUAL THERAPY ASSESSMENT AND MANAGEMENT OF A PATIENT WITH FEATURES OF MIGRAINE AND CERVICOGENIC HEADACHE - A CASE REPORT Journal of

Manual & Manipulative Therapy

6

0 1

18 0

PROMOTING THE USE OF SELF-MANAGEMENT IN PATIENTS WITH SPINE PAIN MANAGED BY CHIROPRACTORS AND CHIROPRACTIC INTERNS: BARRIERS AND DESIGN OF A THEORY-BASED KNOWLEDGE TRANSLATION INTERVENTION Chiropractic & Manual Therapies

8

8 2

8 22

EFFECTS OF INSTRUMENT-ASSISTED SOFT TISSUE MOBILIZATION ON MUSCULOSKELETAL PROPERTIES Medicine and Science in

Sports & Exercise

10

0 4

9 0

EFFECTIVENESS OF DRY NEEDLING FOR IMPROVING PAIN AND DISABILITY IN ADULTS WITH TENSION-TYPE, CERVICOGENIC, OR MIGRAINE HEADACHES: PROTOCOL FOR A SYSTEMATIC REVIEW Chiropractic & Manual Therapies

News stories Facebook posts

Tweets Mendely readers

The PDF version of this infographic includes hyperlinks to the individual pieces of research.

Click here to access https://spxj.nl/2DQf1Pc

Produced by: TIME-SAVING RESOURCES FOR PHYSICAL AND MANUAL THERAPISTS

SYNDESMOSIS INJURY PART 2: TREATMENT AND REHABILITATION If missed or misdiagnosed, syndesmosis injuries are one of the most common causes of chronic ankle dysfunction and potential degenerative disease.

Early and good diagnosis of the grade of injury (covered in Part 1) is crucial for good rehabilitation. With the right management, there is a high rate of return to any level of sport (including preinjury levels) after injury. This article gives you examples of rehabilitation protocols for the different grades of injury that you can amend to provide the best personalised care for your patient’s optimal return to their chosen activity.

Read this article online https://spxj.nl/387kO0F ANKLE | SPRAIN | 20-01-COKINETIC FORMATS WEB MOBILE PRINT All references marked with an asterisk are open access and links are provided in the reference list

By Kathryn Thomas BSc MPhil

S

yndesmotic injuries, or ‘high ankle sprains’, are not as common as lateral ankle injuries; however, they often present with a more complicated picture of prolonged pain and disability, impacting on the athlete’s ability to return to full sporting performance.

Syndesmotic injuries appear to be on the rise, literally, which may partly be the result of better awareness and identification of the injury. Part 1 of this series discussed in detail how to identify and diagnose a syndesmotic injury by listening carefully to the mechanism of injury and performing some specific objective tests. It may be useful to recap, or read for the first time, Part 1 of this article at this link: https://spxj.nl/2ZhRByL. Syndesmotic injuries have been described as one of the most difficult sporting injuries to treat, with rehabilitation often taking more than double the time of an isolated lateral ligament sprain. The most common cause of chronic ankle dysfunction, 6 months after ankle trauma, is related to syndesmotic injuries. So clearly, we need to know how best to tackle the treatment and rehabilitation of the syndesmosis to maximise the athlete’s time and optimise their ankle’s functional and sporting ability.

Surgical Intervention

NON-OPERATIVE TREATMENT FOR GRADE I AND GRADE IIA STABLE SYNDESMOTIC INJURIES HAS SHOWN GOOD RESULTS 14

Traditionally, higher grade syndesmotic injuries have been treated surgically, with screw fixation being the most common method used (75% of the time). This poses problems for the athletic population as the screw requires removal (68% of the time) between 3 and 6 months post-fixation, potentially delaying rehabilitation and return to sport. Screw fixation can lead to mal-reduction in up to 39% of cases, causing chronic instability and symptoms. An unstable syndesmosis

injury requiring surgical fixation will commonly require 4–6 months before successful return to sport (1*).

A novel surgical approach to syndesmosis repair has been developed involving a tightrope procedure. This involves implanting two to four cortical endobuttons and looping a non-absorbable suture around them to provide semi-rigid fixation. Theoretically, it has a number of advantages over traditional screw fixation: it allows for a small amount of normal biomechanical movement at the syndesmosis; it rarely requires a second operation to remove the device; it provides significantly better anatomic reduction and it allows for earlier return to weight-bearing, rehabilitation and ultimately sport (1*,2*).

Rehabilitation following surgery, via either screw fixation or tightrope repair is controversial with little consensus as to the optimal regimen (3). Most regimens consist of a period of immobilisation and restricted weight-bearing, progressing to restoration of ROM, strength and proprioception, and finally sportsspecific drills before return to competition (3,4*).

The resurgence of direct syndesmosis repair has attempted to address the shortcomings of syndesmosis screw fixation and isolated suture-button constructs.

Biomechanically, anatomic ligament repair has been shown to be as strong as syndesmosis screw fixation (5).

The quality of syndesmosis reduction seems to be the main factor for improving clinical outcomes following syndesmotic injury (5).

It is important to ask if the risks associated with surgery can be avoided if the injury is managed carefully with conservative methods.

Clinical and imaging findings should

Co-Kinetic Journal 2020;83(January):14-20

PHYSICAL THERAPY

be correlated when deciding the management plan. Do not rush the decision, as it is possible to manage some higher grade injuries conservatively (6*,7).

Rehabilitation

The ESSKA-AFAS (European Society for Sports Traumatology, Knee Surgery and Arthroscopy–Ankle and Foot Associates) consensus panel provided recommendations to improve the management of patients with isolated (no fracture) acute syndesmotic injury in clinical practice (8). Non-surgical management is recommended for stable ankle lesions and includes: 3-weeks of non-weight-bearing, a below-the-knee cast, rest and ice, followed by proprioceptive exercises.

Surgery is recommended for unstable lesions. Syndesmotic screw is recommended to achieve a temporary fixation of the mortise. Suture-button device can be considered a viable alternative to a positioning screw.

Partial weight-bearing is allowed 6 weeks after surgery (8).

The exact make-up of each rehabilitation regimen differs from study to study according to the differing functional needs of individuals, their sporting requirements and the post-surgical protocol implemented by the surgeons. Rehabilitation post-surgery follows the same steps and principles as conservative management, simply with a delayed start due to a longer period of immobilisation and reduced weight-bearing.

8 weeks after injury (9,10*).

In patients with grade IIb injuries, arthroscopy may be recommended to assess the stability of the syndesmosis dynamically and aid the decision about whether stabilisation is required. Fixation is warranted in the presence of dynamic instability, especially when diastasis greater than 2mm is confirmed arthroscopically.

Return to sports is around 6 weeks in grade IIa and 9 weeks in grade IIb injuries on average (9).

Unstable syndesmosis injuries (grade IIb, III and IV) are more common in rugby and American football, and are usually managed surgically. The rehabilitation process of surgically managed syndesmosis injuries is similar to conservative management. The main difference is a longer period of immobilisation, which should be guided by the surgeon: usually non-weight-bearing for up to 14 days and partial weightbearing up to 3 weeks. As a result, return to sport following surgery may take 9–10 weeks instead of 4–6 weeks for conservatively managed injuries (9,10*). A case series of 18 professional rugby league players by Latham et al. (1*) reported an average return to play of 64 days following surgical repair.

Co-Kinetic.com

Grade I Injury

A grade I syndesmosis injury is a simple injury to manage as long as everyone accepts there may be periods of discomfort. There is no instability, and only isolated ligament injury without significant fibre disruption – the aim is to settle the initial injury. Reassure the player that the discomfort is not going to impact on their performance or increase their risk of further injury. Following a grade I injury the majority of patients are able to play sport within a week.

A period of initial offload, gradual re-load, optimal proprioception for the joint is beneficial. The ankle should be immobilised in a boot and weight -bearing limited for the first 24–48 hours after injury. Beyond the first 48 hours the weight-bearing status does not need to be altered. Circumferential taping around the distal tibia and fibular aims to replicate the role of the syndesmosis, which may be combined with heel locks to avoid aggravating the joint in end-of-range positions.

Taping should give the player confidence to return to performance; if the individual does not feel confident then an accelerated return to sport may not be appropriate (Link 2).

Table 1: Example of treatment/rehabilitation protocol for grade I (mild) syndesmosis injury [Sourced Morgan C et al. Conservative management of syndesmosis injuries in elite football. Aspetar Sports Medicine Journal 2014;3(3):602–613 (5)] Time

Treatment/rehabilitation

Day 1–2

l Soft tissue therapy l Pulsed-shortwave diathermy l Ultrasound l Pool walking/ankle mobilisation (10% body weight) l Protect, rest, ice, compression, elevation (PRICE) regimen

Day 3

l Concentric/eccentric manual ankle strength l Proprioception/dynamic stability circuit l Treadmill walking l Pool jogging (10% body weight) l Anti-gravity (eg. AlterG™) jogging (50–100% body weight)

Day 4

l Gym-based ankle strengthening programme lP rogressive mechanical sports-specific session (this may be on-field, cutting, figure of 8 running, running sideways, lateral hops, etc)

Day 5

l Regular training

Day 8

l Return to play or sport

Overview (Link 1)

Non-operative treatment for grade I and grade IIa stable syndesmotic injuries has shown good results. Initial rest, ice and immobilisation in a boot or cast with non-weight-bearing for between 5 and 7 days to help with swelling and the initial inflammation is recommended. This is followed by 1 to 2 weeks of partial weight-bearing and physiotherapy concentrating on proprioception and ROM exercises. Full weight-bearing is then commenced with strengthening. The ability to perform a single-leg hop for 30 seconds is a good sign of healing; this is usually observed between 6 and

Detailed Rehabilitation Guide Per Grade

15

Table 2: Example of treatment/rehabilitation protocol for a stable grade II (moderate) syndesmosis injury [Sourced Morgan C et al. Conservative management of syndesmosis injuries in elite football. Aspetar Sports Medicine Journal 2014;3(3):602–613 (5)] Time

Treatment/rehabilitation

Day 1–10

ROM limits: no dorsiflexion beyond neutral

Day 1–9

l Soft tissue therapy l Pulsed-shortwave diathermy l Ultrasound l Pool mid-range ankle mobilisation (10% body weight) l Tibialis posterior stability exercises (partial weight-bearing) l Isometric manual ankle strengthening l PRICE regimen

Day 10–12

l Manual therapy l Concentric/eccentric manual ankle strengthening l Proprioception/dynamic stability progressions l Gym-based ankle strengthening programme l Isokinetic ankle inversion/eversion strengthening programme l Anti-gravity jogging (60–100% body weight) l Pool jogging (10% body weight)

Day 14–15

l Progressive straight-line on-field or sports-specific work, cardiovascular fitness rated to address training/match fitness requirements l Pool multi-directional movements

Day 17–20

l Progressive multi-directional field or sports-specific work l Plyometrics

Day 21

l Regular training

ROM, range of motion Table 1 provides an example of a treatment process for a grade 1 (mild) syndesmosis injury, as a guideline to rehabilitation (bear in mind that each injury and patient will differ) (6*).

A patient may still complain of some discomfort with forced rotation for approximately 3 weeks. It could be argued that the player is at increased risk of a more significant syndesmosis injury if the mechanism of injury was repeated. Specific taping applied to the joint can provide comfort and a feeling of stability without limiting performance and may reduce the risk of reinjury (6*).

Grade II Injury

Calder et al. (11*) recommend treating stable (grade IIa) injuries

16

conservatively with 7–10 days of immobilisation in a boot and 6 weeks of rehabilitation. The rehabilitation of stable grade II injuries is different from grade I injuries as dorsiflexion should not be forced for the first 7–10 days. Players should be placed in a boot when walking to limit dorsiflexion during this period. Each day that the foot is in the boot will cause deconditioning of the ankle, so exercises that aim to maintain lower limb musculature should be performed. This may include the use of muscle stimulation and exercises on the bed or in standing that limit ankle dorsiflexion. Alongside ankle rehabilitation, it is important to continue with a general conditioning programme targeting the hamstrings, gluteals and trunk muscles as well as maintaining cardiovascular fitness.

Table 2 shows an example of treatment for a stable grade II (moderate) syndesmosis injury, as a guideline for rehabilitation management (6*).

Grade IIb or III Injury

Players with unstable (grade IIb) injuries or grade III injuries should undergo arthroscopy, and if instability is confirmed, the syndesmosis should be stabilised (11*). Rehabilitation would follow but may vary depending on the duration of immobilisation and weightbearing status agreed upon by the surgeon and therapist.

Table 3 shows two examples of rehabilitation protocols used for two grade III (severe) injuries that were managed conservatively (ie. without surgery) (6*).

As can be seen from these schedules there was a difference of 3 weeks between the return-toplay times of the two rehabilitation programmes. In this example, based on MRI classification the patient who returned to play in 7 weeks (48 days) actually had a more significant injury, whereas the patient who had a returnto-play time of approximately 10 weeks (72 days) had a better MRI but had a positive external rotation test on clinical examination (6*).

In terms of progressions, there is a lack of robust research evidence to support specific management protocols. That which is available is purely anecdotal and less accelerated than the cases described above (6*,12*,13). Progressions may have to be based on clinical experience, functional anatomy, subjective feedback and objective assessment. In terms of functional anatomy, a mild-tomoderate syndesmosis injury (grade I or IIa) should be able to progress relatively quickly owing to no posteriorinferior tibiofibular ligament (PITFL) involvement. The PITFL alone makes up 42% of the strength of the syndesmosis (14*). In keeping with this principle, the injuries that sustain PITFL damage should follow a lengthier rehabilitation protocol (6*).

Once the player is out of the boot, start with simple movement patterns and gradually progress as tolerated.

A simple example of an exercise progression may include a Swiss ball squat and can be progressed to hopping and change-of-direction work.

Exercises can be progressed by: l changing foot position to increase dorsiflexion range Co-Kinetic Journal 2020;83(January):14-20

PHYSICAL THERAPY

l changing the movement plane l moving from bilateral to unilateral l increasing the depth of movement l increasing the complexity of the movement l introducing multiplane movements with increased speed and complexity.

As mentioned in Tables 2 and 3, an AlterG™ treadmill can be used to start loading the limb to avoid the secondary complications associated with immobilisation. The AlterG™ allows for small consistent progression of joint loading. Start at around 50–70% body weight and manipulate the speed to ensure the player is pain-free.

The AlterG™ may be combined with occlusion training to further condition the lower limb muscles.

If you do not have access to an AlterG™, use the boot as a rocker to progress from non-weight-bearing to partial weight-bearing. The boot can be removed after 10 days if the player can walk pain-free without it, which generally requires a knee-to-wall test within 15–20% of their baseline. A player with a lower baseline knee-towall test may need to stay in the boot longer as they will be stressing the joint earlier in range.

Running progression

Running may be introduced at week 3 following injury. Before running, calf function tests should be within 10% of the other side and knee-to-wall range within 15–20% of other side. Running can be used as a mobilising technique for dorsiflexion so the player does not need to have full range before starting running. Start with straight-line running progressions and build in change-ofdirection tasks as tolerated. If available, use GPS data to guide running progression.

Return to Play

There is a high rate of return to any level of sport (including preinjury levels) after ankle syndesmotic injury in both operative and non-operative patient groups (15). Rehabilitation should focus on ensuring the player can perform the tasks required to return to high-level sport. If the patient is going to struggle with a 7-day return to sport, then it will become apparent during highCo-Kinetic.com

level functional tasks. Start with ROM and strength testing around the joint, before progressing to movements of jumping, landing, hopping, box jumps and change of direction. A force plate can be used to assess symmetry with counter movement jumps, drop jumps and hopping.

A variety of return-to-play markers can be used in syndesmosis injuries. The tests used will depend on the equipment available such as force plates, GPS and an isokinetic dynamometer. However, you do not need this equipment to do a good assessment of lower limb function.

Ensure that the patient can perform the tasks with acceptable levels of pain.

It may be appropriate to provide the patient with pain relief to help manage the pain associated with a grade I injury. If the patient is able to perform high-level tasks, reintroduce contact during a training session 1–2 days before a game. Successful completion of a training session, combined with the patient reporting they are ready to return to sport becomes the final clearance. Morgan et al. designed and use a checklist to monitor patients’ readiness or progression to return to play (Link 3) (6*).

Important tests in determining if a patient is ready for return to play may include: 1. Knee-to-wall test for dorsiflexion ROM An increase in pain or swelling, or a reduction in pain-free dorsiflexion range may indicate that the rehabilitation is not being tolerated by the player and may need to be reduced.

2. Hop tests (Video 1) Single-hop distance, triple-hop distance.

3. Y-balance test (Video 2) 4. Star excursion balance test (SEBT) (Video 3) (Link 4) The SEBT involves a measure of maximum distance reached in each direction, scores are normalised against the subject’s leg length with values being expressed as a percentage of leg length. A 6 to 8% change represents minimal detectable change and intra-rater reliability is excellent (16*).

The SEBT is a valid dynamic test

to predict risk of lower extremity injury, to identify dynamic balance deficits in people with lower extremity conditions and to be responsive to training programmes in healthy participants and those with lower extremity conditions (17*).

REHABILITATION SHOULD FOCUS ON ENSURING THE PLAYER CAN PERFORM THE TASKS REQUIRED TO RETURN TO HIGH-LEVEL SPORT

Video 1. ACL Return-to-Play Hop Test Cluster (Courtesy of YouTube user Physiotutors) https://youtu.be/mZk26NvfIVI

Video 2. Y-Balance Test (Courtesy of YouTube user Physiotutors) https://youtu.be/qFVuS-P2FrI

Video 3. Star Excursion Balance Test (Courtesy of YouTube user Physiotutors) https://youtu.be/4GMzE7NV3W0 17

18

l Personal leave/rest l Manual therapy l Proprioception (dry land sitting-standing/pool standing) l Concentric manual ankle strengthening l Tibialis posterior stability exercises (partial weight-bearing) l Non-weight-bearing lower limb strength (quadriceps/hamstrings/gluteals) l Isokinetic ankle inversion/eversion strengthening programme l Anti-gravity walking (70–100% body weight) l Anti-gravity calf strengthening (50–100% body weight) l Anti-gravity jogging (60–100% body weight) l Pool multi-directional progressions l Static/dynamic stability progressions l WB lower limb strength (quadriceps/hamstrings/gluteals) l Calf occlusion training l Ankle dorsiflexion seatbelt mobilisations with movement l Reformer ankle mobilisations

Week 2 Week 3

Week 4

Week 5 l Manual therapy l Proprioception (dry land sitting-standing/pool standing) l Isometric/concentric manual ankle strengthening l Tibialis posterior stability exercises (partial weight-bearing) l Non-weight-bearing lower limb strength (quadriceps/ hamstrings/gluteals) l Isokineticankleinversion/eversionstrengtheningprogramme l Anti-gravity walking (60–100% body weight) l Anti-gravity calf strengthening (50–100% body weight Week 6

Week 5

Week 6

l Anti-gravity jogging (60–100% body weight) l Pool multi-directional progressions l Static/dynamic stability progressions l Weight-bearing lower limb strengthening (quadriceps/ hamstrings/gluteals)

l Soft tissue therapy l Pulsed-shortwave diathermy l Ultrasound l Isometric manual ankle strengthening l Pool effusion control l PRICE regimem

Week 1

l Personal leave/rest

Weeks 1– 4

l As above

l Progressive straight-line pitch-based work/multi-directional pitch-based work, cardiovascular and GPS variables incorporated to address training/ match fitness requirements l Plyometrics

ROM limits: no dorsiflexion beyond neutral

Weeks 1– 3

ROM limits: no dorsiflexion beyond neutral

Weeks 1– 4

Treatment/rehabilitation

Time

Treatment/rehabilitation

Example 2

Time

Example 1

Table 3: Examples of treatment/rehabilitation protocols for grade III (severe) syndesmosis injury [Sourced Morgan C et al. Conservative management of syndesmosis injuries in elite football. Aspetar Sports Medicine Journal 2014;3(3):602–613 (5)]

Co-Kinetic Journal 2020;83(January):14-20

PHYSICAL THERAPY

Co-Kinetic.com

l Patient returned to play, initially for limited duration but with progressive build-up to match time Day 72

l As above plus reintroduction to training/sport Week 9

l Progressive straight-line field work/multi-directional work, general cardiovascular fitness l Plyometrics Week 8

l Progressive straight-line on-field or sports-specific work/ Week 7 multi-directional work, general cardiovascular fitness Day 48 l Multi-directional progressions on a shock absorbing surface (e.g. Aerofloor®) Week 7

l Calf occlusion training l Ankle dorsiflexion seatbelt mobilisations with movement l Reformer ankle mobilisations

l Regular training l Patient played for 80min in top level competition game

A LOW THRESHOLD FOR TREATING THE ACUTE INJURY CAN PREVENT PROBLEMS IN THE FUTURE 5. Isokinetic dynamometry In terms of isokinetic dynamometry, there is conflicting evidence with regards to which muscle group is more adversely affected following ankle injury; the invertors or evertors (18).

Clinical experience suggests that ankle invertor strength diminishes more than evertor strength in those athletes undergoing rehabilitation in excess of 3 weeks (6*). It seems most sensible to strengthen both muscle groups using the contralateral limb or preinjury screening data for comparison. In particular, eccentric strengthening of the ankle invertors.

During closed-chain eversion (a common component of the syndesmosis injury mechanism) pronation and lateral displacement of the leg relative to the stationary foot is controlled by eccentric contraction of tibialis anterior and posterior (6*). Debate continues however as Pontaga et al. established there was a large variation in the eversion/ inversion ratio depending on joint angle and speed (18). However, Sman et al. have concluded that the eversion/inversion ratio does not increase the risk of ankle syndesmosis injury (19).

Ongoing management following RTP should include: l isokinetic dynamometry concentric/ eccentric inversion/eversion strengthening l gastrocnemius/soleus strengthening l balance/proprioception training l dynamic stability exercises l plyometrics l syndesmosis strapping.

Chronic Injury of the Syndesmosis

Missed syndesmosis injuries may result in chronic instability and the early onset of osteoarthritis if associated with lateral talar shift. It is recognised that the late stabilisation of a syndesmosis injury gives less favourable outcomes than

early stabilisation. Tendon grafts may also be used for the reconstruction of the syndesmosis in patients with chronic instability. Grass et al. reported that all of his 16 patients who underwent reconstruction using a peroneus longus tendon graft for late syndesmotic widening had relief of symptoms of instability at a mean of 16.4 months post-operatively (20). As a last resort, when other techniques have failed and when symptoms of instability have continued for more than 6 months, fusion of the syndesmosis can give good relief of symptoms. Return to sports after these late reconstructive procedures is unpredictable, however, and having a low threshold for treating the acute injury can prevent problems in the future (9).

Conclusion

Research studies always have their limitations and conflicts. Hopefully this article has highlighted some assessment and rehabilitation tools for the conservative management of syndesmosis injuries. Correct management of syndesmotic injuries is mandatory to avoid scar tissue impingement, chronic instability, heterotopic ossification, or deformity of the ankle. High rates of malalignment of the syndesmosis have been reported (21). This can result in loss of function, pain and arthritis. Late reconstruction in mal-reduction can be considered, although optimal outcomes and time delays to return to sport are concerns (21).

The contact nature of the mechanism of injury means that this isn’t an injury that can be easily prevented by the specific proprioception exercises that have been shown to reduce non-contact lateral ligament injuries. The injury can be associated with ongoing weakness of the invertors/evertors, the strengthening of which (particularly eccentric strengthening of the invertors) should form part of the post-injury prevention programme along with calf strength, proprioception and taping/strapping to support the joint.

19

References Owing to space limitations in the print version, the references that accompany this article are available at the following link and are also appended to the end of the article in the web and mobile versions.

Click here to access the references https://spxj.nl/2YidXNy

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.

KEY POINTS

lM anagement usually involves a period of immobilisation and altered weight-bearing, even in grade I injuries. lR estricted dorsiflexion ROM is necessary initially to allow tissue healing. lR ehabilitation will combine soft tissue therapy with manual therapy, including manual muscle strengthening. lS trengthening is progressive and should include concentric and eccentric invertor and evertor strengthening. lP roprioception and functional skills can be progressed from pool activities and AlterG™ treadmill work to hop– jump drills, balance and agility drills, cutting and more sports-specific activities. lR ehabilitation post-surgery follows the same steps and principles as conservative management, simply with a delayed start due to a longer period of immobilisation and reduced weight-bearing. lR eturn to sport following surgery may take 9–10 weeks instead of 4–6 weeks for conservatively managed injuries. lF ailure to allow adequate healing, stabilisation and rehabilitation of a syndesmosis injury can lead to chronic ankle instability, loss of function, pain and early onset arthritis.

RELATED CONTENT

lS yndesmosis Injury Part 1: Diagnosis and Evaluation [Article] https://spxj.nl/2ZhRByL

20

Want to share on Twitter?

Here are some suggestions

Tweet this: High grade syndesmosis injuries are often treated surgically but some can be managed conservatively https://spxj.nl/387kO0F Tweet this: Non-operative treatment for grade I and grade IIa stable syndesmosis injuries gives good results https://spxj.nl/387kO0F Tweet this: The rehabilitation of surgically managed syndesmosis injuries is similar to conservative management https://spxj.nl/387kO0F Tweet this: The SEBT is useful to predict risk of lower extremity injury and identify dynamic balance deficits https://spxj.nl/387kO0F Tweet this: Missed syndesmosis injuries may result in chronic instability and the early onset of osteoarthritis https://spxj.nl/387kO0F Tweet this: Invertor/evertor strengthening should form part of the post-syndesmosis-injury prevention programme https://spxj.nl/387kO0F Tweet this: It is possible to manage some higher grade syndesmosis injuries conservatively https://spxj.nl/387kO0F

LINKS

LINK 1: Figure 6: Treatment algorithm for a suspected injury of the syndesmosis. Ballal MS, Pearce CJ, Calder JD. Management of sports injuries of the foot and ankle: an update. The Bone & Joint Journal 2016;98-B:874–883 (9). Available to view on ResearchGate https://spxj.nl/2GRzmFI LINK 2: Figure 15: Syndesmosis strapping for training/matches. Morgan C et al. Conservative management of syndesmosis injuries in elite football.

Aspetar Sports Medicine Journal 2014;3(3):602–613 (6) https://spxj.nl/2M413j0 LINK 3: Table 3: Example of a checklist used to monitor RTP progress after a syndesmosis injury.

Morgan C et al. Conservative management of syndesmosis injuries in elite football. Aspetar Sports Medicine Journal 2014;3(3):602–613 (6) https://spxj.nl/2M413j0 LINK 4: Figure 14: Star Excursion Balance Test.

Morgan C et al. Conservative management of syndesmosis injuries in elite football. Aspetar Sports Medicine Journal 2014;3(3):602–613 (6) https://spxj.nl/2M413j0

DISCUSSIONS

l How confident are you in prescribing a moon boot (immobilisation) and insisting on a period of reduced weight-bearing, especially in a competitive athlete? l Would you consider strapping an ankle and allowing a player to return to sport while still complaining of a ‘lack of confidence’ in their ankle stability? l What are your favourite dynamic balance tests to assess progression and readiness for return to sport?

Co-Kinetic Journal 2020;83(January):14-20

PHYSICAL THERAPY

SYNDESMOSIS INJURY PART 2: TREATMENT AND REHABILITATION References

1. Latham AJ, Goodwin PC, Stirling B et al. Ankle syndesmosis repair and rehabilitation in professional rugby league players: a case series report.

BMJ Open Sport & Exercise Medicine 2017;3(1):e000175 Open access https://spxj.nl/2T9opEs 2. Schnetzke M, Vetter SY, Beisemann N et al. Management of syndesmotic injuries: what is the evidence?

World Journal of Orthopedics 2016;7(11):718–725 Open access https://spxj.nl/2M0nG7T 3. Hsu AR, Garras DN, Lee S. Syndesmotic injuries in athletes.

Operative Techniques in Sports Medicine 2014;22:270–281 4. Porter DA, Jaggers RR, Barnes AF et al. Optimal management of ankle syndesmosis injuries. Open Access Journal of Sports Medicine 2014;5:173–182 Open access https://spxj.nl/2TaLZAF 5. Akoh CC, Phisitkul P. Anatomic ligament repairs of syndesmotic injuries.

Orthopedic Clinics of North America 2019;50(3):401–414 6. Morgan C, Konopinski M, Dunn A. Conservative management of syndesmosis injuries in elite football.

Aspetar Sports Medicine Journal 2014;3(3):602–613 Open access https://spxj.nl/2M413j0 7. Sikka RS, Fetzer GB, Sugarman E et al.

Correlating MRI findings with disability in syndesmotic sprains of NFL players. Foot

Co-Kinetic.com

& Ankle International 2012;33:371–378 8. van Dijk CN, Longo UG, Loppini M et al. Conservative and surgical management of acute isolated syndesmotic injuries: ESSKA-AFAS consensus and guidelines.

Knee Surgery, Sports Traumatology, Arthroscopy 2016;24(4):1217–1227 9. Ballal MS, Pearce CJ, Calder JD. Management of sports injuries of the foot and ankle: an update. The Bone & Joint Journal 2016;98-B:874–883 10. Hunt KJ, Phisitkul P, Pirolo J et al. High ankle sprains and syndesmotic injuries in athletes. Journal of the American Academy of Orthopaedic Surgeons 2015;23:661– 673 Open access https://spxj.nl/2YLNhY6 11. Calder JD, Bamford R, Petrie A et al.

Stable versus unstable grade ii high ankle sprains: a prospective study predicting the need for surgical stabilization and time to return to sports. Arthroscopy 2016;32(4):634–642 Open access https://spxj.nl/2KslLWy 12. Thornes B, Shannon F, Guiney AM et al. Suture-button syndesmosis fixation: accelerated rehabilitation and improved outcomes. Clinical Orthopaedics and Related Research 2005;431:207–212 Open access https://spxj.nl/2Ks2eFH 13. Amendola A, Williams G, Foster D. Evidence-based approach to treatment of acute traumatic syndesmosis (high ankle) sprains. Sports Medicine and Arthroscopy Review 2006;14(4):232–236 14. Ogilvie-Harris DJ, Reed SC, Hedman TP. Disruption of the ankle syndesmosis:

biomechanical study of the ligamentous restraints. Arthroscopy 1994;10(5):558–560 Open access https://spxj.nl/2YKhPtd 15. Vancolen SY, Nadeem I1, Horner NS et al. Return to sport after ankle syndesmotic injury: a systematic review. Sports Health 2019;11(2):116–122 16. Munro AG, Herrington LC. Betweensession reliability of the star excursion balance test. Physical Therapy in Sport 2010;11(4):128–132 Open access https://spxj.nl/2KgusUV 17. Gribble PA, Hertel J, Plisky P. Using the star excursion balance test to assess dynamic postural-control deficits and outcomes in lower extremity injury: a literature and systematic review. Journal of Athletic Training 2012;47(3):339–357 Open access https://spxj.nl/2KkDnop 18. Pontaga I. Ankle joint evertor-invertor muscle torque ratio decrease due to recurrent lateral ligament sprains. Clinical Biomechanics 2004;19(7):760–762 19. Sman AD, Hiller CE, Rae K et al.

Predictive factors for ankle syndesmosis injury in football players: a prospective study.

Journal of Science and Medicine in Sport 2014;17(6):586–590 20. Grass R, Rammelt S, Biewener A et al. Peroneus longus ligamentoplasty for chronic instability of the distal tibiofibular syndesmosis. Foot & Ankle International 2003;24(5):392–397 21. Swords MP, Sands A, Shank JR. Late treatment of syndesmotic injuries. Foot and Ankle Clinics 2017;22(1):65–75.

20i

MANUAL THERAPY

TREATING HEADACHES Can be a Pain in the Neck There are many types of headache but the two that commonly occur with neck pain are tension-type headache and cervicogenic headache. This article will enable you to make a differential diagnosis and to treat your patient appropriately, as well as helping you to recognise the red flag signs for serious pathologies that require further investigation and referral to the appropriate professionals. Read this article online https://spxj.nl/34UeuYq Neck pain and headaches are common co-morbidities. Individuals with disabling neck pain are 10 times more likely to suffer from headaches than those without neck pain (1).

The International Classification of Headache Disorders (ICHD-3) (2*) suggests that two types of headaches are linked to the cervical spine: tension-type headache (TTH) and cervicogenic headache (CGH). It is estimated that 2.33 billion of the worldâ&#x20AC;&#x2122;s population experienced TTHs in 2017 (3*). CGHs are also common in the general population with a prevalence of up to 20%, and as high as 53% in patients suffering headache following a whiplash injury (4*). People who suffer from CGHs commonly report at least five headache days per month (1). So there is a strong possibility you are seeing patients in your practice be it daily or weekly that present with headache and neck pain or neck pain with headache. Which one is it?

This is where the challenge comes in. Do all patients who present with headache and neck pain have CGH? What needs to be considered is that primary headache patients (including migraine and TTH) have a fairly high prevalence of neck pain (68%) (5).

Traditionally the differential diagnosis of headache with neck pain has been subdivided into two categories (5): 1. primary headache disorders a. migraine Co-Kinetic.com

b. TTH with pericranial tenderness 2. secondary headache disorders a. h eadache associated with craniocervical dystonia b. headache

attributed to chiari malformation c. headache

attributed to cervical carotid or vertebral artery dissection d. h eadache attributed to whiplash e. CGH. The problem with headache and neck pain is complicated when more than one condition from the above list is present. The differential diagnosis in this setting raises the questions: could the neck symptoms be part of the primary headache disorder or are the neck symptoms actually the source of the headache, or does the patient have two distinct conditions such as a primary headache disorder complicated by a secondary headache?

(For example a patient who has traditionally suffered from migraines, but now presents with headaches following a recent motor vehicle accident). The emphasis on treatment may depend on your understanding of headache definition as well as your preference of treatment approach.

To lump all headache and neck pain under the heading of CGH will lead to an oversimplification of headache pathology and potentially inadequate or inappropriate treatment (5).

The updated headache classification of the International

By Kathryn Thomas BSc MPhil HEAD | NECK | 20-01-COKINETIC FORMATS WEB MOBILE PRINT All references marked with an asterisk are open access and links are provided in the reference list

MEDIA CONTENTS Co-Kinetic Headache Content Marketing Campaign https://spxj.nl/35e5WMa Co-Kinetic Chronic Pain Patient Information Resources https://spxj.nl/2v5TptP Co-Kinetic Poster: Good Versus Bad Desk Posture https://spxj.nl/2HNLe9H

THE INTERNATIONAL CLASSIFICATION OF HEADACHE DISORDERS SUGGESTS THAT TWO TYPES OF HEADACHES ARE LINKED TO THE CERVICAL SPINE: TENSION-TYPE HEADACHE (TTH) AND CERVICOGENIC HEADACHE (CGH) 21

Video 1: Tension Type Headache | Characteristics & Clinical Presentation (Courtesy of YouTube user Physiotutors) https://youtu.be/QRNguihbvRg

BOX 1: RISK FACTORS OF SERIOUS PATHOLOGY (RED FLAGS) FOR HEADACHES IDENTIFIED DURING HISTORY OR PHYSICAL EXAMINATION (Sourced from Bigal et al.

J Headache Pain 2007;8:263 (30) and Sobri et al.

Br J Radiol 2003;76(908):532–535 (31)) l Worsening headache with fever l Sudden-onset headache (thunderclap) reaching maximum intensity within 5 minutes l New-onset neurological deficit l New-onset cognitive dysfunction l Change in personality l Impaired level of consciousness l Recent (typically within the past 3 months) head trauma l Headache triggered by exertion (eg. cough, valsalva manoeuvre (trying to breathe out with nose and mouth blocked), sneeze, or exercise) l Headache that changes with posture l Symptoms suggestive of giant cell arteritis l Symptoms and signs of acute narrow-angle glaucoma lA substantial change in the characteristics of a patient’s headache l New onset or change in headache in patients who are over 40 years old l Headache waking the patient up l Patients with risk factors for cerebral venous sinus thrombosis l Jaw claudication or visual disturbance l Neck pain or stiffness l Limited neck flexion upon exam l New

onset headache in patients with a history of human immunodeficiency virus (HIV) infection l New onset headache in patients with a history of cancer 22

Classification of Headache Society (ICHD-3) (2*), released in January 2018, lists more than 200 different varieties of headache that can be differentiated from each other on the basis of the history and physical examination alone (6*). This plethora of headache types may seem intimidating, particularly as there are no laboratory or imaging tests that can establish the diagnosis of primary headache or tell one type of primary headache apart from another, not to mention the number of secondary headaches also identified (6*). The full ICHD-3 publication is available for those who wish to read or keep it for clinical reference (Link 1).

What this article aims to do is focus on headache with neck pain, be it CGH or TTH, as potentially these are the patients you will see most often in your practice, or be referred to you by their doctor. It is also an area where the evidence shows non-pharmacological management with physical therapy can be effective.

Differential Diagnosis

When presented with a patient suffering from headache and neck pain, clinicians should conduct a clinical evaluation to rule out major structural or other pathologies (eg. migraines with or without aura, traumatic brain injuries) as the cause of presenting signs and symptoms. The presence of risk factors for serious pathologies (also termed ‘red flags’) identified during the history/examination warrants further investigation and referral to appropriate professionals (Box 1) (7*). This quick reference algorithm from the Guideline for Primary Care Management of Headache in Adults (Link 2) (7*) should be saved in your practice to aid in this first step of ruling out major pathologies and identifying more serious headache conditions.

Once you have established there is no sinister underlying cause of the headache, one should attempt to classify the headache as either TTH or CGH. You may also choose to use a questionnaire to assess the impact that the patient’s headache has on their ability to function in daily life, be it school, work, sport or at home.

The HIT-6 questionnaire correlates, across different diagnostic groups of headache, with both headache severity and quality of life (Link 3) (8).

Tension-Type Headache (TTH)

TTH (frequent episodic or chronic) is defined as being typically bilateral, pressing or tightening in quality and of mild to moderate intensity, lasting minutes to days or unremitting on average for at least 3 months (2). The pain does not worsen with routine physical activity and is not normally associated with nausea. Photophobia and/or phonophobia may be present.

It can be associated with pericranial tenderness on manual palpation of the head and neck muscles (1).

ICHD criteria for TTHs are (Video 1) (2*): 1. frequent episodic TTH with or without pericranial tenderness; and 2. chronic TTH with or without pericranial tenderness.

The presence of pericranial tenderness is indicated by increased tenderness on manual palpation of head and neck muscles, which include (but may not be limited to the following): frontal, temporal, masseter, pterygoid, sternocleidomastoid, splenius and trapezius muscles.

Diagnostic criteria for frequent episodic TTH associated with or without pericranial tenderness include (1,2*): a. At least 10 episodes occurring on 1–14 days per month for >3 months (>12 and <180 days per year) and fulfilling criteria b–d. b. Lasting from 30 minutes to 7 days. c. At least two of the following four characteristics: l bilateral location l pressing or tightening (nonpulsating) quality l mild or moderate intensity l not aggravated by routine physical activity such as walking or climbing stairs. d. Both of the following: l no nausea or vomiting l no more than one of photophobia or phonophobia. e. Not better accounted for by another ICHD-3 diagnosis.

Diagnostic criteria for chronic TTH associated with or without pericranial

Co-Kinetic Journal 2020;83(January):21-28

MANUAL THERAPY

tenderness include (1,2*): a. Headache occurring >15 days per month and >3 months (>12 and <180 days per year) and fulfilling criteria b–d. b. Lasting hours to days, or unremitting. c. At least two of the following four characteristics: l bilateral location l pressing or tightening (nonpulsating) quality l mild or moderate intensity l not aggravated by routine physical activity such as walking or climbing stairs. d. Both of the following: l no more than one of photophobia, phonophobia or mild nausea l neither moderate or severe nausea nor vomiting. e. Not better accounted for by another ICH-3 diagnosis.

Active myofascial trigger points are prevalent in TTH coherent with the hypothesis that peripheral mechanisms are involved in the pathophysiology of this headache disorder (9*).

Active myofascial trigger points in pericranial muscles in TTH patients are correlated with generalised lower pain pressure thresholds indicating they may contribute to a central sensitisation. However, the number of active myofascial trigger points is higher in adults compared with adolescents regardless of no significant association with headache parameters.

This suggests myofascial trigger points are accumulated over time as a consequence of TTH rather than contributing to the patho-physiology (9*).

Cervicogenic Headache (CGH)

CGHs are caused by a disorder of the cervical spine – bony, disc and/or soft tissue structures – and is usually (but not invariably) accompanied by neck pain (2*,5). The diagnosis of CGH is often difficult owing to the conflicting definitions of CGH. The definition of CGH has varied among different groups of physicians with somewhat conflicting views on the basis of defining this headache type. The definition described by The Cervicogenic Headache International Study Group (CHISG) allows for clinical features such Co-Kinetic.com

as unilateral headache with nausea, photophobia, phonophobia, and neck pain, and these features often overlap with other headache types, such as migraine, TTH and occipital neuralgia (ON) (5). The broader definition by CHISG leads to many more patients receiving a diagnosis of CGH. This, however, opens the door to a slippery slope whereby any headache associated with neck pain may be attributed to a cervicogenic source.

As the criteria note in CHISG includes migrainous features such as nausea, vomiting, and photo/phonophobia, there is a risk of missing an underlying migraine disorder which would limit the treatment approach and compromise a successful outcome (5).

Using a symptom-based definition of CGH can lead to further conflict with ON, which can also share many similar features. ON must be distinguished from occipital referral of pain arising from the upper cervical joints (as in CGH) and from tender myofascial points in neck muscles (as in TTH) (5).

Alternatively, the International Classification of Headache Disorders (ICHD-3 beta) (2*) has a more limited definition and defines CGH by its anatomic dependency on a cervical source. Furthermore, neck pain is not the essential symptom for diagnosis.

ICHD diagnostic criteria for CGH include (Video 2) (2*): a. Any headache fulfilling criterion C. b. Clinical, laboratory, and/or imaging evidence of a disorder or lesion within the cervical spine or soft

Video 2: Cervicogenic Headache | Characteristics & Clinical Presentation (Courtesy of YouTube user Physiotutors) https://youtu.be/aad8dMiuyTs tissues of the neck, known to be able to cause headache. c. Evidence of causation demonstrated by at least two of the following: l headache has developed in temporal relation to the onset of the cervical disorder or appearance of the lesion l headache has significantly improved or resolved in parallel with improvement in or resolution of the cervical disorder or lesion l cervical range of motion is reduced and headache is made significantly worse by provocative manoeuvres l headache is abolished following diagnostic blockade of a cervical structure or its nerve supply. d. Not better accounted for by another ICHD-3 diagnosis.

Table 1, below, displays areas of overlapping criteria between migraine, TTH, CGH, and ON as well as key

TABLE 1: Area of criteria overlap and differentiation between migraines, TTH, CGH and ON. Adapted from Blumenfeld A et al. Curr Pain Headache Rep 2018;22(7):47 (5).

Clinical features

Migraine TTH

CGH

Cervical spine or neck soft tissue lesion

X

Exacerbated by movement

X

X

ON

Responds to diagnostic block of cervical X structure or its nerve supply Posterior head and neck pain

X

X

X

X

Myofascial trigger points

X

Migraine features

X

X

X

X

X

Response to greater and lesser

X

X

X

CGH, cervicogenic headache; ON, occipital neuralgia; TTH, tension-type headache.

23

AS TTH AND CGH HAVE OVERLAPPING SETS OF SIGNS AND SYMPTOMS, THE CHALLENGE IS TO MAKE THE CORRECT DIAGNOSIS differences that differentiate CGH (5).

Cervical musculoskeletal abnormalities have been traditionally linked to different headaches. An example of this is headache attributed cervical dystonia. In this situation, involuntary muscle spasm pulls the head and neck from the normal

Tragus of the ear

Figure 1: Measurement of forward head posture

C7 vertebra

Video 3: Tight Upper Traps? Try These Exercises! (Courtesy of YouTube user Physiotutors) https://youtu.be/4D6_sK6hxLQ

Video 4: Neck Flexor Endurance Test | Deep Neck Flexors (Courtesy of YouTube user Physiotutors) https://youtu.be/0JEWM_McBmM 24

anatomical neutral position resulting in abnormal posture, neck tremor, sensory tricks, muscle hypertrophy and tenderness. Trigger points may develop in the trapezius, splenius capitus, splenius cervicis and sternocleidomastoid muscles. These trigger points refer pain into the head, manifesting as chronic headaches with neck pain (5).

A more frequently noted abnormal posture is an excessive forward head position (FHP). FHP is a clinical entity that has been identified by multiple authors as a significant factor in a variety of musculoskeletal pain syndromes, including neck pain and headaches. This posture often results from sustained or frequently repeated tasks in the setting of sub-optimal ergonomics. Disuse of muscles leads to the abnormal posture. The severity of FHP can be assessed by measuring the number of fingerbreadths that can be vertically placed between a line dropped down from the tragus of the ear and the upper portion of the medial trapezius, while the patient stands with their best neutral spine position (5). Alternatively, the craniovertebral angle can be measured (possible on a photograph) by the angle between the horizontal line passing through C7 and a line extending from the tragus of the ear to C7 (Fig. 1). A smaller craniovertebral angle is associated with a greater FHP (10*).

FHP is usually associated with shortening of the cervical extensor muscles. Those muscles that are usually shortened (depending on the degree of FHP) include the suboccipital paraspinals, scalenes, sternocleidomastoid, levator scapulae, upper trapezius (Video 3), pectoralis major and pectoralis minor. Those muscles that are usually overlengthened include the rhomboids, middle trapezius, lower trapezius and thoracic paraspinals (10*). In these instances active trigger points from

these muscles could be contributing to the patient’s head pain; however, one must differentiate from referred pain to the head and actual reproduction of the headache pain (Link 4) (11). A FHP has been found to be greater in CGH and TTH patients than in controls in randomised controlled trials (RTCs) (10,12).

Management

The clinical management of headaches associated with neck pain is often challenging. For TTH or CGH the evidence suggests cervical spine exercises or manual therapy may be effective (13). In addition to this, TTH may be managed with reassurance, acupuncture, exercise, physical therapy (eg. massage, spinal manipulation, hot and cold packs, ultrasound, electrical stimulation) and psychological interventions (7*). Similarly, the guidelines recommend that exercise, spinal manipulation and cervical mobilisation can be considered for the treatment of CGH (7*).

For headaches associated with neck pain, clinicians should provide care in partnership with the patient and involve the patient in care planning and decision-making (1).

Clinicians should aim to understand the patient’s beliefs and expectations about headaches and address any misunderstandings or apprehension through education and reassurance.

Information and education about pain and its mechanism, and about different headaches should be disseminated (See Media Contents). Patients should be advised to stay active or exercise.

A recent review showed that aerobic exercise decreases the number of headache days, as well as potentially decreasing migraine attack duration and pain intensity (14*).

The most recent evidencebased clinical practice guideline (1) was developed to help clinicians deliver effective interventions for the management of headache associated with neck pain. The recommendations aim to promote uniform high-quality care based on recent systematic reviews of the literature and synthesis of best available evidence and RCTs. The guideline identifies interventions that should not be used based on

Co-Kinetic Journal 2020;83(January):21-28

MANUAL THERAPY

effectiveness not yet established, risk to patient, or confounding evidence from clinical trials. The number of treatments and duration recommended in the guidelines comes from randomised controlled clinical trials. It should be noted, however, that each patient must be treated as an individual, and although there are time specific recommendations in the guidelines these should be adjusted according to the individual, their needs and response to treatment, as well as their socio-economic situation.

Episodic TTH

For patients with episodic TTHs, clinicians may consider low-load endurance craniocervical and cervicoscapular exercises in addition to structured patient education. In view of evidence of no effectiveness, clinicians should not offer manipulation of the cervical spine (1). The advice can be summarised as follows.

1. Structured patient education (1): a. Information about the nature, management, and course of episodic TTHs as a framework for initiating the programme of care. b. Patients should be informed and educated about their condition, and participate in the decision-making process.

2. Low-load endurance craniocervical and cervicoscapular exercises: a. Low-load endurance craniocervical and cervicoscapsular exercises (a maximum of 8 sessions over 6 weeks with resistance in a supervised clinical environment) (1). b. Supervised and home-based lowload endurance exercises to perform a slow and controlled craniocervical flexion against resistance over time to train muscular control of the craniocervical and cervicoscapular region (Video 4) (1). c. The exercise programme should be taught to the patient by a healthcare professional. This recommendation is based on one low risk of bias RCT that found adding low-load endurance exercises (6 weeks supervised period, twice a day for 10 minutes per session at home, then at least twice per week after supervised period) to physiotherapy (ie. Western massage, low-velocity Co-Kinetic.com

passive cervical joint mobilisation, instruction on postural correction) is superior to physiotherapy alone for improving headache frequency in the long-term for chronic or episodic TTHs (15).

Chronic TTH

For patients with chronic TTHs, clinicians may consider general exercise (including warm-up, neck and shoulder stretching and strengthening, aerobic exercises), low-load endurance craniocervical and cervicoscapular exercises, multimodal care (combining spinal mobilisation, cranicocervical exercise, and postural correction), or clinical massage in addition to structured patient education. In view of evidence of no effectiveness, clinicians should not offer manipulation of the cervical spine as the sole form of treatment (1). The advice is summarised as follows.

1. Structured patient education as above.

2. Exercise: a. Consider a general clinic and home-based exercise programme (warm-up, neck and shoulder stretching and strengthening, aerobic exercise) limited to a maximum of 25 sessions over 12 weeks (16). b. The exercise programme should be taught and supervised by a healthcare professional. c. Clinicians may consider lowload endurance craniocervical and cervicoscapsular exercises (a maximum of 8 sessions over 6 weeks with resistance). This involves supervised and homebased low-load endurance exercises against resistance over time to train muscular control of the craniocervical and cervicoscapular region (1).

3. Multimodal care: a. Offer a maximum of 9 sessions over 8 weeks of multimodal care that includes spinal (cervical and thoracic) mobilisation, craniocervical exercises, and postural correction (1,17). b. Manual therapy and exercise have been shown to be more effective in reducing headache frequency,

Video 5: Manual Pressure Techniques / MPT | Tension Type Headache (Courtesy of YouTube user Physiotutors) https://youtu.be/s-9vg9udnYA disability and improving cervical function than general practitioner care. A component of that manual therapy is manual pressure techniques (Video 5) (18). c. Recent studies show that cervical spine kinesiotherapy and postural correction combined with a programme of relaxation techniques (Schultz’s Autogenic Training, AT), were effective in reducing TTH by preventing and managing the potential psychophysical causes of this disorder (19*). d. TTH headache can benefit from

EXCESSIVE FORWARD HEAD POSTURE IS FREQUENTLY NOTED WITH NECK PAIN AND HEADACHE 25

THE EVIDENCE SUGGESTS THAT CERVICAL SPINE EXERCISES OR MANUAL THERAPY MAY BE EFFECTIVE FOR MANAGING TTH AND CGH acupuncture and stretching but further pressure-pain-threshold improvements are seen when physiotherapy hands-on techniques were added. In clinical terms, the combination of physiotherapy in the form of myofascial release and microwave diathermy with acupuncture and stretching in order to improve the analgesic effect (pressure pain threshold) is strongly recommended (20).

4. Soft tissue therapy: a. May consider 8×45-minute sessions of clinical massage (2 sessions per week over 4 weeks) (1).

5. Manual therapy: a. Should not offer cervical spine manipulation. This recommendation is based on one low risk of bias RCT suggesting that cervical manipulation combined with massage led to similar outcomes as massage alone (1).

Video 6: Craniocervical Flexion Test / CCFT | Deep Cervical Neck Flexors (Courtesy of YouTube user Physiotutors) https://youtu.be/cAfcQIRm9Ew

Since publication of the most recent guidelines (1), additional clinical trials have been published that may add to your treatment options. TTH is known to be associated with myofascial pain syndrome and the existence of myofascial trigger points. A recent study compared the effectiveness of dry needling and friction massage to treat patients with TTH. Although this was a very short treatment protocol (3 treatments over 1 week) the results showed that both treatment methods significantly reduced headache frequency and intensity, and increased pain threshold at the trigger points.

Concluding that dry needling and friction massage were equally effective in improving symptoms in patients with TTH (21*).

CGH Video 7: Anterior neck stabilisation with BP cuff (Courtesy of YouTube user Rehab My Patient) http://youtu.be/uvxsGEjjs-0 26

For patients with CGHs >3 months duration, clinicians may consider low-load endurance craniocervical and cervicoscapular exercises or manual therapy (manipulation with or

without mobilisation) to the cervical and thoracic spine in addition to structured patient education. However, there is no added benefit in combining spinal manipulation, spinal mobilisation, and exercises (1). The advice can be summarised as follows.

1. Structured patient education: a. Clinicians should provide information about the nature, management, and course of persistent CGHs as a framework for initiating the programme of care.

2. Exercise: a. Low-load endurance craniocervical (Video 6) and cervicoscapular exercise with resistance limited to a maximum of 8 sessions over 6 weeks.

This involves supervised and homebased low-load endurance exercises against resistance over time to train muscular control of the craniocervical and cervicoscapular region (1). b. Studies have shown that applying trans-cranial direct current stimulation during craniocervical flexion exercise can strengthen the sternocleidomastoid muscle more effectively while improving pain and associated functions in patients with CGH. This may make for more effective treatment in the future (22*). c. Application of craniocervical flexion exercise and suboccipitalis relaxation in CGH patient is effective in decreasing fatigue of cervical muscles, tone of sternocleidomastoid muscle. This in turn may help address the common contributing factor to CGH of FHP. For application of suboccipitalis relaxation, the therapist positioned him/herself over head of the subjects, placed fingertip just subocciput of subjects and supported occiput of the subjects with his/her palm. The suboccipital region was protracted with a fingertip so that it would make an axis and the head was lightly supported with the palm so that the neck wouldn’t be fully extended for 20 minutes, releasing the suboccipitalis (23*). d. Cervical stretching and stabilisation exercises have greater amount of change in tone, stiffness, and cervical posture. This benefits patients with CGH, aiding in the maintenance of improvements more effectively (24*).

Co-Kinetic Journal 2020;83(January):21-28

MANUAL THERAPY

3. Manual therapy: a. Manual therapy (manipulation with or without mobilisation) to the cervical and thoracic spine limited to a maximum of 10 sessions over 6 weeks (1). b. There was a linear dose–response relationship between spinal manipulative therapy visits and days with CGH. For the highest and most effective dose of 18 spinal manipulative therapy visits, CGH days were reduced by half and about 3 more days per month than for the light-massage control (25*). c. The application of dry needling into trigger points of suboccipital and upper trapezius muscles induces significant improvement of headache index, trigger points tenderness, functional rating index and range of motion in patients with CGH. Deep dry needling had greater effects on cervical range of motion and function (26).

4. Multimodal care: a. Clinicians should not offer a multimodal programme of care that includes a combination of exercise, spinal manipulation, and spinal mobilisation. This recommendation is based on two low risk of bias RCTs suggesting that: (i) combining low-load endurance exercises with spinal manipulation and mobilisation is not more clinically beneficial than providing either intervention alone (27); and (ii) combining craniocervical flexion exercise (Video 7) and spinal mobilisation is less effective than spinal manipulation. What should be noted from this study is that both spinal manipulation patients and patients receiving a combination of spinal mobilisation with exercises had significant improvements in their headache symptoms, pain and disability over a 3-month period.

However, if you were to choose a treatment as being superior, the results from this study indicate that spinal manipulation is more effective in managing patients with CGH (4*).

Re-evaluation and Discharge

Clinicians should reassess the patient at every visit to determine if (1): 1. additional care is necessary; 2. the condition is worsening; or Co-Kinetic.com

3. the patient has recovered.

Patients should be discharged as soon as they report significant recovery.

Healthcare professionals should use the self-rated recovery question to measure recovery: “How well do you feel you are recovering from your injuries?”

(28*). The response options include: 1. completely better 2. much improved 3. slightly improved 4. no change 5. slightly worse 6. much worse 7. worse than ever.

Patients reporting to be ‘completely better’ or ‘much improved’ should be considered recovered. The self-rated recovery question is a valid and reliable global measure of recovery in patients with headaches (28*). Patients who are not recovering should be re-assessed to ensure the treatment is targeted at the correct source; and/or their history and symptoms be re-evaluated to ensure no other pathology was missed during the initial consultation.

Although not discussed in the guidelines, addressing the patient’s ergonomics which could be contributing to their FHP and muscle imbalances resulting in CGH or TTH are vital to ensure long-term success and prevention of headache. This can be part of patient education and may involve an assessment of their workspace or home environment (see Media Contents).

Conclusion

one general population study provided findings for the self-reported effectiveness for chiropractic and physiotherapy at 25.6 and 25.1%, respectively, for those with primary chronic headache and 38 and 38%, respectively, for those with secondary chronic headache. So that’s not great! Clearly we need to up our game – be it making sure we are treating the right condition, using the right techniques and educating the patients adequately. As well as using the rest of the medical profession to provide a holistic management strategy for the patient.

What we do need to do is better ‘advertise’ ourselves to the public and medical fraternity about the benefits of physical therapy in headache management. Referrals of headache patients from general practitioner to chiropractor average 55.7%, whereas referral from friends/relatives ranged from 33.0 to 43.8% (mean: 38.7%) and self-referral approximately 5.6%. For massage therapy, referral from a general practitioner averaged 36.6%, whereas referral from friends/relatives 40.4% and self-referral approximately 23.1% (29*).

Ensuring treatment success may boil down to the first consultation with your patient. It is vital you know what type of headache the patient is suffering from so that you direct your treatment appropriately, as well as to be realistic about the short- and long-term outcomes for that patient. When assessing and diagnosing a patient, be aware there may be two different headache types overlapping each other and the presence of neck pain may or may not be a contributing factor.

A recent review showed that 63% of headache sufferers’ motivation to seek manual therapy treatment was for pain relief (29*). The second most common motivation was because of concerns about safety and side effects of standard medical treatment and a third motivation was dissatisfaction with medical care. So this bodes well; as we know manual therapy can be effective in treating pain and headaches. However, when patients reported on the effectiveness of their manual therapy treatment (including chiropractor, massage, acupressure, physiotherapy, osteopathy), a mean of 42.5% (range 17–82%) said it was partially or fully effective. In addition, 27

References Owing to space limitations in the print version, the references that accompany this article are available at the following link and are also appended to the end of the article in the web and mobile versions. Click here to access the references https://spxj.nl/387amq5

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

RELATED CONTENT

lT he 11 Rs in Concussion: Part 1 Screening [Article] https://spxj.nl/2WDJGu4 lT he 11 Rs in Concussion Part 2: Treatment, Rehabilitation and Recovery [Article] https://spxj.nl/2OAkz5E

Want to share on Twitter?

Here are some suggestions Tweet this: Two types of headaches are linked to the cervical spine: tension-type and cervicogenic https://spxj.nl/34UeuYq Tweet this: Cervicogenic headaches are caused by a disorder of the cervical spine https://spxj.nl/34UeuYq Tweet this: Excessive forward head posture is frequently noted with neck pain and headache https://spxj.nl/34UeuYq Tweet this: A key step in headache treatment is patient education https://spxj.nl/34UeuYq Tweet this: Cervical spine exercises are effective in both tension-type and cervicogenic headache https://spxj.nl/34UeuYq 28

KEY POINTS

lC linicians should rule out major structural or other pathologies as the cause of headaches. l I n the absence of major structural or other pathologies, clinicians should classify headaches associated with neck pain as tension-type headache (TTH) or cervicogenic headache (CGH). lB oth primary and secondary headache disorder may be observed concomitantly in the same patient. lF ocusing on only one aspect of the patient’s headache and failing to recognise additional headache features may result in unresponsiveness to treatment and an unsatisfied patient. l I n the context of shared decision-making, clinicians should discuss with the patient the range of effective interventions available for the management of headache associated with neck pain. lS tructured patient education, giving information about the nature, management, and course of their headaches and a framework of care is step 1 in treatment. lC linical massage, stretching, acupuncture and myofascial release may be beneficial in treating TTH. l L ow-load endurance craniocervical flexion exercises are recommended in both TTH and CGH. lM anual therapy including spinal manipulation is beneficial in treating CGH. lF orward head posture is greater in both CGH and TTH patients, treatment should include ergonomic correction and postural rehabilitation exercises.

LINKS

LINK 1: Headache Classification Committee of the International Headache Society (IHS). The international classification of headache disorders, 3rd edition. Cephalalgia 2018;38(1):1–211 (2) https://spxj.nl/2XnL2qS LINK 2: Figure 1: Quick reference algorithm from the Guideline for Primary Care Management of Headache in Adults. Becker WJ, Findlay T, Moga C et al. Guideline for primary care management of headache in adults.

Canadian Family Physician 2015;61(8):670–679 (7) https://spxj.nl/2Xm8bdm LINK 3: HIT-6™ Headache Impact Test. Available to view online https://spxj.nl/35fkEC6 LINK 4: Figure 1: Referred pain pattern from myofascial trigger points in the upper trapezius, sternocleimastoid, and temporalis muscles.

Fernández-de-Las-Peñas C, et al. Myofascial trigger points, neck mobility, and forward head posture in episodic tension-type headache. Headache 2007;47(5):662–672 (10) https://spxj.nl/37dccoW

DISCUSSIONS

l Headache with neck pain can be complicated to diagnose with many overlapping conditions. Having read this article and the latest ICHD recommendations, do you feel there is better clarity in identifying and diagnosing patients with either tension-type headache and cervicogenic headache? lW hat test or treatment technique do you use to monitor progress when managing a patient with headache? lA part from low-load craniocervical flexion exercises, what other strengthening exercises for the neck have you found to be beneficial in managing headache patients?

Co-Kinetic Journal 2020;83(January):21-28

MANUAL THERAPY

References

1. Côté P, Yu H, Shearer H et al. Nonpharmacological management of persistent headaches associated with neck pain: A clinical practice guideline from the Ontario protocol for traffic injury management (OPTIMa) collaboration. European Journal of Pain 2019;23(6):1051–1070 2. Headache Classification Committee of the International Headache Society (IHS).

The international classification of headache disorders, 3rd edition. Cephalalgia 2018;38(1):1–211 Open access https://spxj.nl/2OvLsYi 3. Global Burden of Disease 2017 Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017.

Lancet 2018;392(10159):1789–858 Open access https://spxj.nl/33b98pX 4. Dunning J, Butts R, Mourad F et al. Upper cervical and upper thoracic manipulation versus mobilization and exercise in patients with cervicogenic headache: a multi-center randomized clinical trial. BMC Musculoskeletal Disorders 2016;17:64 Open access https://spxj.nl/2O5FvSI 5. Blumenfeld A, Siavoshi S. The challenges of cervicogenic headache. Current Pain and Headache Reports 2018;22(7):47 6. Arne A. Hints on diagnosing and treating headache. Deutsches Arzteblatt International 2018;115(17):299–308 Open access https://spxj.nl/343eJA5 7. Becker WJ, Findlay T, Moga C et al.

Guideline for primary care management of headache in adults. Canadian Family Physician 2015;61(8):670–679 Open access https://spxj.nl/2Xm8bdm 8. Nachit-Ouinekh F, Dartiques JF Henry P et al. Use of the headache impact test (HIT-6) in general practice: relationship with quality of life and severity. European Journal of Neurology. 2005;12(3):189–193 9. Do TP, Heldarskard G, Kolding LT et al.

Myofascial trigger points in migraine and tension-type headache. The Journal of Headache and Pain 2018;19(1):84 Open access https://spxj.nl/2KIVq7v 10. Fernández-de-Las-Peñas C, Cuadrado ML, Pareja JA. Myofascial trigger points, neck mobility, and forward head posture in episodic tension-type headache. Headache 2007;47(5):662–672 Open access https://spxj.nl/37dccoW 11. Travell J, Simons DG, Simons LS. Myofascial pain and dysfunction: the trigger point manual: volume 1, 3rd edn. Lippincott Williams and Wilkins 2013. ISBN 978-0781755603 (Kindle £118.74 Print £79.40) Buy from Amazon https://spxj.nl/2qxRuzB 12. Fernández-de-las-Peñas C, AlonsoBlanco C, Cuadrado ML, et al. Forward head posture and neck mobility in chronic tension-type headache: a blinded, controlled study. Cephalalgia Co-Kinetic.com

TREATING HEADACHES Can be a Pain in the Neck 2006;26(3):314–319 13. Varatharajan S, Ferguson B, Chrobak K, et al. Are non-invasive interventions effective for the management of headaches associated with neck pain? An update of the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders by the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration.

European Spine Journal 2016;25(7): 1971–1999 14. Lemmens J, De Pauw J, Van Soom T et al. The effect of aerobic exercise on the number of migraine days, duration and pain intensity in migraine: a systematic literature review and meta-analysis. The Journal of Headache and Pain 2019;20(1):16 Open access https://spxj.nl/37sg6KQ 15. van Ettekoven H, Lucas C. Efficacy of physiotherapy including a craniocervical training programme for tension-type headache; a randomized clinical trial.

Cephalalgia 2006;26(8):983–991 16. Söderberg EI, Carlsson JY, StenerVictorin E et al. Subjective well-being in patients with chronic tension-type headache: effect of acupuncture, physical training, and relaxation training. Clinical Journal of Pain 2011;27(5):448–456 17. Cumplido-Trasmonte C, FernándezGonzález P, Alguacil-Diego IM et al.

Manual therapy in adults with tension-type headache: a systematic review. Neurologia 2018;pii:S0213-4853(18)30013-6 18. Castien RF, van der Windt DA, Grooten A, et al. Effectiveness of manual therapy for chronic tension-type headache: a pragmatic, randomised, clinical trial. Cephalalgia 2011;31(2):133–143 19. Álvarez-Melcón AC, Valero-Alcaide R, Atín-Arratibel MA, et al. Effects of physical therapy and relaxation techniques on the parameters of pain in university students with tension-type headache: a randomised controlled clinical trial. Neurologia 2018;33(4):233–243 Open access https://spxj.nl/2XxYhVW 20. Georgoudis G, Felah B, Nikolaidis P, et al. The effect of myofascial release and microwave diathermy combined with acupuncture versus acupuncture therapy in tension type headache patients: a pragmatic randomized controlled trial. Physiotherapy Research International 2018;23(2):e1700 21. Kamali F, Mohamadi M, Fakheri L, et al. Dry needling versus friction massage to treat tension type headache: A randomized clinical trial. Journal of Bodywork and Movement Therapies 2019;23(1):89–93 Open access https://spxj.nl/2KIOxmN 22. Park SK, Yang DJ, Kim JH et al. Effects of cranio-cervical flexion with transcranial direct

current stimulation on muscle activity and neck functions in patients with cervicogenic headache. Journal of Physical Therapy Science 2019;31(1):24–28 Open access https://spxj.nl/3399Kwk 23. Yang DJ, Kang DH. Comparison of muscular fatigue and tone of neck according to craniocervical flexion exercise and suboccipital relaxation in cervicogenic headache patients. Journal of Physical Therapy Science 2017;29(5):869–873 Open access https://spxj.nl/2rh0Z64 24. Park SK, Yang DJ, Kim JH et al.

Effects of cervical stretching and craniocervical flexion exercises on cervical muscle wcharacteristics and posture of patients with cervicogenic headache.

Journal of Physical Therapy Science 2017;29(10):1836–1840 Open access https://spxj.nl/35iiD8g 25. Haas M, Bronfort G, Evans R et al.

Dose-response and efficacy of spinal manipulation for care of cervicogenic headache: a dual-center randomized controlled trial. Spine Journal.

2018;18(10):1741–1754 Open access https://spxj.nl/2DfHlul 26. Sedighi A, Nakhostin Ansari N et al.

Comparison of acute effects of superficial and deep dry needling into trigger points of suboccipital and upper trapezius muscles in patients with cervicogenic headache.

Journal of Bodywork and Movement Therapies 2017;21(4):810–814 27. Jull G, Trott P, Potter H et al. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine 2002;27(17):1835–1843 28. Carroll LJ, Lis A, Weiser S et al. How well do you expect to recover, and what does recovery mean, anyway?

Qualitative study of expectations after a musculoskeletal injury. Physical Therapy 2016;96(6):797–807 Open access https://spxj.nl/2Xy6VDY 29. Moore CS, Sibbritt DW, Adams J. A critical review of manual therapy use for headache disorders: prevalence, profiles, motivations, communication and selfreported effectiveness. BMC Neurology 2017;17(1):61 Open access https://spxj.nl/2rcyPcJ 30. Bigal ME, Lipton RB. The differential diagnosis of chronic daily headaches: an algorithm-based approach. The Journal of Headache and Pain 2007;8:263 Open access https://spxj.nl/2OAkHBM 31. Sobri M, Lamont AC, Alias NA et al. Red flags in patients presenting with headache: clinical indications for neuroimaging. The British Journal of Radiology 2003;76(908):532–535.

28i

MANUAL THERAPY

NECK | LOWER BACK | SACRUM | 20-01-COKINETIC FORMATS WEB MOBILE PRINT All references marked with an asterisk are open access and links are provided in the reference list

By Joanne Elphinston

O

ur posture should flow with ease through dynamically changing positions as we move, and so is constantly adapting. In healthy movement we select from a range of stabilising possibilities, calibrating our neuromuscular pattern according to the task we are performing (1). However, if our postural control is compromised in response to our emotional, behavioural, functional or neurosensory landscape, our choices can narrow to adopt a habitual specific stabilising strategy.

This becomes a lock – the stereotypical immobilising response in a part of the body that is used for stabilisation regardless of the task’s demands.

Locks can be classified as being either foundation or functional. A foundation lock is one that is present in the person’s posture whether they are in motion or at rest. It is a consistent postural feature and does not vary greatly in response to movement demands.

A functional lock appears in response to the impulse to move. Chapter 3 of my book The Power and the Grace discussed the process by which our bodies prepare for movement: the feedforward response. This response ensures that our support musculature establishes the initial groundwork for our bodies to be able to accept load and generate force before the movement actually begins. We have many possibilities for this, and muscles like transversus abdominis, multifidus and the vastus medialis of the quadriceps have all been identified as behaving in this preparatory way (2,3,4*). However, in the presence of pain, a history of injury, or any one of the other postural influences that were discussed in Chapter 5 of the book, alternative feedforward responses can appear and become the primary preparatory strategy for the body. In Chapter 3 we also talked about looking for where a movement starts – the point of preparation.

Co-Kinetic.com

HOW TO UNPICK POSTURAL LOCKS Many people, most of the time, move without thinking about what they are doing. The right muscles fire at the right time to prepare, support and execute the desired moment. Sometimes, though, perhaps in response to pain or injury, we change the way we move, using some muscles too much as a stabilising strategy, which can become a ‘lock’ and create knock-on imbalances in the kinetic chain.

This article looks at some of the locks that you are likely to see in your patients and how you can treat them. This article has been extracted from chapter 6 of the author’s book The Power and the Grace.

Read this article online https://spxj.nl/2YyEdDx Persistent, habitual points of preparation that are used regardless of the movement challenge are in fact functional locks.

Distinguishing between foundation and functional locks helps us to identify how to address them. In the case of a foundation lock, there may be structural joint stiffening and soft tissue restriction that can benefit from direct treatment, mobilising or stretching.

These techniques create movement potential, which must then be integrated using active movement to make the brain aware of how to access and use the new motion in

the area.

Functional locks appear in response to movement, but subside at rest. Although a person will complain of tightness and stiffness in the lock area, this is the result of active

A ‘LOCK’ IS AN IMMOBILISING RESPONSE IN A PART OF THE BODY THAT IS USED FOR STABILISATION REGARDLESS OF THE TASK DEMAND 29

muscle contraction rather than passive structural limitation. As such, stretching, massage and mobilisation can offer symptomatic relief and address the adaptive tissue shortening that may develop over time, but none of these treatments will make lasting change, because this is a motor programme issue – it is in the wiring.

Working with functional locks therefore involves: l making sure that the load or skill requirement of the exercise is within the person’s capabilities, so that they aren’t forced into the lock as a coping strategy l using a cue that communicates the movement impulse clearly l establishing an awareness of relaxation in the locking area before beginning the movement.

Sticky Links

There are several common central body locks. Posteriorly, we have the upper (cervical) lock, the posterior rib lock and the lower (lumbosacral) lock.

Anteriorly, we have the upper (throat) lock, the anterior rib lock (discussed in Chapter 9) and the anterior hip lock.

Although for ease of consideration we have identified the locks as separate entities, their biomechanical,

Figure 1: Posterior upper lock

Figure 2: A folded towel can place the head in a relaxed position to encourage optimal muscle activity

30

structural and neural relationships create significant interplay between them. Understanding these relationships can help us to avoid simply using forced muscle action to counter the locks, offering us, instead, the opportunity to uncover other neuromuscular possibilities, by gently unpicking them. In this article we take a look at the posterior upper (cervical) lock, the anterior upper (throat) lock and the posterior lumbosacral lock.

Posterior Upper (Cervical) Lock The first of the locks is the posterior upper lock, sometimes referred to as the atlanto-occipital lock (Fig. 1). This downward compression of the head on the upper neck, together with the accompanying backward rotation of the skull, influences global body reflexes, and as such it is the master key for the entire spine.

In Chapter 3, we discussed the cues of being lifted from the scruff of the neck, looking into a pool of water, and projecting out from the very top, or crown of the head rather than looking forward. This was followed in Chapter 5 by the introduction of cues such as the balloon, the elongated ears and the suspended puppet, which specifically address the upper lock.

All of these cues modify the motor programme. They don’t just address the point of preparation but also introduce a sense of active intention to carry through the movement.

The posterior upper lock has an equally strong influence when working in supine. If the head is allowed to rest in backward rotation, the spine will be facilitated into extension via reflex activation. If you are hoping to relax the spine toward the floor, work with breathing or establish a neutral lumbar position from which to move the limbs, the upper lock will block it.

Taking the upper neck out of the extended position reduces extensor tone, which enables easier access to the back of the rib cage in breathing and diminishes the urge to force the spine toward the floor using the abdominal muscles. It should also make lumbopelvic mobility easier, as it will reduce the muscular resistance and joint compression caused by excessive spinal extensor tone.

Figure 3: Anterior upper lock. The head is held in a fixed position on the neck. Note the skin creases under the jaw

Figure 4: Neutral head carriage. The head floats in balance over the body, with an open throat angle

Rather than forcing the head and neck into a counter-lock, fold a towel to a thickness that will allow the person’s head and neck to settle into a relaxed neutral position when placed under their occiput (Fig. 2). There might be a need for many folds to begin with, but over time as this area of the body learns to open and lengthen, the thickness of the support can be reduced.

Anterior Upper (Throat) Lock

The anterior upper lock, or throat lock, is caused by a fixed contraction of the deep muscles on the front of the neck.

Like an over-trained show pony, the chin is tucked down or pulled in at the front, immobilising the head on the neck. This posture is just as responsible for neck pain as the posterior upper lock and can result from posture cues that encourage a person to pull their head back onto the plumb line. It is also prevalent in members of the health and fitness professions who have conscientiously attended to preventing the posterior upper lock, only to find themselves in a counter-lock (Fig. 3).

Co-Kinetic Journal 2020;83(January):29-36

MANUAL THERAPY

Rectus capitis anterior

Obliquus capitis superior Rectus capitis posterior minor Rectus capitis posterior major Longus capitis

Figure 5: Flexors and extensors of the head on the neck

Both the anterior and posterior upper locks alter the normal lordotic curve in the cervical spine and affect postural control by interfering with finely tuned head on neck movements.

A neutral head carriage allows the head to float in balance over the spine and be able to move freely and smoothly in all directions (Fig. 4).To balance the muscle activity between the muscles at the front and back of the upper neck, ‘head slides’ provide a low-stress opportunity for the brain to discover its mobility possibilities (Movement Exploration 1: Head Slides).

A low-effort motion such as the head slides reminds the muscles on both the front and back of the upper neck that they can lengthen and shorten, rather than being caught in a single point of range. It mobilises the joints and wakes up a connection to the deep upper cervical flexor muscles, key stabilisers of the neck (Fig. 5).

Movement Exploration 1: Head Slides

Lie comfortably on your back with knees bent. Allow your head to settle comfortably with your nose pointing toward the ceiling, placing a folded towel under the point where your head rests on the floor if necessary. Place a hand on the central bony projection that you can feel where your Figure ME1.1: Head slide start position neck meets your body (Fig. ME1.1). This is your C7 spinous process. Become aware not only of the point of contact where your head rests on the floor but of its distance from the spinous process under your hand. Slowly slide the point of head contact along the floor toward your hand just a little, subtly deepening the curve of your neck to introduce a sense of motion awareness (Fig. ME1.2). This Figure ME1.2: Gently sliding the head often persuades the neck muscles to release more easily toward the hand initially as you then slide your head in the opposite direction, away from your hand. As you do this, feel how the back of your neck starts to open and that your chin tucks in a little. The muscles at the back of the neck start to stretch slightly, storing elastic energy (Fig. ME1.3). When you reach a comfortable end point, reverse the movement, allowing a sense of mild recoil until you move just a little past your Figure ME1.3: Lengthening and opening original start point to emphasise the sensation of contrast. the back of the neck Slowly repeat this procedure, gliding smoothly and with minimal effort in each direction, feeling the mobility starting to become more available. Finally, allow your head to rest on the floor, and let that movement information assimilate in the nervous system.

was seen as desirable in the 1990s, but now that we understand more about it, we need to accept that more cocontraction isn’t necessarily better, and constant co-contraction is definitely not normal.

Fighting back tension with front tension is energetically costly, and increasing total tension results in the natural movement associated with postural control being blocked.

Posterior Lower (Lumbosacral) Lock

Deepening of the lumbar lordosis and tightening of the erector spinae in this area in response to movement creates what we will call the lower or lumbosacral lock (Fig. 6).

Abdominal weakness is often blamed for this postural response.

However, attempting to correct the lumbosacral position by increasing active abdominal tension creates excessive co-contraction, which – as we have discussed (see Chapter 1) – is a common neuromuscular dysfunction associated with chronic low back pain when used as a habitual postural strategy. Remember, co-contraction Co-Kinetic.com

“There’s no need to fight tension with tension: it leads to immobility. Posture is a dance, not a battle.”

If conscious correction isn’t the answer, what are our other possibilities?

When this postural lock is being driven by chronic muscle tension, we

Figure 6: Lower, or lumbosacral, lock

need to calm down the excessive activity in the erector spinae in order to make a deeper change. With the research indicating that the inability to effectively release the trunk muscles is strongly linked to the risk of low back pain (5), unpicking the lumbar lock is of even greater significance.

At this point we need to issue an invitation to the lumbar spine to relax and decompress. When we downregulate this habitual postural strategy, the brain must consider its other options. We open the door for the lower level autoactivation of the deep abdominals. This can be done using sacral rocks (Movement Exploration 2: Sacral Rocks).

You may still feel uncertain about the idea of relaxing into this position instead of creating it with

A FUNCTIONAL LOCK IS THE RESULT OF ACTIVE MUSCLE CONTRACTION RATHER THAN PASSIVE STRUCTURAL LIMITATION 31

Movement Exploration 2: Sacral Rocks To change the relationship between the lumbar spine and the pelvis, we need to develop an awareness of our sacrum. To perform a sacral rock, it is essential first to build the image of the sacrum as a curved bone that can be rolled over. Many people think it is flat, a misconception that creates a conflicting image for the movement that will be involved.

Cup your hand over your sacrum, with your fingertips pointing down toward your coccyx. Imagine the bone tapering down to that tip.

Feel the curved shape under your palm, and rub it to let the brain know where it is and how it feels (Fig. ME2.1). Once you have made that connection, we can begin.

Lie on your back with your knees comfortably bent. If you naturally have a little upper lock, place a folded towel under your head at the point where you feel the skull curve outwards. If you don’t neutralise the upper lock first, it will be very difficult to move the pelvis with ease. Finally, rest the palms of your hands on your ilia, the bones on either side of your pelvis (Fig. ME2.2).

Now notice where your body rests on the sacrum. Those with a habitual lower lock will normally rest toward the bottom tip of their sacrum. Those who have been trained to actively flatten the lumbar curve toward the floor in supine will want to assume a position at the top of their sacrum. It’s important to recognise that this is just another form of lock, a point of immobilisation that trains a lumbar posture that makes no sense once a person stands up.

“If you are training a spinal position lying down, make sure that it makes sense when standing up.”

If we know what our habit is, we can play with it. With minimal effort, roll slowly over the sacrum toward the tip of your tailbone. This will accentuate the lumbar extension (Fig. ME2.3). But wait ... isn’t this the

32

position that we are trying to avoid?

That’s the old attitude sneaking through. We identify a position we aren’t happy with and do the opposite, right? It’s time to update our thinking. Our aim is not to avoid a position but to teach the lumbar spine to be able to move freely through its entire range. A lock occurs at a specific point in that range and the spine needs to be reminded how to move smoothly through it in both directions.

To unpick a lock, we first need to introduce some motion. Moving more deeply into extension is in essence moving into the direction of preference, which will require less effort than heading into the resistance of flexion. Think of it as your sock drawer being stuck – you don’t pull harder to open it, do you? You push the drawer inwards to release whatever is catching it, and then it pulls open easily.

By moving into extension, you remind the erector spinae muscles how to dynamically contract again, the microscopic cross-links within each muscle recalling how to shorten the muscle fibres into inner range.

Instead of creating a lock by working continuously at a fixed point in their range, the muscles themselves are on the move.

Now that you have introduced some motion into the area by heading toward the tip of your tail, you can deepen your awareness of the soles of your feet connecting with the floor, and slowly roll back over your sacrum toward its upper margin (Fig. ME2.4). You are going to use as little effort as possible to do this, letting your abdominals fall toward the back of your pelvis. The erector spinae lengthen, allowing the lumbopelvic junction to open.

You will only move as far as the top of the sacrum at this point - if you go farther, you might be tempted to start forcing the spine down into the floor by overusing your abdominals.

Remember: we want the brain to discover that this is easy. This is an unlocking, not a forcing activity.

Figure ME2.2: Sacral rock start position, with hands on front of pelvis

Figure ME2.3: Sacral rock to the bottom tip of the sacrum. (Arms have been placed to illustrate the spinal position)

Figure ME2.1: Discover the curved shape of the sacrum

Figure ME2.4: Sacral rock to the top of the sacrum, with the abdomen falling toward the spine

“The sacral rock is much more specific to the lower lumbar spine than the more commonly used pelvic tilt, which often engages higher activity in the superficial abdominals. This increased abdominal activity actually blocks lower lumbar motion, shunting the movement farther up the lumbar spine and missing the opportunity to open the lumbosacral lock.”

Allow yourself to freely, smoothly, and slowly move from the top of your sacrum toward the tip of your tailbone, feeling how this draws your hands up and away from you. As you reverse the direction, feel how your hands not only move toward you but also drop back toward your spine. After a few repetitions, just switch off, relax, and note where your body falls onto your sacrum. For most people, this will now be somewhere near the middle of the sacrum, the apex of the curve of the bone. This is your sacral support position.

Co-Kinetic Journal 2020;83(January):29-36

MANUAL THERAPY

conscious abdominal setting. Let’s look at it logically: when supine, gravity is acting downward upon us.

This should encourage our spine to drop toward the floor, so to imagine that an excessive curve is caused by abdominal weakness makes no sense!

The only way it can be lifting off the floor into extension is if we are actively contracting the muscles of our back to push upward against gravity. It is primarily a tension problem of the back, rather than a weakness problem at the front.

In relaxed supine, there is no movement, neither is there any demand for postural control, so there is no reason for the erector spinae to be firing. If we cannot invite the spine to relax under these conditions, anything we teach to prepare for movement in this position is a coping strategy.

The sacral rock unpicks the

The Greyhound series is fundamental to the JEMS concept. It is an ideal first step toward learning how to feel a responsive but secure CLA (with balance between the anterior and posterior chains) and establish the sense of elastic connection between the limbs and trunk. Why is it called the Greyhound? The inspiration came from the shape of the slender racing dogs: as their limbs extend away from their bodies, their abdomens tuck up toward their spines reflexively in order to enhance the stretch and recoil of the myofascial structures connecting forelimbs through the body to hind limbs (Fig. ME3.1). So it will be with you.

Take up the position of lying on your back with knees bent and head on the folded towel if necessary.

Take a moment to find that relaxed central place on your sacrum, doing a few sacral rocks to remind yourself of what it is like to switch off and just let the body rest on the floor.

Place one hand on your belly just above your pubic bone. Lift the other and bend the elbow so that your fingertips trail toward the floor beside your head (Fig. ME3.2).

Relax completely, and slide your

Co-Kinetic.com

erector spinae’s fixed point of contraction, breaking the continuous neuromuscular holding pattern. When the sacrum can rest on a relaxed centre point, the spine takes up a natural, unforced position. From this easy point of reference, a person can explore the relationship between limb and movement and the central body.

Proprioceptively, it is much simpler than trying to work out where your spinal position should be relative to the floor, and it allows for individual variation in structure and shape. Elastic limb movement becomes possible as the myofascial tissues throughout the front of the body are allowed to lengthen in the absence of the fixed, conscious abdominal contraction that is conventionally used.

Think of wiring instead of just positioning. As far as the brain is concerned when it comes to moving

THE LUMBOSACRAL LOCK IS PRIMARILY A TENSION PROBLEM OF THE BACK RATHER THAN A WEAKNESS PROBLEM AT THE FRONT a limb, if the erector spinae muscles provide an adequate spinal stabilising strategy, it doesn’t invest more of the body’s energy in additionally firing the abdominals. When we observe this, we conventionally interpret it as weakness and fight the tension in the back by ramping up abdominal activity. Although this might change the spinal position, it also initiates an unnecessary battle that blocks the muscle length change necessary to make myoelastic connections

Movement Exploration 3: Greyhound Hand Slide hand along the floor until your arm has reached the end of its available range, allowing your spine to follow it (Fig. ME3.3). If you have accidentally held your breath, let it go, and feel how your back softens in response, dropping softly to the floor instead of arching upward. If you have remained relaxed, with no sign of bracing or setting your abdominals, you will find that your belly has sunk down toward your spine, just like the greyhound’s. From here on, we will refer to this as the Greyhound abdomen, as it will apply in many techniques. This is often taught as a conscious contraction, referred to in the research as abdominal hollowing or caving in, but it should occur naturally as an automatic postural response (6*).

Wherever the belly has sunk to, you will simply maintain it there to provide an anchor point that supports the motion of your hand sliding back in. Initially, you may feel your belly pop upward into your hand as you bring your arm in. This is just your brain trying out the old strategy. There’s no need to fight it. Just relax your spine again, repeat the sliding motion, and, this time, trust your body to support the movement without the need for so much effort.

You will see the Greyhound shape

appear in experienced practitioners in a wide variety of poses and movements, as it reduces tension and allows greater freedom in the hips and pelvis (Fig. ME3.4).

Figure ME3.1: The greyhound’s shape inspires this action

Figure ME3.2: Greyhound Hand Slide start position

Figure ME3.3: Greyhound Hand Slide lengthened position

Figure ME3.4: The Greyhound shape appears frequently in experienced movement practitioners

33

between the limbs and trunk.

If we take away the current stabilising strategy, however, the brain is provoked into finding another solution. By inviting the back muscles to relax, we create the opportunity for the abdominals to come back online.

It’s like tuning a stereo system – if we turn down the base a little, we can hear the treble. If our approach is one of neuromuscular balance, we can progress the strength of the entire pattern systematically without compromising movement potential.

This understanding will form the foundation of any of the supine movements that follow.

Integrating the Postural Learning

We have altered the balance of muscle activity around the lumbopelvic area, but this is not enough to make a transferable functional change – it has simply opened a window of possibility.

To make it meaningful, we need to learn what it is to move with an unlocked spine and a secure but elastic central longitudinal axis (CLA); to make it achievable we need to do this at a low level of skill and load demand. The Greyhound Hand Slide is a good way to do this (Movement Exploration 3: Greyhound Hand Slide).

“From a JEMS® (Joanne Elphinston Movement Systems) perspective, breathing during movement should be natural and uncontrived. lt is very tempting to cue action/breath matching (breathe in when you do this, and out when you do that), but at this low level of skill and load demand, you should be able to breathe independently of the movement, as you would in an everyday activity. We can, after all, walk and talk simultaneously without having to match our breathing to our steps. The easiest way to ensure this is to hum something simple to yourself, or speak out loud (complete nonsense is best) throughout the motion.”

Erector spinae: release or strengthen?

With our emphasis so far on releasing tension in the erector spinae, you might wonder whether you should still be including direct strengthening of this group in your programmes. The answer is an unequivocal yes. Erector spinae strength has been identified as a factor in spinal stability as well as in rehabilitation of lumbar spine injuries.

34

However, for safe, strong spinal extension, there needs to be a balance of forces around the spine to stabilise it throughout the motion. The erector spinae group is made up of relatively long fibres that cross many joints and – when unopposed – has a long line of pull, much like the string of an archer’s bow. To prevent excessive stress at any one level, a collaboration of stabilising muscles acting close to the spine (including psoas, multifidus and transversus abdominis) control the alignment relationships between each spinal segment and ensure that each level participates appropriately in the motion created by the erector spinae (Figs. 7–10). In this way, we preserve the CLA and create a foundation for strong, secure extension.

When the brain uses the lumbar lock as its primary stabilising strategy, the cooperative partnership that should balance the forces applied to the spine becomes distorted.

The altered ratio of erector spinae to transversus abdominis activity affects tensions in the thoracolumbar fascia (7*). Multifidus, the series of short, deep overlapping muscles lying adjacent to the spine, functions less effectively as a stabiliser in the shortened state that the lumbar lock imposes (8). A fixed lumbar position will affect the healthy variable function of psoas, which changes its role in response to spinal position (9*).

Easing the lumbar lock is therefore an important step toward re-establishing equilibrium.

From a strength point of view, if any muscle is habitually held at the fixed, shortened length, as the lower erector spinae are in a lumbar lock, they do not necessarily function well when asked to change length eccentrically and concentrically. The muscles may be strong in a limited range but behave as if functionally weak once asked to work outside this range. They may even forget how to release – which they should at endrange spinal flexion (10*). Releasing the lock allows the muscles to reset to a more neutral length at a lower baseline level of activation. This makes more of the microscopic cross-links within the muscle fibres available, which, in turn, creates greater strength potential.

Psoas minor Psoas major Iliacus

Figure 7: The significant spinal attachments of psoas

Multifidus

Figure 8: The short fibres of multifidus sit close to the spine

Figure 9: The long fibres of the muscles comprising the group known as the erector spinae

Co-Kinetic Journal 2020;83(January):29-36

MANUAL THERAPY

The Power and the Grace

Transverse abdominis

Figure 10: Transversus abdominis contributing to spinal support through its connections into the thoracolumbar fascia

Once you have released the lumbar lock, the next step is to integrate the change. Hot Toffee (Chapter 8) and Superman (Chapter 4) movements both offer a low-load opportunity for the deep abdominals, psoas, multifidus and erector spinae to renegotiate their roles.

Summary

This article has described what postural locks are and how they can be created by the adoption of a habitual specific stabilising strategy. The posterior upper (cervical) lock, the anterior upper (throat) lock and the posterior lumbosacral lock have been discussed along with techniques for encouraging the gentle release of these locks.

Chapter 6 of the book then goes on to discuss the posterior rib lock, the anterior hip lock and how a good breathing action can improve posture.

References 1. Hodges PW, Coppieters MW, MacDonald D et al. New insight into motor adaptation to pain revealed by a combination of modelling and empirical approaches. European Journal of Pain 2013;17(8):1138–1146 2. Tsao H, Galea MP, Hodges PW. How fast are feedforward postural adjustments of the abdominal muscles? Behavioral Neuroscience 2009;123(3):687–693 3. Lee LJ, Coppieters MW, Hodges PW. Anticipatory postural adjustments to arm movement reveal complex control of paraspinal muscles in the thorax. Journal of Electromyography and Kinesiology 2009;19(1):46–54 Co-Kinetic.com

By Joanne Elphinston Handspring Publishing 2019; ISBN 978-1-912085-38-5 Buy it from Handspring https://www.handspringpublishing.com/product/thepower-and-the-grace/ Designed for Pilates and yoga teachers, health and rehabilitation professionals, The Power and the Grace demystifies functional movement and integrates the science of movement with the art of teaching it. It aims to help the holistically minded movement professional achieve rewarding results in neuromuscular function.

From brain science to physics, fascia to emotion, this book distils a seemingly complex field into a practical and instantly usable approach that will resonate with movement teachers at all levels of experience. Find the colour in your language; learn the difference between talking to the brain or to the mind; and discover how to communicate the intention and sense of a movement with ease!

Contents

Introduction Chapter 1: The movement kaleidoscope Chapter 2: Moving the brain Chapter 3: Dancing with Forces Chapter 4: Myofascial magic Chapter 5: Vibrant self carriage Chapter 6: Locks and keys Chapter 7: The living spine Chapter 8: Control through ease Chapter 9: Base notes Chapter 10: Ups and downs: mastering the vertical Chapter 11: A leg to stand on Chapter 12: Elegant, effective gait Chapter 13: A shoulder to lean on Chapter 14: Winning our wings Chapter 15: Speaking the brain’s language Chapter 16: Reflections

4. Müller R, Häufle DF, Blickhan R. Preparing the leg for ground contact in running: the contribution of feedforward and visual feedback. Journal of Experimental Biology 2015;218(Pt 3):451–457 Open access https://spxj.nl/347e28e 5. Cholewicki J, Silfies SP, Shah RA et al.

Delayed trunk muscle reflex responses increase the risk of low back injuries. Spine 2005;30(23):2614–2620 6. Vleeming A, Schuenke MD, Danneels L et al. The functional coupling of the deep abdominal and paraspinal muscles: the effects of simulated paraspinal muscle contraction on force transfer to the middle and posterior layer of the thoracolumbar fascia. Journal of Anatomy 2014;225(4):447–462 Open access https://spxj.nl/2RHHyi7 7. Ward SR, Kim CW, Eng CM et al.

Architectural analysis and intraoperative measurements demonstrate the unique design of the multifidus muscle for lumbar

spine stability. Journal of Bone & Joint Surgery (Am) 2009;91(1):176–185 Open access https://spxj.nl/2OTdexZ 8. Regev GJ, Kim CW, Tomiya A et al. Psoas muscle architectural design, in vivo sarcomere length range, and passive tensile properties support its role as a lumbar spine stabilizer. Spine 2011;15;36(26):E1666–1674 9. Laird RA, Keating JL, Ussing K et al. Does movement matter in people with back pain? Investigating “atypical” lumbo-pelvic kinematics in people with and without back pain using wireless movement sensors.

BMC Musculoskeletal Disorders 2019;20(1):28 Open access https://spxj.nl/37LG9g3 10. Bordoni B, Marelli F. Failed back surgery syndrome: review and new hypotheses. Journal of Pain Research 2016;9:17–22 Open access https://spxj.nl/2QUHStA. 35

KEY POINTS

lA ‘lock’ is an immobilising response in a part of the body that is used for stabilisation regardless of the task’s demands. l L ocks can be classified as either foundation or functional. lA foundation lock is one that is present in the person’s posture whether they are in motion or at rest. lA functional lock appears in response to the impulse to move – the feedforward response. lP ain, injury or other postural influences can create alternative feedforward responses, and these habitual points of movement preparation are in fact functional locks. lS tretching, massage and mobilisation can treat the symptoms of these functional locks, but lasting change comes from changing the motor programming. lC ommon postural posterior locks include the upper (cervical) lock, posterior rib lock, lower (lumbosacral) lock. lC ommon anterior locks include the upper (throat) lock, the anterior rib lock and the anterior hip lock. lT reating the locks involves uncovering different neuromuscular and postural possibilities rather than simply countering them with forced muscle actions. l The movement exercises performed to unpick the locks are done at a low level of skill and load demand.

DISCUSSIONS

l What purpose is a functional lock fulfilling as part of a person’s movement strategy? Ie. why might you see a functional lock appearing? l Think about the functional locks discussed in this article.

How could you plan to identify them when assessing your patients? l Work through the movement exercises and observe the effect on your own posture. How do you feel about your own neuromuscular balance and how you would communicate the desired effect to your patients?

Want to share on Twitter?

Here are some suggestions

Tweet this: Our posture should flow with ease through dynamically changing positions as we move https://spxj.nl/2YyEdDx Tweet this: If postural control is compromised, we can adopt a habitual stabilising strategy, creating a lock https://spxj.nl/2YyEdDx Tweet this: Excess co-contraction is a common neuromuscular dysfunction associated with chronic low back pain https://spxj.nl/2YyEdDx Tweet this: Inability to effectively release the trunk muscles is strongly linked to the risk of low back pain https://spxj.nl/2YyEdDx Tweet this: The movements performed to unpick postural locks are done at a low level of skill and load demand https://spxj.nl/2YyEdDx 36

THE AUTHOR Joanne Elphinston is a high performance consultant for professional dancers, musicians and elite athletes at Olympic level; a consultant physiotherapist specializing in chronic and persistent neuromusculoskeletal conditions; a former coach and fitness instructor and the author of several popular books in the field of movement.

Joanne has been teaching her unique JEMS® approach for over twenty years, training rehabilitation, health and fitness professionals around the world to explore, inspire and optimize movement in people of all ages and walks of life. Her work is the subject of current research into management for hypermobility related pain, falls prevention, stroke rehabilitation and sports performance, and her programs are used in such diverse fields as child development, chronic pain management, and athletic training.

Joanne has a passion for communicating complex concepts in simple, elegant ways that bridge the gap between professionals and their clients, allowing them to work holistically yet functionally, supported by science, and balancing knowledge with skill and humanity.

Website: http://www.jemsmovement.com/ Facebook: https://www.facebook.com/joanne.elphinston.1

RELATED CONTENT

lR ole of the Thorax in Treatment of Recurrent Hamstring Injury [Article] https://spxj.nl/2Qwjxu8 l Assessment of Fascial Dysfunction [Article] https://spxj.nl/35L1gNV l Yoga and Biomechanics: A New View of Stretching Part 1 [Article] https://spxj.nl/2KAQEd8 lY oga and Biomechanics: A New View of Stretching Part 2 [Article] https://spxj.nl/2ZcRCEZ

Co-Kinetic Journal 2020;83(January):29-36

ENTREPRENEUR THERAPIST

THE BLUEPRINT FOR RUNNING A SUCCESSFUL OPEN CLINIC EVENT: Part 5 ON SCORES S R THE DOO LE SSONS LEARNT

And Where to Start With Your Event

By Vicki Marsh, Massage Therapist, Owner of the HeadStart Clinic 20-01-COKINETIC FORMATS WEB MOBILE

Overview

PRINT

These results are taken from the past two years of the Open Clinic event that I run at my Headstart Sports Injury and Performance Clinic, based in Cambridge, UK. In 2018, we focused on offering only 1-to-1 appointments with the aim of testing a range of follow-up offers to convert these taster appointments into paying clients. We also worked with some fellow therapists to offer a range of additional appointments such as nutrition and gait analysis. This helped all those of us involved to build our email list and expose ourselves to more prospective customers. We had 287 appointments available in total (145 of which were non-massage and 142 of which were specifically massage).

In the results below, we’ve focused on the massage-only appointments so

If you’ve been following along with this series, then this is the article you’ve probably been waiting for. This is where we give you the numbers behind our Open Clinic event, show you just how effectively events like this can help to build your business, offer you some lessons we continue to learn every time we run these events, and, most importantly, where to start when it comes to organising your own Open Clinic event.

There are four articles that precede this one, which take you through the full planning, organisation and marketing of your event, you can find links to those articles in the Related Content box at the end of the article. Read this article online https://spxj.nl/2RETdyo we can compare like with like across 2018 and 2019, but it was a great experience to team up with fellow therapists and I’d definitely do this again in future events.

In 2019, we had one less room available to run the event, so we had less availability, and I had a 2-monthold baby – so the aim for 2019 was to make the week EASY, rather than overcomplicate it with additional therapists as we did in 2018.

In 2019, we had 145 free

30-minute trial massage appointments available, which we sold out.

S E DOOR H T N O S CORES 2018 2019 Email sign-ups

463

516

Attendees (for massage appointments)

142

145

l Pre-event new clients sales

£300

£375

l New clients sales

£1026 £927

Immediate sales

l Membership sales × 6 (annual value) £3960 £4320 TOTAL INCREASED REVENUE

Co-Kinetic.com

£5286 £5622

37

As I described in the previous articles, I sent emails to my existing email list asking them to sign up to an early-bird list if they were interested in getting early notice of the free appointments offered during our Open Clinic event.

We also used Facebook to encourage additional sign-ups to this early-bird list and spent £60 in Facebook advertising which generated an additional 34 new leads (cost per lead of £1.76).

When someone signed up to the early-bird list, they received a one-time-offer (OTO) on the thank you page offering them a discounted massage before they attended their free appointment. In 2018, we offered a 60-minute massage session for £19.

In 2019, we offered the same session for £25. Uptake was about the same regardless of the price increase. These were classified as the ‘pre-event sales’ and covered our advertising costs more than 6-fold.

If we’d had a greater capacity for appointments, we could have easily generated more bookings, unfortunately we didn’t have the space, as we were also continuing to deliver our usual appointment bookings for that week.

In addition to the new sales, we also sold six memberships at each event. The membership package is based on an annual commitment to a given appointment length and regular frequency like once or twice a month, with a discount applied. This has the benefit of giving us a reliable source of recurring revenue, which allows us to plan more reliably for ongoing staffing and other business overheads.

It’s definitely something I would recommend offering.

The figures in the table covered

38

just bookings from new clients to the clinic, but we also reactivated some old clients. Unfortunately I’ve moved booking systems since we ran the event, so I don’t have access to this data yet.

One major benefit of this kind of event, which is often underestimated, is the morale boost to both the team and the clients overall, which also helps significantly with rebooking and retention rates for the following few months.

As you can see, in 2018 we generated an additional £5,286 in revenue from our Open Clinic event, and in 2019, £5,622, so all in all, a very good result.

The point is, that just because the price is low or free, doesn’t mean people are going to sign up in their hundreds, we still have a responsibility to let them know how awesome our service is and make sure we explain it in ways they can understand (aka not medical talk!). Patient information is really important here.

LESSON 2: You Can Never Contact People Too Much

T S LEARN N O S S E L

LESSON 1: Despite What You Might Think, it’s Actually Hard to Give Things Away for Free

Every year we run this event, I’m consistently surprised at how difficult it is to give away a free appointment.

You would think that people would come flocking, and be SO grateful for the opportunity to get our services for free. But every single year, I still have to explain the value of what we do.

And this is where your content marketing is SO important. Getting in touch with them on a regular basis, is really, really important. Ideally this would be through regular emails to your email list, but you can also use social media.

This is a key element in communicating the value of what you do, and how it can benefit them by increasing their quality of life, reducing their risk of injury and pain and having a beneficial effect on other health markers.

Each year I test sending more emails to the list, both to the new clients, AND to our current clients. And every single year those extra emails result in additional sign-ups we would have otherwise missed. And contrary to what you might think, the unsubscribe rates don’t increase either.

If someone’s going to unsubscribe they’re likely to do it in the first few emails that you send. So these extra emails are for the client who hasn’t been opening previous ones, or has been opening them but may have been too busy or forgotten to sign up, register or buy.

We still get about 10% of the email list sign up every time we send an email to people who haven’t yet registered. 10%! For most clinics that’s a decent number of clients coming through the door that we’d miss, if we didn’t email them that extra time.

Make sure you’re using a proper email service provider, something like Mailchimp, so that people can unsubscribe freely. You can never email them enough, and remember we’ll always tend to under-promote rather than over-promote, so I’d definitely encourage you, especially if you have been giving them value in between your Open Clinic events, to email that extra time, just to get those additional one or two people to register.

Co-Kinetic Journal 2020;83(January):37-40

ENTREPRENEUR THERAPIST

LESSON 3: You Must Have a Follow-Up Plan

You can’t rely on clients attending an event like this to automatically ask you about how to rebook.

If you are doing free appointments for your Open Clinic, remember a jump to a full price appointment might be quite a big step for them, so make sure you have a plan of how to take them on that journey from the free appointment to becoming a regular client.

Yes, some clients want to rebook straight away and that’s fantastic. But don’t forget about those ones who need a little bit more warming up and perhaps need another one or two appointments with you to fully realise the benefits of what you offer. One of the strategies we use if we feel the customer needs a bit of extra warming up, is to offer an additional one or two appointments at a discounted or stepped price, to make the graduation to full price, a little easier.

LESSON 4: Leave the Door Open

We have two types of clients from these events – those who rebook within 6 weeks (short sell), or those who do rebook but take longer than 6 weeks to do it (long sell).

In most cases for events like this about 60–70% of attendees will be long sell, meaning that they will come back, but at a later date.

So leave the door open and keep in contact with them. If you have a good email nurture process in place focused on adding value throughout the year, this will help hugely. Don’t just shut off the potential of a relationship with them, because they didn’t book straightaway. That’s a bit like telling someone you won’t see them again, because they don’t want to marry you

Co-Kinetic.com

on the first date!

This is where your content marketing and regular nurturing is going to be super-important. We use the Co-Kinetic system for this because it’s really easy to deliver high-value emails with great patient information resources, and blog posts each and every month. Then when the topic comes up that is relevant to your longsell person, they’re much more likely to take action and book in.

In terms of what you can expect, a 30–40% rebooking rate from Open Clinic events like this is normal, so don’t forget those ones who didn’t rebook at the time but just need more warming up.

LESSON 5: If You Work With Other People, it’s Vitally Important to Train Your Team

You may have spent a bunch of time reading articles like this one, learning about how to market an event like this and understanding how to convert clients from a trial appointment or an offer, but your team probably hasn’t.

So when it comes to running an event like this, never underestimate the importance of training your team.

Regardless of whether you have a large team, or just one other therapist that you’re teaming up with for an Open Clinic event, it’s really important that you’re on the same page. If you’re going to put in the effort to get clients coming to the practice, then you want to make sure that you can retain and convert as many of them as possible as well as deliver a great experience, so they will recommend you to other people in the future.

Explaining to your team that these clients are not the same as your normal clients is really important. We are normally fortunate that the clients who

come to appointments with us are hot, meaning that they are already looking and prepared for multiple appointments to fix the problem.

But somebody coming for a taster session is unlikely to be in this position.

They are literally just wanting to try an appointment out, and probably weren’t planning on that day necessarily, to sign up for a course of treatment.

Let your team know this, so they can focus on informing and educating clients about what you can do and how you can help people.

LESSON 6: An Offer is Worth Running Even if Nobody Buys

In 2019, because I had such a lot on my plate, I kept the event simple for both myself and the team, and stuck with offering free massage taster sessions. In 2018, however, I was more experimental.

We tested offering lots of different types of events, particularly specialist massage treatments like cupping, to get a feel for the uptake, and to get a better idea of what our client base actually wanted.

A lot of us when we’re looking at growing a business get really worried about doing offers. We worry about it being too expensive, or too cheap, or whether we’re going to sell any, or too many. But actually all of that is great, because we get data, we get information.

We need to test to find out if what we’re offering is what our client base actually wants. If we sell a lot of certain types of treatments or offers, we know that we’re giving them something they really want. If we don’t, then we know that we need to tweak something about that offer.

Last year we did an offer on exercise rehabilitation and it failed

39

miserably, but that wasn’t because my clients didn’t want practical steps to help improve their situation, it was because the marketing copy that I wrote didn’t actually explain the value of the offer to them. When I spoke to clients individually and recommended the offer to them, they bought it. The lesson I learnt, was that testing how I describe an offer is just as important as the offer itself.

In order to be able to grow, or in the future if you’re hiring a team, you want to have a good set of tried-andtested offers or experiences in the bag, that you can pull out as and when needed, and these Open Clinic events are a fantastic testing ground for those offers. So, don’t get disheartened if something doesn’t sell, just remember that you’re the boss, and there’s nothing to stop you, one week later,

sending out a different offer with a slight name change or adjustment and try again. It really doesn’t matter, no one’s going to care, but you’ll be in a much stronger position to make more money in the longer term.

Where to Start

So, if this article series has inspired you to run your own Open Clinic event, where should you start?

Firstly, remember that the event I’ve described, is only one form of an Open Clinic event. There are lots of variations on a theme such as smaller evening education events, or tasters of other appointment types that you can offer like bike fits, or gait analysis.

The important thing is to get new prospective clients in front of you, with a plan to convert them to a paid plan.

The type of event that you run is

THE AUTHOR Vicki Marsh teaches massage therapists and clinic owners how to start, grow and scale their business freeing up their time, building confidence and earning more money. She is the founder of the Massage Therapist Business School, hosting the Massage Therapists’ Business & Marketing Podcast and running the Clinic Business Growth Membership site which provides actionable business advice tailored to massage therapists & clinic owners. To find out more visit www.massagetherapistbusinessschool.com or www.massagetherapistbusinessschool.com/clinicbusinessgrowth to get your 7 day trial of Clinic Business Growth.

RELATED CONTENT lT he Blueprint for Running a Successful Open Clinic Event: Part 1 Concept and Planning [Article] https://spxj.nl/2rrhPME lT he Blueprint for Running a Successful Open Clinic Event: Part 2 Strategies for Marketing Your Event for Free [Article] https://spxj.nl/2QRQsHe lT he Blueprint for Running a Successful Open Clinic Event: Part 3 Your Paid Marketing Strategy [Article] https://spxj.nl/2XvD9Pm lT he Blueprint for Running a Successful Open Clinic Event: Part 4 Your Sales and Conversions Strategy [Article] https://spxj.nl/32dyq6T

40

completely your choice. I have a multitherapist set-up, where predominantly massage appointments are offered, and I like the ‘occasion’ of an Open Clinic event.

EVENT THE N W O R U O Y FOLLOWING N A L P

STEPS WILL HELP:

1. Go back and re-read the articles now that we’ve outlined the full picture. By doing this you’ll be able to pick out what you want to do for your event much more clearly.

2. Listen to my Massage Therapist Business and Marketing podcast (see links below).

3. Keep your first event simple.

4. Have a clear focus, eg. to bring in more new clients or fill a new therapist’s diary (the goal in this case would be to promote their specific services).

5. Be prepared to run a repeat event in 6 months’ time.

This way you’ll be able to refine the process and use the lessons you’ve learnt to build an amazing event that will eventually, like we do, reach hundreds, even thousands of new clients each and every year.

If you have any questions about this process, or want any support, make sure you subscribe to the Massage Therapists’ Business and Marketing podcast and you can contact Vicki over at hello@ massagetherapistsbusinessschool.com. I’d love to see some photos of you at your Open Clinic event.

The Massage Therapist’s Business and Marketing Podcast

For those of you who are not familiar with Vicki Marsh’s Podcast, it’s worth checking out because it features some extremely clever but practically-focused tips and strategies for overcoming many of the marketing hurdles that physical and manual therapists commonly experience.

Recent Episodes

l Ways to easily fill a new therapist’s diary! https://spxj.nl/36rlT1X l 5 Secrets to creating Social Media Content when you’re feeling Burntout! https://spxj.nl/38qgYjG l 11 Easy Ways to add Extra Income to your Business https://spxj.nl/2P81LMd l What is a fair wage for a therapist anyway?! https://spxj.nl/2NFT63g l Overcoming fear around rebooking https://spxj.nl/2ZmtRdC l The Secrets behind the offers I use for our Health Week (step-by-step walkthrough episode!) https://spxj.nl/2ZrgF2h

l 3 ways to break the feast:famine diary cycle https://spxj.nl/2KYjXGa l How to make scarcity your friend (and earn you cash!) https://spxj.nl/30AH7Ic l Turn Cancellations into Rebookings https://spxj.nl/328ThrQ

Listen at the Links Below

l Soundcloud https://spxj.nl/2NzlF2z l Spotify https://spxj.nl/2MERNlF l iTunes/Apple https://spxj.nl/341WefE l Google Podcasts https://spxj.nl/2ZxUc7I l Or through Co-Kinetic https://spxj.nl/2Ht1jnB l It’s also available on all the major podcast mobile apps.

Co-Kinetic Journal 2020;83(January):37-40

ENTREPRENEUR THERAPIST

Should I Use Social Media For My Physical Therapy Business?

If So Why, and How? 20-01-COKINETIC FORMATS WEB MOBILE

PRINT

BY TOR DAVIES, CO-KINETIC FOUNDER

Social media. Some people love it, some people hate it and the rest of us tolerate it, mostly begrudgingly. However, as a small business owner you’d be a little bit mad to ‘diss’ it. Yes, it’s unlikely that you’ll ever hit on something that will go ‘viral’, despite your best efforts and yes, you can get yourself in hot water if you’re very outspoken. Perhaps more importantly, you can waste a huge amount of time on social media, and never get any kind of return on that investment. But in reality, that will only happen if you post without having a solid strategy. In this article, I’ll outline the strengths of having active social network pages but more importantly review what you can achieve for your business by having a good social media presence.

I will look at the key objectives for healthcare-based businesses and explain what you should be prioritising and why.

Lastly, I’ll answer some frequently asked questions such as which platforms should you be using, how many times a day should you be posting and whether or not you should you be spending time on more than one platform. We also cover some social media trends for 2020. Hold onto your horses….! Read this article online https://spxj.nl/2rst0bG Co-Kinetic.com

S

ocial media has become a vast and wide open canvas, and taking full advantage of it requires careful strategic planning. A good social media strategy, not just should, but WILL, have a positive and demonstrable influence on sales.

Let’s jump right in and look at some of the strengths of social networks and what you can achieve with a social media presence.

What Are The Strengths of Social Networks?

lT hey’re great for building relationships - specifically designed for human interaction, engagement and sharing lG reat networking potential

lY ou can do it all from the comfort of your living room lY ou have access to a huge, highlytargetable group of people lR eviews and testimonials, which feature highly, at least on Facebook, are very influential sales converters l Social

networks are widely used - 67% of the UK population are on Facebook, 72% of Australians, 60% of New Zealanders, 77% of Canadians and 69% of Americans lA ll the major social networks are free (until you utilise paid ads) lP eople are on social networks, primarily to socialise, so they encourage a more personal, valueadd approach, than a sales approach which suits healthcare practitioners.

41

What Can You Do with a Social Media Presence?

I’ve divided this section into subjective and objective goals. If you know me, you know which my favourite will be, but I’ve covered both because I’m trying to give you a ‘global’ view of how social media can help build and support a business.

Subjective Goals (RelationshipBuilding and Influencing) 1 Interact with your customers/ develop and build relationships – ask for opinions, reply to concerns ld o a free Q+A once a week – you could use one post and always link back to it and pin it to the top of the page on your Q+A day – builds engagement and reduces the risk of people asking the same questions 2 Humanise you and your business lg ood in healthcare because health is intimidating to many lh aving a good social media profile can break down barriers of the unknown and make you less intimidating 3 Establish and build trust and reputation – our health makes us feel vulnerable, we have to expose pain which can be very personal, trust is a key element in the decision process to become a paying customer 4 Networking and participation in local groups helps to raise awareness of you and if the group is a local group, you know your audience is targeted

SOCIAL MEDIA IS A GREAT WAY OF STAYING TOP-OF-MIND

42

5 Establish your brand as a thought-

important if you publish a blog, good if you combine with email lead collection 16 Use it to carry out research – by using polls and asking questions 17 Inbuilt reporting and analytics – proving direct ROI

leader by publishing content, particularly when new research emerges or something topical happens in your industry 6 Encourage reviews and testimonials which are a key feature of particularly Facebook, and are one of the most powerful influencing factors for sales conversions 7 Partner with external influencers or other complementary local businesses to promote each other lw ord-of-mouth as a marketing strategy can generate 20% of all sales 8 Social media is a great way of staying top-of-mind 9 Your competitors are most likely to also be on social media which means if you’re not, you’re potentially losing customers. On the plus side, it also gives you a way of keeping an eye on your competitors 10 Social media is a great way for customers to research YOU 11 Search engines may already be using “social presence” as a factor in their rankings, something which is likely to grow with time.

Objective Goals and Preferably SMART Goals

The most important thing when it comes to social media, is to start with what you want to achieve from your efforts and at least some of these goals need to be specific and measurable, so that you can be confident you are getting a return on your investment.

As small businesses, most of us don’t have the luxury of assigning budget that doesn’t result in something quantifiable. Bigger companies have more financial ‘space’ to do it, for most of us, we don’t. Return on investment is superimportant and the same goes for social media.

It may not therefore surprise you, that as I’m quite a results-orientated person, I’m going to start by prioritising quantifiable objectives, and particularly the first three in the list above.

Objective Goals (Nice and Quantifiable ) 12 Generate email leads using

Goal 1: Using Your Social Networks to Build an Email List

email lead collection forms or information requests in return for free downloads 13 Reviews, testimonials and social proofing 14 Utilise paid advertising to target new customers or retarget previous visitors to your site or social media profile 15 Increase traffic to your website –

For me, Facebook is one of my main ways of building my email list. I do this in the same way that I recommend you do it. That is, by giving away content and knowledge, in exchange for an email address and an opportunity to build trust and continue to add value.

At the same time in a very low key way, I take opportunities to raise awareness of what I can offer, to help you do the parts of your job that you don’t necessarily enjoy, more quickly and hopefully also more effectively.

The trouble is that as we know, Facebook in particular, has dramatically reduced the number of organic (unpaid for) page posts that are shown on personal profiles. And when I say dramatically, I mean it. Nobody actually knows the real number, but it’s believed that less than 1% of your Facebook followers will even see a Page post that you post.

That means if you have 300

Co-Kinetic Journal 2020;83(January):41-46

ENTREPRENEUR THERAPIST

followers, only 3 people are likely to see a post you publish on your page.

Just 3 people. And of course the 3 who do, will be the ones who engage most frequently with your content.

Which means it will always be the same handful of people that see all your posts…not that helpful when you’re trying to spread the word about your business further afield, at least without paying to do it.

But to be fair, why shouldn’t we have to pay for it? Just because social networks have always been free, why do we expect them to help us grow our businesses for nothing?

We accept that we have to pay to promote our business in a local newspaper or magazine, or an online directory, but we begrudge having to pay a social media network like Facebook, despite the fact that we can target in such a specific way, that no local publication could get near in terms of specificity.

Never in the world have we had the power, literally at our fingertips, to be able to target for example, men with a serious, club-level interest in cycling, between the ages of 35-50, who live within 5 miles of our clinic. But we can through Facebook, and damn that’s worth paying for if you ask me!

I’d rather spend £500 collecting email leads of, or promoting a professional bike fit service to, 200 people who live within 5 miles of my clinic who I know have a serious interest in cycling, rather than to 20,000 readers of Cycling Weekly who live all over the country, potentially all over the world, who may or may not even see, let along open that particular copy of the magazine I’ve placed my ad in.

Not only that but my ad has got to be spotted through the noise of everything else going on in that magazine which is way too much of a gamble in my view (and I’m a publisher of a magazine!).

And if you take one step away from selling an actual product or service in that ad, and concentrate on building your email list by offering high-value, targeted content to your audience in exchange for an email address, then you own that contact. They become part of your email list, which if you follow my recommendation to nurture those leads, by continuing to add Co-Kinetic.com

value, instead of spamming them with sales offers, that lead becomes infinitely more valuable, and you’re in charge, not Facebook. Suddenly, that £500 has become a real and genuine investment.

A GOOD SOCIAL MEDIA STRATEGY WILL HAVE A POSITIVE AND DEMONSTRABLE INFLUENCE ON SALES

Goal 2: Social Media and Social Proofing or Word of Mouth Marketing (WOMM)

Another key part of my strategy is to build social proof through my social networks, in the form of reviews and testimonials about the things I do (be it my webinar) or the subscription services I provide, in the words of the people who are actually using my content.

I can tell you that my products are amazing until the cows come home, but in this day and age, where there is so much spin applied to so many aspects of our lives, it’s hardly surprising that most of us wander around feeling perpetually dizzy and confused. The words of my subscribers and webinar attendees are many times more powerful, persuasive and believable for prospective customers, than anything I could ever say, and quite rightly so. The same is true for your patients.

This is why I place such an emphasis on it in my webinar (details at the end of the article), and why it ranks so highly in my 20% of activities that will give you 80% of your marketing results.

‘Word of mouth’ referrals are probably the oldest and most influential form of ‘marketing’ in the world, (can anyone think of anything that’s been around longer?), and with the addition and value placed on social proofing on social networks, it’s influence looks set to continue growing.

Some Statistics (1) l8 3% of consumers say they either completely or somewhat trust recommendations from family, colleagues, and friends about products and services – making these recommendations the highest ranked source for trustworthiness [Nielsen] l9 0% of people trust suggestions from family and friends [HubSpot] 43

people to sign up to my webinar and trusting my information, through to purchasing my subscriptions.

l7 0% of people trust consumer reviews online [HubSpot] l7 4% of consumers identify word-ofmouth as a key influencer in their purchasing decision [Ogilvy Cannes] l6 8% of people trust online opinions from other consumers, which places online opinions as the third most trusted source of product information [Nielsen] l8 8% of people trust online reviews written by other consumers as much as they trust recommendations from personal contacts [BrightLocal] l7 0% of consumers reported always or sometimes taking action based on online consumer opinions [Nielsen] lH owever…only 33% of businesses are actively seeking out and collecting reviews.

Goal 3: Use of ‘Paid Social’ or Paid Ads

How many reviews do you need in order for social proofing to count?

In 2014, 4-6 reviews were deemed sufficient to get 56% of people to trust your business [BrightLocal]. In 2017, the stats were suggesting that viewers would read at least 7 reviews before making a decision [RealTimeReviews. com]. In 2019, TrustPilot are saying you can never have enough reviews.

I certainly believe the more the merrier, as long as the reviews are real, genuine and authentic, and they don’t all have to be good, as long as you deal with the negative ones in a positive way.

There are a couple of other factors about reviews that are important in addition to the stats above.

1 They represent user-generated content and user-generated content is being increasingly prioritised, particularly in search engine rankings, so it’s very feasible that your reviews will positively impact your SEO, perhaps increasingly so as time goes by.

2 Social proofing is a great way to quickly build credibility with new customers and strengthen your credibility with existing customers.

3 Online reviews boost conversions all the way through the marketing funnel, or customer journey as I prefer to refer to it, all the way from, in my case, encouraging 44

As I’ve already described, utilising ‘paid social’ like Facebook ads, can be extremely powerful when you have a proper strategy and a quantifiable goal that can generate actual revenue ie. building your email list which you then nurture and convert using conversion events (see my webinar for more details).

You can obviously also use paid ads to promote events which lead to direct sales, I just happen to be a fan of a more subtle, less-salesy, more valueadd approach. It might be a slightly longer game plan, but ultimately it will reap better rewards. Or you can use a combination of both. But if you’re going to spend money, please make sure that you have a way of generating a return on investment ie. a full customer journey in place which leads to paid bookings.

You can also use retargeting very effectively. For example you could promote an event such as a minibike fit, to people who have visited a blog post on your website on cycling injuries. Because you’re targeting someone you know has a specific interest in the promotion you’re running, your ‘conversion’ rate ie. getting that person to take the action you want, is likely to be much higher, than if targeting colder people.

Other Quantifiable Goals

Increase Traffic to Your Website Publish a blog post on your website (ideally with an inbuilt email lead collecting component – see my webinar for more details) and use social media to promote this blog post.

This is great for establishing trust and building reputation and authority and obviously you can use tools like Google Analytics to see the number of people this pushes to your site. I have a couple of caveats. Yes, blog content is good for SEO but it’s hard to quantify and it takes time to have an effect. If you add in an email lead collection component, in other words offer your

Co-Kinetic Journal 2020;83(January):41-46

ENTREPRENEUR THERAPIST

reader even more value content in exchange for their email address, then that blog post becomes even more useful.

Supplement promoting those social media posts which lead to your blog post, with paid advertising so that it reaches a much wider (but targeted) audience, and things get much more interesting. But you can’t just publish content to your blog, and expect it to work wonders without investing in promoting it.

l

l

l

l Polls and Surveys These are great for building engagement as well as getting a better feeling for what your audience is looking for or interested in. Why not say something like, you’re thinking of producing some injury leaflets on the following topics, offer a list of topics, and ask them to vote. Or you could ask people if they’ve ever had trouble sleeping as a result of back pain – yes/ no. Then post a link to a leaflet with advice on getting better sleep if you suffer from back pain.

It’s a good idea to build the engagement first, before you go and provide the leaflet, because you’ll get more traction on the post. Again you could supplement this by using paid ads to push the post out more widely.

Reports and Analytics The beauty of most social networks is that they provide this for you, for free.

You can gather all sorts of data, and it’s all collected and analysed for you without you having to get involved with spreadsheets.

Subjective Goals

I think the first section went into this in sufficient detail but the ways I feel social media can benefit healthcare practitioners most of all under this category are: l T o build and reinforce trust, authority, reputation, credibility and confidence in YOU - by publishing content on your social network page that is authoritative, reflects knowledge, professionalism and helps to increase awareness of, and reinforce the role you can play in various elements of health l T o build trust and break down Co-Kinetic.com

barriers by showing the human face to your business A s we’ve mentioned above, drive positive reviews and patient sentiment B uild relationships in the local community by participating in local online groups, particularly ones consisting of people who match your target customer D emonstrate thought-leadership by publishing relevant, timely content S taying top-of-mind so when someone reaches their clinical tipping point, you’re the first solution to pop into their head.

Some Frequently Asked Questions

Next, let’s briefly look at some practical elements of your social media strategy. These are the questions I get asked most frequently.

Which Social Networks Should You Prioritise?

My answer to this question will always be, go where your customers are.

Research the demographic breakdown of the social network you’re looking at, and if a large number of your customers are on there – all is well and good.

Instagram is growing at a rate of knots. It’s just caught up with LinkedIn and there’s no doubt it’s only going to get more popular. But as of October 2019, its biggest user demographic worldwide, by a long shot, is people between the ages of 18-34. If this is the age group of your customer base, Instagram is your social network (2).

That age group makes up 58% of all Instagram users in the UK specifically (3). If that’s not your age group, by all means keep an eye out on the numbers as they move fast, but you’d be better off prioritising another social network which has a higher proportion of your customer base.

Incidentally, 57.4% of Facebook’s users in the UK specifically, are age 35 or over and that demographic also applies worldwide (4). Sure, this time next year, maybe even in 6 months, those numbers may be different, but for now, that is the real picture.

That said, as Facebook has so

dramatically reduced the number of posts that it shows on personal profiles, this could be an argument for trying Instagram. Even if your target demographic is smaller in numbers, you may still manage to get your content in front of more people. The trouble is….who owns Instagram? Yup, you’ve got it, Facebook! So I suspect it won’t be long before Facebook starts to squeeze organic posts on Instagram, and drive us, just as they have with Facebook, towards paid ads.

Should You Be Posting to Multiple Social Networks?

Better to do one well, than spread yourself too thin and do more than one badly. First and foremost, get a good, solid strategy in place. Set some SMART goals. Achieve those

Social media trends in 2020

l F acebook – for the first time in 5 years, marketers plan on decreasing their organic marketing on Facebook l M essenger bots haven’t caught on – only 14% of marketers plan to use them in 2020 l I nstagram is hot – it’s now the second most important platform behind Facebook (just narrowly surpassing LinkedIn) and more marketers plan to increase their organic posting on Instagram in 2020 - but there’s a catch to that which I’ll cover under the “Which channels should I use?” section l M arketers are prioritising engagement – probably because of Facebook’s changes to the news feeds prioritisation l I nterest in YouTube is high – 62% of marketers plan on using it more in 2020 and it’s the leading video channel with Facebook native videos just behind l L inkedIn is on the up too, with 52% of marketers planning on increasing their use of it in 2020 l B ut Twitter is down with only 35% of marketers planning to increase their use of it l F acebook dominance is still strong – 94% of marketers use Facebook compared with 73% Instagram l F acebook ads is still the dominant paid social channel with 59% of marketers planning to increase their use of it in 2020.

Reference: Social Media Marketing Report 2019 (9) Note: Remember, this is a survey of marketers, NOT business owners. That’s two very different beasts when it comes to the data. The priorities of marketers may not necessarily be exactly aligned with the priorities of a small business owner.

45

goals. If that’s working, then by all means invest a bit more time, testing another platform (while continuing with the other platform) to see if you can achieve better goals, but make sure you’re comparing like with like.

Most people I work with don’t have a strategy full stop. And pretty much nobody has goals, let alone SMART goals, but they’re still stressing about posting to Facebook and Instagram and maybe even Twitter. Unfortunately, without a strategy they’re just wasting 3 x as much time, instead of 1 x as much time.

As far as I’m concerned you’re asking the wrong question. The questions instead should be have I got a strategy with SMART goals and a clear way to demonstrate my return on investment on one social network? Am I following the strategy consistently?

Am I achieving the goals I’ve set, if not why not, do I need to re-evaluate/ recommit? And finally, if the honest answer to all those questions is yes, I’m crushing it on one social network, then by all means test whether you can achieve those same goals (which should be overarching business goals) more effectively, by introducing a second platform.

People, please stop going after every new shiny thing! Get your foundation strategy and your processes in place first. To put it bluntly, few people can legitimately prioritise focusing on any social network other than Facebook, unless your ideal customer is skewed to a different demographic than most physical therapy practices, or you deliver a service which you can promote better to the same size audience, using another platform.

How Often Should You Post?

l F acebook and LinkedIn the recommendation is between 1-2 posts a day. Focus on quality and adding value. l T witter the recommendation is 15 posts a day (what a load of twittering frankly!). l G oogle+ the recommendation is 2 posts a day l I nstagram 1-2 posts a day But to be honest guys, this is so 46

dependent on the type of content you’re posting, the quality and value to your followers and remember, most people won’t see your organic posts, particularly on Facebook.

What Time of Day Should You Post?

Frankly these numbers change faster than Donald Trump’s mood swings and you’re getting down to very small, possibly even non-existent incremental gains at this point. You’d be better off getting the big stuff right like strategy and consistency before worrying about this level of detail.

Tor’s Top Tips

l W hen you are using social media for business, you should make sure to keep your social media profile updated consistently, and maintain a constant presence for your business’s exposure. Remember, “out of sight, out of mind” is very true where social media pages are concerned. l A t all times be authentic and focus on adding value wherever you can l H ave a strategy and stick with it consistently l M ake sure you have at least one or two goals in your strategy that are quantifiable and can demonstrate a return on investment l I f you use repeat text like hashtags on Instagram, there are a couple of tools that can help. Apparently Apple has a function called text replacement (5) which lets you save shortcuts for commonly used sets of text (thanks to Vic Paterson on my Business Success for Physical Therapists Facebook Group for this tip (6)). There is also a Windows and Mac piece of software called Text Expander (7) (which I use many times a day and saves me a shed load of time), which does something very similar. l N eed some practical down to earth advice about setting a marketing strategy? Sign up for my webinar (8).

In conclusion, social media if used with a good strategy, can help you to achieve things that no other communication medium in isolation

can achieve as effectively, in other words it helps you kill many birds with just one stone, and we like effective use of time.

I hope this article has given you a clear idea of what and how you can utilise social media to greatest effect for your business. I will be putting together a webinar in the next few months, so keep your eyes peeled for my emails.

References, Further Reading and Information Sources

1. 40+ Word-of-Mouth Marketing Statistics That You Should Know https://spxj.nl/2RJYfK1 2. Distribution of Instagram users worldwide as of October 2019, by age and gender https://spxj.nl/38iBt1s 3. Instagram users in the United Kingdom (UK) as of May 2019, by age of users https://spxj.nl/2PwlBQp 4. Facebook users in the United Kingdom as of June 2019, by age of users (in percentage) https://spxj.nl/2PBpnIa 5. Apple’s Text Replacement function – scroll down the page to find the text replacement component https://spxj.nl/358D87V 6. Co-Kinetic Business Success for Physical Therapists Facebook Group https://spxj.nl/2PvQcNV 7. Text Expander https://textexpander.com/ 8. Sign up for Tor’s webinar “Discover the 20% of Marketing Activities That Will Give You 80% of Your Marketing Results” https://spxj.nl/2PBq6Jo 9. Social Media Marketing Report 2019 (free download) – survey of nearly 5,000 marketers on how they’re using social to grow the businesses that employ them - https://spxj.nl/2PxkdNy 10. The Complete Guide to Social Media for Small Business https://spxj.nl/2Pbm5wB

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 2020;83(January):41-46

25

1

Relieve stress

2

Relieve postoperative pain

3

Reduce anxiety

4

Manage low back pain

5

Help fibromyalgia pain

6

Reduce muscle tension

7

Enhance exercise performance

8

Relieve tension headaches

9

Sleep better

10

Ease symptoms of depression

11

Reduce OA pain

12

Improve cardio-vascular health

13

14

15

Decrease stress in cancer patients Improve balance on older patients Decrease rheumatoid arthritis pain

REASONS TO GET A MASSAGE Temper effects of dementia

16

Promote relaxation

17

Lower BP

18

Decrease symptoms of carpal tunnel syndrome

19

Help chronic neck pain

20

Reduce joint replacement pain

21

Increase range of motion

22

Decrease migraine frequency

23

Improve quality of life in hospice care

24

Reduce chemotherapy related nausea

25

The information contained in this article is intended as general guidance and information only and should not be relied upon as a basis for planning individual medical care or as a substitute for specialist medical advice in each individual case. ŠCo-Kinetic 2019

PRODUCED BY:

TIME-SAVING RESOURCES FOR PHYSICAL AND MANUAL THERAPISTS

Should I get a Massage Today?

How do You Feel?

I feel great, I would love to BUT…

I feel super healthy, I don’t think I need one!

I would, but I don’t feel great

EXCUSES?

I am feeling ILL l Fever/temperature l Flu l Cold l Stomach ache

Not enough time l Can I take a longer lunch every week or second week l Arrive early, to leave early from work l Arrange a babysitter, aftercare, play date Have a set monthly/weekly massage time, then you can schedule around that On a budget l Consider take away coffees, bought lunches and dinner outings – cut those back once or twice a week, and it’s easy to save for a monthly massage Do I have to get naked? l Most massages require outer garments to be removed, but underwear stays on l Some massages like Thai can be done over the clothing l Tell your therapist what you are comfortable with and they can plan around that Massage is painful/ it’s just skin polishing! l Some massage can be painful for effect but speak to the therapist l They can adjust pressure throughout the massage, to harder or lighter l You should never feel uncomfortable

Rest until symptoms subside then have a massage to BOOST your Immune System in a day or two

I have a HANGOVER l Rehydrate yourself l Rest I have/ I am feeling l Headache l Sinus l Migraine l Tired l Stressed l Overwhelmed l Sad l Anxious

Do you want to maintain that healthy feeling?

NO Are you crazy?

Get a massage

YES You got it right!!

10 Ways a Regular Massage can Improve Your Life

1 Manage anxiety and stress – promotes

2

3

4 5

6 7 8 9 10

release ‘happy’ hormones and reduces stress hormones Muscle relaxation – relieve headaches, body pains, neck and shoulder pain, aid in injury prevention and recovery Increase blood flow and circulation – promotes tissue health and healing, reduced feelings of fatigue Relieves low back pain Enhances your mood – by increasing release of serotonin and dopamine ‘happy’ hormones. This includes improved sexual desire and reduced symptoms of depression Relief from symptoms (pain and mobility) of fibromyalgia and chronic pain, arthritis pain Improves sleep quality Improves mental alertness Improves athletic performance Improved cardiovascular health

Get a MASSAGE

It’s not just pampering luxury, there are REAL HEALTH BENEFITS The information contained in this article is intended as general guidance and information only and should not be relied upon as a basis for planning individual medical care or as a substitute for specialist medical advice in each individual case. ©Co-Kinetic 2019

PRODUCED BY:

TIME-SAVING RESOURCES FOR PHYSICAL AND MANUAL THERAPISTS

ADVICE HANDOUT

LIVE BETTER

1. Stress and Relaxation

Adrenaline and cortisol are both stress hormones which are released to boost your heart rate and blood sugar level. These are prehistoric reactions that were part of human survival. However, when there’s never any relief from stress, it can manifest in physical symptoms like headaches, upset stomach, elevated blood pressure, chest pain, insomnia, anger, drug and alcohol abuse, and depression to name a few.

Experts estimate that 90% or more of disease is stress-related. High levels of cortisol and adrenaline have been linked to cardiovascular disease, diabetes and cancer. Nothing ages you faster, internally and externally, then high stress. While eliminating anxiety and pressure altogether may be unrealistic, massage can, without a doubt, help manage stress.

Two things happen during a massage, stress hormones are decreased, and endorphins, the ‘feel good’ hormones, are increased. The increase in endorphins, serotonin and dopamine, results in a feeling of calm relaxation that makes chronic as well as acute stress much easier to overcome.

Stress relief alone can improve your vitality and state of mind.

By decreasing cortisol and adrenaline levels, rest and recovery can take place, potentially improving your health profile and disease risk. A regular massage programme can decrease blood pressure, which can contribute to lowering the odds of having a heart attack, kidney failure, or a stroke.

Recent studies have shown the benefit of massage to cancer patients in reducing pain and nausea associated with treatment, as well as improving emotional state.

2. POSTURE

The number one culprit for sore necks and backs is poor posture. When you hunch forward, be it sitting at a desk, driving a car, or computer your body is incorrectly aligned. Poor posture forces some muscles to work incredibly hard while others get weaker and shorten in length. Massage can relieve pain and loosen tight muscles, allowing your body to position itself in its natural and pain free posture.

MASSAGE:

Get in touch with its many benefits Brush aside any thoughts that massage is only a feelgood way to indulge or pamper yourself, massage can be a powerful tool to help you take charge of your health and wellbeing. This article outlines the three main areas in which there is particularly good scientific evidence supporting the role of massage.

3. BREATHING

Massage plays an important role in training the body how to relax and help improve breathing, which can be affected by high levels of stress. Respiratory issues, such as allergies, sinus problems, asthma and bronchitis, are one group of conditions that can benefit from massage therapy. Plus, when the parasympathetic nervous system responds to massage your breathing rate slows and becomes deep and regular.

Get Physical

Massage therapy has always been a cornerstone of treatment for musculoskeletal and neuromuscular conditions, postoperative recovery and sports injuries. It not only improves circulation to the area promoting repair and healing but it also flushes out toxins in the muscle that build up following injury. Massage therapy is essential to reduce pain, and scar tissue formation, as well as stretch soft tissue structures to recover good flexibility. However, you don’t have to wait for an injury to have a massage.

Massage, if received regularly, can improve athletic performance and speed recovery.

No matter your level of participation, if you exercise you can benefit from massage by improving body conditioning and preventing injury.

Studies have shown that in relation to exercise and athletic participation massage can: l Reduce muscle tension and spasm l Help athletes monitor muscle tone l Promote relaxation

l Increase range of motion around a joint or within a muscle l Improve soft tissue function l Support recovery l Decrease muscle stiffness and fatigue after exercise l Reduce inflammation and swelling l Enhance athletic performance l Prevent injuries Muscle injuries are more common now than they were 50 years ago, not because we’re exercising harder but because we’re more sedentary. As we age our joints tend to tighten which reduces the range of motion and flexibility of your joints. Regular massage can keep your joints fluid and less injury prone.

Boost Immunity

When the body is under a large amount of stress, the excess of stress hormones suppresses the immune system, leaving the body more vulnerable to infection and sluggish to recover. Clinical studies show that regular massage can increase the immune system’s activity level, boost lymphocytes (your white blood cells and decrease the number of T-cells, which in turn improves the body’s immune function overall.

Find out how you can benefit from adding massage therapy to your health and wellness regimen by contacting your local massage therapist.

The information contained in this article is intended as general guidance and information only and should not be relied upon as a basis for planning individual medical care or as a substitute for specialist medical advice in each individual case. ©Co-Kinetic 2017

PRODUCED BY:

TIME-SAVING RESOURCES FOR PHYSICAL journal AND MANUAL THERAPISTS

PEA E AND L VE W

hen it comes to the most effective healing approach to soft tissue injury, we’ve gone from RICE (Rest, Ice, Compression and Elevation), to PRICE (Protect was added in front of RICE), then briefly it became POLICE (Protect, Optimal Load, Ice, Compress, Elevate) and now we’ve reached PEACE and LOVE (happy sigh). Out with the old and in with the new.

The reality is that just like many aspects of our world, science and medicine are constantly evolving and new

findings, research, drugs, therapies and surgeries emerge that help us to better manage our health.

The management of soft tissue injuries like strained hamstrings, ligament strains or sprained ankles, for example, is no different. It’s not to say the ‘old’ way was wrong, but new studies into how the body heals itself has given scientists a better understanding and further insight into what protocols might work best in promoting faster, more optimal recovery from injury.

Immediately after a soft tissue injury (up to 24 – 72 hours) do no HARM*, let guide you.

PEACE

PROTECT Unload or restrict movement in the area for 1 to 3 days.

This may require the use of crutches for a leg injury, or a sling for the arm. This will minimise further damage or aggravation to the injury.

ELEVATE Elevate the injured area above the level of your heart to reduce swelling.

AVOID ANTI-INFLAMMATORIES Although they may help with pain reduction and improve function in long-standing chronic injuries; during the acute phase anti-inflammatories can inhibit tissue repair. Simple analgesics like paracetamol can be used for pain relief.

COMPRESS External mechanical compression with a brace, bandage or taping can reduce local swelling and prevent further bleeding within the injured tissues.

EDUCATION Speak with your physical therapist about the injury and get a guideline for recovery and a therapy plan. Discuss whether seeing a specialist or considering surgery would be required and avoid unnecessary injections and passive treatments (like high-tech machines). Set goals about recovery times and expectations. Understand that active recovery is crucial and the restrictions for loading the area and being physically active is only a temporary protective measure for the first 2 to 3 days.

PROTECT

P

ELEVATE

E E

AVOID ANTIINFLAMMATORIES

A

C

COMPRESS

EDUCATION

* HARM Heat Alcohol Running Massage

PATIENT ADVICE

Immediate Management of Soft Tissue Injuries An acute injury is one that happens suddenly, or unexpectedly that results in pain, loss of movement or function, which can be mild or severe and disabling. What you do in those first 2 to 3 days may be critical to how well that injury recovers. If you sustained an injury before, you may be aware of the ‘old’ advice being RICE – rest the area, apply ice and compression (like a bandage or brace for support) and elevate the area to reduce swelling.

The ‘new’ emerging protocol is called

PEACE and LOVE. Bear with us! This is a scientifically-based acronym to promote healing and optimise recovery.

This protocol of PEACE & LOVE applies to everyone at all ages and at any activity level. If you’ve hurt yourself, regardless of how, you should start this protocol immediately at home or on the ‘field’ and then contact your physical therapist who will help you further with any strapping or equipment needs. Make plans to see your therapist to start working on an active approach to get you moving again.

After the first few days have passed, soft tissues need

LOVE

LOAD An active approach, with movement and exercise, benefits most injuries. Loading or stressing the joint or muscle (essentially making it work) within the limits of pain early on, actually promotes healing and stimulates tissue repair.

OPTIMISM Science has shown that depression and fear about an injury and the recovery, can actually result in worse outcomes and a worse prognosis. Staying realistic and positive is important, your brain plays a key part in your recovery.

VASCULARISATION That’s a fancy word for improved blood supply to an area. Better blood flow means more oxygen and nutrients which ensure good tissue healing. Moving and working the joint or muscle and exercising the tissues around the area will increase blood flow to the injured site.

EXERCISE Controlled exercise, within pain limits, is key from the beginning of your recovery. Restoring mobility and building strength will speed up your recovery and help prevent a recurrent injury.

The information contained in this article is intended as general guidance and information only and should not be relied upon as a basis for planning individual medical care or as a substitute for specialist medical advice in each individual case. ©Co-Kinetic 2019

LOAD

L

OPTIMISM

O E

V

VASCULARISATION

EXERCISE

Discover the 20% of Marketing Activities That Will Give You 80% of Your Marketing Results Tired of working all the hours in the day for a physical therapy business that feels like it only just survives? Or fluctuating between “feast or famine” with your clinic bookings?

Well, it’s time to change all that. Sign Up to My Free Webinar

Host: Tor Davies While Tor trained as a physical therapist, she has been an entrepreneur now for more than two decades. Her focus is providing resources to help practitioners and therapists develop their businesses and to work more efficiently, a topic that she speaks on regularly at global conferences. The marketing practices and principles that Tor advocates, will help you turn a business that is only just surviving into one that thrives in just a matter of weeks.

Take Action Today

You’ll discover a unique three-step formula for attracting new patients, that allows you to attract only motivated prospects, who understand the value of what you are offering, and are predisposed to trust you.

By using this formula you can increase your earnings by over £6,000 a month - more than enough to move into a new premises, take on another therapist, or even open a new clinic.

Register Now!

https://spxj.nl/2PAsnVq