Co-Kinetic Journal Issue 92 - April 2022

1999

2022

ISSUE 92 APRIL 2022 ISSN 2397-138X

Discover the 20% of Marketing Activities That Will Give You 80% of Your Marketing Results

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Post 9 Covid-1

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what’s inside

PRACTICAL

50

45-49

SHOCKWAVE EDUCATION-BASED MARKETING CAMPAIGN

CONTENT UPDATE

THE CHALLENGES FACING PHYSICAL THERAPY BUSINESSES IN 2022 AND BEYOND – AND WHAT TO DO ABOUT THEM

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12-13

25-29

PHYSICAL & MANUAL THERAPY AND PHUSICAL ACTIVITY & DIET MOST DISCUSSED RESEARCH

30-44

IS COLD THERAPY STILL APPLICABL TODAY

UPPER QUADRANT ASSESSMENT FOR MYOFASCIAL DYSFUNCTION: PART 1

14-24 THORACIC OUTLET SYNDROME – WHO GIVES A TOS

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JOURNAL WATCH

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

TECHNICAL

1999

is published by

2022

ISSUE 92 APRIL 2022 ISSN 2397-138X

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

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CLICK ON RESEARCH TITLES TO GO TO ABSTRACT The purpose of this study was to compare muscle coactivation levels developed in the lower limb during two running techniques: forefoot (FF) versus rearfoot (RF). Fourteen amateur runners were evaluated (eight men, six women; age, 23.21±3.58 years; mass, 63.89±8.13kg; height, 1.68±0.08m). Their average running speed was 8.68km/h, with a running frequency equal to or greater than three times a week (5km each day). All reported initial contact with rearfoot as their primary technique but in this cross-sectional study they ran with both techniques.

Surface electromyography was

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= OPEN ACCESS

CHANGES IN MUSCLE COACTIVATION DURING RUNNING: A COMPARISON BETWEEN TWO TECHNIQUES, FOREFOOT VS REARFOOT. Araya D, López J, Villalobos G et al. Archivos de Medicina del Deporte 2021;38(5):332–336 used to measure muscle activity during running on a treadmill, considering the muscle pairs: rectus femoris–biceps femoris (RFe-BF), lateral gastrocnemius– tibialis anterior (LG-TA), and medial gastrocnemius–tibialis anterior (MG-TA).

These were calculated in three windows of the gait cycle (0–5%, 80–100%, and 0–100%). To compare FF versus RF, the Student’s t-test for paired data was used. It was observed that there were significant differences in the MG-TA pair during 0–5%, and RFe-BF during 80–100%.

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Co-Kinetic comment

A study quoted in this paper states that some epidemiological studies indicate that more than 50% of regular runners report more than one injury annually and that the majority are due to overuse. Another quoted study suggests that there is less risk of injury in FF runners because it lessens the energy absorbed by the knee, generating less acceleration of the tibia and impact on the ground. Yet another, affirms that the coactivation of antagonistic muscle pairs could be a neural control mechanism to improve joint stability. The practical implications of this are that if you are training/rehabbing runners, their muscle use is different depending on their running style so knowing it will be a good starting point.

THE EFFECT OF SLEEP ON THE PREVALENCE OF SPORTS INJURIES IN ATHLETES. Vermeir P, Arickx L, De Clercq E et al.

British Journal of Sports Medicine 2021;55(Suppl 1):A1–A188 This poster presents a systematic review carried out on the correlation between sleep and the prevalence of sports injuries. The ‘usual suspect’ databases were searched for papers published between 1 January 2010 and 3 December 2020 using the keywords ‘sleep’, ‘circadian rhythm’, ‘insomnia’, ‘jetlag’, ‘(elite) athletes’, ‘(sports) injuries’ and ‘rehabilitation’.

A summary of the general findings was that athletes do not meet the total sleep time recommended by the American Academy of Sleep Medicine (AASM) and the National Sleep Foundation. The importance of this is that one of the reasons for an

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increased risk of sports injuries is sleep deprivation. Sometimes sleep extension is needed to partially repair this by scheduling a short nap of about 30min in the morning or early afternoon. In addition to sleep quantity, poor sleep quality also plays a role in the risk of sports injuries.

Both sleep quantity and quality are negatively affected by air travel over different time zones, which is further enhanced by a heavy training schedule.

Co-Kinetic comment

There is a lot to be said for a siesta.

The AASM recommendation is that adults should have 7–9 hours sleep per night. Their website is well worth a visit. It contains a wealth of free information on all things sleep, including sleep disorders together with some tip sheets. However, to dig deep into the subject you must pay. If you are really interested there is a whole medical speciality of Sleep Medicine.

KINESIOTAPING; DOES IT REALLY PREVENT SPORTS INJURIES? Kaplan Y. British Journal of Sports Medicine 2021;55(Suppl 1):A1–A188 This is a poster presentation reported in the BJSM. An electronic search was conducted up to June 2019 using medical subheadings and free-text words. The subject-specific search included the terms ‘Kinesio tape’, ‘injury prevention’, ‘motor control’, and ‘proprioception’. Twenty-one articles were found. The majority of the articles did not support the use of Kinesio tape in the prevention of injury nor in the increase of joint positioning sense, proprioception or increased motor control. The conclusion was that it remains questionable whether Kinesio tape should be used in order to prevent sport injury.

Co-Kinetic comment

Yes, but it’s ‘magic tape’ – you see thousands of athletes on TV wearing it. They and their therapists can’t all be wrong... can they?

Co-Kinetic Journal 2022;92(April):4-7

RESEARCH INTO PRACTICE

Journal Watch Physical Therapy

EFFECT OF MANUAL THERAPY AND CONVENTIONAL PHYSIOTHERAPY ON PAIN, MOVEMENT, AND FUNCTION FOLLOWING ACUTE AND SUB-ACUTE LATERAL ANKLE SPRAIN: A RANDOMIZED CLINICAL TRIAL. Prabhakaradoss D, Sreejesh MS, Hameed S et al. International Journal of Sport, Exercise and Health Research 2021;5(2):76-82 Forty patients diagnosed with acute and sub-acute grade 1 or 2 lateral ankle sprain were randomly allotted to two groups. Both groups received a package of therapeutic measures during 8 sessions over 4 weeks that included a compression bandage, immobilisation in a posterior ankle brace for no more than 2 weeks, a general PRICE regime and ankle ROM exercises progressing to strengthening exercises using resistance bands. They were encouraged to walk with an aid if required. As soon as the patient could stand comfortably without using an assistive device, he or she was moved to weight-bearing exercise which included forward lunges, bilateral squatting and heel raises with a progression to unilateral squatting and heel raises. When weight-bearing was comfortable, balance training began.

This is actually a book chapter, in which each topic is presented as a systematic review. This one addresses the origin and mechanisms of pain in the neck–shoulder and low back regions, the individual and workrelated physical and psychosocial risk factors, and the most recent evidence-based approaches for prevention and management of pain within this population.

A very brief summary is that a relatively static flexion posture, sustained muscle activity, repetitive arm movements, and

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In addition, the experimental group (n=20) received Mulligan’s mobilisation with movement (MWM). With the patient in the supine position, the distal fibula was given a pain-free posterior, superior, and lateral force while the tibia was stabilised in supine. The subjects were instructed to perform active ankle plantar flexion and inversion to the maximal pain-free range while this force was maintained. While performing the technique, passive over-pressure was applied during plantarflexion and inversion only when the patient could attain a full pain-free ROM with a maximum of 3 sets of 9 repetitions.

In addition to the MWM, two layers of rigid tape were applied to the skin above the distal fibula, spiralling proximally up the leg. No more MWM or tape application was given to these patients in that session if pain-free ROM

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could not be attained after a maximum of three trials of MWM. Both experimental groups significantly reduced pain and improved ankle dorsiflexion ROM and function following the treatment duration with greater improvement in the MWM group.

Co-Kinetic comment

Someone should tell them that PRICE has been superseded by POLICE, but other than that this is a very thorough rehab programme and the MMW is icing on the cake.

PAIN MECHANISMS IN COMPUTER AND SMARTPHONE USERS. Heredia-Rizo AM, Madeleine P, Szeto GPY. In: Rajendram R, Preedy V, Patel V, Martin C (eds) Features and assessments of pain, anaesthesia, and analgesia; ch27, pp291–301. Academic Press 2022. ISBN 978-0128189887 insufficient rest are the most known physical risk factors. Psychosocial risk factors include stress, depressed mood, cognitive functioning and pain behaviour. Ergonomic interventions have shown to reduce pain intensity, with some conflicting evidence.

Strengthening exercise programmes are cost-effective and recommended, with compliance as one of the main barriers for implementation.

Overall, education for the responsible use of smartphones, tablets and computers is important and should be stressed in today’s society. Keeping an active physical and social life directly benefits mental health and wellbeing

and should be balanced with a rational use of visual display units.

Co-Kinetic comment

This is a paper for everyone. According to studies quoted in it, approximately 57% of occupations require the use of visual display units. Add the prevalence of home computer and phone use to this and there is a massive potential for injury. In fact, compared with other jobs, white-collar workers report the highest incidence (35–60%) and annual prevalence (40–70%) of neck–-shoulder pain. Low back pain is also a frequent and disabling condition within this population, with a 1-year prevalence of 35–40%, and an incidence rate at 14–23%. In addition to this topic, the book contains everything you need to know about pain in various medical complaints, military medicine and post-surgical procedures.

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Forward head posture (FHP) is also called ‘scholar’s neck’, ‘wearsie neck’, ‘I hunch’, ‘reading neck’ or ‘texting neck’ and has been the prevalent postural issue in modern times. The upper cervical vertebrae are extended, and the lower cervical vertebrae are bent, as result of which the weight of the head over the neck is increased. The extension of the upper cervical joint and atlanto-occipital joint causes the upper cervical vertebrae to project forward with the facet pointing upwards; in order to compensate for this there is a change in the curvature of the neck accompanied by rounded shoulders. The common treatment is the chin tuck, which in theory recruits deep

IMMEDIATE EFFECT OF CHIN TUCK EXERCISES ON CRANIOVERTEBRAL ANGLE AND SHOULDER ANGLE AMONG COLLEGIATES WITH FORWARD HEAD POSTURE. Anbupriya Sureshbabu M, Nishanth H, Aishwarya A. Biomedical and Pharmacology Journal 2021;14(4):doi:https://dx.doi.org/10.13005/bpj/2330 cervical flexors. This study investigates the exercise.

Forty-three male physiotherapy and occupational therapy students aged 18–25 years, with an FHP above 2.5cm (measured by a plumb line) had double tape applied as markers at the tragus of the ear, C7 vertebra and acromion process. All were taught to do chin tuck exercises in standing. Photos were taken before and after exercises and analysed using AUTOCAD

ASSESSMENT OF LUMBAR SPINE KINEMATICS

BY POSTERIOR-TO-ANTERIOR MOBILIZATION. Oh KO, Lee SY. Physical Therapy Rehabilitation Science 2021;10(4):450–456 Thirty subjects with no back pain participated in this study. X-ray testing equipment was used to verify the segmented movement of their lumbar spines before and after treatment.

An experienced physiotherapist stood to the right side of the subject and performed posteroanterior joint mobilisation at the L3 segment using the pisiform of their lower hand with the assistance of the other hand.

The mobilisation was taken up to the point of maximum resistance, which was the end range at which the joint can move without pain (grade 4).

Significant differences were observed in the lumbar displacement,

Sixteen recreationally active adults (25±3 years old; 8 men and 8 women) participated in the study. After an initial visit to assess cardiorespiratory fitness, each participant performed two 40min training sessions on a cycle ergometer, either with or without a fan (~4m/s), while workload was continually adjusted to elicit and maintain 70% of heart rate reserve. Workload parameters of rating of perceived exertion (RPE) and thermal sensation were recorded every 5min.

Blood lactate was recorded pre-, mid-, and post-sessions and nude body mass 6

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intervertebral angle, and lumbar lordosis angle in all lumbar vertebrae before and after the mobilisation.

The intervertebral height indicated significant differences in all ventral vertebrae and only in L3–L4 and L4– L5 in dorsal vertebrae.

Co-Kinetic comment

This could be a companion piece to the Tuzson study on the measuring device (p7). Changes are made to the joints using accessory mobilisations without worrying too much about the amount of actual movement in millimetres. Take it to the end of available range and work from that point for a therapeutic effect.

2017 software.

A positive association was found between the pre- and post-test results for craniovertebral angle and no significant association between the pre- and post-test for shoulder angle.

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Co-Kinetic comment

The clinical conclusion is that the chin tuck exercise works on the neck, but you need a separate exercise for the rounded shoulders.

THE SUBSCAPULARIS MUSCLE: A PROPOSED CLASSIFICATION SYSTEM. Zielinska N, Tubbs RS, Borowski A et al. BioMed Research OPEN International 2021;2021:7450000 doi:https://doi.org/10.1155/2021/7450000 Sixty-six adult cadavers of Central European population were examined. A subscapularis muscle was found in all 66 specimens (45 females, 21 males; 31 left and 35 right sides).

After meticulous dissection, nine types were identified based on number of bellies. Type 1 was characterised by a single belly and occurred in 1.5%. Type 2 had a double belly and was present in 3%. Type 3, the most common type, occurring in almost 32% of the studied population, had three bellies. The frequency of type 4, characterised by four bellies, was also high, just over 30%. The following types were less frequent: type 5 with five bellies (18.2%), type 6 with six bellies (7.6%), type 7 with seven bellies (3%), type 8 with eight bellies (1.5%), and type 9 with nine bellies (3%). All the types had their origin on the anterior surface of the scapula.

Co-Kinetic comment

The authors speculate that the changes are probably due to evolutionary changes and that the more bellies there are, the less stability there is, leading to a greater incidence of glenohumeral dislocation.

FAN COOLING IMPROVES SUBMAXIMAL EXERCISE CAPACITY IN AN INDOOR THERMONEUTRAL ENVIRONMENT. Fernandez A, Wimer GS, Culver MN et al.

Research Quarterly for Exercise and Sport 2022;doi:https://www.tandfonline.com/doi/ abs/10.1080/02701367.2021.1946467 was obtained pre-post. The results showed that the fan group recorded greater mean workload (+15%) and oxygen consumption(+9%). Thermal sensation, but not RPE, was lower with fan cooling (3.8±0.7) compared to without fan cooling (5.5±0.8), and body mass loss was attenuated with fan

Significantly higher blood lactate values were observed in the fan group (3.0±1.9 mmol/l) versus the no fan (2.5±1.4mmol/l) trials.

Co-Kinetic comment

Obvious but cool nevertheless.

Co-Kinetic Journal 2022;92(April):4-7

RESEARCH INTO PRACTICE

THE CLINICAL BURDEN OF SEVERE SPORTS INJURIES IN ENGLAND AND WALES. Davies MAM, Lawrence T, Edwards A et al. British Journal of Sports Medicine 2021;55(Suppl 1):A1–A188 This was another poster presentation, this time to the IOC World Conference on Prevention of Injury and Illness in Sport.

It was given a couple of years ago, but it has only just surfaced in the BJSM. A 5-year retrospective study was conducted between January 2012 and December 2017 using data from all Hospitals in England and Wales. Data were collected about all patients whose injury mechanism was indicated as sport, or whose incident description field featured one of 62 sporting activities, and qualified for inclusion in the Trauma Audit and Research Network (TARN) database.

Inclusion criteria were transfers or direct admissions whose inpatient stay is 3 days or more, admissions to High Dependency Areas and mortality after admission.

There were 15,799 sports injuries reported. In 2012, there were 2,087

This study set out to determine if patient education material was doing its job. A systematic search of the literature using PubMed/ MEDLINE, Embase, and the CINAHL databases was performed. Studies were included if they (i) were published between 2000 and September 2020, (ii) were English-language publications and complete studies from peerreviewed journals, and (iii) evaluated online information directed toward patients with common sports injuries.

Eleven studies met inclusion criteria and were included. The mean Flesch– Kincaid grade level for online education information was 10.5, whereas the mean Flesch reading ease was 51.2, indicating existing health resources are written above the recommended readability grade

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injuries (13.3% of incidents), and by 2017 there were 2,906 (18.6% of incidents). Patients were on average 37.7±19.5 years old, and 6,396 (40.5%) were female. The average length of hospital stay was 9.5 days (SD±15.6, range 1 to 738).

Horse-related activities accounted for 5,585 of injuries, followed by football (soccer) with 1,439 injuries; followed by motor racing (n=938), cycling (n=917), motocross (n=826), off-road cycling (n=669), rugby (n=660), trampolining (n=620), running (n=501), and skiing (n=326).

Co-Kinetic comment

These are just the very serious ones.

Imagine the figures for the minor injuries that spend a few hours in A&E and go home or the countless number of injuries that don’t get that far. There is a lot of rehab work out there for someone.

VALIDATING THE MOBIL-AIDER OPEN TO MEASURE JOINT ACCESSORY MOTION IN HEALTHY ADULT SHOULDERS. Tuzson A, Tarleton G. Open Journal of Health Science & Medicine 2021;2(1):106 The purpose of this project was to validate, in vivo, a device designed to measure joint accessory motion magnitude by comparing Mobil-Aider device measurements with measurements obtained from an Ascension electromagnetic motion analysis system. One orthopaedic clinical specialist performed 10 posterior glides (grade 4) of the left humeral head on 20 healthy adults: 16 female and 4 male (27.5±7.1 years old). The magnitude of movement between the humeral head and the clavicle was measured simultaneously by both devices. The measurements recorded by both correlated closely. On average, the electromagnetic system measured the Mobil-Aider device movement of 18mm (±3mm). The Mobil-Aider itself demonstrated an average movement distance of 10.5mm (±2.3mm).

Co-Kinetic comment

Ignore the fact that a difference in measurements of 10.5mm and 18mm does not seem to come under the heading of ‘closely correlated’, and consider whether it is worth $2,495 for the Deluxe model with 7 easy snap-in attachments for shoulder, elbow, wrist, knee, and ankle to know the exact amount of movement during an accessory mobilisation?

Disciples of Cyriax, Grieve, Kaldenberg and Maitland have been performing them very successfully for many years using only the power of touch.

ONLINE PATIENT EDUCATION MATERIALS FOR COMMON SPORTS INJURIES ARE WRITTEN AT TOO-HIGH OF A READING LEVEL: A SYSTEMATIC REVIEW. Abdullah Y, Alokozai A, O’Connell S, Mulcahey MK. Arthroscopy, Sports Medicine, and Rehabilitation 2022;doi:https://doi.org/10.1016/j.asmr.2021.12.017 level [no greater than a sixth grade (age 11/12) reading level]. This study demonstrates that online patient information regarding common sports injuries does not match the readability recommendations of the American Medical Association and National Institutes of health.

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Co-Kinetic comment

As the paper says, “Accurate, easy-to-understand educational tools can improve efforts to help patients identify misconceptions about treatment options, and to guide patients to choices that are consistent with their values”. The Flesch–Kincaid tests are readability tests designed to indicate how difficult a passage in English is to understand. There are two tests: the Flesch reading ease, and the Flesch–Kincaid grade level. Although they use the same core measures (word length and sentence length), they have different weighting factors. They were developed by the USA Navy in 1975 presumably because they hoped that sailors with their fingers on the triggers of powerful weapons could read the instructions. They produced a scale with 100 being easy to read, stuff that an 11-year-old could cope with, up to 10 which is extremely difficult to read and is best understood by university graduates. You may not be aware, but the tests are built into most word processing programmes including Microsoft Word and Grammarly. For the record, this edition of JW scored 33. How readable is the information you give to your patients?

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CLICK ON RESEARCH TITLES TO GO TO ABSTRACT

OPEN EFFECTS OF DRY NEEDLING IN LOWER EXTREMITY MYOFASCIAL TRIGGER POINTS: SYSTEMATIC REVIEW. Khan I, Ahmad A, Ahmed A et al. Journal of the Pakistan Medical Association 2021;71(11):2596–2603

This is a systematic review using the Cochrane Library, PubMed, SPORTDiscus and PEDro databases published in the English language from 2000 to July 2019 using the search terms ‘dry needling’, ‘trigger points’, ‘myofascial trigger points’, ‘trigger area’ and ‘acupuncture therapy’. There was variation in the methodology of the dry needling intervention strategies. The studies reviewed had applied either the multiple insertion method of dry needling or the superficial needling technique. The multiple insertion technique correlates positively to the effectiveness of dry needling. The placebo or sham dry needling group in some studies used the blunted tip needle on the superficial skin surface. Of the 564 articles initially found, 30 (5.3%) were shortlisted for fulltext assessment. Of them, 10 (33.3%) were selected for final assessment, with 7 (70%) scoring high and 3 (30%) fair on the PEDro scale. All 10 (100%) studies documented improvement in pain over time with dry needling strategy.

Co-Kinetic comment

Dry needling reduces pain in trigger points when compared to sham or placebo. So, if you are in the pain reduction business, do a course and get stuck in!

MEDLINE, Web of Science, Scopus, Cochrane Library, Trip and PEDro databases were searched from inception to September 2021. PICO search strategy was used to identify randomised controlled trials applying manual therapy on patients with carpal tunnel syndrome. Methodology quality and risk of bias were assessed by PEDro scale. Outcomes assessed were pain intensity, physical function and nerve conduction studies.

Eighty-one potential studies were identified and six studies involving 401 patients (52 males and 349 females) were finally included. Pain intensity immediately after treatment 8

MANUAL COMPRESSION AT MYOFASCIAL TRIGGER POINTS AMELIORATES MUSCULOSKELETAL PAIN. Takamoto K, Urakawa S, Sakai S et al. In: Rajendram R, Preedy V, Patel V, Martin C (eds) Features and assessments of pain, anaesthesia, and analgesia; ch29, pp317–328. Academic Press 2022. ISBN 978-0128189887 A myofascial trigger point (MTrP) is suggested to cause muscle pain. They can be identified by the presence of a localised hypersensitive palpable nodule in a taut band of muscle fibres, and the induction of characteristic referred pain when compressing the point. Epidemiological studies showed significant relationships between the presence of MTrPs and musculoskeletal pain in the neck, shoulder, low back, knee, etc, and the relationships between presence of MTrPs and disability in life. Recent clinical trial studies reported that compression at MTrPs is effective to ameliorate musculoskeletal pain in various parts of the body. There could be two possible sites of action for MTrP compression effects: peripheral direct effects on muscles and indirect effects mediated through the central nervous system. In muscles with MTrPs, local contracture (ie. MTrPs) induces mitochondrial deficits due to local muscle ischaemia/hypoxia. Deficits of energy and oxygen supply cause release of algesic substances, which induce hypersensitivity and pain.

Compression at MTrPs increases regional blood flow and decreases neuromuscular excitability. Thus, compression at the MTrP may alleviate pain by improving energy balance in the muscle. In patients with chronic musculoskeletal pain with MTrPs, morphological and functional changes in pain-related brain regions such as the prefrontal cortex insula and anterior cingulate cortex have been reported, so treating the MTrPs can have more than just a local physiological effect.

Co-Kinetic comment

This is another chapter from the book mentioned in ‘Pain mechanisms in computer and smartphone users’ described elsewhere in Journal Watch (p5). It is estimated that the prevalence of active MTrPs is between 30 and 85% of patients with acute or chronic pain, so if you treat soft tissue this is a ‘must-read’ which will allow you to quote evidence-based support for your treatment choice.

THE EFFECTIVENESS OF MANUAL THERAPY ON PAIN, PHYSICAL FUNCTION, AND NERVE CONDUCTION STUDIES IN CARPAL TUNNEL SYNDROME PATIENTS: A SYSTEMATIC REVIEW AND META-ANALYSIS. Jiménez-Del-Barrio S, Cadellans-Arróniz A, CeballosLaita L et al. International Orthopaedics 2022;46(2):301–312 showed an improvement. Physical function measured with the Boston carpal tunnel syndrome questionnaire (BCTS-Q) showed an improvement of symptom severity and functional status.

Nerve conduction studies showed an increased motor conduction and sensory conduction.

Co-Kinetic comment

Three cheers for manual therapy. It was

successful when compared OPEN to control, sham, simulated or placebo interventions.

The trouble is that it is not clear which manual therapies or combination of them does what. A list of them is included: neural mobilisation, Graston, neural tension, mobilisation, manipulation, massage, diacutaneous fibrolysis, and even surgical release.

Take your pick.

Co-Kinetic Journal 2022;92(April):8-11

RESEARCH INTO PRACTICE

Journal Watch Manual Therapy

COMPARATIVE EFFECTS OF DENTAL TREATMENT AND TWO DIFFERENT PHYSICAL THERAPY INTERVENTIONS IN INDIVIDUALS WITH BRUXISM: A RANDOMIZED CLINICAL TRIAL. Miotto CS, Vieira GF, Firsoff EFO et al.

Journal of Clinical and Medical Research 2021;3(6):1–5

A total of 72 individuals with bruxism were randomly allocated to the massage (massage with stretching exercises), relaxation (relaxation with imagination therapy) groups (n=24 each; biweekly 40min sessions over 6 weeks) or the dental group (n=24; direct restoration, two 2h sessions 1 week apart). The massage treatment includes sliding, kneading and trigger point deactivation with emphasis on the masseter, anterior temporalis, trapezius and sternomastoid muscles bilaterally both extra- and intra-orally. Passive stretching was added to these and other head and cervical spine muscles. The relaxation group underwent progressive muscular relaxation involving contraction and relaxion of the same muscles with the patients encouraged to use imagery such as sunsets, flowers and being on a beach. Both groups

were trained in diaphragmatic breathing. Participants in the dental group received direct composite resin restoration for anterior guidance (incisal edge of the incisors and canines) in two 2h individual sessions conducted a week apart, and maintenance periods at 30, 60 and 90 days at 2 months after the initial intervention. All interventions were administered by a specialised physiotherapist and dentist.

After 6 weeks, the improvement with difference among massage and relaxation groups and dental group was assessed in muscle pain, symptoms, anxiety, stress, depression and sleep quality. The relaxation group exhibited significantly greater improvement in oral health than dental group. These effects were sustained for up to 2 months.

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Co-Kinetic comment

People with bruxism may unconsciously clench their teeth when they are awake (awake bruxism) or clench or grind them during sleep (sleep bruxism). Sleep bruxism is considered a sleep-related movement disorder. It is not good for the sufferer and not good either for roommates on a road trip. The dental intervention of direct adhesive composite restoration is a technique to restore tooth defects by bonding composite resin materials, to dental caries or other tooth defects. Bottom line here is: 4 hours in a dentist’s chair or a few sessions with a therapist – which would you choose?

INFLUENCE OF CUPPING THERAPY ON THE PAIN THRESHOLD PRESSURE AND MUSCLE FLEXIBILITY OF THE SUBSEQUENT CHAIN LEG IN FOOTBALL ATHLETES. Corrêa GP, Peil T, Ferreira GD, da Silva FM. Fisioterapia e Pesquisa 2021;28:318–323 This study aimed to evaluate the pressure pain threshold (PPT) and flexibility in the entire posterior muscle chain of the lower limb of soccer players before and after cupping therapy. Sixteen athletes from an under 20s team, all male and over 18 years old, were given cupping therapy applications (twice a week, for two weeks), utilising dry cupping. The therapy is described as ‘light intensity (one suction), dosed by the amount of manual pumping, for 5min, using mineral oil for better suction cup slippage’. The intervention was applied along the posterior lower limb. PPT was measured using the Instrutherm® Co-Kinetic.com

pressure dynamometer (algometer), applied to myofascial trigger points of the biceps femoris muscles (short and long head), semitendinosus, semimembranosus, popliteal, gastrocnemius (medial and lateral head), and soleus. The results showed that flexibility was increased but there was no change in the pain threshold.

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Co-Kinetic comment

When used therapeutically, cupping affects the superficial fascia. Without wishing to be accused of being a Luddite, it is surely better and safer to try myofascial release using trained hands. If you think cupping is safe, try a Google search for images of when it goes wrong.

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TO FIND OUT THE EFFECTS OF MYOFASCIAL RELEASE IN THE MANAGEMENT OF PLANTAR FASCIITIS. Javed A, Riaz R, Khalid I et al.

Journal of Bashir Institute of Health Sciences 2021;2(2):85–92 Subjects with a clinical diagnosis of chronic plantar fasciitis (n=30) were dived into two equal groups. Group 1 received myofascial release (MFR) with conventional physical therapy (ultrasound and exercise therapy), whereas group 2 received conventional physical therapy alone. The treatment was given on alternate days for 2 weeks.

The results showed that the mean percentage of visual analogue scale

(VAS) scores for pain for both groups were the same at the baseline; however, for the experimental group this score significantly decreased from baseline to midline and at the end of session.

In addition, the MFR group improved their score on the foot functional index (FFI) compared to the control. VAS and FFI scores were statistically significant in both groups.

THE INFLUENCE OF SELF-MYOFASCIAL RELEASE ON MUSCLE FLEXIBILITY OPEN IN LONG-DISTANCE RUNNERS. Sulowska-Daszyk I, Skiba A. International Journal of Environmental Research and Public Health 2022;19(1):457 Sixty-two long-distance, recreational runners (aged 20–45 years) who regularly ran between 30 and 100km per week were randomly divided into two groups: group 1 (n=32), in which subjects applied a self-myofascial release technique with a foam roller between baseline and the second measurement of muscle flexibility, and group 2 (n=30) who were measured at the same time without any intervention.

The self-myofascial release technique was performed according to a standardised foam-rolling protocol to the hamstring, gluteus maximus, hip adductors, quadriceps, tensor fasciae latae and gastrocnemius. Pressure on bones, joints or tendons was avoided. A 45cm high and 14cm diameter, high-density foam roller (4Fizjo) was used. The rolling was applied to both legs along the muscle fibres, from proximal to distal muscle insertion, and inversely, with a constant pressure and speed of 2.5cm/s. This was repeated 10 times for each muscle making an average time of 2min for each muscle group. The results showed that after the foam rolling, significant improvement in ROM were noted for the piriformis, tensor fasciae latae muscle and adductor muscles.

For the iliopsoas and rectus femoris muscles, lower values were observed. In group 2, significant improvement was observed only in measurements for the iliopsoas muscles.

Co-Kinetic comment

OPEN

Co-Kinetic comment

This is a deeply frustrating study for readers who want to learn from successful clinical practice used elsewhere. The results are great but there is no explanation of exactly how the MFR was conducted or the ultrasound dosage or the stretching protocol. Come on people, we should all share good practice for the benefit of the patients.

INFLUENCE OF CLASSICAL MASSAGE ON BIOCHEMICAL MARKERS OF OXIDATIVE STRESS IN HUMANS: PILOT STUDY. Skubisz Z, Kupczyk D, Goch A, et al. Biomedical Research International 2021;2021:6647250

OPEN

This study was designed to assess changes in oxidative stress parameters in healthy volunteers after a single session of classical massage. Twenty-nine healthy volunteers aged 22.24±3.64 years participated in the study. Blood samples were taken by experienced personnel before and 30min after the massage procedures. The massage protocol was the use of successive techniques of effleurage, friction, petrissage, tapotement, rolling, shaking, and vibration, at a depth of not crossing the pain barrier and performed by one experienced physiotherapist. The area covered was the dorsal part of the torso, including the spinal and dorsal area (lateral part of abdominal oblique muscles, trapezius, rhomboids, latissimus dorsi and erectors of the spine). Blood samples were collected before and after the massage.

Analysis demonstrated that massage therapy caused a statistically significant decrease in the concentration of glutathione peroxidase, and an increase in the level of superoxide dismutase and malondialdehyde. In contrast, statistically significant changes in haematocrit, glutathione, NO /NO , and oxidase ceruloplasmin were not observed. The results show that the complex influence of classical massage therapy on human organism may be reflected in parameters of the oxidative stress.

Co-Kinetic comment

A lot of blood chemistry components are identified in this study but in a nutshell, oxidative stress is a phenomenon caused by an imbalance between production/accumulation of reactive oxygen species in cells and tissues and the ability of a biological system to detoxify these reactive products. It is known to be detrimental to human health so the knowledge that massage is having an effect at the cellular level is positive. As the authors admit, however, more research is needed.

This supports other research that states that foam rolling improves flexibility, at least in the short term, but the fact that there was a deterioration in ROM of the hip flexors in the rolling group but an improvement in the control group is strange. The authors suggest it might have something to do with using the modified Thomas test as a position for measuring flexibility, but the argument is not convincing.

Someone needs to repeat this study.

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RESEARCH INTO PRACTICE

THE USE OF THE MULLIGAN CONCEPT FOR THE TREATMENT OF A FIRST-DEGREE SPRAIN OF THE FIRST METATARSOPHALANGEAL JOINT. Hendley C, May J, Wallace JJ, Cheatham SW. Athletic Training & Sports Health Care; Thorofare 2021;13(6):e1–e5 doi:10.3928/19425864-20210609-01 This is a case study on a single incidence of a sprain to the first metatarsophalangeal joint, also known as turf toe. A 19-year-old women’s soccer player reported to the clinic 4 days after the initial injury. This was sustained during a morning practice, with pain noted approximately 30min into the session after repetitive extension force of the great toe during sprinting and agility drills. The patient continued practice and participated in a game the following day. Previous injury history included a grade 1 Achilles strain and grade 1 peroneal strain of the affected extremity within the past month. She reported pain with active and resisted great toe extension and flexion, as well as tenderness with palpation on the dorsal and plantar aspect of the first metatarsophalangeal joint. A vertical Lachman’s test had positive results for laxity without pain.

Nine healthy men aged between 20 and 30 years old were recruited and randomly assigned to a control group (n=5) and massage group (n=4). Both groups performed a 5min warm-up on a treadmill followed by knee flexion and extension exercises using an isokinetic dynamometer to exhaustion and a 10min cool-down consisting of calf and thigh muscle stretching. The experimental group were then given a massage to the anterior and posterior of the thigh for 10min in total. The control group rested in a seating position for 10min. The participant’s heart rate variability (HRV) was recorded as the beat-to-beat interval by a heart rate monitor device (Model V800, Polar) for 5min while lying quietly in the supine position a few days before the data was gathered during a familiarisation session to act as a base line, before the warmup, post-exercise and post-intervention.

Co-Kinetic.com

Long bone compression, percussion, and valgus and varus stress test results were negative. There was no swelling or ecchymosis present at the first metatarsophalangeal joint or surrounding area. However, the patient had an antalgic gait, so she avoided using the toe and used excessive supination of the foot during the stance phase of gait. Active ROM goniometry yielded a great toe extension of 76°.

She was treated for a grade 1 sprain of the first metatarsophalangeal joint.

She was treated using mobilisation with movement. The therapist stabilised the distal aspect of the first metatarsal in a finger and thumb pinch grip and applied a medical glide to the joint using a similar grip on the proximal aspect of the first phalanx. While the glide was sustained the patient actively extended the great toe and applied over-pressure using her index finger for

3 sets of 10 repetitions. After treatment, the patient reported decreased pain and increased function. This was repeated over 10 days (8 visits), and pain and function improved each time.

In between each session, tape was applied to match the direction and force of the glide.

Co-Kinetic comment

If you are already a disciple of the Mulligan technique this is not news to you. If you are not, it works, try it (after suitable training of course).

ACUTE MASSAGE STIMULATES PARASYMPATHETIC ACTIVATION AFTER A SINGLE EXHAUSTIVE MUSCLE CONTRACTION EXERCISE. Isar NENM, Halim MHZA, Ong MLY. Journal of Bodywork and Movement Therapies 2022;doi:https://doi.org/10.1016/j. jbmt.2022.02.016 The HRV was presented as low frequency (LF), peak (Hz) and high frequency (HF), peak (Hz), as well as LF/HF ratio. HRV is amount of time between heartbeats. It is used as a non-invasive method for monitoring the heart’s autonomic influence and the balance between the parasympathetic nervous system (PNS) and sympathetic nervous system (SNS). This study quotes others that indicate that cardiac PNS reactivation following exercise is key to recovery and that PNS activity has been reported to be increased following massage on the lower limb and craniofacial muscles.

The results showed that spectral power analysis demonstrated that there

were no significant differences in the LF indices and LF/HF ratio with massage.

HRV normalisation data revealed a within-subject difference with massage which (in non-science speak) indicates that massage caused an immediate parasympathetic activation and thus can be used to aid recovery from exercise.

Co-Kinetic comment

Excellent work in trying to discover exactly what effect massage has on the body. This study started with 20 participants and finished with only 9 so it’s too small a sample size to definitively say massage is good for recovery, but it’s a start. They do give the full massage protocol and state that all strokes were at a massage pressure grade of ‘3’ but there is no indication of which scale they were using which is a pity.

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THE 10 MOST DISCUSSED PIECES OF RESEARCH IN PHYSICAL ACTIVITY & DIET (JAN - MAR 2022)

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Thoracic Outlet Syndrome If you have a patient with pain, numbness and/or weakness in their neck, shoulder and/or arm, thoracic outlet syndrome (TOS) could be the cause. However, it is hard to diagnose and therefore probably hugely underreported. This article takes you through all the stages for suspecting, diagnosing and treating TOS, so that you can make a massive difference to the life of patients who may have been suffering for some time. Read this article online https://bit.ly/3KFLLv7

By Kathryn Thomas BSc MPhil 22-04-COKINETIC FORMATS WEB MOBILE PRINT All references marked with an asterisk are open access and links are provided in the reference list

MEDIA CONTENTS

Neurogenic Thoracic Outlet Syndrome Diagnosis | nTOS [Video] Courtesy of YouTube user Physiotutors https://youtu.be/iHP0F3flLzY Tinel Sign | Thoracic Outlet Syndrome (TOS) [Video] Courtesy of YouTube user Physiotutors https://youtu.be/jvWvW3Bk4R8 Tinel Sign Elbow | Cubital Tunnel Syndrome [Video] Courtesy of YouTube user Physiotutors https://youtu.be/ASRatLbu8i0 Tinel Sign of the Wrist | Carpal Tunnel Syndrome (CTS) [Video] Courtesy of YouTube user Physiotutors https://youtu.be/SOHdFU3hllE Spurling’s Test | Cervical Radicular Syndrome [Video] Courtesy of YouTube user Physiotutors https://youtu.be/3ZSNdv0o0yk Roos / Elevated Arm Stress Test | Thoracic Outlet Syndrome (TOS) [Video] Courtesy of YouTube user Physiotutors https://youtu.be/0oGGdcQsBKY Thoracic Outlet Syndrome Treatment | Stretches [Video] Courtesy of YouTube user Physiotutors https://youtu.be/eONCDrH5vB0

WHO GIVES A TOS?

W

ell, we should all give a toss for the poor individuals suffering with unnecessary symptomology, and who are becoming frustrated, angry and depressed at the perceived lack of end to the pain, numbness and weakness in their neck, shoulder and arm. Thoracic outlet syndrome (TOS) has traditionally been a diagnosis derived through exclusion of any other condition. It can take patients up to 60 months (5 years) with symptomatic TOS to gain an appropriate diagnosis. By this stage they have seen, on average, six different specialists or doctors or therapists. They have often had at least one surgery with no relief from their symptoms or temporary relief only to have the symptoms return. Some athletes have had to stop participating in their sport as a result of their unresolved condition.

These are shocking facts. It is known that TOS is a cluster of pain with neurological and vascular deficits that range from intermittent to permanent impairments. It is also known that presentation of these symptoms varies from patient to patient. It is often difficult to specifically pinpoint the site of compression, and radiological and electrophysical testing results can present as normal. Some patients have no symptoms at rest, whereas others are in constant pain. So what exactly can you – the clinician – look for during an assessment to assist with diagnosis and where do you go from there? Once the correct diagnosis is made then the logic to choose manual therapy techniques and exercises that release and ‘open’ the thoracic outlet makes sense. Previously, incorrect or missed diagnosis, unnecessary surgery and physical therapy directed at other structures has led to dissatisfied customers. Patients can get written

off as being ‘difficult’ when your clinical hypothesis doesn’t match any investigations. You may even attempt to ‘explain their pain away’ with a central sensitisation pain model.

Remember, many patients have had symptoms for years and years, and the huge problem is that you’re not simply dealing with something that may have been relatively easy to sort out, but now a complexity has developed with chronic pain, modification in terms of movement patterns, posture and weakness in the upper quadrant.

Introduction

TOS constitutes a group of potentially disabling conditions believed to be caused by compression of neurovascular structures supplying the upper extremity (1*). The thoracic outlet is an anatomical area in the lower neck, between the clavicle and the first rib. It can be defined as a group of three spaces through which several important neurovascular structures pass (described in more detail below), including the brachial plexus, subclavian artery and subclavian vein. Compression of this area instigates a constellation of distinct symptoms, which can include upper-extremity pallor, paraesthesia, weakness, muscle atrophy and pain (2*).

Based on the principal anatomic structures involved and the resultant clinical syndromes, three distinct types of TOS exist: neurogenic (nTOS), venous (vTOS), and arterial (aTOS) (1*).

Diagnosis, treatment and outcomes vary across the different types of TOS and hence must be reported as separate entities (1*). What is more, neurovascular compression can potentially occur at three different anatomic levels: the interscalene

IT CAN TAKE PATIENTS UP TO 5 YEARS WITH SYMPTOMATIC TOS TO GAIN AN APPROPRIATE DIAGNOSIS 14

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triangle, the costoclavicular space, or the pectoralis minor space (2*). nTOS is by far the most common of the three types of TOS, representing about 95% of cases (Video 1) (2*). Here, the brachial plexus trunks or cords, originating from nerve roots C5 to T1, are involved. nTOS can be further divided into true or symptomatic TOS (symptomatic TOS may also be referred to in the literature as ‘disputed TOS’).

Symptomatic TOS constitutes over 80% of all neurogenic TOS cases. The symptoms of true and symptomatic nTOS are largely the same, although patients with symptomatic nTOS have no radiological or electrophysical abnormality in their objective screening tests (3*,4*,5*).

Thought to be initiated by brachial plexus compression or irritation at the scalene triangle or pectoralis minor space, neurogenic symptoms are the most common. Potential manifestations of nTOS include (individually or a combination of) local pain, upper limb neurologic symptoms and tenderness at the affected areas (1*). nTOS can be difficult to manage, in part because of non-specific symptoms, poorly understood pathophysiologic mechanisms, limited objective testing procedures, and potential overlap with other clinical disorders, as well as an absence of

well-defined or consistently applied criteria for diagnosis and treatment.

This can lead to missed diagnosis, unnecessary surgery and highly variable management (1*). As the most common type of TOS, this article will focus on the clinical presentation, diagnosis and management of nTOS.

Basic Anatomy and Pathophysiology

The thoracic outlet lies at the base of the neck, consists of the first rib and adjacent structures, and extends to the axilla. The symptoms of TOS arise from compression of the brachial plexus nerves, subclavian artery and vein (1*).

Table 1 describes the anatomical spaces and their contents where compression of nerves and vasculature occur. For an image of the anatomy involved, see Figure 1: Thoracic outlet and relevant anatomy in Jones et al.

(Link 1) (2*).

Numerous mechanisms elicit the characteristic pathology of TOS, including anatomical variations, trauma, and repetitive motions or habits. Of the many anatomic variations that incite TOS, the presence of a cervical rib places patients at a higher risk of nTOS, with up to 20% of nTOS cases attributable solely to this cause (2*,5*). Congenital variations in musculature, for example

Table 1: Anatomic spaces of thoracic outlet syndrome Adapted from Jones MR et al. Thoracic outlet syndrome: a comprehensive review of pathophysiology, diagnosis, and treatment. Pain and Therapy 2019;8(1):5–18 (2*) Compartment

Borders

Contents

First/most medial compartment

Interscalene triangle

Anterior: anterior scalene muscle Posterior: middle scalene muscle Inferior: first rib

Brachial plexus Subclavian artery

Second compartment

Costoclavicular space

Anterior: subclavius muscle Inferoposterior: first rib and anterior scalene muscle Superior: clavicle

Brachial plexus Subclavian artery Subclavian vein

Third compartment

Subcoracoid space

Anterior: pectoralis minor muscle Posterior: ribs 2–4 Superior: coracoid

Brachial plexus Axillary artery Axillary vein

Co-Kinetic.com

Video 1: Neurogenic Thoracic Outlet Syndrome Diagnosis | nTOS (Courtesy of YouTube user Physiotutors) https://youtu.be/iHP0F3flLzY supernumerary scalene muscle, have also been reported to cause TOS (2*).

Traumatic events are typically high velocity, for example a motor vehicle accident or fall from a mountain bike. Whiplash injuries have a known association with nTOS, especially in patients presenting with a cervical rib.

Haemorrhage, hematoma or displaced fracture can directly compress the nerves or vasculature. A midshaft clavicular fracture is a common cause of TOS. Fibrosis can develop some time after the initial insult/injury and then produce symptoms (2*,5*).

Repetitive motions, be it at work or sport, can lead to muscle hypertrophy, muscle imbalance, and poor postural alignment that may contribute to compression. An overuse injury due to repetitive movements can cause swelling, minor haemorrhage and subsequent fibrosis, which can also account for symptom development (2*). Tumours and malignancies within the thoracic outlet should also be remembered as possible culprits to producing TOS symptoms (2*,5*).

In an athlete, the underlying mechanism of nTOS is an ongoing

THORACIC OUTLET SYNDROME (TOS) HAS TRADITIONALLY BEEN A DIAGNOSIS DERIVED THROUGH EXCLUSION OF ANY OTHER CONDITION

15

process of repetitive injury leading to fibrosis and hypertrophy of the scalene or pectoralis minor muscles, followed by scar deposition onto the brachial plexus nerves themselves.

This may be exacerbated by predisposing anatomical factors such as musculotendinous abnormalities or cervical ribs (6*).

Diagnosis and Clinical Presentation

Thoracic outlet syndrome is actually not a rare disorder. Studies have reported its incidence ranging from 3 to 80 per 1000 (5*). The diagnosis of TOS remains disputed as there is no standard objective test to confirm clinical impressions. Traditionally, it has been a ‘diagnosis of exclusion’.

Hence, it is unclear whether the current epidemiologic data underestimate (or overestimate) the condition. TOS usually develops in patients between 20 and 50 years old and is more common in women (5*). The symptoms

can be severe and debilitating, and is frequently misdiagnosed as radicular pain, other entrapment syndromes, or muscle- or tendon-origin pain.

Treatment will vary according to the type of TOS; however, the appropriate treatment can produce good outcomes in individuals, hence the importance of accurate and early diagnosis (5*).

As mentioned in Illig et al. (1*), nTOS should be defined/diagnosed by the presence of three of the following four criteria:

a. This criterium includes symptoms consistent with irritation or inflammation at the site of compression (within one of the three thoracic outlet compartments, eg. the scalene triangle), along with symptoms due to referred pain in the areas near the thoracic outlet. Patients may complain of pain in the chest

Table 2: CORE-TOS clinical diagnostic criteria for neurogenic TOS Ohman JW, Thompson RW. Thoracic outlet syndrome in the overhead athlete: diagnosis and treatment recommendations. Current Reviews in Musculoskeletal Medicine 2020;13(4):457–471 (6*) Upper extremity symptoms extending beyond the distribution of a single cervical nerve root or peripheral nerve, present for at least 12 weeks, not satisfactorily explained by another condition, AND meeting at least 1 criterion in at least 4 of the following 5 categories: 1. Principal symptoms Pain in the neck, upper back, shoulder, arm and/or hand 1a.

Numbness, paraesthesia, and/or weakness in the arm, hand, or digits 1b.

2. Symptom characteristics Pain/paraesthesia/weakness exacerbated by elevated arm positions 2a.

Pain/paraesthesia/weakness exacerbated by prolonged or repetitive arm/hand use, including 2b. prolonged work on a keyboard or other repetitive strain tasks

Pain/paraesthesia radiate down the arm from the supraclavicular or infraclavicular spaces 2c.

3. Clinical history Symptoms began after occupational, recreational, or accidental injury of the head, neck, or 3a. upper extremity, including repetitive upper extremity strain or overuse

3b.

3c.

Previous ipsilateral clavicle or first rib fracture, or known cervical rib Previous cervical spine or ipsilateral peripheral nerve surgery without sustained improvement in symptoms

Previous conservative or surgical treatment for ipsilateral TOS 3d.

4. Physical examination Local tenderness on palpation over the scalene triangle and/or subcoracoid space 4a.

Arm/hand/digit paraesthesia on palpation over the scalene triangle and/or subcoracoid space 4b.

Objectively weak handgrip, intrinsic muscles, or digit 5, or thenar/hypothenar atrophy 4c.

5. Provocative manoeuvres Positive 3-minute elevated arm stress test (EAST) 5a.

Positive upper limb tension test ( ULTT) 5b.

wall, axilla, upper back, shoulder, trapezius region, neck or head (including headache). b. Pain and tenderness on palpation of the affected area as above, or palpation may reproduce their symptoms. a. Arm or hand symptoms consistent with central nerve compression.

Symptoms may include numbness, pain, paraesthesia, vasomotor changes, and weakness (with muscle wasting in extreme cases). b. Peripheral symptoms are often exacerbated by manoeuvres that either narrow the thoracic outlet (lifting the arms overhead) or stretch the brachial plexus (dangling; often driving or walking/running). c. Palpation of the affected area (scalene triangle or pectoralis minor insertion site) often reproduces the patient’s peripheral symptoms. d. Provocative manoeuvres that are believed to narrow the scalene triangle (EAST) or to stretch the brachial plexus (ULTT) (both described later) can produce or worsen their peripheral symptoms.

3. Absence Absence of another reasonably likely diagnosis (cervical disk disease, shoulder disease, carpal tunnel syndrome, chronic regional pain syndrome, brachial neuritis) that might explain/produce the majority of the patient’s symptoms. Cervical nerve root pathology would be the biggest suspect and peripheral nerve entrapment. However, one would expect positive findings on imaging and specific investigations.

Cervical nerve root compression would also present with more specific dermatomal and myotomal presentation accompanied with positive imaging findings.

4. Positive response to scalene block or injection (7) This is preferential but may not be available to everyone depending on hospitals/specialists/cost.

Sanders et al. reported that among 50

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patients, symptom distribution in nTOS included upper-extremity paraesthesia (98%), trapezius pain (92%), shoulder pain (88%), arm pain (88%), neck pain (88%), supraclavicular pain (76%), occipital headache (76%), chest pain (72%), and paraesthesia (98%) in all five fingers (58%), fourth and fifth fingers (26%), first through third fingers (14%) (8*).

A recent publication of standardised clinical diagnostic criteria for nTOS (Table 2) has brought more uniformity and recognition to the diagnosis of this condition (1*,6*,9*).

In addition to presenting with the criteria discussed above, there are some additional tools that may be helpful to diagnose nTOS. Although these factors are not required for diagnosis, most patients have prolonged symptoms (>6 months), deteriorate over time, and have a history of trauma or repetitive overhead action.

The Cervical Brachial Symptom Questionnaire (CBSQ) (downloadable at Link 2) can help differentiate between cervical and thoracic outlet causes of arm symptoms (10*). To score this, add together the sum of all 12 numerical questions. A patient with no disability will score 0; one with maximal disability will score 120 (10*).

The Shortened Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire (downloadable at Link 3) may also be a helpful tool. Scoring instructions are at the bottom of the questionnaire.

To score, add the sum of responses, divide by the number of responses, and subtract 1 from this, then multiply by 25 (a minimum of 10 of the 11 items must be answered to score the instrument). A patient with no disability will score 0; one who has maximal disability will score 100. The QuickDASH questionnaire may be used free of charge for clinical purposes, but users are asked to read the conditions of use and copyright disclaimer.

Subjective Assessment

You should have thorough documentation of as many of the following factors as possible (1*).

Symptoms – pain, numbness, Co-Kinetic.com

tingling and weakness.

The type and distribution of the symptoms.

What causes or exacerbates the symptoms – specifically overhead activities, driving, exercising and activities of daily living.

Sleeping difficulties, pain at night.

Temporal pattern of symptoms – how long have they been present, waxing and waning versus steady worsening (or plateauing).

History of trauma, with single episode vs repetitive motion injury clearly described and differentiated.

Duration of symptoms – as many patients are only diagnosed after 60 months (5 years!) you need to establish how long this has been present.

Previous treatment and results – there may be a long list of interventions, surgeries and doctors (patients have often seen six different types of doctors or medical professionals).

Occupation, with specific description of any potential relevant factors (prolonged keyboarding, arms overhead).

Relevant hobbies, sports.

Arm dominance.

Completed the CBSQ/QuickDASH assessments.

In the high-level athlete, symptoms can fluctuate, which often leads to a long interval from symptom onset to clinical diagnosis. Periods of minimal symptoms often correspond to periods of rest in their training/competing schedule or even normal day-today activities, whereas exacerbation of symptoms may correlate with increased training loads. Highperformance athletes tend to have minimal symptoms at rest and only be symptomatic during or after athletic activities; this is in comparison to nTOS patients in the general population who may have significant symptoms at rest (11). Athletes’ ‘symptoms’ may be described differently from the general population – for example they may complain of significant fatigue, or heaviness in their arms. They may complain that they are unable to perform as many repetitions (or diminished speed, power and force)

Video 2: Tinel Sign | Thoracic Outlet Syndrome (TOS) (Courtesy of YouTube user Physiotutors) https://youtu.be/jvWvW3Bk4R8

Video 3: Tinel Sign Elbow | Cubital Tunnel Syndrome (Courtesy of YouTube user Physiotutors) https://youtu.be/ASRatLbu8i0

Video 4: Tinel Sign of the Wrist | Carpal Tunnel Syndrome (CTS) (Courtesy of YouTube user Physiotutors) https://youtu.be/SOHdFU3hllE

Video 5: Spurling’s Test | Cervical Radicular Syndrome (Courtesy of YouTube user Physiotutors) https://youtu.be/3ZSNdv0o0yk

17

when throwing, bowling, serving, weight lifting or shooting hoops for example. Using these semi-objective metrics may be useful in uncovering (and monitoring progress) in nTOS for the overhead athlete (6*,12*).

Objective Examination

1. Observation and Palpation (1*) This should involve checking: posture and any abnormal movement; scapular posture; spontaneous use of affected arm; presence or absence of visible hand (thenar, hypothenar, or interosseous) muscle atrophy compared with contralateral side; presence or absence of Tinel signs along the radial, ulnar, and median nerves (Videos 2–4); point tenderness at scalene triangle or pectoralis minor insertion site; axillary tenderness; subjective swelling or tightness, asymmetry at the base of the neck; reproduction of arm or hand symptoms on palpation over supraclavicular scalene triangle or subcoracoid pectoralis minor muscle insertion site; and any other manoeuvres performed to exclude other diagnoses (eg. the Spurling test can be used to rule out cervical radiculopathy) (Video 5) (13).

PRESENTATION OF TOS SYMPTOMS VARIES FROM PATIENT TO PATIENT 18

2. Neurological Examination The neurological examination should include assessing muscle wasting, testing reflexes and looking at sensation both pinprick and thermal.

Often patients with suspected nTOS are sent for investigations including magnetic resonance imaging (MRI), magnetic resonance neurography and nerve conduction studies only to return with normal findings (3*,4*,5*), which can become very frustrating and confusing. Traditionally, patients with suspected neuropathies undergo neurological investigations including light touch, muscle strength and reflex testing. These tests, along with nerve conduction studies, focus solely on the function of large-diameter nerve fibres; however, recent work suggests that small-diameter fibres are often affected in peripheral neuropathies and nerve compression. These smalldiameter fibres may deteriorate before a compromise in large-fibre function becomes apparent (14*,15).

In people with suspected neuropathies, neglecting to examine small-fibre function may result in the underreporting of sensory changes (16*). Quantitative sensory testing (QST) can be used to assess the functional properties of small fibres.

Specifically, warm/cold detection thresholds and the perception of pinprick stimuli are known to examine the function of the C- and A-delta fibres (16*). Although QST is a great analysis of small-fibre function, it does, however, require costly equipment and is often not available to clinicians outside specialised health centres. Therefore, the use of simple bedside tests to determine smallfibre degeneration is clinically very relevant, and studies have proven them to correlate significantly to QST, suggesting that they can be a reliable tool for assessing sensory dysfunction (17*,18*). There are several tests that can be used, and these are described below.

Neurotip (Owen Mumford Ltd) is used to establish the ability to detect sharp stimuli. The Neurotip is first applied to the ventral forearm (innervated by the median nerve proximal to the carpal tunnel) and then to the palmar tip of the index

finger (affected median nerve territory). The Neurotip is applied with pressure sufficient to produce blanching of the skin, but without penetration. The patient is asked whether the sharpness of these two stimulations are comparable. A reduction in sharpness sensation at the fingertip is rated as a reduced mechanical pain threshold. A toothpick can be used to determine sharp sensations. The toothpick can be gently pressed over the lateral upper arm innervated by the radial nerve, and then over the palmar aspect of the index fingertip.

Patients are asked to compare the sharpness of these two pricks.

Comparable to the Neurotip, a reduced sharpness in the fingertip was rated as a reduced mechanical pain (nociception) threshold (17*).

A metal coin can be used to determine the ability to discriminate thermal sensations. A coin held at room temperature is placed over the lateral upper arm. The coin is then placed over the palmar aspect of the index fingertip, and the patient is asked whether the temperature of the coin was comparable between the two sites. Patients are asked to compare the perceived temperature of the coin at the fingertip to that at the lateral upper arm (the same, colder, or warmer). Metal is a good heat conductor and is perceived as ‘cold’ at room temperature. Thus, a perception of ‘warmer or less cold’ at the fingertip is rated as a deficit in cold detection (17*).

The same procedure is repeated with a coin that has been placed in the clinicians pocket for at least 30 minutes. This coin is perceived as neutral or slightly warm in a healthy population. A perception of ‘colder or less warm’ over the palmar tip of the index finger compared to the lateral upper arm is interpreted as a deficit in warm detection (17*).

If both warm and cold detection thresholds are normal then there is a strong possibility there is no smallfibre degeneration. If the patient has reduced pinprick sensation, there is a strong possibility of smallfibre degeneration. However, the issue with pinprick sensation being Co-Kinetic Journal 2022;92(April):14-24

PHYSICAL THERAPY

normal is that it doesn’t necessarily rule out nerve involvement and so it is critical that both pinprick and thermal testing are performed in the assessment to get a better neurological picture (17*,18*).

3. Provocative Tests There are multiple tests that can be performed to assess TOS, including the Adson manoeuvre, the Wright manoeuvre, and the Halsted manoeuvre (5*). Take care to choose the correct provocative test as false-positive results are common in provocative testing for TOS with, for example, the Adson test (2%), costoclavicular test (10%), and Wright tests (16.5%) (19). Therefore, two reliable tests stipulated for assessing nTOS are the elevated arm stress test (EAST), commonly also referred to in literature as the Roos test, and the second test being the upper limb tension test (ULTT) (1*).

Elevated arm stress test (EAST) (Video 6). This test is used to assess symptoms caused by narrowing of the scalene triangle. The test is positive if pain, paraesthesia, heaviness or weakness are provoked locally or distally, so essentially

reproducing the patient’s symptoms.

The word ‘stress’ in the test name refers to the fact that the arms are abducted to 90°, elbows bent to 90°, and brought backwards – the surrender position. The hands are usually briskly opened and closed for up to 3 minutes in this position, although this is not strictly necessary.

The patient can stop if symptoms are provoked before the end of the 3-minute test duration. This test is reported to have 90% sensitivity (1*). Two very important points to note when conducting the test are the timing and the positioning. The patient must be absolutely up in the surrender position, with slight extension of the shoulder putting stress on the thoracic outlet region.

As the patient fatigues (3 minutes is a long time!), their arms will drop and move forward, so maintaining positioning is crucial. One can imagine if the patient drops their arms down or lets them drift forward, then potentially they could have a false-negative result with this test. The second point is that the mean time to onset of symptoms is 1 minute 42 seconds – again that’s longer than one thinks. To gain true

Table 3: Differential diagnoses for thoracic outlet syndrome and their distinguishing clinical features Chang MC, Kim DH. Essentials of thoracic outlet syndrome: a narrative review. World Journal of Clinical Cases 2021;9(21):5804–5811 (5*) Disorder Raynaud’s syndrome Vasculitis

Distinguishing features Cold fingers, colour changes in the skin in response to cold or stress that are relieved by warmth Severe sudden-onset pain involving more than one limb, elevated C-reactive protein level, skin lesion (eg. purpura, petechiae, ulcer)

Rotator cuff tear Pain during shoulder movement that is easily differentiated by

Video 6: Roos/Elevated Arm Stress Test | Thoracic Outlet Syndrome (TOS) (Courtesy of YouTube user Physiotutors) https://youtu.be/0oGGdcQsBKY value from the test it must be timed and the patient must not stop before provocation of symptoms or the end of the 3-minute time limit (5*,6*,20*).

Results should be recorded as (1*): Time (in seconds) to onset of symptoms and what/where they are.

Time (in seconds) to dropping arm/unable to complete test.

Upper limb tension test (ULTT).

See Figure Upper limb tension test (ULTT) from Sanders et al. at Link 4 (8*). This is a modified ULTT in that the patient is sitting up and executing the manoeuvres actively rather than having the examiner perform them passively.

Carrying out the test in this way permits both limbs to be tested simultaneously and permits the asymptomatic side to serve as a control for the symptomatic one (8*). The modified ULTT is performed with three

ultrasound

Cervical radiculopathy

Acute pain (disc rupture), insidious onset (spinal stenosis), spurling sign (+), denervating potential of cervical paraspinalis on electromyography

Cubital tunnel syndrome Guyon’s canal syndrome Neuralgic amyotrophy Pancoast tumour Complex regional pain syndrome

Tinel sign (+) over cubital tunnel; differentiated by nerve conduction study

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Tinel sign (+) over Guyon’s canal; differentiated by nerve conduction study Extreme sudden-onset pain followed by rapid motor weakness and atrophy Pain in the shoulder radiating to the inner part of the scapula, possible Horner syndrome, tumour on the apex of the lung Diffuse pain, predominant vasomotor features, history of stroke, trauma, or peripheral nerve injury

THE THORACIC OUTLET IS AN ANATOMICAL AREA IN THE LOWER NECK INVOLVING THE INTERSCALENE TRIANGLE, THE COSTOCLAVICULAR SPACE, AND THE PECTORALIS MINOR SPACE 19

manoeuvres in succession as follows: Position 1: abduct both arms to 90° with the elbows straight.

Position 2: dorsiflex both wrists.

Position 3: tilt the head to one side, ear to shoulder. The head is then tilted to the other side.

Positions 1 and 2 elicit symptoms on the ipsilateral side, and position 3 elicits symptoms on the contralateral side.

Pain down the arm, especially around the elbow, and/or paraesthesia in the hand is a positive response. Production of symptoms in position 1 is the strongest positive test with increased symptoms in positions 2 and 3. The weakest response would be onset of symptoms only in position 3. On rare occasions for patients with severe pain at rest, this test can be performed passively by the examiner moving the arm through each position (1*,8*). A positive ULTT is not pathognomonic of nTOS; however, it indicates compression of the nerve roots or the branches of the brachial plexus in one of three areas: the thoracic outlet space, pectoralis minor space, or in the cervical spine.

In diagnosis of nTOS, a positive ULTT should be viewed together with results from other tests and assessment (discussed above) (8*).

Electrodiagnostic and brachial plexus imaging studies are not required for diagnosing nTOS, unless another disease is suspected. Brachial plexus imaging studies (including ultrasound, computed tomography, MRI) have not yet been shown to be correlated with outcomes in

NEUROGENIC TOS IS THE MOST COMMON OF THE THREE TYPES OF TOS, REPRESENTING ABOUT 95% OF CASES 20

nTOS, although imaging of the cervical spine may be useful to eliminate other conditions (1*,5*).

Finally, the patients should be asked to rate their global overall disability. TOS disability scale (0 being none, 10 being complete), establishes the impact of not just pain related to TOS symptoms but also the effect on home, work, school, social and sports activities (1*).

A thorough data collection/ assessment sheet for patients with nTOS, encompassing all of the factors, tests and TOS disability scale, as discussed in this section of clinical assessment and diagnosis, should be utilised. The Neurogenic TOS: First Visit datasheet developed by Illig et al. is available to download from their paper at Appendix III (Link 5) (1*).

Before moving on to treatment, a judgment of severity should be made on two axes. Firstly, the degree of suspicion that nTOS exists, ranked as low, medium, or high, determined by the clinician/physical therapist, is represented along the x-axis. Secondly, the degree of severity, as mild (low), moderate (medium), or severe (high) derived from the patient’s perspective of how severely the symptoms affect his or her life is represented along the y-axis (1*). The two-axis severity tool can be downloaded from Figure 8 from Illig et al. (Link 6) (1*).

Differential Diagnosis

Owing to similarity in symptoms with other disorders, TOS is frequently misdiagnosed. Other disorders, such as cervical radiculopathy, inflammatory neuropathy, and other nerve entrapment syndromes, should be excluded in order to confirm TOS (5*). The disorders (along with their distinguishing clinical features) that should be ruled out before confirming the diagnosis of nTOS are described in table above (Table 3).

Conservative Management of nTOS

The main features of the initial stages of treatment for nTOS involves (i) rest of the affected extremity; (ii) physical therapy to release the scalene muscles and decompress the scalene triangle and subcoracoid spaces; and (iii) the

use of muscle relaxants and antiinflammatory or analgesic medications.

Many patients with nTOS symptoms gain relief through conservative treatment, and as such physical therapy is a first-line treatment for this condition. The usual initial rehabilitation therapies include (i) patient education of posture, relaxation techniques, and weight management; (ii) exercise including stretching and strengthening of targeted muscles, and (iii) activity modification. The physical therapist has a capital role and is the guarantor of the effectiveness of the initial treatment. One study demonstrated symptomatic relief in more than 60% of patients with nTOS following 6 months of physical therapy (21*). Even in patients with substantial levels of pre-treatment disability, physical therapy alone can be effective in 31% of patients (9*).

Oral pain medications can be used to relieve neuropathic pain. Botulinum toxin injections into the scalene muscles and/or pectoralis muscle and corticosteroid injections into the pathologic areas have also been shown to be useful for managing nTOS (2*,5*,22*). If patients do not respond to these conservative treatments, surgical treatment, such as first rib and/or cervical rib resection, may be considered (2*,9*).

When physical therapy and conservative management is deemed insufficient, then surgical intervention can provide substantial symptom improvement in approximately 90% of patients (9*). It is important, however, to ensure an adequate trial of conservative management before considering surgery. Some studies have elected for surgery following inadequate improvement in symptoms and disability following 4–6 weeks (9*) of conservative management, whereas other research suggests a longer trial of 4–6 months before considering surgical intervention (23*). The initial physical therapy treatment is invaluable even for patients considered likely to require surgical treatment, because the physical therapy sessions allow the therapist to establish a baseline status for the individual patient, teach nTOS-specific protocols, help manage expectations for treatment, educate Co-Kinetic Journal 2022;92(April):14-24

PHYSICAL PHYSICALTHERAPY THERAPY

on pain science and better anticipate specific needs that might arise during postoperative rehabilitation (9*). This point of waiting for surgery only after ‘failed’ conservative management may be contentious. If there is any evidence of nerve function compromise, especially gross changes, as part of your assessment, then the recommendation may be for early referral to a surgeon as this may give those patients the best chance of a successful outcome.

Physical Therapy

Traditionally, physical therapy focuses on exercises aimed at creating and increasing the space between the first rib and clavicle, and decrease the tensile load of the upper limb.

Postural retraining and optimising diaphragmatic breathing, to reduce accessory muscle over use that can contribute to compression of the thoracic outlet, should be targeted (22*). Research by Balderman et al. showed that 27% of patients with nTOS obtained satisfactory improvement with physical therapy alone (9*), whereas another study demonstrated symptomatic relief in 25 of 42 patients after 6 months of physical therapy (21*).

More recently, work by Collins et al. has shown that physical therapists are applying novel techniques in neuroscience and cognitive behavioural therapy in the form of informed physical therapy for improving outcomes (24). This entails physical therapists striving to improve patient function and symptoms through several techniques that target various domains including: external support, such as a shoulder girdle or sling used in the initial stages, short term, to improve symptoms; function and ergonomics, such as posture training and changes to home or work space ergonomics; neural glides; psychologically informed physical therapy; pain-science education; and movement pattern retraining, which allows for a greater tolerance to functional activities and can have a positive impact on quality of life (24).

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Scapular protraction and head forward posture tightens the anterior and middle scalenes, sternocleidomastoid, trapezius, levator scapulae, pectoralis muscles, suboccipital muscles, and elongates the middle and lower trapezius muscles. This, in turn, narrows the thoraco-coraco-pectoral space. These muscles, in a shortened or lengthened position, are at a mechanical disadvantage. Posture correction includes reducing forward head posture and encouraging scapular retraction, which opens up the thoraco-coraco-pectoral space (19).

Release of tight structures possibly contributing to compression in the thoracic outlet can be done using massage, manual therapy techniques, muscle energy techniques, active release techniques, mobilisation and manipulation. Relaxation and pain management can be addressed using massage techniques as well as heat and transcutaneous electrical stimulations as well as any other form of relaxation technique the patient may choose (tai-chi, yoga, meditation) (25). Passive and active neuro-dynamic techniques, avoiding amplitudes that trigger painful symptoms should be included in treatment. Stretching of scalene muscles, sternocleidomastoid muscles, upper and middle trapezius, pectoral muscles, shoulder stabilisers and para-vertebral muscles can be prescribed (Video 7) (25).

Evaluation of joint mobility, scapular kinematics and parascapular control of the rhomboids, serratus anterior, and the middle/lower trapezius is necessary. Frequently patients present with weakness in the lower scapular stabilisers and hypertrophy in scapular elevators. This is due to overused arm movements, especially the upper trapezius, levator scapulae and upper rhomboids (19).

Muscular strengthening is generally to be avoided except for all the para-vertebral muscles, serratus and small pectoralis muscles (the muscles that open the costoclavicular interspace). This active work must not trigger pain or neural sensations (25).

Strengthening is generally discouraged as shortening or spasm of the muscles around the neck may exacerbate TOS symptoms. However, weak muscles of

Video 7: Thoracic Outlet Syndrome Treatment | Stretches (Courtesy of YouTube user Physiotutors) https://youtu.be/eONCDrH5vB0 the cervical spine and shoulder girdle may be contributing to TOS symptoms through spasm developed from muscle fatigue or poor postural alignment.

Individualised and supervised exercise therapy with ongoing posture correction and proprioception training will be beneficial (25). Emphasis should be on stretching the muscles that close the thoracic outlet (such as the scalene and pectoralis muscles) and strengthening the muscles that open the thoracic outlet (such as the scapular

Table 4: Instructions for graduated resisted shoulder elevation exercises Adapted from Kenny R et al. Thoracic outlet syndrome: a useful exercise treatment option. American Journal of Surgery 1993;165(2):282–283 (26). © Elsevier Inc 1993 Exercise: elevate shoulders and hold for count of 5, then relax shoulders. Repeat as outlined below Week 1:

No weights

Day 1

15 exercises, 5 times daily

Day 2

15 exercises, 5 times daily

Day 3

15 exercises, 6 times daily

Day 4–7

20 exercises, 6 times daily

Week 2:

1.25kg weight held in each hand

Day 1

10 exercises, 5 times daily

Day 2

15 exercises, 5 times daily

Day 3

20 exercises, 5 times daily

Day 4-7

20 exercises, 6 times daily

Week 3:

2.5kg weight held in each hand

Day 1

10 exercises, 5 times daily

Day 2

15 exercises, 5 times daily

Day 3

20 exercises, 5 times daily

Day 4–7

20 exercises, 6 times daily

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PHYSICAL THERAPY CAN SIGNIFICANTLY IMPROVE PATIENT SYMPTOMS ACROSS ALL PARAMETERS stabilising muscles, the rhomboids and the middle/lower trapezius muscles) (19). Targeted, progressive strengthening aims to improve muscular endurance with low weight and a high number of repetitions (19).

Albeit an older study with a small sample size, research by Kenny et al. showed that a simple graded exercise programme (Table 4) significantly improved patient symptoms across all parameters (pain in hand, arm and neck, pins and needles, and weakness in the upper limb) after 3 weeks (26).

At all visits for nTOS, as many as possible of the following should be reported: description and severity of interval symptoms, including impact on work, school, recreation, and daily activities; extent of interval involvement in physical therapy and progress achieved; adjunctive procedures or interventions performed; current medications, including opioid narcotics; results from scoring instruments – QuickDASH, CBSQ, TOS disability; and physical examination.

A thorough data collection sheet for patients with nTOS, encompassing all of the above factors should be utilised. The Neurogenic TOS Therapy datasheet developed by Illig et al. is available to download at Appendix IV (Link 7) (1*). Results should be reported specifically at 3, 6, 12, and 24 months after the initiation of any therapy or surgery.

Ongoing symptoms of nTOS at any interval after treatment are characterised as either: persistent (no improvement after previous treatment); or recurrent (return of symptoms of equal or greater severity than 22

previously present, after a period of at least 3 months since last treatment).

The majority of instances of recurrent nTOS occur within 12 to 18 months after surgical treatment, after which recurrence is relatively uncommon.

If this is a follow-up appointment after some time (be it a break from treatment, following surgery or a recurrence), thorough documentation should be done. The Neurogenic TOS Follow-Up datasheet developed by Illig et al. is available to download at Appendix V (Link 8) (1*).

Surgical Intervention in nTOS

Most surgical candidates exhibit nTOS with uncontrolled pain, inadequate response to conservative management, or progressively worsening upper-extremity weakness (2*). The surgery of choice is a first rib resection, often combined with a scalenectomy or scalenotomy, aimed at brachial plexus decompression, and can be performed by thoracic surgeons, neurosurgeons, orthopaedic surgeons and plastic surgeons. Brachial plexus decompression, by removal of the first rib, can be performed via three approaches: transaxillary, supraclavicular and infraclavicular techniques. Each approach has achieved good outcomes, with no definitively superior technique (2*,27*).

Overall outcomes from surgical decompression are very positive.

Following surgical intervention, 95% of patients with nTOS report ‘excellent’ results (2*,28*).

Research by Shutze et al. reported satisfaction with outcomes in a survey of competitive athletes who had undergone surgical treatment, namely first rib resection and scalenectomy (FRRS), for nTOS (27*). There was an improvement in pain medication use in 96% and resolution of symptoms in 82%, with 75% reporting that they would undergo contralateral decompression if necessary. Ninetyfour percent of athletes stated that they were unlimited in performing standard day-to-day activities, and 70% of these athletes had returned to the same or better subjective levels of activity. Half of the individuals reached

that goal 1 year after surgery (27*).

Postoperative Rehabilitation

As with most surgical interventions, immediate postoperative care after thoracic outlet decompression is focused around pain control, maintenance of full range of motion at the shoulder and the neck, optimisation of wound healing, and initiation of light physical therapy to avoid muscle spasm (6*). From here, physical therapy is progressed over the next 3–4 weeks, focusing on passive and assisted exercises based on shoulder range of motion, avoidance of strength training at this stage, ‘nerve glides’ for neural mobilisation, maintenance and improvement of posture, addressing scapular kinematics, teaching diaphragmatic breathing patterns, and maintaining general conditioning.

At approximately 8 weeks, resistance strength training for the mid and lower trapezius, serratus anterior, and rotator cuff muscles begins, as well as continued efforts to maintain full range of motion and corrected movement patterns. For an athlete, gentle throwing or overhead activities can begin. At the 12-week mark, a more formal graduated throwing/overhead sporting activity programme may begin and progress as tolerated (6*).

It is critical that all of these steps work in concert during the rehabilitation process, as attempts to rush the process may lead to the development of excessive muscle spasm with subsequent perineural scar tissue deposition and increased risk of recurrent nTOS symptoms (6*). Full rehabilitation and return to high-level athletic competition often takes 9–12 months following surgery.

An overview of postoperative rehabilitation for neurogenic TOS includes the following stages (6*).

Stage I: Inpatient Hospital length of stay: 3–5 days.

Do self-directed exercises (cervical and shoulder ROM).

Follow-up visit with surgeon, postoperative day 5–7, drain removal.

Stage II: First Postoperative Month Protect surgical tissues to promote Co-Kinetic Journal 2022;92(April):14-24

PHYSICAL THERAPY

healing and minimise muscle spasm (propping arm with pillows while sitting and sleeping, ice, medications).

Maintain cervical and glenohumeral range of motion.

Begin light conditioning activity (walking, bicycle).

Stage III: Second postoperative month Have physical therapy, 1–2 sessions per week.

Continue pain management.

Attend to posture (head, shoulders, and scapulae), monitor for scapular winging.

Begin light neural mobilisations.

Begin gentle stretching of levator, upper trapezius, and pectoral muscles.

Begin movement of scapula into upward rotation and elevation.

Attend to breathing pattern, teaching diaphragmatic breathing.

Continue conditioning activity (walking, bicycle, elliptical, treadmill) but avoid vigorous use of involved upper limb.

Begin activities of daily living, ergonomics, work environment.

Cautions: no strengthening including use of weights or bands, avoid manual therapies that may irritate sensitive healing tissue, no immersion in water until incisions fully healed.

Stage IV: Third and Fourth Postoperative Months Continue physical therapy, 1–2 sessions per week.

Continue symptom management, may introduce manual therapies.

Continue conditioning activity (bicycling, walking, elliptical, treadmill).

Begin strengthening mid and lower trapezius, serratus anterior, and rotator cuff muscles.

Increase range of motion of upper limb, begin throwing motion, optimise movement patterns.

Introduce gentle throwing and progress as tolerated.

Stage V: Fourth to Sixth Postoperative Months Follow a supervised throwing Co-Kinetic.com

programme, progressing as tolerated (the one below is for baseball pitchers, but can be modified according to sport/activity, for example number of shots in basketball, number of serves, bowling in cricket, volleyball shots instead of number of throws, as long as it’s slow and progressive): step 1: 1×25 throws at 60ft step 2: 2×25 throws at 60ft step 3: 1×25 throws at 60ft, 1×25 throws at 90ft step 4: 1×30 throws at 60ft, 1×25 throws at 90ft step 5: 1×30 throws at 60ft, 1×25 throws at 90ft step 6: 1×30 throws at 90ft, 1×25 throws at 120ft step 7: 2×20 throws at 120ft step 8: 1×20 throws at 120ft, 1×20 throws at 150ft step 9: 1×20 throws at 150ft, 10 pitches from mound step 10: long toss, 35-pitch bullpen session Gradually increase activity toward unrestricted return to competition at 6 to 9 months.

Evaluating the athlete’s range of motion, muscle strength, and functional athletic ability should be included when considering return to sport. Sport-specific testing is recommended to recreate similar athletic activities. Considering mental readiness to return to play is included in the safety evaluation, especially for contact sports. Finally, open communication with athletic trainers, coaches, team physicians, and other medical personnel can help gather information necessary for return-toplay decision-making.

Conclusion

We may encounter many patients on a daily basis in clinic that present with upper limb pain with or without motor weakness. Of these, only a few are likely to have TOS. To ensure diagnostic accuracy and appropriate treatment, clinicians should have better knowledge of TOS. Too many patients are remaining undiagnosed, living with symptomology, for too long when accurate diagnosis and appropriate treatment could change

their lives. Early identification and treatment of TOS provide the greatest opportunity for optimal recovery.

Regrettably, the throng of non-specific symptoms, which makes diagnosis challenging, can delay treatment and increase the risk of the development of complications.

Despite advances, substantial controversy regarding the diagnosis remains. This is evidenced by the lack of objective findings surrounding nTOS, the most common type of TOS. The challenges associated with diagnosis complicate the selection of the appropriate treatment options.

As discussed in this article, the North American Society for Vascular Surgery reporting standards for nTOS (1*) were published in 2016 to produce greater consistency in diagnosis and management. Since then a large cohort study has shown that by using these guidelines more than 56% of patients were confirmed with an accurate diagnosis and referred for treatment. Of these 40% had successful physical therapy treatment and 60% successful surgical intervention (29). Significant improvements in disability scores were seen across all patients. A multidisciplinary team guiding patients, using diagnostic criteria and reporting standards discussed in this article, might significantly benefit patient outcomes.

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://bit.ly/3KFLLv7

RELATED CONTENT Medical Screening in Physical Therapy: Understanding Neurodynamics [Article] https://bit.ly/3vaap2t Patient Information Leaflet: Exercises and Advice for Carpal Tunnel Syndrome [Printable leaflet] https://bit.ly/3sgAKKh The Brain, Movement and Pain: Part 1 [Article] https://bit.ly/3fzr99G The Brain, Movement and Pain: Part 2 [Article] https://bit.ly/3vgvntv

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DISCUSSIONS

In your years of practice do you recall an individual that may have presented with the necessary criteria for nTOS diagnosis that could have been ‘missed’?

How confident are you in performing the simple bedside clinical tests (Neurotip and coin) in your neurological examination?

Do you have a specific technique, stretch or exercise that works well in relieving thoracic outlet symptoms?

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

LINK 1: Figure 1: Thoracic outlet and relevant anatomy in Jones et al. Thoracic outlet syndrome: a comprehensive review of pathophysiology, diagnosis, and treatment. Pain and Therapy 2019;8(1):5– 18 (2*) https://bit.ly/36sDVGc LINK 2: Cervical Brachial Symptom Questionnaire (CBSQ), developed by Jordan et al. Differentiation of thoracic outlet syndrome from treatment-resistant cervical brachial pain syndromes: development and utilization of a questionnaire, clinical examination and ultrasound evaluation. Pain Physician 2007;10(3):441–452 (10*) https://bit.ly/3pfblyF LINK 3: Shortened Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire, Institute for Work & Health 2006-2020, Toronto, ON Canada M5G 1S5 https://bit.ly/3IhXlfd LINK 4: Figure Upper limb tension test (ULTT). Sanders et al.

Diagnosis of thoracic outlet syndrome. Journal of Vascular Surgery 2007;46(3):601–604 (8*) https://bit.ly/3JSC3VA LINK 5: Neurogenic TOS: First Visit datasheet. Developed by Illig et al., this is available to download from their paper at Appendix III. Illig KA, Donahue D, Duncan A et al. Reporting standards of the Society for Vascular Surgery for thoracic outlet syndrome. Journal of Vascular Surgery 2016;64(3):e23–35 (1*) https://bit.ly/3pbLYxy LINK 6: Two-axis severity tool. Available at Figure 8 in Illig KA, Donahue D, Duncan A et al. Reporting standards of the Society for Vascular Surgery for thoracic outlet syndrome. Journal of Vascular Surgery 2016;64(3):e23–35 https://bit.ly/3p9VQbq LINK 7: Neurogenic TOS Therapy datasheet. Developed by Illig et al., this is available to download from their paper at Appendix IV. Illig KA, Donahue D, Duncan A et al. Reporting standards of the Society for Vascular Surgery for thoracic outlet syndrome. Journal of Vascular Surgery 2016;64(3):e23–35 (1*) https://bit.ly/3JLL030 LINK 8: Neurogenic TOS Follow-Up datasheet. Developed by Illig et al., this is available to download from their paper at Appendix V. Illig KA, Donahue D, Duncan A et al. Reporting standards of the Society for Vascular Surgery for thoracic outlet syndrome. Journal of Vascular Surgery 2016;64(3):e23–35 (1*) https://bit.ly/353OXRS

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KEY POINTS

Thoracic outlet syndrome (TOS) comprises a group of potentially disabling conditions believed to be caused by compression of neurovascular structures supplying the upper extremity.

Neurogenic TOS (nTOS), the most common type, can potentially result from neurovascular compression at three different anatomic levels: the interscalene triangle, the costoclavicular space, or the pectoralis minor space. nTOS can be caused by anatomical variations, trauma, repetitive stress, overhead activities, hypertrophy, muscle imbalance and poor postural alignment.

Diagnosis of nTOS is based on the presence of at least three out of four criteria from local and peripheral findings of pain, numbness, weakness, paraesthesia and vasomotor changes, to positive provocative manoeuvres, the absence of another diagnosis and a positive scalene block or injection.

Provocative tests include the elevated arm stress test (EAST), also known as the Roos test, and the upper limb tension test (ULTT).

Simple bedside, cost-effective tests can determine small nerve fibre degeneration, a Neurotip or toothpick for sharp stimuli and a metal coin for thermal sensation.

Physical therapy is a first-line treatment for nTOS. Rehabilitation therapy, including patient education (postural mechanics, relaxation techniques, and weight control), exercise (stretching and graded strengthening of targeted muscles), and activity modification are suggested and produce successful outcomes.

Surgical intervention performing a first rib resection and scalenectomy (FRRS) produces excellent outcomes in the majority of patients.

Postoperative physical therapy is critical, full rehabilitation and return to high-level athletic activity can take 9–12 months.

Co-Kinetic Journal 2022;92(April):14-24

PHYSICAL THERAPY

22-04-COKINETIC FORMATS WEB MOBILE

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

By Kathryn Thomas BSc MPhil

IS COLD THERAPY

Still Applicable Today?

Localised cold therapy (ice) has long been an accepted part of initial treatment of acute soft tissue injury, but it is now recognised that inflammation is necessary to promote healing and ice is no longer recommended. However, in the absence of soft tissue injury, whole-body cold therapy can be useful for optimising recovery from sports training. Read this article to understand when localised or whole-body cold therapy should or shouldn’t be used so that you can provide individualised recovery advice for your patients. Read this article online https://bit.ly/3t0uZkr

THE USE OF ICE (COLD THERAPY) FOR ACUTE SOFT TISSUE INJURIES IS NO LONGER RECOMMENDED, AS THE REDUCTION OF INFLAMMATION MAY ALSO DELAY HEALING Co-Kinetic.com

M

elting ice is not just a hot topic when it comes to global warming, but it seems to be slowly melting away from its prime position as the ‘go to’ modality in acute soft tissue management.

It has been ingrained in us as professionals, and it seems in the public’s perception, as the thing to use (albeit convenient and cheap) when you suffer from any acute injury, pain or swelling. Recently, however, the application of cold/ice therapy has become extremely controversial in sports medicine and acute soft tissue injury rehabilitation.

Traditionally, this therapy was often used for its immediate analgesic effects following injury. Cold therapy was thought to be beneficial as it lessens the inflammatory response to trauma, reduces oedema, reduces haematoma formation, reduces muscle spasm, decreases tissue metabolism, and reduces enzymatic activity. Additionally, it can also reduce nerve conduction velocity and vascular permeability, and cause vasoconstriction (1*). Considering what is needed for tissue healing and recovery, it is understandable that these physiological effects are questionable.

There are a limited number of randomised controlled trials and relatively low level of evidence, with significant heterogeneity, for the use of traditional ice therapy (1*,2*). As the process of inflammation is an essential component to recovery, anything that reduces inflammation may also delay healing. However, if the goal is to limit the extent of the oedema (eg. severe joint sprain), then cold therapy could be a useful option, as excessive or prolonged swelling has been proven to hinder the healing process during the recovery period. Conversely, when

the oedema level is less severe – in the case of a muscle strain for example – cold therapy may in fact act as a barrier to recovery (1*).

When injured, the body triggers inflammatory cells (macrophages) to release the hormone insulin-like growth factor 1, which initiates the healing process. This initially causes local vasodilation and increased blood flow and permeability to allow the cells and proteins required for repair to migrate to the damaged tissue.

When ice is applied topically, the vasoconstriction may impede this transport of inflammatory chemicals to injured cells thereby delaying the initiation of the healing process (3*).

Thus the generic application of ice to all things may need to be better customised.

The Evolution

As our understanding of pathophysiology evolves with advancements in science, so too must our clinical management. The historical acronym for acute injury management, originated with ICE (ice, compression and elevation). The term RICE (rest, ice, compression and elevation) was then entrenched in sports and musculoskeletal rehabilitation for nearly 20 years before they added ‘protection’ altering it to PRICE. Protection and rest made sense after injury, supporting the need to shield, unload or restrict movement so as to prevent further damage.

Studies with animal models did show that short periods of unloading are required after acute soft tissue injury. However, the rest should be of limited duration and restricted to just immediately after trauma (4*). Adverse changes to tissue biomechanics and morphology can result from prolonged periods of unloading, thus proving to be harmful instead of helpful (5*). Studies have shown that 25

early mobilisation with accelerated rehabilitation is effective after acute ankle strain. Functional rehabilitation, involving early weight-bearing usually with an external support, is superior to cast immobilisation for most types of ankle sprain. Thus, progressive mechanical loading is more likely to restore the strength and morphological characteristics of collagenous tissue than rest (6*,7*).

The principles of mechanotherapy imply that mechanical loading prompts cellular responses that promote tissue structural change, thereby aligning with the principles of functional rehabilitation (5*). For example, mechanical loading upregulates mRNA expression of key proteins associated with soft tissue healing. If tissues are stressed too aggressively after an injury, the mechanical insult may cause re-bleeding and further damage, thus delaying healing. And so the challenge in a clinical setting is finding that balance between loading and unloading while tissues are healing.

Too much emphasis on protection, care and unloading can result in fear, avoidance, catastrophising, and impact an individual’s mental health.

Thus, optimal loading delivers us to a place between rest and incremental rehabilitation, where early activity

encourages early recovery. The right amount of activity can help reduce oedema; movement and muscle contraction can facilitate drainage and move the swelling up against gravity.

Thus, the acronym POLICE was fashioned to represent protection, optimal loading, ice compression and elevation. This was a reminder for clinicians to think differently and seek out new and innovative strategies to safely and effectively load acute soft tissue injuries earlier on in management. Optimal loading could include manual therapy and even massage refined to maximise the mechano-effect. Interestingly crutches, braces and supports, traditionally prescribed for rest, may have a greater role in adjusting and regulating optimal loading in the early stages of rehabilitation (4*).

In 2019, however, the latest and most inclusive acronym was published: PEACE & LOVE (standing for protection, elevation, avoid antiinflammatory drugs, compression, and education & load, optimism, vascularization, and exercise) (Fig. 1) (2*). These new acronyms considered a rehabilitation continuum rather than simply the first 48 hours following injury. Although localised ice application may have provided an

analgesic effect, management of soft tissue injuries needs to be more than short-term damage control. What you do now will affect what happens in weeks to come. Focusing on favourable long-term outcomes and treating the person with the injury rather than the injury in isolation will be beneficial.

With that, localised conventional cryotherapy (the application of ice, cold packs or cold sprays) was removed from the acute management of soft tissue injury guidelines as it has the potential to cause serious side effects such as nerve injury, delayed healing, neuromuscular impairment and skin burn. But, does that leave cold therapy dead in the water?

Can Cold Therapy Recover?

Although localised cold therapy is no longer recommended for acute soft tissue injuries, cold therapy of the whole body in the absence of soft tissue injury may be beneficial for other reasons. In recent years, sports medicine research has prioritised strategies for optimal training recovery for elite athletes, based on the premiss that suboptimal recovery can lead to fatigue, reduced quality of subsequent training sessions and/or competitive performances, increased risk of injury and potential hampering of adaptive processes (8*). In the absence of acute injury, cooling the body results in a generalised decrease in training-induced muscle-damage and inflammatory markers, thereby accelerating recovery from training (1*,8*,9*,10*).

The cold therapy techniques described below have the potential to positively affect human physiological and psychological conditions, thereby aiding sports recovery and performance.

1. Cold-Water Immersion

Figure 1: PEACE & Love acronym for treating acute soft tissue injuries © Co-Kinetic 2020

26

Cold-water immersion (CWI) involves submersing a part of the body (for example a limb) or the whole body except the head in a cold-water bath (<15°C) for 10 to 12 minutes. For an example, see Figure 2, panels A–C in Qu et al. (9*; https://bit.ly/3JwVXWi).

A combined mechanism of action has been proposed for CWI. Decreased nerve conduction velocity reduces pain Co-Kinetic Journal 2022;92(April):25-29

PHYSICAL THERAPY

perception, combined with pressureand temperature-induced changes in blood flow and reduced skeletal muscle temperature. The result being that cold temperatures may facilitate enhanced recovery through reduced intramuscular temperature and metabolism, thereby limiting hypoxic stress and the production of reactive oxygen species (ROS) (8*). Coldinduced reduction in muscle blood flow is proposed to limit inflammatory signalling, oedema and subsequent secondary damage to the muscle fibres. However, as with traditional localised cryotherapy, reducing or eliminating the inflammatory response may not be beneficial as it is required for the cell signalling and remodelling processes involved in the post-exercise adaptive response (11*). Traditionally, studies have focused on performance and subjective outcome measures alongside systemic inflammatory markers in the blood. Analysis of the skeletal muscle inflammatory response has been absent, possibly due to ethics and the invasive method of muscle biopsy which has to be performed.

Peake et al. were the first to show no difference in post-resistance-exercise inflammatory and cellular stress response between CWI and active recovery in human skeletal muscle (via muscle biopsy), potentially questioning whether CWI reduces the post-exercise inflammatory stress response at a cellular level as previously believed (11*).

Can there be too much of a good thing though? Chronic CWI (twice a week for 12 weeks) has been implicated in a blunting effect of key proteins and satellite cells in skeletal muscle, suggesting that a reduction of inflammatory signalling may be responsible (12*). The mechanisms by which chronic CWI induced a dampened response to resistance training are not fully understood (11*,12*). There may be no positive (or negative) implications of postexercise CWI upon the inflammatory and cellular stress response – a current research paradox. The benefits of CWI may go beyond functional recovery and improved subsequent performance, to reduced delayed onset muscle soreness (DOMS), Co-Kinetic.com

analgesia and placebo effect (8*).

CWI may be useful within certain competition settings, particularly those that require a short turn-around (such as tournament situations, multiday events, athletic meets and cycle tours), are of a particularly damaging/ unfamiliar nature, or are carried out in high environmental temperatures.

Regularly using CWI in the ‘pre-season’ or preparation phase, particularly where the goals include a hypertrophic response, may not be justified.

2. Contrast-Water Therapy

Contrast-water therapy (CWT) involves immersing a part of or the whole body, except the head, in alternating cold (15°C for 1 minute) and hot (38°C for 1 minute) water for 6 to 7 cycles, totalling 12 to 14 minutes. It has been suggested that CWT may reduce oedema by alternating peripheral vasoconstriction and vasodilation. This theory is commonly referred to as a ‘pumping action’ within the literature.

The physiological basis upon which CWT may benefit athletic performance include alterations in tissue temperature and blood flow, reduced muscle spasm and inflammation, and improved range of motion. The exact mechanisms by which CWT may improve athletic recovery have yet to be established and presently there is little evidenced-based consensus (13*).

3. Whole-Body Cryotherapy

Whole-body cryotherapy (WBC) exposes the body to extremely cold air (-110°C to -195°C) in a specifically designed room or cryochamber for 3 to 4 minutes (8*,9*,10*). During these exposures, individuals wear minimal clothing, which usually involves shorts for males and shorts and a crop top for females. Additionally, gloves, a woollen headband covering the ears, a nose and mouth mask, as well as dry shoes and socks should be worn to reduce the risk of cold-related injury to the extremities.

Although the research examining WBC is typically limited, some studies have described a reduction in creatine kinase activity after training, increases in parasympathetic activation and an increase in anti-inflammatory cytokines after WBC exposure (10*).

COLD THERAPY MAY STILL BE USEFUL FOR ACUTE SOFT TISSUE INJURIES IF THERE IS EXCESSIVE OR PROLONGED SWELLING, WHICH HINDERS THE HEALING PROCESS A reduction in the severity of muscle damage after exercise and an increase in anti-inflammatory cytokines posttreatment may help to reduce both the initial damage and the secondary inflammatory damage associated with exercise-induced muscle damage.

Recently, elite athletes have used the treatment to alleviate DOMS following exercise (10*). WBC is commonly employed shortly (within 0 to 24 hours) after exercise, and the treatment is often repeated on the same day or over several days (15,16*).

As little is known from a mechanistic perspective, the physiological and biochemical rationale for using WBC in the management of DOMS is not fully validated. Reductions in muscle and skin tissue temperature may stimulate cutaneous receptors and excite the sympathetic adrenergic fibres, resulting in a constriction of local arterioles and venules.

Reduced muscle metabolism, skin microcirculation, receptor sensitivity and nerve conduction velocity may be effective in relieving soreness (10*).

The potential psychological benefits of using cold exposure (eg. CWI) to reduce the subjective feeling of DOMS following exercise cannot be ruled out.

Figure 1 in Costello et al. illustrates a logic model describing the potential benefits and adverse effects of WBC (10*; https://bit.ly/34IXXfd)).

Partial-body cryotherapy (PBC), using a portable cryo-cabin has recently been developed to facilitate accessibility to this treatment. This portable system has an open tank and exposes the body, except the head and neck, to temperatures below -100°C (10*). For an example, see Figure 2, panels D–F in Qu et al. (9*; https://bit.ly/3JwVXWi).

Timing and care around training needs to be considered when looking at WBC prescription (17*). Using the 27

standard protocol of one WBC session, of 3-minute duration, following high intensity interval training (HIT) does not negatively affect aerobic adaptation over a 4-week period (18*).

However, after a prolonged cycle of consecutive sessions (twice daily for seven days) there are concerns that WBC could limit the release of intracellular enzymes, subsequently attenuating the cascade of injury– repair–regeneration of skeletal muscles, and so delaying skeletal muscle regeneration (19*). Therefore, if a combination of WBC and exercise training is to be considered, the extent of exercise-induced muscle damage and possible disturbance of anabolic signalling should be taken into account – especially when planning the subsequent day’s training load (17*).

WBC should only be performed in the presence of skilled personnel.

Risks associated with extreme cold exposure include burns, frostbite, eye injury, asphyxiation and loss of consciousness. Patients are instructed to wear a bathing suit, surgical mask, ear band (head or earmuffs), triplelayer gloves, dry socks, and sabots with thermal protection to protect their extremities and to dry sweat (9*).

A variety of medical conditions are contra-indicated for WBC including cryoglobulinemia, cold intolerance, Raynaud disease, hypothyroidism, acute respiratory system disorders, cardiovascular diseases (unstable angina pectoris, cardiac failure in III and IV stage according to NYHA), uncontrolled hypertension, sensory neuropathies, purulent-gangrenous cutaneous lesions, sympathetic nervous system neuropathies, local blood flow disorders, cachexia, previous cold injury, and claustrophobia (17*,20*).

4. Hyperbaric Gaseous Cryotherapy or Neurocryostimulation

Hyperbaric gaseous cryotherapy or neurocryostimulation (NCS) is similar to WBC; however, it uses a handheld medical ‘ice gun’ to spray CO2 microcrystals at a localised area. On contact with skin, the CO2 microcrystals become CO2 gas through the process of sublimation, which 28

reduces the skin temperature to about 4°C within 30 seconds – drastically shortening the cooling time (1*). This technique induces a physiological response called ‘thermal shock’, which triggers a swift systemic response of cutaneous vasoconstriction proven to induce greater analgesia, antiinflammatory, vasomotor, muscle relaxing, anti-oedematous, and other beneficial effects than conventional cold therapy (1*).

Does it Matter Which Cold Therapy I Use?

Research comparing the sports recovery methods CWI, CWT and WBC in middle- and long-distance runners with exercise-induced muscle damage, found WBC to be more effective (9*). WBC reduced perceived muscle soreness (based on visual analogue scale (VAS)); diminished the increase in muscle-damage markers, such as plasma creatine kinase activity; inhibited the increase in plasma C-reactive protein activity; and promoted the fastest recovery of vertical jump height. Recovery using CWI and CWT also had positive effects on the above parameters but to a lesser extent (9*). Improvements in muscle tiredness, pain, and wellbeing using WBC following strenuous exercise have been reported (17*).

The efficacy of cold therapy for recovery may also be dependent on timing post-exercise. The benefits in recovery from both CWI and CWT, during the first 24 hours, appear to be from the attenuation of the detrimental effects of exercise. However, studies have shown that by 48 hours, irrespective of recovery intervention, control or CWI/CWT intervention participants had returned to within 2% of their baseline test scores. The efficacy of intervention, either CWI or CWT, on restoring performance beyond 48 hours is unclear (21*).

Muscle soreness, muscle damage, strength, and power all appear to recover quicker after CWT compared to no intervention, rest, or passive recovery. However, when CWT was compared to other commonly employed recovery modalities little difference was observed (13*).

Consequently, athletes and coaches

can be advised to choose a recovery modality that is best suited to their individual training schedules, preferences, facilities and equipment.

Likewise, the choice of which cold therapy to use in athlete recovery may be guided by access to a facility (cryotherapy chamber) as well as cost.

Conclusion

Traditional cold or ice therapy (ie. topical icing of an injured area) may not be helpful and could act as a barrier to the healing process. Prolonged icing on the skin has been reported to lead to reduced blood flow, resulting in tissue damage and/or potentially damaging nerves. Thus it is no longer included in acute soft tissue management. However, given that CWI and WBC enhance muscle recovery and reduce muscle-performance decrements, these methods may be a useful non-pharmacologic and non-invasive therapy for promoting recovery from sport training (9*,17*).

Determining the correct periodisation of cold therapy (CWI and WBC) requires further research. Recovery programmes using cold therapy should adopt an individualised approach: with particular focus on athlete goals, their training/competition schedule and surrounding environment.

References

1. Wang ZR, Ni GX. Is it time to put traditional cold therapy in rehabilitation of soft-tissue injuries out to pasture? World Journal of Clinical Cases 2021;9(17):4116– 4122 Open access https://bit.ly/3gKZBz8 2. Dubois B, Esculier J-F. Soft-tissue injuries simply need PEACE and LOVE. British Journal of Sports Medicine 2020;54(2):72– 73 Open access https://bit.ly/3sKxBRU 3. Khoshnevis S, Craik NK, Diller KR. Cold-induced vasoconstriction may persist long after cooling ends: an evaluation of multiple cryotherapy units. Knee Surgery, Sports Traumatology, Arthroscopy 2015;23(9):2475–2483 Open access https://bit.ly/3rOLtLC 4. Bleakley CM, Glasgow P, MacAuley DC. PRICE needs updating, should we call the POLICE? British Journal of Sports Medicine 2012;46(4):220–221 Open access https://bit.ly/3LEeAtg 5. Khan KM, Scott A. Mechanotherapy: how physical therapists’ prescription of exercise promotes tissue repair. British Journal of Sports Medicine 2009;43(4):247–252 Open access https://bit.ly/3HRNZ9H 6. Jones MH, Amendola AS. Acute treatment of inversion ankle sprains. Clinical Co-Kinetic Journal 2022;92(April):25-29

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Orthopaedics and Related Research 2007;455:169–172 Open access https://bit.ly/3LxIQFX 7. Bleakley CM, O’Connor SR, Tully MA et al.

Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial.

BMJ 2010;340:c1964 Open access https:// bit.ly/3sC9Xae 8. Allan R, Mawhinney C. Is the ice bath finally melting? Cold water immersion is no greater than active recovery upon local and systemic inflammatory cellular stress in humans. The Journal of Physiology 2017;595(6):1857– 1858 Open access https://bit.ly/3uRvles 9. Qu C, Wu Z, Xu M et al. Cryotherapy models and timing-sequence recovery of exercise-induced muscle damage in middleand long-distance runners. Journal of Athletic Training 2020;55(4):329–335 Open access https://bit.ly/3JwVXWi 10. Costello JT, Baker PR, Minett GM et al. Whole-body cryotherapy (extreme cold air exposure) for preventing and treating muscle soreness after exercise in adults.

Cochrane Database of Systematic Reviews 2015;(9):CD010789 Open access https://bit.ly/34IXXfd 11. Peake JM, Roberts LA, Figueiredo VC et al. The effects of cold water immersion and active recovery on inflammation and cell stress responses in human skeletal muscle after resistance exercise. The Journal of Physiology 2017;595(3):695–711 Open access https://bit.ly/3gOfchG 12. Roberts LA, Raastad T, Markworth JF et al. Post-exercise cold water immersion attenuates acute anabolic signalling and long-term adaptations in muscle to strength training. The Journal of Physiology 2015;593(18):4285–4301 Open access https://bit.ly/3uVpWmv 13. Bieuzen F, Bleakley CM, Costello JT. Contrast water therapy and exercise induced muscle damage: a systematic review and meta-analysis. PLoS One 2013;8(4):e62356 Open access https://bit.ly/3v71uPp 14. Ferreira-Junior J, Vieira C, Soares S et al. Effects of a single whole body

cryotherapy (-110°C) bout on neuromuscular performance of the elbow flexors during isokinetic exercise. International Journal of Sports Medicine 2014;35(14):1179–1183 15. Costello JT, Algar LA, Donnelly AE. Effects of whole-body cryotherapy (-110°C) on proprioception and indices of muscle damage. Scandinavian Journal of Medicine & Science in Sports 2012;22(2):190–198 Z. Whole-body cryostimulation – potential beneficial treatment for improving antioxidant capacity in healthy men – significance of the number of sessions. PLoS One 2012;7(10):e46352 Open access https://bit.ly/3HV1Wn6 17. Lombardi G, Ziemann E, Banfi G. Whole-body cryotherapy in athletes: from therapy to stimulation. An updated review of the literature. Frontiers in Physiology 2017;8:258 Open access https://bit.ly/3Boal0b 18. Broatch JR, Poignard M, Hausswirth C et al. Whole-body cryotherapy does not augment adaptations to high-intensity interval training. Scientific Reports 2019;9:12013 Open access https://go.nature.com/3HSOb8E 19. Zembron-Lacny A, Morawin B, Wawrzyniak-Gramacka E et al. Multiple cryotherapy attenuates oxi-inflammatory response following skeletal muscle injury.

International Journal of Environmental Research and Public Health 2020;17(21):7855 Open access https://bit.ly/3BkE8Xi 20. Patel K, Bakshi N, Freehill MT, Awan TM. Whole-body cryotherapy in sports medicine.

Current Sports Medicine Reports 2019;18(4):136–140 Open access https://bit.ly/3HLBlcd 21. Higgins TR, Greene DA, Baker MK. Effects of cold water immersion and contrast water therapy for recovery from team sport: a systematic review and meta-analysis.

Journal of Strength and Conditioning Research 2017;31(5):1443–1460 Open access https://bit.ly/3rM9Zx4.

RELATED CONTENT DIY Sports Recovery [Article] https://bit.ly/3ozbaOV Is Massage an Effective Sports Recovery Strategy? [Article] https://bit.ly/3GmAJJ5 Immediate Treatment of Soft Tissue Injuries is all about PEACE and LOVE [Poster and Patient Leaflet] https://bit.ly/34SQIyK

DISCUSSIONS

What advice or explanation do you give patients who still want to use ‘ice packs’ for their pain or injury?

Does cold therapy still have a place in your practice?

Does your practice or do your patients have access to facilities such as cryo-chambers or cold-water baths to facilitate recovery?

Co-Kinetic.com

KEY POINTS

Localised, topical application of ice can cause serious side effects such as nerve injury, delayed healing, neuromuscular impairment and skin burn.

Traditional ice therapy is no longer advocated in acute soft tissue injury management.

Research has focused on the benefits of cryotherapy/cold therapy on athlete recovery with the premise that suboptimal recovery can impede performance, subsequent training and increase injury risk.

Cooling the body results in a generalised decrease in training-induced muscle-damage and inflammatory markers, thereby accelerating recovery.

Cold therapy enhances muscle recovery and reduces muscle-performance decrements after exerciseinduced muscle damage from high-intensity interval training (HIIT), resistance exercise and endurance type activities.

Whole-body cryotherapy may be more effective than cold-water immersion and contrast-water therapy for recovery effect.

Cold therapy may be a useful non-pharmacologic and non-invasive therapy for promoting muscle recovery.

Prolonged and chronic use of cold therapy may have a blunting effect on muscle adaptation and the hypertrophic goal of training.

Timing and care around training needs and competition must be considered and customised to the athlete.

THE AUTHOR Kathryn Thomas BSc Physio, MPhil Sports Physiotherapy is a physiotherapist with a Master’s degree in Sports Physiotherapy from the Institute of Sports Science and University of Cape Town, South Africa. She graduated both her honours and 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 29

UPPER QUADRANT ASSESSMENT FOR MYOFASCIAL DYSFUNCTION: Myofascial dysfunction can be the cause of many patients’ problems resulting from alterations in freedom and quality of body movement. The correct treatment can only be embarked on after proper and careful assessment, which has to be extensive and wide ranging because of the complex nature of fascia and its interplay with other body systems.

This article, Part 1, is an extract from the first half of Chapter 14 ‘Upper quadrant assessment’ (which also has a contribution from Eduardo Castro-Martín) from the author’s book Myofascial Induction™ – An anatomical approach to the treatment of fascial dysfunction Volume 1: The Upper Body, and concerns the global functional assessments of stability and mobility of the upper quadrant (Handspring Publishing 2022). Reading this article (along with Part 2 in the upcoming issue of Co-Kinetic) will allow you to develop a complete understanding of the fascial involvement in the patient’s problem and so together with the patient decide on the best treatment pathway. Read this article online https://bit.ly/3KsqTaq 22-04-COKINETIC | FASCIA FORMATS All references marked with an asterisk are open access and links are provided in the reference list

By Andrzej Pilat RPT

Introduction

Principles of Clinical Reasoning

In Chapter 10 of the book Myofascial Induction™ – An anatomical approach to the treatment of fascial dysfunction Volume 1: The Upper Body, clinical reasoning is described as a complex and non-linear process. Its purpose is to understand, from a biopsychosocial dimension, what the patient’s situation is and what their problem is. It is necessary to understand the patient’s

Learning point 1

Metacognition is a concept introduced by John Flavell (61) and it refers to “thinking about thinking” (the knowledge you have of your own thinking). The process consists of three parts: knowledge, experience, a certain process by selecting and using appropriate strategies.

30

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problem from the perspective of both the patient and the practitioner.

The Assessment Process

It is only through a complete and systemic and systematic assessment that an accurate diagnosis can be made. During this process, the intertwined spirals of changing information should be analysed, meaning that the process must be constantly verified. In Jones’s clinical reasoning flowchart (1,2), the route to metacognition is highlighted (Fig. 1; Learning Point 1).

Well-developed metacognition is an asset; however, if metacognition is only based on incomplete information and presupposition, it can lead us down the wrong path.

Therefore, decision-making should be inseparably linked with evidence

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in order to reduce errors in decisions based on critical thinking. Haskins et al. (3) suggested that: “A notable advantage of statistical prediction tools over unassisted clinician judgment is the control of human biases that are common contributors to decisionmaking errors”, and which are the consequences of the limitations of human cognitive capacity (3; and references therein). Digital technology is developing at a frenetic pace and is transforming the field of healthcare.

It is also increasing the number of distractions in healthcare settings, meaning it is necessary to have a strategic and systematic approach when adopting new technology. An evidence-based algorithm will require some adjustment. Statistical predictions do not form a clinical decision but instead inform a clinical Co-Kinetic Journal 2022;92(April):30-44

MANUAL THERAPY

decision (3). Based on patient information, digital technology can generate alerts for interactions between therapeutic procedures and contraindications that might otherwise be missed. It can also provide diagnostic recommendations as options with different levels of probability for each. The algorithm can raise alerts but cannot replace the opinion of the practitioner. The diagnosis must be the decision of the treating practitioner who has the last word and (probably most importantly) takes responsibility (Learning Point 2).

Clinical reasoning Practitioner/patient perspective

Information Perception Interpretation

An algorithm offers support for clinical decisions but cannot replace them.

Characteristics of the Upper Quadrant

Co-Kinetic.com

Data History taking Assessment Complementary tests

Multiple hypotheses

Learning point 2

Movement of the human body is related to non-linear and selforganising features. Both the bipedal position and locomotion are influenced by gravitational force. It has been suggested that inadequate transmission of gravitational force could be the starting point for changes in the extracellular matrix, the onset of dysfunctions, and the source of pain.

Movement dysfunctions and consequent pain in the upper quadrant are estimated to affect about 70% of the population (4*,5*,6*).

Among work-related illnesses, upper quadrant dysfunctions are second only to low back pain (7).

The structures of the neck, shoulder and arm (mostly on the dominant side; (4*)) are the most affected areas (6*), with dysfunctions being related to a wide range of circumstances. It is difficult to accurately identify the specific structure(s) that generate the symptoms.

A wide range of terms is used to describe the symptomatology, ie. cumulative trauma disorders, cervicobrachial disorders, repetitive strain injury, and work-related upper limb disorders (4*). It is not possible to designate simply one anatomical structure as the source of dysfunction and pain in the neck–shoulder–arm area; the input can have a variety of origins.

Patient

Practitioner

Patient’s own hypotheses

Evolving concept of the person and problem Hypotheses modified

Evolving concept of the problem

Diagnostic management

Understanding of diagnosis and treatment proposal

Therapeutic procedure

Education Exercises Motor imagery

Knowledge Cognition Metacognition

Self-management Self-efficacy

Reassessment

Biomechanical Aspects

The main cause of disorders of mechanical origin is maintaining a forward head posture and remaining in a sitting position for long periods of time doing repetitive tasks, particularly when using an electronic device.

Adults in the USA spend an average of three hours per day on mobile devices (8*). The adaptive posture is usually an exaggerated flexion of the cervical spine and simultaneous reduction of lumbar lordosis. Details of the biomechanical and neurological adaptations and unfavourable consequences related to this posture

are summarised in Chapter 15 of the book (see Tables 15.4 and 15.5).

Neurological Aspects

In Chapter 10, dysfunction was defined as a failure of stability and/or mobility, resulting in alteration in the freedom or quality of body movement.

A biomechanical analysis of local

AN ACCURATE DIAGNOSIS CAN ONLY BE MADE THROUGH A COMPLETE AND SYSTEMATIC ASSESSMENT 31

AMONG WORK-RELATED ILLNESSES, UPPER QUADRANT DYSFUNCTIONS ARE SECOND ONLY TO LOW BACK PAIN

patients with local pain usually also exhibit pain in distant areas. These areas do not always correspond to peripheral distribution zones. This situation may simultaneously create mechanosensitivity, neurogenic inflammation, and neuropathic pain and ‘neuroprotective’ responses. Studies have reported increased sensitivity to pressure pain in both the original area of trauma and also distant areas without pain, suggesting an extrasegmental spread of sensitisation in different local syndromes. Research on the presence of free nerve endings (sensitive fibres A , A , and C) within the connective tissue matrix has changed the focus toward understanding neuropathic pain (9,10,11*,12,13). For more information see Chapters 8 and 15.

anatomy does not always match the integral dysfunction of the fascial system. Local changes may reflect different underlying pathophysiological mechanisms that may be involved in the processes of peripheral or central sensitisation and pain (4*). Symptoms are not always reflected through segmental distribution. Over time,

Stage or phase

Irritability

Severity

Stability Signs and Symptoms

Subjective experience

Exteroception

Interoception

Proprioception

Biomechanics Neurophysiology Neuroscience

ASSESSMENT

Background

History taking

Misuse

Disuse

Autonomic response

Trigger points in taut bands

Restriction at deep levels

Abuse

Skin quality (Skin mobility)

Functional assessment

Global functional assessment

Palpatory assessment

Neural tests

Stability

Global functional assessment MRI, EMG, US imaging, etc.

Complementary assessment Mobility

Patient and practitioner interpretation 32

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Cognitive Aspects

span and encourages multitasking rather than a sustained (continued) approach.

The ubiquitous and rapid access to objective online information competes with previous transactional systems and potentially even internal memory processes.

The online social world exists in parallel with the cognitive processes of the ‘real world’. It confuses our offline sociality, introducing the possibility that the unique characteristics of social networks may impede our ability to deal with real life situations.

Excessive and ever-increasing consumption of digital products via the screens of electronic devices, in particular those with touch screens, remodels the fascial system. More than two hours of daily use of a smartphone and/or a tablet can produce diverse changes (14*,15,16,17,18,19*,20), for example: decreased functioning of the hypothalamus; loss of interpersonal skills; reduction in abstract reasoning and reading capacity; decrease in the ability to retain information; and appearance of withdrawal syndrome with manifestation of anxiety and panic disorders.

The above points demonstrate why a biopsychosocial approach is necessary when assessing the patient’s problem, particularly as it relates to dysfunction of the fascial system. Hence the importance of the history taking process.

According to Firth et al. the internet is influencing our brains and cognitive processes (Learning Point 3), particularly in the following respects (21*).

Cortical representation in touchscreen smartphone users differs compared to people who use conventional cell phones. The frequency of smartphone use influences cortical activity (22*).

It leads to an alteration in attention

Visceral tests

Circulatory tests

Assessment of the Upper Quadrant as a Functional Complex The role of fascia in the behaviour of the upper quadrant is analysed in more detail in Chapters 15, 16 and 17.

A knowledge of myofascial links and the continuity of fascia will help the practitioner to understand the clinical Specific functional tests

Static stability

Postural control Gravitational load Postural neuroprotection pattern

Dynamic stability

Motor control Force Resistance

ROM

Internal: local ROM related to each of the segments External: entire ROM related to the external environment

Learning point 3 Life activities and experiences shape our brain.

Learning point 4

It is only through a complete and systemic assessment that an accurate diagnosis can be made.

Learning point 5

Movement synergy

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Synergistic redistribution of energy generated by the muscles

History taking is the story of the patient’s illness narrated by its protagonist.

manifestations of dysfunctions (and the consequent pathologies) and pain in the regions that may be far away from the area of initial trauma. Movements in the upper quadrant involve, directly or indirectly, the craniocervical segments, the shoulder complex, the thorax, and the upper extremities.

The Assessment Process

The overall assessment process is discussed in detail in Chapter 10. The process is not exclusively used for the assessment of fascial tissue; rather, it focuses on the functional assessment and efficiency of body movement in which fascia is integrated. This process can be easily incorporated into other therapeutic concepts (Fig. 2; Learning Point 4).

History Taking

History taking is a procedure that should not be overlooked. It allows the practitioner to understand the disease from the patient’s viewpoint and find out information that cannot be obtained from sophisticated tests (Learning Point 5). This part of the assessment is discussed in detail in Chapter 10. The focus is mainly on the quality of life, the performance of daily tasks (work, housework, leisure, sports, relationships, quality of sleep), questions about activities such as walking up and down stairs and daily movements involving the head, neck, and arm structures. The practitioner also checks for the presence and behaviour of pain, restriction of mobility, increased muscle tone and myofascial tensions, dermalgia, myalgia, etc. Bear in mind the usefulness of functional scales (see Chapter 10), which are questionnaires about a person’s ability to perform daily tasks. They are useful tools for monitoring the patient over time and evaluating the effectiveness of an intervention.

Both analyses (of the antecedents as well as of the present signs and symptoms) should always be conducted within a framework of biomechanics, neurophysiology and cognition (neuroscience).

Remember to: relate the results of history taking to the results of the whole assessment, 33

contrasting the signs with the symptoms; determine the degree of irritability, severity, and the possible nature of the process; identify the presence of alterations in other myofascial structures that share the same levels of innervation as the affected region (an in-depth neuroanatomical and myofascial knowledge is essential); check the initial assessments with the results of complementary tests, if they are available; identify psychological and emotional aspects, such as anxiety, depression, catastrophism, or kinesiophobia; and

determine possible yellow flags that can chronify dysfunctional processes.

Functional Assessment

Functional assessment is divided into different blocks: global functional assessment, neural tests, viscerofascial tests, circulatory tests, and specific functional tests. In this article I will do the following things: Focus mainly on global tests as they are the basis of functional assessment (see Tables 1–4). As mentioned in Chapter 10, it is recommended that these tests be performed before specific functional tests (that focus on a particular

Static stability

Postural control Gravitational load Postural neuroprotection pattern

Dynamic stability

Motor control Force Resistance

ROM

Internal: local ROM related to each of the segments External: entire ROM related to the external environment

Movement synergy

Synergistic redistribution of energy generated by the muscles

Static stability

Postural control Gravitational load Postural neuroprotection pattern

Stability

Global functional assessment

Mobility

Stability

Global functional assessment

Dynamic stability

Motor control Force Resistance

ROM

Internal: local ROM related to each of the segments External: entire ROM related to the external environment

Movement synergy

Synergistic redistribution of energy generated by the muscles

Mobility

34

structure) or pain provocation tests.

Describe the main neural components and discuss the most likely findings in the assessments.

Outline important points relating to viscerofascial components (see also Chapter 10).

Outline the most clinically relevant tests associated with vascular structures. The specific functional tests are described in the sections on clinical applications in Chapters 15, 16 and 17.

Global Functional Assessment

The reader should refer to Chapter 10 for more detailed information on the parameters of functional assessment.

Global functional assessment is divided into two main parts: stability assessment and mobility assessment (Fig. 3): 1. Stability assessment Static stability postural control gravitational load distribution postural neuroprotection pattern Dynamic stability motor control force resistance 2. Mobility assessment Range of movement internal: local range of motion (ROM) related to each of the external: global ROM related to the external environment Movement synergy Synergistic redistribution of energy generated by the muscles.

Stability Assessment As indicated in Chapter 10, there is no clear scientific consensus on the choice of a specific test or its means of application. In this area, the scientific evidence is inconclusive and there are many versions of each test. Depending on the training (practitioner’s experience) and clinical demands (patient category: age, sex, beliefs, etc), the individual practitioner has the freedom to select the tests that they consider to be necessary for the assessment of musculoskeletal dysfunction.

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Static Stability Assessment (Fig. 4, Table 1) For the practitioner the analysis of static stability is a useful starting point in the assessment process.

However, remember that the body is not symmetrical and also that symmetry does not guarantee optimal performance of the body in the face of daily tasks.

Static stability assessment tests the following: postural control, gravitational load distribution, and the postural neuroprotection pattern. The static postural analysis can serve as an indicator, together with the symptoms and other tests, to situate the patient in a scenario of alteration of the neuromyofascial system.

The static stability assessment enables the practitioner to analyse the distribution of gravitational load

and discover the areas that require more precise attention and further confirmation using other tools of exploration. The procedure is described below.

Assess the patient anteriorly, posteriorly, and laterally. It would also be useful to see the patient from above to determine how the body is placed spatially (threedimensionally). Perhaps in the future drone technology will make this possible.

The patient should stand normally in a relaxed position, barefoot, and in minimal underwear (with the patient’s consent) to allow for assessment of the anatomical points and lines.

Observe how the patient deals with their body weight and how the body adapts to the gravitational load with

the passage of time.

First, it is recommended that you check the volume symmetry (not the exact geometrical symmetry) of the waist triangles and then the position of the patient’s hands in relation to the corresponding thighs.

Next, note the relationships between the different parts of the body.

Do not relate marked asymmetry to a specific symptomatology.

This procedure can also be useful to a newly qualified professional as a point of reference for reassessment.

Dynamic Stability Assessment (Fig. 5, Table 2) To understand why we move in a specific way relates to the following question: How does the central nervous system produce purposeful,

Table 1: Static stability assessment Postural control – gravitational load distribution – postural neuroprotection pattern Test

Aim

Postural control Front and rear views A

B

C

D E

F

Lateral view G F D

E C

B A

Assessment of postural control (which maintains the body in an upright position) in relation to stability and orientation (Shumway-Cook & Woollacott (27))

Description

Interpretation (positive sign)

Clinical analysis

References

The patient stands barefoot in a relaxed position Observe the patient from the ground upwards from the front, rear, and sagittal views

Asymmetry between C and D suggests a tendency to lateral flexion (on the side of the triangle with the larger volume)

Presence of alteration of

Preece et al.

(28*)

Front and rear views Check for asymmetries in the distribution of gravitational loading.

Reference points: lateral inclination of the head (A*), lateral rotation of the head (B*), volume of the waist triangles (C and D), position of the hands in relation to the lateral thigh (E and F) Lateral view Assess for the following: A Feet. Achilles tendon verticality B Tendency to genu flexum or genu recurvatum C Pelvic tilt D Forward abdominal muscles E Dorsal kyphosis F Depressed sternum G Forward head posture

The asymmetry ratio of the hand position in relation to the lateral thigh (E and F) suggests a tendency to rotation; eg. the right hand over the right anterior thigh indicates a leftward rotary trend Tendency to lateral bending and rotation

and responses.

Functional asymmetry between the right and left sides of the body represents a much higher risk factor for injury (Kartal (29)

Kartal (29) ShumwayCook & Woollacott (27)

A consistent postural alignment is assumed (in terms of spinal curvature and pelvic inclination) when an individual is asked to stand comfortably erect Anterior pelvic tilt is associated with a loss of core stability, and therefore the degree of pelvic tilt is used to assess core strength (Preece et al. (28*))

A*, B* These are the positions of the head, not active movements Co-Kinetic.com

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Table 1 cont: Static stability assessment Postural control – gravitational load distribution – postural neuroprotection pattern Test

Aim

Description

Interpretation (positive sign)

Clinical analysis

References

Gravitational load distribution

Assessment of gravitational load distribution in standing. All muscles must be activated to work in complete synergy

The patient stands in a relaxed position

Front view

Loss of balance between the feedback and feedforward actions. This also affects the cellular level. Each individual molecule in the body experiences gravitational force that is distributed throughout the body (see Chapter 9).

Winter (30)

E D C B A

H G F

Postural neuroprotection pattern

Postural control requires the production of movements or muscular contractions that help keep the body upright in space

To determine the presence of a compensatory postural strategy as a mechanism to protect the mechanosensitivity of the nervous system

A Position of the feet (excessive eversion) B Position of the knees: Up or down?

Right or left displacement?

C Thigh fold symmetry D Superior pubic position E ASIS position

Observe the patient from the ground upwards

Rear view F Achilles tendons verticality G Popliteal fossa position H Gluteal fold symmetry

The patient stands barefoot in a relaxed position Assess the craniocervical posture in the sagittal plane

Extension in the upper cervical segment results in an effective shortening of the medulla (meninges) structures in cases of neural tension

Occasionally, cephalic protrusion may be a postural strategy to accommodate the mechanosensitivity of the nervous system. The forward head posture approximates the cervical roots to the trajectory of the cervical plexus and the brachial area.

36

Butler (33) Shacklock (34)

In cases of stenosis of the spinal canal or intervertebral foramen and lower cervical segments can relieve symptoms

Static stability

Postural control Gravitational load Postural neuroprotection pattern

Dynamic stability

Motor control Force Resistance

ROM

Internal: local ROM related to each of the segments External: entire ROM related to the external environment

Movement synergy

Synergistic redistribution of energy generated by the muscles

Stability

Global functional assessment

The various theories relating to motor control are discussed in Chapter

DIGITAL TOOLS CAN SUPPORT BUT NOT REPLACE THE OPINION OF THE PRACTITIONER

Aruin et al.

(32)

The changes show how the body copes with its weight and has adapted over time

Physiologically the nerve roots emerge posteriorly, and in the forward head posture the degree of their mechanical load is reduced

coordinated movements in its interaction with the rest of the body and with the environment (23*)? With this in mind, the dynamic stability assessment examines three basic areas: motor control force resistance.

Latash (31)

Mobility

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Table 2: Dynamic stability assessment Motor control – force resistance Test

Aim

Description

Interpretation (positive sign)

Clinical analysis

References

Motor behavior during craniocervical

To evaluate motor synergy during neck flexion

The patient performs craniocervical flexion (with the chin directed toward the sternal manubrium) from the neutral position

The test is positive if there is excessive participation of the sternocleidomastoid muscles when performing the movement and also if the movements of rolling the head on the neck and the neck toward the sternum fai

Weakness of the deep flexor muscles of the neck

Cagnie et al. (35*)

To establish if there is weakness of the deep flexor muscles of the neck

The head is lifted slightly and the neck flexes in the infrahyoid region The progressive lifting of the head over the neck and the neck toward the thorax is observed

Scapular dyskinesis test (Kibler classification)

This test is used to monitor the scapular stabiliser muscles

The patient stands and moves the upper extremities through three positions:

It involves measuring the distance from the inferior angle of the scapula to the nearest vertebral spinous process

1 With the arms hanging by the sides 2 With the hands resting on the hips and the thumbs placed posteriorly 3 With the arms abducted 90° with full shoulder internal rotation

Recruitment of the abdominal muscles and the momentary inspiratory stop are also observed

Possible cervical instability

Jull et al. (36) O’Leary et al. (37) Falla et al. (38) Jull et al. (39)

Severe alteration of the motor synergy of the neck

Jull & Falla (40)

Excessive lateral sliding and winging of the medial border are signs of

Kibler et al. (41*)

When the head is raised, the chin is advanced significantly

side exhibits a greater scapular distance than the uninjured side and a bilateral difference of 1.5cm should be the threshold for deciding whether scapular asymmetry is present

the scapular stabilizing muscles An asymmetrical position may indicate the presence of thoracic scoliosis or glenohumeral capsular retraction Pain or inability to adopt positions 2 and 3 may indicate injury or the rotator cuff

10. Motor control dysfunctions are manifested by mechanical deficit and/ or a feeling of instability; however, mechanical input is not required for this to happen (see Chapter 10). Motor impairment can be expressed in three areas: action (muscle tone and muscle strength); Co-Kinetic.com

perception (registration or integration of sensory information); and cognition (attention, emotions, motivation).

The assessment of function should not be based on a single static test – in the same way that a radiographic examination

GLOBAL FUNCTIONAL ASSESSMENT SHOULD PRIMARILY FOCUS ON THE WHOLE (BIG) PICTURE 37

Table 2 cont: Dynamic stability assessment Motor control – force resistance Test

Deep squat test

Aim

Description

Interpretation (positive sign)

Clinical analysis

References

This test challenges total body mechanics when performed properly.

It is mainly used to assess bilateral, symmetrical, and functional mobility of the hips, knees, and ankles

The patient stands with

Overall impression

Lower crossed syndrome is present

The dowel held overhead helps in the assessment of bilateral and symmetrical mobility of the shoulders as well as the thoracic spine

required (hip, knee, and ankle). The knees should not extend beyond the feet and the trunk should be parallel with the tibia

“It is a practical and useful clinical tool to assist diagnosis and help better understand the development and perpetuation of most spinal related disorders” Key (42)

The ability to perform a deep squat requires appropriate pelvic

of knees and hips, and extension of the thoracic spine, as abduction of the shoulders Motor behavior during cervical extension

To assess ROM and eccentric activity of the deep flexor muscles of the neck

shoulder-width apart and extends the arms toward the ceiling. A dowel is held with both hands (so that the behavior of the scapular girdle can also be tested)

Instruct the patient to squat slowly as far as they can (without pain) and return to the start position The patient performs three repetitions.

Observe the movement from the front, rear, and lateral views

What is the ROM? Can the patient complete the squat?

Front view The feet turn in or out too much The knees move inward or outward Lateral view The arms move up and down excessively. There is an excessive forward tilt in the lumbopelvic-hip complex The lower back hyperextends Rear view The heels elevate

Observe the feet, ankles, and knees anteriorly and posteriorly and the lumbopelvic-hip complex, shoulder, and cervical complex laterally In a neutral standing or sitting position, the patient is asked to perform cervical extension. The movement is performed progressively

Overactivation of the SCM alters the recruitment sequence When the effects of gravity increase the mechanical demands during extension, the movement is accelerated and the cervical segment causes a cessation of movement.

There is core muscle instability Knee orthopedic dysfunctions or pathology (ACL, meniscus) Hypomobility and/ or instability of the ankle structures Other alterations of balance Limited mobility in the upper torso can be attributed to poor glenohumeral and/or thoracic spine mobility

Key (43) Ishida et al.

(44) Moran et al.

(45)

Limited mobility in the lower extremity, including poor closed-kinetic chain dorsiflexion of the ankle and/ or poor flexion of the hip may also cause poor test performance

Mitchell et al.

(46*)

Limitation in ROM of the lower neck segment

Jull et al. (39)

Teyhen et al.

(47*) Cook et al.

(48*) Cook et al.

(49)

Inhibition of the prevertebral and deep flexor muscles

This usually occurs when cervical pain is present

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Table 3: Mobility assessment Range of movement (ROM) Test

Assessment of basic neck movements

Aim

Description

Interpretation (positive sign)

Clinical analysis

References

To assess the basic movements of the craniocervical junction

Assessment parameters can be found in numerous articles and books.

This assessment is a quick way to track the progress of treatment.

Norkin & White (50)

For further details see Tables 15.4 and 15.5 in Chapter 15

The patient should be involved in consecutive reassessments

A diagnosis cannot be made from this assessment alone.

Mouth opening Measuring maximum comfortable mouth opening: The test focuses on the increase in vertical dimension and the degree of opening The distance between the incisal edge of the upper and lower incisors is noted

The normal width of the mandibular opening in an interincisal measurement is 53–58mm Lower than normal width is less than 40mm

To observe the ROM and to check for asymmety and, in particular, compensatory changes. To test for the presence of symptoms such as pain, paresthesia, tinnitus, etc.

Mouth opening

To assess the ROM and quality of mandibular movements To identify the presence of pain during the movement

Measuring maximum mouth opening: Subsequently, the patient performs an active maximum opening of the mouth, even if pain is present

cannot tell us how bones move. An assortment of tests is needed. The findings of individual tests should be analysed together and not in isolation.

Each piece of information must be examined in relation to the whole.

and its contents.

ROM can be defined as: internal: local ROM relating to one part of the body; and external: global ROM relating to the external environment.

Mobility Assessment Mobility Assessment – ROM (Fig. 6, Table 3) It can be assumed that a patient’s homeostasis is a decisive factor in relation to dynamic balance and ROM. However, it should be remembered that the body does not move in isolation. Its movement is also closely related to the external environment

In ROM tests, both internal and external ranges are examined. Internal ROM is defined as the amplitude of movement of individual parts of the body and their relationship to other parts. External ROM is the movement of the whole body in relation to external factors, such as the type and quality of the support surface (eg. rock or sand, rain or snow, high or low

Co-Kinetic.com

The results should be examined in conjunction with other diagnostic tests

The test identifies temporomandibular mobility

Okeson (51)

A lower than normal measurement (reduced opening) is usually related to intracapsular or extracapsular alterations

temperature). Thus, alterations in ROM (hypomobility or hypermobility) are not only related to local events (capsular retractions, muscle shortening) but are also associated with the external environment. The measurement and analysis of ROM should not be limited to quantification. Even if the external ROM is appropriate, it may be due to an internal compensatory process, meaning that the deficiency in local amplitude was corrected (compensated) by borrowing the range from another, inappropriate, structure (or structures).

Research shows that when the movement is guided by external 39

Static stability

Postural control Gravitational load Postural neuroprotection pattern

Dynamic stability

Motor control Force Resistance

ROM

Internal: local ROM related to each of the segments External: entire ROM related to the external environment

Movement synergy

Synergistic redistribution of energy generated by the muscles

Stability

Global functional assessment

Mobility

factors there are different neural pathways, which are activated in relation to the movement guided by internal stimuli, which means that there are separate pathways that guide the two groups of impulses. The existence of separate networks of action leads to the following three considerations.

Movement distortion can be linked to the inadequacy or failure of internal (structural) factors and/or deficiency in uptake or interpretation of external factors.

The learning process (recovery of range) requires internal and external

stimulus.

In the therapeutic process the difficulty or impossibility of using one of the reception channels (internal or external) does not prevent the possibility of action, but rather suggests promotion of external generation of movements, which may be a helpful strategy (24).

Since range is part of performance then performance can never remain constant.

To assess the influence of the neuroconnective tissue on ROM, the

Static stability

Postural control Gravitational load Postural neuroprotection pattern

Dynamic stability

Motor control Force Resistance

ROM

Internal: local ROM related to each of the segments External: entire ROM related to the external environment

Movement synergy

Synergistic redistribution of energy generated by the muscles

Stability

Global functional assessment

Mobility

40

application of neural tension tests is recommended. The assessment of mobility and ROM is summarised in Figures 8 and 9 in Part 2 of this article.

Mobility Assessment – Movement Synergy (Fig. 7, Table 4) Muscle activity represents the functional outcome of the nervous system. The assessment of underlying neural strategies, which result in movement and function, is a very complicated task. It cannot be measured directly, especially in patients with motor disorders. Thus, the exploration of muscle activation may reflect the condition of neural mechanisms (25*). The analysis of muscle synergies (flexibility and adaptability) may provide a better understanding of functional deficiency of the nervous system. Research

by Overduin et al. supports that clinical output is related to the neural organisation of muscle synergies both at the spinal and cortical levels (26*).

Thus, the assessment of abnormalities with different muscle co-ordination patterns allows deficiencies in movement planning and execution to be identified.

Final Observations on Global Functional Assessment This assessment should primarily focus on the whole (big) picture, and patterns should be analysed rather than specific parts of the body. Specific components can be assessed later using the local (specific functional) tests. The tests need to be simple so that they can be easily administered.

The static stability and dynamic stability assessments should not be omitted. They can be used to complement the global and local functional tests in the analysis of the presence of pain and its behaviour. The interpretation of pain is essential in the assessment process (see Chapters 8 and 10); however, we should bear in mind that the mere presence of pain does not tell us the whole story of the patient’s health-related quality of life and their perspective on the outcome (see Chapter 1).

The global functional assessment will not disclose an exact picture of the patient’s problem. It is simply a Co-Kinetic Journal 2022;92(April):30-44

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Table 3 cont: Mobility assessment Range of movement (ROM) Test

Aim

Description

Interpretation (positive sign)

Clinical analysis

References

Laterotrusion

To assess the extent of lateral movement of the jaw

Laterotrusion The distance between the upper and lower central incisors is noted. The maximum laterotrusion movement is performed in both directions (right and left). The displacement is measured in relation to the

The normal width of mandibular laterotrusion is 10mm

The test identifies temporomandibular mobility

Neumann (52)

Protrusion At the end of the movement, the displacement of the lower incisors beyond the upper incisors is measured

The normal width of mandibular protrusion is 10–12mm

The patient is asked to place one arm behind their head and reach behind the neck to touch the upper back.

Observe their ability to touch the medial border of the contralateral scapula (A)

The degree of difficulty in reaching the positions indicates limitations in the range of the aforementioned movements

Protrusion

Apley scratch test

B

A

To assess the extent of mandibular condylar movement

To test for ROM of the upper extremity structures: Shoulder extension A) Internal and external rotation of the humerus at the shoulder Scapular abduction and adduction (B) The test should be performed bilaterally to facilitate comparison

momentary reflection of the patient´s reality. The neurofascial components involved in dysfunction can distort the mechanical analysis.

Summary

This article, Part 1, covers the first half of Chapter 14 ‘Upper quadrant assessment’ from Volume 1: The Upper Body of the author’s book, concerning the global functional assessments of stability and mobility of the upper quadrant. Part 2, in the next issue of Co-Kinetic, will discuss the assessment of other systems linked Co-Kinetic.com

The patient is instructed to reach for the opposite shoulder with the other hand.

Observe the patient’s ability to touch the opposite inferior angle of the scapula (B)

to the fascia, including the neurofascial components, neural tests, viscerofascial components and the lymphatic and superficial circulatory system of the upper quadrant.

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://bit.ly/3KsqTaq

Laterotrusion of less than 8mm is considered to be outside the normal range

Protrusion of less than 8mm is considered to be outside the normal range

A measurement below the normal measurement (reduced opening) is usually mostly related to intracapsular changes The test identifies temporomandibular mobility

Neumann (52)

A measurement below the normal measurement (reduced opening) is usually mostly related to intracapsular changes Limitation of ROM may indicate glenohumeral dysfunction, increased mechanosensitivity of the brachial plexus, and dysfunction of the fascial system of the upper quadrant

Konin et al.

(53) Hoving et al. (54*) Edwards et al. (55)

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

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Table 4: Mobility assessment Movement synergy Test

Aim

Description

Interpretation (positive sign)

Clinical analysis

References

Forward and backward head posture

To assess the features of head movement in the sagittal plane

The patient is standing or sitting and performs the protrusion and retraction movements of the head. The flexion–extension movement should be avoided

Analyze the range of movement (correct movement is without compensation).

Incorrect movement might be: raising the shoulders performing cervical extension the presence of pain (retraction) adaptations to dorsal kyphosis advanced position of shoulders (protrusion)

Impaired muscle performance due to stretched and weak lower cervical and upper thoracic erector spinae and scapular retractor muscles (rhomboids, middle trapezius), anterior throat muscles (suprahyoid and infrahyoid muscles), and capital flexors

Kim et al.

(56*)

Muscle control during swallowing

To assess coordination of cervical and hyoid behavior during swallowing

The craniocervical and hyoid regions are palpated without impeding swallowing

A slow and upward movement of the hyoid bone (as opposed to the normal rapid up-anddown movement) and concurrent contraction of the suboccipital muscles suggest a tongue thrust and indicate hyperactivity of the masticatory muscles

Poor hyoid glide

Kraus (57)

Excessive cervical coupling motion

Petty & Moore (58)

To assess coordination of cervical and temporomandibular behavior during mouth opening

Assess the patient from the side

Craniocervical motor behavior during mouth opening

KEY POINTS

The patient swallows water several times

Request maximum mouth opening Look for associated compensatory movement: cervical hyperextension and/or a forward head

A small amount of cervical extension is normal at the end of the mouth-opening movement Associated hyperextension or a forward head indicates overload of the cervical structures with a high energy expenditure

The focus of the therapeutic process not only looks to alleviate symptoms, for example pain, but also seeks to make the person aware of their own body image, which is an intentional state that “one has of one’s own body” and includes perceptions, mental representations, beliefs, and attitudes.

It is necessary to understand the patient’s problem from the perspective of both the patient and the practitioner.

Digital technology can help to inform a clinical decision but the practitioner must take responsibility for the ultimate diagnosis.

Increased use of electronic devices is having unfavourable consequences not only on our posture but also on our brains.

Taking a detailed and accurate account of the history of the patient’s condition is crucial.

Functional assessment is divided into different blocks: global functional assessment, neural tests, viscerofascial tests, circulatory tests, and specific functional tests.

Global tests are the basis of functional assessment and should be performed before specific functional tests.

Global function assessment requires the assessment of stability and mobility.

Stability assessment requires analysis of both static and dynamic stability.

Mobility assessment requires analysis of range of motion and movement synergy.

42

Altered masticatory muscle behavior

Craniocervical motor control may be altered

La Touche (59)

Possible dysfunctional movement strategy

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

Email: tupimek@hotmail.com Website: https://tupimek.com/ Co-Kinetic Journal 2022;92(April):30-44

MANUAL THERAPY

Table 4 cont: Mobility assessment Movement synergy Test

Aim

Description

Interpretation (positive sign)

Clinical analysis

References

Alterations in the opening path

To assess mandibular behaviour during mouth opening

Assess the patient from the front

Along the buccal opening the jaw should move without deviating from the straight line between the first upper and first lower incisors

Impaired muscle performance due to stretched and weak lower cervical and upper thoracic erector spinae and scapular retractor muscles (rhomboids, middle trapezius), anterior throat muscles (suprahyoid and infrahyoid muscles), and capital flexors

Okeson (51)

Facial dyskinesia during mandibular lateroretrusion can be a sign of altered motor strategy

La Touche (59)

Disturbances (in the sequence) of motor synergy can be correlated with dyskinesia of the shoulder girdle, especially if there is a deficit in the dynamic stabilization of the glenohumeral and scapulothoracic joints

Janda (60)

A

Request maximum mouth opening A Deviation The opening path is altered, but returns to the midline on reaching the maximum mouth opening B Deflection The opening path deviates to one side and increases as the opening increases

Any deviation from this line implies an alteration of movement

The deflection is at its greatest when the mouth is completely open

B Facial behaviour test during mandibular lateroretrusion

Janda’s test of shoulder muscle recruitment patterns

To assess facial behaviour during mandibular laterotrusion

Assess the patient from the front

To assess muscular activation (motor synergy of the scapular girdle) during shoulder abduction

The patient performs an active and progressive arm abduction up to 90o

DISCUSSIONS

Request maximum mandibular laterotrusion on each side Analyse the recruitment of facial musculature during movement

Palpate the trapezius, supraspinatus, infraspinatus, and paravertebral muscles, and the quadratus lumborum contralaterally. Determine the rhythms of muscle recruitment sequencing involved in arm abduction

Discuss your understanding of fascia with a colleague.

Are you aware of the symptoms that fascial dysfunction can cause?

Bearing in mind the continuity of fascia, move parts of your own upper body and notice any movement

Co-Kinetic.com

There should be no other facial movement while the jaw is being moved Facial musculature is activated only on one side, coinciding with limitation on the other side

The sequence of muscular activation should first be the supraspinatus region along with the deltoid, then the neck muscles, infraspinatus, and finally the contralateral lumbar region (quadratus lumborum muscle) A change in this sequence may indicate a deficit in muscular behaviour

restrictions. Are they close to the point of movement of further away?

Think about your usual assessment process. What will you do differently after reading this article?

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

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

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

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

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

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

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

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

CONTENTS

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

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

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

Co-Kinetic Journal 2022;92(April):30-44

ENTREPRENEUR THERAPIST

The Challenges Facing Physical Therapy Businesses in 2022 and Beyond AND WHAT TO DO ABOUT THEM

By Tor Davies, physiotherapist-turned Co-Kinetic founder

A

multi-month, if not -year, recession has arguably been due for some time now. I look after investments for a small handful of people and most of the people in that industry that I talk to agree that a recession has been due for a while. As usual we just don’t know when.

First in the UK we had Brexit (2019), quickly followed by the internationally-devastating Covid 19 (2020), then just as we were starting to emerge from that in September 2021, the UK was hit by an energy crisis (very interesting article if you want to understand that better), which has already led to around a 4-fold increase in the price of gas. And if that wasn’t enough, now there’s the war between Russia and Ukraine, the former of whom the UK disappointingly relies upon heavily for gas. This is fuelling a fire that is essentially accelerating an already deteriorating situation.

I’m writing this article on the 9th March 2022 and here are some of today’s headlines: Bank of America manager predicts 7% inflation for UK in 2022 (FT Adviser) UK household incomes facing biggest decline since mid-70s (The Guardian) Living costs rising at their fastest rate for 30 years (BBC) UK’s economic growth to halve this year (British Chambers of Commerce)

Let’s face it, we’ve been incredibly privileged as a generation that we haven’t had to deal with too much national or international threat to our livelihoods (unless of course you count the ongoing destruction of our environment). But let’s not beat about the bush, life is about to get much, much more expensive and running a business is going to get significantly harder, not just for months but potentially for years. Whether we like it or not, as business owners, we’re going to have to adapt. If we don’t, our businesses are going to die. And we need to take action quickly. One way or the other, a lot of businesses still won’t make it through. This article details some strategic decisions and actions that you can take now, to help your business survive this latest financial challenge, that’s fast taking hold. The sooner you act, the better off both you and your business will be. Read this article online https://bit.ly/3q4hRst etc. It’s not just heating our houses or fuelling our vehicles that we’re talking about, but the full cycle of production, from food and drink, to the manufacturing and production of just about everything.

Think about everything you buy for your business, not just the cost of heating and lighting your treatment rooms but also the medical supplies, computer and therapy

22-04-COKINETIC | MARKETING FORMATS WEB MOBILE PRINT

MEDIA CONTENTS Timeless Testimonials: The Power of Reviews [Article] https://bit.ly/3vRqeHN

While these headlines are UK-centric, the impact of rising energy prices is already being felt worldwide.

Ultimately, there is very little that we produce, that doesn’t require chemical energy, ie. gas, petroleum, Co-Kinetic.com

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‘ THE KEY TO RAISING YOUR PRICES IS TO DO IT STRATEGICALLY equipment, cleaning supplies, stationery, marketing materials and software, to name just a few. All of those companies will be dealing with increased costs, at least some of which they will have to pass on to you.

In my small business alone in just three months of 2022, I’ve had to accommodate rises in postage prices (although to be fair that happens twice a year anyway), not one but two significant rises in paper costs (15–20%) and now energy surcharges on printing and I’m well aware that this is only the start.

Inflation is defined as a sustained increase in the price of goods and services. It means that the money we have now won’t buy as much in the future as it does today. It doesn’t take a rocket scientist to see that increasing prices combined with reduced consumer spending is not a good combination for most businesses, including those offering physical therapy services.

How Can We Protect Our Businesses From What’s Coming?

Well the most obvious thing is to increase your prices. However, I fully appreciate that’s like telling most physical therapists to strip off their clothes and run naked into a burning fire, even in the good times.

But your costs are going up which means your profit will go down. The biggest risk is that you then cut costs on the things that can bring you new customers, ie. marketing and sales.

Do that and it won’t be long before it’s game over for your business.

The key to raising your prices is to do it strategically and the companies that master this will come out much stronger in the process.

Strategies We Can Use to 1. Reduce costs – but make sure the costs you cut don’t compromise 46

your ability to bring in new customers or deliver better value to, and build loyalty with, your existing customers.

2. Increase sales – put your prices up, reduce no-shows, increase retention rates of existing customers, attract more new customers, re-engage old customers, step up your customer referral efforts.

3. Increase productivity (you and your team) – have a clear strategy, reduce the time spent on activities that aren’t a good use of your time and outsource where necessary, focus clearly on things that ‘move the needle’, stick to the strategy and be consistent in your commitment.

4. Increase efficiency – the key thing here is to identify which patients, injuries and treatments earn you the most money per minute, for the time you spend with them, then clearly define and build audiences of ‘perfect patient prospects’ based on those priorities. It’s not as bad as it sounds, more on that below.

5. Expand into new market sectors, or develop new products or services – you’re looking for opportunities to increase the amount you can earn per 30–60 minutes of your time, than you would under current circumstances. For example working with smaller groups, the combined revenue of which is worth more than a single patient consultation.

The success of your business adaptation will revolve around your patients and your prospects – so let’s delve into that aspect in more detail.

The Perfect Patient Prospect

Although most business owners believe that customers are the lifeblood of their enterprise, this is not actually 100% correct. It’s more a case that the right customers are the lifeblood of a business.

If you are a proponent of Pareto’s Law aka the 80:20 principle (and I am), 20% of your customers are likely to generate around 80% of your sales. So it makes sense to identify who those 20% of people are and then build audiences of those same groups of people to focus your marketing efforts on.

Paul Gough is a UK physio, multi-clinic owner and author, who also leads a programme and team of people who teach physical therapists worldwide how to market their clinics. As you’d expect he talks a lot of sense.

This is how he once defined the perfect prospect: “Your job is to find a prospect with the highest probability that they’ll require your services (and soon), the motivation to seek your services and the means to pay for them. And your marketing needs to be talking to a very specific pocket of people (ie. 50+) about a problem they are living with (ie. back pain), that you can help them solve.”

Let me add a further refinement to that statement, which asks: Is there a group of patients or type of injury that earns you more than others? Let me expand.

Take shockwave treatments for example. After the initial assessment, each shockwave treatment (even with some preamble and some followup advice on exercises/stretches to complement the shockwave treatment), can be done in less than 30 minutes and usually costs a premium. That means a shockwave appointment most likely earns you more money per minute than a nonshockwave treatment.

Shockwave application also has the added advantage that you need a minimum of three treatments to see any improvement but the accepted gold standard is generally six (or more) which means that you have a built-in and clinically justified retention strategy.

So now ask yourself what injuries are most effectively treated by shockwave? Well lots, but particularly tendon-related injuries. Who gets lots of tendon injuries? Well for starters, runners and cyclists.

Is it unethical, therefore, to build local audiences of runners and cyclists, knowing that they’re most likely to have tendon issues which can be very effectively treated with shockwave? Of course not. You’re Co-Kinetic Journal 2022;92(April):45-49

ENTREPRENEUR THERAPIST

just priming your audience as per Paul’s quote, which I’ve adapted with the new criteria.

“Your job is to find a prospect with the highest probability that they’ll require your services (and soon), the motivation to seek your services and the means to pay for them. And your marketing needs to be talking to a very specific pocket of people (ie. cyclists living within 10 miles of your clinic) about a problem they are living with (ie. ITBS, patellofemoral/hip/ Achilles pain), that you can help them solve (using shockwave).”

It’s about building target audiences of people who have the greatest chance of being the most profitable customers. It’s not unethical. You’re simply selecting people who by virtue of their ‘qualification’ represent greater value to your business. That’s one excellent way to increase your business ‘efficiency’ and your profitability in the process and building these audiences should be a major focus of your marketing strategy.

How Do You Build These Target Audiences?

As an advocate of the education-based marketing approach, where the priority is always about adding value to your prospects and cultivating trust, while at the same time building an audience with the qualities you’ve identified, my first step would be to use a paidsocial-media lead-generation strategy offering high-value content that’s relevant and desirable to the audience you want to attract, downloadable in return for an email address.

Until you have at the very least an email address, you don’t own the right to the conversation. Once you have an email address, then you can undertake a nurture process to further segment and build trust with your prospects.

This nurture process is, in my view, the single most important aspect of your marketing. It may seem boring and a bit tedious but successful marketing is really about just two things: (i) growing a relevant and targeted audience (as discussed above), and then (ii) building the ‘know, like, trust factor’ between you, your business and that audience.

Co-Kinetic.com

The Importance of Cultivating Trust

Let’s recap on the three key roles of marketing: 1. Build an audience (ideally a strategically planned one) authority and cultivate trust with that audience (nurturing) 3. Lead your audience on a path towards a purchase There’s lots of research on the role that trust plays in a purchasing decision (Google this if you’re interested ‘role of trust in purchase intention’) but here are a couple of highlights: 63% of people agree with this statement: “A good reputation may get me to try a product or service – but unless I come to trust the company behind it I will soon stop buying it, regardless of its reputation.” (Edelman) Marketing executives at businessto-business (B2B) and business-tocustomer (B2C) service firms rank ‘trusting relationships’ ahead of ‘low price’ and ‘superior innovation’ among their customers’ priorities.

(The CMO Survey) As we build relationships, we build trust. Edelman’s 2018 report found that company content is twice as trusted after a customer-brand relationship has been formed.

Marketing has a lot of functions but this one is the most vital. All of our efforts are doomed without this crucial piece of the puzzle. (Top Rank Marketing)

Utilising Social Psychology in Building Trust

There are two important psychological phenomena, or cognitive biases, that are really important to consider here.

The first one is known as the ‘mereexposure effect’ by which people tend to develop a preference for things merely because they are familiar with them. In social psychology, this effect is sometimes called the familiarity principle.

Most of the time, the mereexposure effect happens subliminally, or at a subconscious level. In fact, researchers have found that the effect is more powerful when we are unaware of a stimulus.

There are two reasons why the

mere-exposure effect is important: 1. It reduces uncertainty. We are programmed by evolution to be careful around new things because they could pose a danger to us. As we see something repeatedly without noticing (this part is important), we are led to believe it is safe.

2. It helps us to understand more easily. We are better able to understand and interpret things we have already seen before.

Think about watching movies with complicated storylines, they’re easier to understand the second time around. Our mind generally looks for the path of least resistance, and so we prefer stimuli that we have already been exposed to.

The second psychological phenomenon is known as the ‘bandwagon effect’ and refers to the tendency people have to adopt a certain behaviour, style, or attitude simply because everyone else is doing it. The more people that adopt a particular trend, the more likely it becomes that other people will also hop on the bandwagon.

This is where testimonials and social proofing become important.

To learn more checkout my article Timeless Testimonials: The Power of Customer Reviews here [https://bit. ly/3vRqeHN].

Why Your Nurture Process Now Becomes Key

The easiest, most scalable way (ie. a growing audience doesn’t affect your workload) to build the mereexposure effect is by using a regular, consistent, nurture (non-sales) email programme. By regularly showing up in your prospects’ inboxes (as long as it’s in a good way), helps you to become familiar to them.

IF YOU DO YOUR MARKETING WELL, YOU SHOULD NEVER BE IN SHORT SUPPLY OF CUSTOMERS 47

Remember what we said above about the mere-exposure effect: If we see something repeatedly without

This is why I regularly stress the importance of not adding any salesy information into your nurture emails, because those are ‘bad consequences’ – that salesy content will have the opposite effect to making people feel your content is safe! Sales information in your nurture emails undoes the good and changes the personality of what should be an email sent purely for the benefit and value of the reader, to an email sent for your business’s own interests.

What’s equally important to the non-selling aspect of these emails is that the emails are regular and consistent. This helps to demonstrate at a subconscious and subliminal level that you are reliable and trustworthy.

With Your Audience

Another key component to cultivating trust is establishing authority and credibility, which makes this another key role for your marketing. Remember marketing is all about the soft-skills – the priming and education process.

Sales comes in at the point that you convert your primed, warm, nurtured prospect into a paying client and if you do the marketing well, the sales will happen in most cases automatically.

Remember those 3 marketing steps again: 1. Build a strategically planned audience (build your email list). authority and cultivate trust with that audience (nurturing).

3. Lead your audience on a path towards a purchase.

The thing to remember here is that you don’t need to be the expert. You don’t need to know everything. Nobody knows everything! But you do know more than your patients and your job is to demonstrate that to the people listening to or reading your content.

What’s particularly important about the trust-building process is that your pricing becomes significantly less of an issue, which makes it much easier to raise your costs.

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Increasing Your Productivity Here are some ideas for ways that you can stand out and make an impact. in newspapers, print publications or on local forums/groups or online outlets.

– it’s a great way to connect with your audience, increase traffic to your website, and establish yourself as an expert in your subject matter.

Ideally you need to be publishing a blog post a couple of times a month.

Build a social media following – share news, quick tips, information, resources, opinions, links to your blog posts and questions. Use your social media pages to talk to your page followers. such as leaflets, handouts, special reports, newsletters, ebooks. You can either give them away, use them as lead magnets to build your email list, or sell them. and post regular short videos with helpful information or tips.

Run educational classes and workshops – having a captive audience is one of the most powerful ways to market yourself and then promote your workshops to your target audiences.

Be a guest on a local radio show or podcast – have you got a cycle ride or triathlon coming up in your area? Why not offer to be interviewed by your local radio station about the 6 most common cycling injuries with tips on how to prevent them.

1 2

3 4 5 6 7

8

– this offers the advantage of giving you time to generate a good number of sign-ups.

If you already have a good-sized target audience to promote an event to, you could run a live online event. Only do this when you can ensure you can be confident of getting at least 10 or 20 people to attend for the full event, otherwise it risks looking weak. with your target groups or organise your own meets from your clinic – this works brilliantly if you want to target runners or cyclists for example, particularly if you or a colleague is a keen runner/cyclist.

Form strategic alliances with people who already reach your target audience. For example, if you want to focus on cyclists with cycling injuries, team up with a cycle shop to offer injury prevention/treatment workshops or distribute helpful resources.

– obviously a bit more involved and may not appeal to everyone!

9

10

11

12

Apart from the YouTube channel and the book, a CoKinetic Clinic Growth subscription includes all the content and material you need to make the other 10 activities happen – and happen quickly.

One of the biggest weaknesses of small business owners is the tendency to try and do everything themselves, instead of focusing on what they do best and the reason why they started their business in the first place. Even if you enjoy the blend of treating patients along with the business management aspects, try and focus your non-patient time on things that you enjoy.

Every business must do marketing whether you like it or not. Not having a marketing strategy and not implementing that marketing strategy is a bit like trying to train to win The All England (Wimbledon) Tennis Championship without having a coach and without going to the gym. Mastery and success, in any context, comes from doing the right things at the right time and practice – lots and lots of practice.

You can’t run a successful business if you don’t want to do the necessary jobs, such as marketing, that will help you achieve it.

We have produced lots of free tools and resources to help you learn what marketing activities you should be doing, and when (see the Further Resources box for more details).

What about outsourcing your marketing? Absolutely, but before you do that, you need to have a very clear picture about what it is you want to do and what success looks like in terms of both outcomes and your return on investment (ROI). Outsourcing should not be an excuse to delegate something just because you don’t like doing it. You must understand what it is you need to achieve, you delegate it.

And last but not least, do not waste precious time producing marketing content that helps you achieve the objectives above, when you can buy high-quality, peer-reviewed, ready-touse content from us, including: blog posts; nurture emails; social media; lead magnets; email-lead collection pages; literally 100s of high-value resources you can use across a whole range of marketing activities; posters to promote your activities; and lots more!

Co-Kinetic Journal 2022;92(April):45-49

ENTREPRENEUR THERAPIST

Unless you particularly enjoy writing blog posts or nurture emails, or building email-lead collection pages, or creating high-value lead magnets to help you attract your perfect prospect onto your email list, then for goodness sake save yourself the time, energy and cost and use one of our subscriptions.

If you do your marketing well, you should never be in short supply of customers, so weigh up how much time you spend creating marketing content with how much you’d earn if you were seeing patients (which presumably you’d also find much more enjoyable) and that’s how much you can afford to spend to get those resources from somewhere else.

Some Final Thoughts

When you do put your prices up, be bold – it’s better to be safe than sorry and our cost of living is going to keep rising for months and possibly years. If you’ve followed the advice in the article above, you’ll be attracting the right kind of customers who come to you because they trust you, and you’ve demonstrated that you have the right expertise to help them.

Commit to ongoing, regular, consistent marketing every few weeks – success won’t happen

GOOD MARKETING IS ABOUT BUILDING A TRUSTED RELATIONSHIP WITH A STRATEGICALLY TARGETED AUDIENCE

BY CONSISTENTLY ADDING VALUE TO THAT AUDIENCE overnight, which is why so many people fail to do it at all. Focus on building and educating an audience about your business, establishing authority and cultivating trust with that audience (ie. nurturing), and leading those prospects through a customer journey towards a purchase opportunity. Every business should be doing this as routine marketing.

If you have the budget you can also run targeted ad promotions, for example through Google Ads or Facebook, that will help you accelerate the process I’ve outlined above and bring in sales more quickly – but that shouldn’t stop you from continuing with the regular audience building and nurturing.

Remember, good marketing is about building a trusted relationship with a strategically targeted audience by consistently

FURTHER RESOURCES Practical Ways to Use Content to Promote Yourself and Your Business [Article] https://bit.ly/373sGS6 How to Promote Your Marketing Activities [Article] https://bit.ly/3ApKS4n Part 1: How to Set Up and Use the Co-Kinetic Marketing System and Where to Find Your Marketing Content [Article] https://bit.ly/3CoSC7s Part 2: What’s Included in a Co-Kinetic Marketing Campaign and How to Use It to Grow Your Business [Article] https://bit.ly/3MKIIDN Just started or starting out in business? Use our Marketing Grader to see what marketing tasks you’ve got covered, what else needs doing, why and how to do it – https://bit.ly/3vZtBAu Want to learn what the 20% of marketing activities are that will give you 80% of your marketing results? Watch my 5-star rated webinar – http://co-kinetic.com/8020

adding value to that audience. When you achieve this, turning that prospect into a customer will happen naturally.

KEY POINTS

The chances are that the UK is heading for a recession.

As a result of Brexit, Covid and now the Russian invasion of Ukraine, costs are going up.

Businesses will have to adapt to survive.

Profitability can be increased by targeting the right prospective patients.

The key to nurturing your audience is to build trust and establish authority.

Demonstrating your knowledge through non-salesy blog posts, nurture emails, lead magnets, etc, is a good way to build trust and establish authority.

If you do your marketing well, you should never be in short supply of customers.

It’s important to weigh up how much time you spend creating marketing content with how much you’d earn if you were seeing patients: that’s how much you can afford to spend to get those resources from somewhere else.

THE AUTHOR

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

journal for physical and manual therapists. With a passion

is on providing resources to help therapists develop

Looking to accelerate the growth of your clinic? Try out our Clinic Growth Accelerator Tool – https://bit.ly/3lAPwH1 Need a ‘readable’ marketing guide? Check out our Compendium of Marketing and Clinic Growth for Physical Therapists and Manual Therapists – www.co-kinetic.com/compendium

Co-Kinetic.com

conferences. www.facebook.com/CoKinetic/ Connect with Tor: www.facebook.com/cokinetic.tor 49

Shockwave Education-Based Marketing Campaign Overview: This campaign is designed to help you educate your audiences about the role shockwave can play in quickly and effectively resolving a wide range of musculoskeletal injuries.

Target Audience/s: Research has shown shockwave to be particularly effective at reducing pain and increasing functionality across a wide range of soft tissue injuries and particularly acute tendonitis and chronic tendinopathies – meaning it’s a great fit for runners, cyclists, golfers, basketball, football (soccer) and tennis players. It has also been proven to work well for rotator cuff injuries and hip pain.

RESOURCE 4: Social Media Awareness Campaign

Icons indicate what content is included in which subscription Patient Information

Clinical Education

Social Media

Clinic Growth

RESOURCE 1: Shockwave Therapy Customer Newsletter

How to Use: Designed as a short overview on the use of shockwave in physical therapy to help you build authority and trust with your audience. The newsletter is ideal for printing out for your clinic waiting room, or using the Share Link to send in a nurture email, on your social networks and in online discussion forums. You could also print it out and post it to past customers to re-engage them or offer it to local media for publication as part of your authoritybuilding strategy. While we’re happy for you to take the lion’s share of the glory and we don’t insist on a credit we do appreciate it if we get one. This kind of thing works well: “Written by [insert your name and your clinic] in association with Co-Kinetic.”

RESOURCE 2:

What is Shockwave Therapy and How Does it Work?

What to Expect from Shockwave Therapy Treatment Who Can Benefit from Shockwave Therapy Shockwave Therapy and Running Injuries

RESOURCES 5+6+7: Pre-Built Email Lead Collection Page, Lead Magnet Delivery Page and Email Autoresponder

How to Use: Used in your social media and even better when combined with some paid social media ads to help you grow specific targeted audiences. When a new lead signs up to your campaign they will also receive a customised email autoresponder which you can edit.

RESOURCES 8+9: Pre-Written Blog Post and Customer Nurture Email (including 1-Click Mailchimp template)

How to Use: Publish the blog post to your website to boost your search engine optimisation and send the pre-written nurture email to your email audience to cultivate trust, add value to your prospects and help you to segment your email list by interest areas. Text and images provided.

How to Use: These are more detailed leaflets covering specific aspects of shockwave therapy or answering commonly asked questions. They are designed to help you build authority with and add value to your readers.

Again you can share them in discussion forums, on your social networks or in your customer nurture emails, or you can email them to relevant clients post-appointment.

RESOURCE 10: Education Workshop and Web Sign-Up Page

RESOURCE 3: and Exercise Handouts

RESOURCE 11: Range of Promotional Material

Golfer’s Elbow Iliotibial Band Syndrome Tennis Elbow ‘Shin Splints’ Jumper’s Knee Hip Pain (4 leaflets) Plantar Fasciitis Shoulder Impingement Phase 1-4 Achilles Tendinopathy How to Use: These can be sent as Share links in emails as part of a post-appointment follow-up and are designed to complement your treatment sessions.

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How to Use: Use the social media to help build authority and grow your reputation through your social media pages while also adding value to your social media followers. Some posts offer specific educational resources downloadable through a pre-built email lead collection form, giving you the opportunity to build and segment your email list.

How to Use: Designed to help you raise awareness of your business, build authority and trust and get in front of prospective customers.

We provide you with a pre-written PowerPoint presentation and prebuilt web sign-up page. Use the content to run a webinar or deliver live education workshops/presentations.

How to Use: This includes fully-editable Canva templates including a poster, social media ad, and a postcard you can send to your mailing list. All print items can be ordered through Canva (service is available internationally).

RESOURCE 12: Customisable Landing Page

Our campaign wild-card allows you to do just about anything from offering free downloads, providing printed tickets, redirecting to other web pages, and taking single and recurring payments. The page can be fully edited via a simple online form.

Co-Kinetic Journal 2022;92(April):50

NEWLY RELEASED

Menopause Content Marketing Campaign

CONTENT UPDATE

CONTENT

We released a social media campaign in the latter stages of 2021 and have now expanded this content to add the extra elements of a fully-featured content marketing campaign.

This new content includes: Managing the Menopause – How to Survive and Thrive Through Changing Times (Blog Post) How to Survive and Thrive During the Menopause (Nurture Email with 1-Click Mailchimp template) Mastering the Menopause Education Workshop/ Webinar PowerPoint Presentation Mastering the Menopause Workshop Web Sign-Up Page Menopause-Themed Wildcard Web Page – allowing you to take sign-ups, redirect to other web pages, offer downloads, take single or recurring payments or create a membership group Menopause Campaign Promotional Artwork – Canva Templates This content is now available to all Clinic Growth subscribers at the following link. https://bit.ly/3u0Yp0S

Don’t Run into Trouble Running Injury Campaign Updates

This is one of our most popular and enduring campaigns so we’ve added some additional features to help you run and promote running injury events.

The new content includes: Editable Promotional Posters - Canva Template Social Media Ad artwork – Canva Template Downloadable Event Ticket – Canva Template Postcard – Canva Template You can find this content at the following link. https://bit.ly/3KOjhPV

Mother’s Day Voucher Campaign

To be used with our inbuilt voucher sales and management tool, this campaign is designed to help you sell vouchers on Mother’s Day (funnily enough!).

It includes: Pre-written voucher sign-up page A choice of voucher templates Ready-to-post social media to promote your campaign A choice of 2 promotional posters You can find the voucher campaign at the following link.https://bit.ly/36pmVRq Co-Kinetic.com

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For other enquiries: Email: info@co-kinetic.com

The old polybag, while a step in the right direction, only breaks

IF UNDELIVERED PLEASE RETURN TO: Co-Kinetic, 88 Nelson Road, London, SW19 1HX, UK

CBP006075

1. Our paper is now offset through the World Land Trust 2. We’ve scrapped our starch-based polybag and gone ‘naked’ (lost the polybag)

In a bid to further reduce the carbon impact of our journal we’ve taken two new steps:

We’ve gone NAKED!