Co-Kinetic Journal Issue 94 - October 2022

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1999 2022 ISSUE 94 OCTOBER 2022 ISSN 2397-138X QUEEN ELIZABETH II 1926 - 2022

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

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

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THE EFFECTS OF CALF MUSCLE SELF MASSAGE ON ANKLE JOINT RANGE OF MOTION AND TENDON-MUSCLE MORPHOLOGY. Yoshimura A, Sekine Y, Furusho A et al. Journal of Bodywork and Movement Therapies 2022;32:196–200

This study aimed to investigate extensibility changes in the gastrocnemius muscle (GM), muscle-tendon unit, and the Achilles tendon (AT) in terms of maximum ankle dorsiflexion (max-DF) following a foam rolling intervention. Study participants consisted of 10 students: 4M, 6F; mean age±standard deviation, 22.7±2.5 years; height, 164.2±6.7cm; weight, 57.9±7.9kg. The foam rolling intervention was performed on the right leg plantar flexor muscles for 3 sets of 1min each with 30s rest between each set. The foam roller used was a GRID roller with a height of 33cm and a diameter of 14cm. The intervention was performed with the assistance of a force

plate so that participants could maintain 15–25% of their body weight on the foam roller. An electronic goniometer was used to measure dorsiflexion.

The results showed that the range of ankle joint DF increased significantly following the foam rolling intervention, GM extensibility increased 4.0mm, although no significant difference was observed pre- and post-intervention.

Co-Kinetic comment


Anyone that has used one knows that a foam roller properly applied can increase joint ROM. The good thing about this study is that they controlled the force being applied via the use of a force plate. Can we have some more studies using different amounts of body weight please?


Aeini M. Journal of Humanistic Approach to Sport and Exercise Studies 2022;2(2):248–258

This study aimed to investigate the effect of massage on fatigue and mood in female rowers. Thirty rowers were randomly assigned into an experimental and control group (15 people in each group). There was no significant difference between the groups in height, weight and BMI. Both groups continued their normal rowing exercise, but the experimental group participated in 12 massage sessions over a 2-week period. Each session lasted 30min and consisted of effleurage, friction, petrissage and tapotement strokes using an aromatherapy lotion (lemon and lavender). Data came from pre- and postcompletion of a Borg rating of perceived exertion and fatigue scale and a mood questionnaire.

The results suggested that perceived intensity and fatigue were significantly reduced in the massage group compared to the control group. Also, anger, confusion, depression, mood fatigue and stress were significantly decreased in the massage group compared to the control.

Co-Kinetic comment

This is a very detailed report. It even comments on the therapists “personal appearance, hygiene, makeup of the skin and nails, and not wearing a watch and ring” which makes it surprising that the only comment on the depth of the strokes was during a description of friction as being during “circular movements of the thumb tips we moved the muscles towards the bone and stopped on the desired area and put a lot of pressure on it”.

Journal 2022;94(October):4-11


Journal Watch

This paper quotes the fact that about 10% of people worldwide experience heel pain at some point in their lives and that plantar fasciitis is considered among the primary causes of foot and ankle pain in athletes, especially runners, baseball, basketball and football players. Conservative treatments (anti-inflammatory steroid-free drugs, physiotherapy, foot splints/braces, extracorporeal shockwave therapy) are effective in 80–90% of cases so the purpose of the study was to see if the additions of steroid injections or autologous blood injections could improve the effectiveness.

A total of 88 participants with mild-to-severe symptomatic plantar fasciitis for more than 6 weeks were divided into two equal groups. Group A (23M, 21F; average age 37 years) were treated with autologous blood injections. They were given 2ml of their own venous blood plus 1ml of 2% xylocaine in their heel at the most tender point. Group B (19M, 25F;

This is a case series composed of 87 consecutive concussed ice hockey players aged 10–18 years (66M, 21F) referred to a Toronto Concussion Clinic from 1997 to 2017 and followed longitudinally by clinic visits and questionnaires. Data about the mechanisms and symptoms of concussion were obtained from patient self-reports often assisted by reports from team coaches, physicians, parents and siblings. Eleven of the concussions came from legitimate bodychecks in open ice, 21 were against the boards, and 2 were in unknown locations. In the remaining 53 players the mechanisms were falls (5), fighting (4), collisions (11), multiple mechanisms (4), struck by objects such as sticks or


average age 38 years) had a heel injection of 1ml of DepoMedrol (methylprednisolone acetate 40mg), which is a an anti-inflammatory glucocorticoid, plus a similar amount of xylocaine to group A.

Those patients with plantar fasciitis who had gone through certain surgical procedures (heel surgery, ankle dislocation, rupture of plantar fascia, calcaneal fracture, tarsal bone fracture, and metatarsal bone fracture) before having the condition were excluded from the study.

The results showed that in group A, treatment was effective in 26/44 patients and in group B it was effective in 31/44 patients.

Co-Kinetic comment

Similar previous studies have included a no-treatment control group and concluded that both treatments can be effective. This study supports those findings, but success is nowhere near 100%. There was no mention of post-treatment exercise other than a suggestion not to indulge in heavy weightlifting. The question is, was it the blood/steroid or the analgesic administered with it, that improved the condition?

PERSISTING CONCUSSION SYMPTOMS FROM BODYCHECKING: UNRECOGNIZED TOLL IN BOYS’ ICE HOCKEY. Tator CH, Blanchet V, Ma J. Canadian Journal of Neurological Sciences 2022;doi:10.1017/cjn.2022.289

pucks (9), elbow to the head (9), hits other than bodychecking (8), and unknown in 3. Persisting concussion symptoms (PCS) include headaches, dizzinessa and problems with concentration and memory that last longer than the expected recovery period. PCS occurred in 80.4% of the concussed players which lasted 1–16 months in males and 3–26 months in females.

Co-Kinetic comment

If you are a fan of contact sports this is unhappy, but not unexpected, reading. This one is about ice hockey, but it could be rugby or football or almost all of the team sports – even the ones like basketball where contact is an illegal play but collisions are common. The recommendation of the authors is that body checking should not be allowed until the over-18 age group (it is 13–14 at the moment). That is a fundamental change to the way players develop that is bound to have consequences as they progress into senior sport. However, the numbers here need to be put into context. The Greater Toronto Hockey League and its affiliates have around 40,000 youth players. RESEARCH INTO PRACTICE

This is a systematic review of potential adverse events (AEs) from manual therapy (MT) to peripheral joints. MT is defined as a “broad group of passive interventions in which manual therapists use their hands to administer skilled movements designed to modulate pain, increase joint range of motion, reduce or eliminate soft tissue swelling, inflammation or restriction, induce relaxation, improve contractile and non-contractile tissue extensibility, and improve pulmonary function”. MT interventions currently in use by healthcare providers and in alternative or complimentary medicine may include, but are not limited to, spinal mobilisation and manipulation, peripheral joint mobilisation and manipulation, dry needling, massage, soft tissue mobilisation, instrumentassisted soft tissue mobilisation, myofascial cupping, myofascial release,

acupressure, manual lymphatic drainage, and muscle energy techniques.

A search of the medical databases revealed 20 articles documenting 53 AEs were analysed. Most AEs which were benign. Little evidence exists for serious AEs with manual therapy. Scant serious AEs were reported with acupuncture or massage near the shoulder, hip and knee.

Co-Kinetic comment

That list of techniques is a lot of tools in the manual therapists tool box. They will not all work on all patients but at least, in the right hands (literally) they are safe.

The purpose of this study was to examine the effects of submaximal isometric neck muscle fatigue and manual therapy on wrist joint position sense (JPS) within healthy individuals and individuals with subclinical neck pain (SCNP).

Twelve healthy participants and 12 participants with SCNP were recruited. Each group completed 2 sessions, with 48h between sessions. On day 1, both groups performed two wrist JPS tests using a robotic device. The tests were separated by a submaximal isometric fatigue protocol for the cervical extensor muscles. On day 2, both groups performed a wrist JPS test, followed by a cervical treatment consisting of manual therapy (SCNP) or neck rest (20min, control group) and another wrist JPS test. JPS was measured as the participant’s ability to recreate a previously presented wrist angle. Each

wrist JPS test included 12 targets: 6 into wrist flexion, and 6 into wrist extension. Kinematic data from the robot established absolute, variability, and constant error.

The results showed that absolute error significantly decreased from baseline to postfatigue in the SCNP group and increased in the control group. The single session of manual cervical treatment significantly decreased absolute error in participants with SCNP.

Co-Kinetic comment

The important point about this study is that it demonstrates a link between neck pain or fatigue, altered afferent input to the central nervous system and wrist JPS. What it means in practice is that you need to take a holistic approach. Just because there is an issue at one end of the kinetic chain does not mean that is where the problem is.


ADVERSE EVENTS ASSOCIATED WITH MANUAL THERAPY OF PERIPHERAL JOINTS: A SCOPING REVIEW. Sheldon A, Karas S. Journal of Bodywork and Movement Therapies 2022;31:159–163 INFLUENCE OF NECK PAIN, CERVICAL EXTENSOR MUSCLE FATIGUE, AND MANUAL THERAPY ON WRIST PROPRIOCEPTION. Reece A, Marini F, Mugnosso M et al. Journal of Manipulative and Physiological Therapeutics 2022;45(3):216–226
Co-Kinetic Journal


This is a meta-analysis to ascertain whether or not manual therapy (MT) can affect posture. The usual medical databases were searched with the criteria of randomised controlled studies in any population in which the primary intervention was the use of any MT technique aimed at joint mobilisation or myofascial tissue and that evaluated the immediate-, short-, medium-, or long-term effects of interventions on body posture. Eventually 35 studies were included.

The authors state, “with moderate certainty”, that, when compared to no intervention or sham, in the short and medium term MT reduced forward head posture and thoracic kyphosis, improved lateral pelvic tilt and pelvic torsion, and increased plantar area. There was no significant effect on shoulder protrusion, shoulder alignment in the frontal plane, scoliosis or pelvic anteversion. They had low certainty that MT had no effect on scapular upward rotation. They had low to very low certainty that MT was not superior to other interventions in the short or medium term regarding the improvement of forward head posture and shoulder protrusion.

Co-Kinetic comment

This is a bit of a mixed result for MT. Good for a few things but not for shoulders. Unfortunately, if you are looking to find out exactly which of a very wide range of MT techniques works for each condition you will have to find the original papers.

WHAT IS THE BELIEVABILITY OF EVIDENCE THAT IS READ OR HEARD BY PHYSICAL THERAPISTS? Cook CE, Bonnet F, Maragano N et al. Brazilian Journal of Physical Therapy 2022;26(4):100428

This is a survey into how physical therapists (PTs) obtain information from a variety of sources. It asks if these sources influence their believability and use in clinical practice. In total, 1098 PTs from 36 countries completed the survey in one of six different languages.

The results showed that PTs had strong beliefs in what they read or hear about exercise, sports/occupational performance, pain science/ patient education, and psychologically informed interventions. There was only moderate believability regarding manual therapy treatment, and weak believability associated with thermal/electrical agents and pain science/ patient education. Whether or not the PTs believed what they were reading was influenced by social media use, years of practice, time and access to literature, specialisation, confidence in reviewing literature and attributions of the researcher.

Co-Kinetic comment

The authors state that “even well-informed, motivated clinicians have difficulty navigating the extreme amount of information” (ie. more than 1.275 million biomedical papers are published each year). We do our best at Journal Watch to turn that into a readable number for you!

This was a study to explore the experiences of osteopaths, physiotherapists and chiropractors who work together in the same clinic location and to explore their attitudes towards each other. The history of the three professions is one of ideological tensions, turf-wars and boundary-work conflict at either an individual or group level. This is despite a shared use of manual therapy techniques. Semi-structured interviews were adopted to generate data on the experiences of 13 clinicians (6 physiotherapists, 4 osteopaths, 2 chiropractors, and 1 dual-qualified chiropractor and physiotherapist) who work with at least one clinician from the other two professions. The results showed that physiotherapists, chiropractors and osteopaths who work together in the same clinic may collaborate while simultaneously navigating blurred professional lines. These results suggest that working together in the same clinic is a meaningful form of contact, which in turn allows for collaborative practices that may reduce tension between professions.

Co-Kinetic comment

Not quite peace in our time but a step in the right direction. The most telling finding in the study is that “professional titles may not reflect actual practices of these clinicians”.

WHEN WORLDS COLLIDE: EXPERIENCES OF PHYSIOTHERAPISTS, CHIROPRACTORS, AND OSTEOPATHS WORKING TOGETHER. Toloui-Wallace J, Forbes R, Thomson OP et al. Musculoskeletal Science and Practice 2022;60:102564

The object of this study was to investigate whether a core exercise programme in a specific sports group can improve core and sport-specific performance. A total of 40 college students majoring in basketball were randomly assigned to training and control groups. Their average age, height and weight were 22±4 years, 184±3cm and 74±4kg, respectively, in the training group, and 22±3 years, 184±8cm and 78±11kg, respectively, in the control group. Individuals who had previously suffered from low back pain, sustained injuries, or practised sling exercises over the last 6 months were excluded from the study. All the subjects routinely engaged in 1.5h basketball training sessions 3 times per week and in 1.5h resistance training sessions 2 times per week. Each resistance training session consisted of 4 sets of 6 exercises involving the upper limbs, trunk and lower limb muscles using a load of 6–10 repetition maximum. An additional set of an 11-exercise training protocol with sling exercises was added to the training group and performed twice a week for 8 weeks.

A standardised set of core endurance and basketballspecific performance tests were used to determine and assess the effects of sling training on trunk strength, endurance and control. The results showed that flexor, extensor, and right and left lateral trunk flexor muscle endurance was significantly greater in the training group than in the control group, and that the time to complete a basketball-specific lay-up obstacle course was shorter than in the control group at the end of the training programme. No differences between the two groups were found in the penalty shot, the fixed position shot, or the vertical jump and reach at the end of the training programme.

Co-Kinetic comment

Adding the sling exercises improves core endurance and strength, and their speed over an obstacle course. It doesn’t do anything for their shooting accuracy.

The purpose of this study was to identify how primary care physicians (PCPs) prescribe physical activity for patients with chronic disease and to determine the characteristics of physical activity interventions that improve the clinical outcomes for chronic disease.

A systematic review of the usual medical databases was performed from inception to 7 March, 2022. Eligibility criteria for selecting studies involved PCP-delivered physical activity prescriptions or counselling for participants with a chronic disease or mental health condition that

The purpose of this study was to assess the perceived usefulness, actual use and barriers to the implementation of recovery strategies among basketball practitioners.

An online survey was completed by 107 participants (strength and conditioning coaches, sport scientists, performance specialists) from different countries and competitive levels. Most participants rated recovery strategies as either extremely (46%) or very (49%) important. Active recovery, massage, foam rolling, and stretching were perceived as most useful (80, 73, 72 and 59% of participants, respectively) and were most frequently adopted (68, 61, 72 and 67%, respectively). Participants mentioned lack of devices and facilities (51%), excessive cost (51%), lack of time (27%), players’ negative perception (25%) and lack of sufficient evidence (16%) as barriers to the implementation of recovery strategies. These findings reveal that there is some dissociation between scientific evidence and perceived effectiveness among the

study participants. A possible solution would be to ensure that scientific evidence-based guidelines are followed when considering the application of recovery strategies. Regarding actual use, participants favoured easily implementable strategies (eg. active recovery, stretching), rather than evidence-supported but expensive and/ or impractical strategies (eg. wholebody cryotherapy). Possible solutions may include the use of practical tools that don’t need specific facilities, the development and validation of new lowcost recovery devices, the promotion of players’ education regarding recovery strategies, and conducting further research to increase the scientific knowledge in the area.

Co-Kinetic comment

As Journal Watch often reports, evidence can be contradictory and academically controversial. Working out what works best for your team is probably the best strategy but even then, does one size fit all?

reported clinical outcomes. Studies in which other healthcare providers prescribed exercise were excluded.

The initial search identified 4992 records, of which 15 met the full inclusion criteria. Characteristics of physical activity prescriptions that improved clinical outcomes included personalised advice, brief intervention, behavioural supports (handouts and/ or referrals), and physician follow-

up. Reported adverse events were rare. Research gaps include optimal timing and length of follow-up, and the long-term and cost-effectiveness of interventions.

Co-Kinetic comment

If GPs are starting to realise that exercise rather than medication is a miracle cure there is hope for the future of humanity. A full physical therapy team with a rehab gym in every surgery would guarantee that future!

THE APPLICATION OF RECOVERY STRATEGIES IN BASKETBALL: A WORLDWIDE SURVEY. Pernigoni M, Conte D, CallejaGonzález J et al. Frontiers in Physiology 2022;1115 OPEN EFFECTS OF SLING EXERCISE ON THE CORE ENDURANCE AND PERFORMANCE OF BASKETBALL PLAYERS. Liu Q, Zhu C, Huang Q. Revista Brasileira de Medicina do Esporte 2023;29:e2021_0013
8 Co-Kinetic Journal 2022;94(October):4-11

Sixty patients (20M, 40F; mean age, 32 years), were randomly allocated to the post-isometric (PI) group or the myofascial release (MR) group. For the PI group, the subjects were placed in a supine position and therapist resistance applied to a combined movement of neck flexion and contralateral sidebending using one hand on the head and the other on the shoulder. An isometric contraction was held for 10s followed by relaxation and the head being taken into the opposite position where a stretch was again held for 10s. A second contraction was applied to the levator scapulae muscle with the neck in full lateral flexion and rotation to the contralateral side.

MR was performed in sitting. The neck was placed in a position of flexion and rotation to place the muscles under a slight stretch then the therapist applied a block to the overlying fascia while the subject actively extended the stretch. This was help for 10s and repeated 5 times for each muscle.

Both groups were also treated with conventional exercises, which included isometric strengthening exercise (which was performed on both groups in all six directions) and cryotherapy (which was

A previous study identified that that almost half (47.9%) of female collegiate athletes in the United States of America experienced a breast injury during participation in basketball, soccer, volleyball and softball. The aim of this study therefore was to ascertain if female athletes in water polo suffered the same rate of breast injury.

A questionnaire was emailed to 18 members of the USA women’s water polo team and 16 responded. Their mean age was 23.5 years old. Half reported that they sustained a breast injury, and 62.5% (5/8) of those that had an injury indicated having at least 6 or more to their breast. None of the women informed a medical professional about their injury.

The women with 6 or more injuries commented on the nature of their injuries. Bruising and discoloration, scratches, redness from being kicked,

elbowed, or hit with the ball were commonly reported. One athlete had 4 separate injuries, one athlete had 3 injuries, and one athlete had 2 separate breast injuries.

Co-Kinetic comment


The number of injuries in water polo is not surprising. It is an aggressive sport in which much skulduggery takes place under water and out of sight. There are nail checks to ensure that players’ claws are not sharp enough to damage their opponents. What is disturbing is that not one player in this study reported an injury to a medical professional. This, sadly, is similar to the study on breast injury in collegiate sport mentioned at the start of this piece. In that one, it was reported that less than 10% of the injured athletes reported it and of those only 2.1% received treatment for their injury. There is little mention of the long-term effects of breast injury other than to state that fat necrosis can develop causing persistent pain. It’s a subject crying out for further research.


applied for 10min at the end of each of 6 sessions over a 3-week period).

Participants in the PI group demonstrated significant improvements in outcome scores for visual analogue scale for pain (VAS), neck disability index (NDI), cervical extension and left side rotation ranges, plus the World Health Organization quality of life (brief version) questionnaire WHOQOL-BREF) at a 2-week post-treatment review when compared with the MR group. The MR group recorded better scores for cervical extension and left sidebending range.

Co-Kinetic comment

This paper starts with “Non-specific neck pain is the most prevailing musculoskeletal disorder which has a large socioeconomic burden worldwide” and that

is the problem with this and many other studies. There is no such thing as “nonspecific pain”. All pain has an origin. You just have to find it. Having said

OPEN RESEARCH INTO PRACTICE BREAST INJURY IN USA FEMALE WATER POLO ATHLETES. Smith LJ, Eichelberger T, Kane EJ. International Journal of Sports and Exercise Medicine 2022;8:216

The objective of this study was to compare ultrasound and transverse friction massage in chronic Achilles tendinopathy.

Seventy-six patients (aged 18–65 years) with pain on Achilles tendon palpation, activity limitation due to symptoms for the last 6 months and Victorian Institute of Sport AssessmentAchilles questionnaire (VISA-A) score of >20 and <80 points were randomly allocated into group A (28M, 9F) who were treated with transverse friction massage along with eccentric exercises and group B (25M, 11F) who were treated with ultrasound therapy along with eccentric exercise.

The eccentric exercises of plantar flexion were performed while standing on a step with 6 sets of 15 reps. The gastrocnemius and soleus were targeted by 3 sets of plantarflexion while the knee was in extension and 3 sets while the knee was in slight flexion. The ultrasound settings were pulse 20% duty cycle 8ms interval/2ms emission, 2ms burst of 1.0MHz sinewaves repeating at 100Hz, 0.5w/ cm² of intensity. Transverse friction massage was performed by thumb for 3min over 3–5cm area. The duration of treatment was 6 weeks with 3 sessions

per week. The assessment was done at the baseline on the first session, and at the end of the 9th and 18th sessions. Outcome measuring tools were numeric pain rating scale (NPRS) for pain, the VISA-A for severity and goniometry for ROM.

The results showed that both groups improved significantly throughout the treatment duration with a large effect size for all variables. The transverse friction group showed more improvement in all variables compared

to the ultrasound therapy group after the 3rd week as well as after the 6th week of intervention.

Co-Kinetic comment


It is a long time since there has been a positive result for transverse friction. The authors should read Tsuji S, et al. 2022 (Effects of different bed heights on the physical burden of physiotherapists during manual therapy: an experimental study. Industrial Health 2022; 9 June) reported here also and stop using their thumbs.


The aim of this study was to compare weight-bearing exercises with and without Kinesio tape in ankle pain in soccer players. Sixteen players [9M (56.3%), and 7F (43.8%)] were assigned to two groups. Their mean base-level scores were: age 34±5.35 years, weight 68.5±5.83kg, height 166±11.65cm, and BMI 25.25±4.38kg/m². Group 1 (n=8) were treated with weight-bearing exercises with Kinesio taping, and group 2 (n=8) with only weight-bearing exercises.

The exercises were toe raises, heel and toe walking, lateral step up and down using a step bench, one-leg balance, one-leg squat, step up onto balance board, balance board with half-squats performed several times a day with progressive reps or difficulty

as tolerated. How/where the tape was applied is not described.

The results showed that there was significant difference between the mean value of visual analogue pain scale (VAS), 36item short form health survey questionnaire (SF-36), and foot and ankle outcome score (FAOS) before treatment and after treatment. Significant difference was also found between the treatment group (group 1) and control group (group 2) in favour of treatment group.

Co-Kinetic comment

The tape helps. It would help us if there had been a couple of pictures of the taped ankle.

Journal 2022;94(October):4-11


The purpose of the study was to compare the effects of total cold-water immersion (TCWI) to ice massage (IM) on muscle damage, performance and delayed onset of muscle soreness.

Sixty participants were randomised into two groups and they completed a muscle damage protocol which consisted of a 5min jog to warm up, followed by 5min of muscle endurance exercise (light load of 15kg over 10 repetitions), strength testing of the quadriceps and a series of 5 sets of 20 drop jumps from a 60cm high box with 2min of rest between sets. After each drop from the box and landing on the floor, participations were instructed to perform a maximally explosive vertical jump upward, the height of which was measured and then land on the floor.

Participants were told to flex their knees to at least at 90° during all landings and to keep their hands on their hips during the jumps. They were verbally motivated to exert maximal effort during every repetition.

Participants allocated to the TCWI

group completed a session of 15min in cold water with a temperature of 12°C. Those allocated to the IM group were subjected to a circular local massage through the use of an ice cube. Massage was applied for 15min with no extra pressure added by the tester, for each thigh, over the region of the quadriceps muscle.

Data were collected at baseline, 2h, 24h, 48h, and 72h post-intervention. Both groups had significant statistical differences preand post-testing for all variables.

Serum creatine kinase (CK) values peaked at 24h for both groups. At 72h, CK values dropped to baseline in the TCWI group, while remaining high in the IM group. At 72h, the values of a 1-RM knee extension test, countermovement jump, and VAS approximated baseline values only in the TCWI group.

Co-Kinetic comment

Participants were recruited via WhatsApp messages sent to all the investigators’ contact lists, which is a sign of the times. This shows that both recovery methods work. Can we have a repeat with pressure applied during the ice massage to see if that makes a difference please?

This study aimed to determine the effect of different bed heights during manual therapy on the physical burden on physiotherapists. Thirty-three male physiotherapists (20–40 years of age, each with less than 10 years’ experience, and BMIs of less than 25kg/m²) were recruited for the study. None reported low back or upper limb pain that interfered with their routine daily.

They performed tasks simulating lumbar massage and passive hip abduction ROM exercise on the bed with low height (LH), which was set at 45cm from the ground, and adjusted height (AH), which was a height at which the physiotherapist felt comfortable working. Each task performed three times. A volunteer was used as a simulated patient. He was a 25-year-old male, 169.0cm tall, weighing 68kg (BMI, 23.8kg/m2). The weight of the lower limb of the simulated patient was set to 17.2%


of the body weight, and was calculated to be 5.8kg.

The anterior inclination angle of the physiotherapist’s trunk was measured, the surface electromyograms of the erector spinae and trapezius muscles were recorded, and perceived stress was assessed. Additionally, the lumbar disc compression force and flexion torque were estimated.

The results showed that bending and the biomechanical burden and perceived stress were increased at LH than AH. In ROM tasks using the right hand, the muscle activity was lower at the left lumbar region at LH than at AH. At LH, the anterior inclination angle increased and the lumbar muscle activity declined as the number of tasks increased. The burden on the shoulders was not significantly different by bed height.

Co-Kinetic comment

Physical therapists have one of the highest rates of work-related stress disorders. The most commonly affected body part is the low back, followed by the upper limbs (including the neck, shoulders, hands and fingers). In a 2008 study, Campo et al. (Work-related musculoskeletal disorders in physical therapists: a prospective cohort study with 1-year follow-up. PTJ 2008;85:608–619; https:// reported an incidence of work-related musculoskeletal disorders of 20.7% in a group of 507 physical therapists. You need to look after yourselves. It is not always possible to work on an adjustable height bed, so adjust your techniques to protect your own body.


recovery strategies for Breast Cancer

Exercise can positively influence certain breast cancer and treatment-related side effects, quality of life, recurrence and survival.

After breast cancer diagnosis, being physically inactive is a greater risk to survival rate than being overweight (although both reduce overall survival rate).

A growing body of evidence shows that exercise strengthens the immune system and reduces the chance of breast cancer recurrence.

Being physically active after breast cancer diagnosis has been shown to reduce:

34% deaths from all causes by 41% disease recurrence 24%

Let’s get physical!

In breast cancer rehabilitation, physical activity can have a positive influence on:

insulin sensitivity immune and cardiopulmonary function bone loss body composition

sleep disturbances


mental health and quality of life

Breast Cancer Rehabilitation Exercise Recommendations x 2 /week mins or150 75 Strength training exercises 2 times/week 150 min of moderate or 75 min of vigorous physical activity/week Emphasise strength training for those treated with adjuvant chemotherapy or hormone therapy

Breast Cancer Rehabilitation – Lifestyle Recommendations

Resume normal daily activities as soon as possible

Weight management is important

Get active and avoid inactive lifestyles

Massage for people with all types of cancer is a natural way to help you relax and cope with:

tirednessheadachesstress anxiety pain

mood disturbances

There is evidence that massage therapy can help in cancer recovery by:

Scan the QR code to add your branding, print or order professionally printed A1-A4 sized posters

A physical therapist can help if you have pain, stiffness, numbness, limited movement, or other physical problems due to breast cancer treatment.

Together, you’ll come up with goals for therapy. Your physical therapist will create a plan for how to meet them. Physical therapy after breast cancer diagnosis might include: Massage

Manual stretching to loosen your joints and muscles

Strength and flexibility exercises

Techniques to prevent tissue swelling

lifting mood improving sleep promoting relaxation enhancing a sense of wellbeing

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The information contained in this poster is intended as general guidance and information only and should not be relied upon as a basis for planning individual medical care or as a substitute for specialist medical advice in each individual case. ©Co-Kinetic 2022


There is a growing evidence base demonstrating that extracorporeal shockwave therapy (ESWT) is beneficial for the treatment of musculoskeletal conditions, reducing pain and promoting tissue healing in the short term. It is a non-invasive therapy and is of particular interest as it may well allow your client to continue with the training/competing demands of the season. This article provides the most up-to-date information about the indications and contraindications for ESWT, the evidence base for its use and what protocols have been used. This information will allow you to determine if ESWT will benefit your client and how to begin to use it for their condition. Read this article online

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

Extracorporeal shockwave therapy (ESWT), also referred to simply as shockwave therapy (SWT), is used to treat a range of musculoskeletal conditions. Technically, there are two types of ESWT: focused SWT and radial SWT (which uses radial pressure waves). Some may view them as distinctly different therapeutic modalities; however, despite their differences (in physical characteristics, method of energy generation and shockwave propagation), both types of ESWT share common clinical indications. Historically, ESWT was indicated as a secondary conservative treatment choice for recalcitrant musculoskeletal conditions, unresponsive to standard care (1,2*). This may include conditions such as plantar fasciitis, Achilles tendinopathy,

patellar tendinopathy, calcific and non-calcific shoulder tendinopathy, and lateral epicondylitis (3*). Bone- and cartilage-related disorders, such as non-union of fractures, osteonecrosis of the femoral head and kneeosteoarthritis-related bone marrow oedema, may also be included in the range of clinical indications for ESWT. As ESWT reduces pain and promotes tissue healing and has shown greater efficacy in the short term over the long term, it seems clear that ESWT should be used as a primary conservative treatment option, rather than merely a secondary tool.

Clinicians may find this tool useful to treat musculoskeletal conditions, particularly as the body of evidence supporting its efficacy grows. ESWT parameters – type of shockwave, number of impulses, energy flux density (EFD), area of application, number/frequency/duration of treatment session, use of analgesia – can be adjusted depending on the condition and patient’s tolerance. Optimal evidence-based, standardised

treatment protocols specific to given conditions are yet to be determined owing to the heterogeneity across clinical trial methodology. This article aims to highlight areas of research supporting the clinical use of ESWT to treat musculoskeletal conditions.

For an interesting and in-depth discussion about the use of ESWT, listen to the podcast by Physiotutors with leading UK shockwave therapist Paul Hobrough (https:// Podcast 022 Paul Hobrough shockwave ( watch?v=nq7zk027nSg).

How the EWST Works

1. Types of Shockwave Shockwaves are a form of energy that develop a peak pressure up to approximately 1000 times higher than that of ultrasound. Two primary forms of ESWT are used in clinical practice: focused shockwave and radial shockwave (4*).

Focused shockwaves are generated through three mechanisms:

Co-Kinetic Journal 2022;94(October):14-21

electrohydraulic, piezoelectric or electromagnetic methods that convert electrical energy into kinetic energy. They produce a higher maximal energy level and a deeper maximal force. The higher energy can be a more painful treatment application.

Radial shockwaves are generated pneumatically. They produce a lower maximal energy level, with its peak force absorbed by superficial structures attenuating the energy at greater depths. The lower energy can be a less painful treatment application.

2. Mechanism of ESWT

The mechanisms of ESWT are not completely understood, but shockwaves are thought to have a mechanical (mechano-transduction) and cellular effect that enhances tissue regeneration, healing and alters pain signalling (Tables 1 & 2). Mechanical stimuli – referred to as cellular mechano-transduction, or mechanotherapy – explain how cellular migration, proliferation, differentiation and apoptosis occur as a result of ESWT. Apart from a purely mechanical stimulus, the higher energy levels transmitted through the tissues may result in disruptive shear stresses that affect calcifications. Cellular changes, induced by pain modulation, can be explained by the principle of hyperstimulation analgesia (5*,6*,7*).

Myofascial pain syndrome (MPS), is a common musculoskeletal syndrome characterised by muscle stiffness, pain, taut intramuscular bands, local twitch response, and hyperirritable muscle fibres or myofascial trigger points. The energy crisis hypothesis may explain the effects of ESWT, whereby increasing perfusion of damaged ischemic tissues, increasing vascularisation and changing pain stimuli in ischemic tissues may improve symptoms of pain, fatigue, sleep, depression and quality of life (9*). Although many theories have been proposed, the exact mechanism of action of ESWT still remains to be elucidated.

3. ESWT Parameters

With each ESWT treatment, there are several parameters that can be adjusted. In a clinical environment,

Table 1: Proposed cellular mechanisms of action for extracorporeal shockwave therapy (ESWT) Tenforde AS, Borgstrom HE, DeLuca S et al. Best practices for extracorporeal shockwave thera py in musculoskeletal medicine: clinical application and training consideration. PM & R 2022;14:611–619 8, Reproduced under Creative Commons Attribution License 4.0 (


Increased collagen synthesis

Cellular proliferation and wound healing

Mechanism of action

l Enhanced fibroblast proliferation (increased transforming growth factor beta [TGF-ß]) and upregulation of collagen I and III

l Regulation of scleraxis, tenomodulin

l Upregulation of tendon-derived tenocytes

l Increased ATP release and downstream extracellular signalregulated kinase activation

l Enhancement of osteogenesis

l IL-6 and IL-8 mediated tendon remodelling

Pain reduction


Decrease in soft tissue calcifications

Decrease in inflammation

l Gate-control theory

l Modifies substance P release

l Decreased calcitonin-gene-related peptide

l Induction of TGF-ßI and insulin-like growth factor I

Table 2: Specific postulated mechanisms of action of ESWT

Tenforde AS, Borgstrom HE, DeLuca S et al. Best practices for extracorporeal shockwave therapy in musculoskeletal medicine: clinical application and training consideration. PM & R 2022;14:611–619 8, Reproduced under Creative Commons Attribution License 4.0 (



Mechanism of action

l Decreased oedema and inflammatory cell infiltration within tendons

l Tissue regeneration via conversion of mechanical stimulation to biochemical signal

l Increase transforming growth factor beta-1 and insulin-like growth factor I levels to stimulate tenocyte and collagen proliferation (important in healing)

l Scleraxis upregulation (promotes tendon growth and development)

l Proliferation of anti-inflammatory cytokines

l Increased proliferation and migration of tendon-derived tenocytes

l Decreased metalloproteinase expression (enzymes that can degrade collagen)

l Reduction of inflammatory interleukins


l Protein upregulation may enhance angiogenesis and neovascularisation of the bone

l Osteogenesis and bone remodelling by release of growth factors

l Bone morphogenic protein 2

l Vascular endothelial growth factor

l Promotion of periosteal bone formation

l Decreased osteoclast activity

l Increased osteoblast activity

l Decreased inflammation

Joints (knee) Spasticity

l Decreased oedema

l Improvements in subchondral bone architecture

l Increased chondrocyte activity (cartilaginous repair)

l Decreased spasticity at the level of the muscle and neuromuscular junction

l Reduced rigidity of connective tissues (muscle level)

l Stimulate synthesis of nitric oxide

l Neuromuscular junction formation

l Neovascularisation PHYSICAL THERAPY


machine settings should be recorded with each treatment. Optimal protocols vary by indication, and there are few accepted ‘routine’ settings. The parameter most commonly adjusted with ESWT application is EFD, which is defined as the energy per impulse at the focal point of a shockwave. In focused ESWT, EFD is often reported in mJ·mm2 and for radial ESWT in bar (for comparison, typical measures of radial shockwave 2 bar is approximately 0.09mJ·mm2 and 4 bar is approximately 0.18mJ·mm2) (4*).

Even within focused ESWT devices, the EFD can vary; for example, the EFD of an electrohydraulic device does not equate to that of a piezoelectric device.

When assessing the effectiveness of ESWT and translating clinical trials into practice the type of wave (focused or radial), EFD, number of impulses, number of treatment sessions, days between sessions, area of application, use of coupling gel, and use of analgesia during application should all be considered. See Table 2 in Shroeder A et al. ( for a summary of the available evidence and clinical recommendations/practice for the different ESWT parameters (4*). Multiple head-to-head studies have been conducted comparing the effectiveness of focused versus radial SWT for conditions including tendinopathy and spasticity. It is apparent from the results that both forms of SWT are appropriate; however, owing to the mechanistic differences outcomes may differ across given conditions (10,11*,12*).

Where To Use ESWT

The physiologic effects of shockwaves have been widely investigated, and observations have been made on how the different energy forms can affect the musculoskeletal system, reducing pain and facilitating tissue healing. The beneficial effects from a clinical perspective have been shown across a variety of clinical trials in

the management of musculoskeletal disorders.

The International Society for Medical Shockwave Treatment (13*,14*) has outlined numerous indications for the use of ESWT. It is a non-invasive option with minimal side effects that may allow an individual to continue participating in their sport or activity, pain permitting, while receiving a course of treatment. This may be preferable to more-invasive treatment options, such as corticosteroid injections, tenotomy, and platelet-rich plasma injections, which carry the risk of tendon rupture or require variable amounts of time away from sport or activity (4*).

Indications for the use of ESWT in musculoskeletal conditions include:

1. Tendon pathologies

1.1 rotator cuff tendinopathy 1.2 lateral epicondylopathy of the elbow

1.3 greater trochanteric pain syndrome

1.4 hamstring tendinopathy

1.5 patellar tendinopathy

1.6 Achilles tendinopathy

1.7 plantar fasciopathy

1.8 adductor tendinopathy 1.9 pes anserine tendinopathy

1.10 peroneal tendinopathy

1.11 distal biceps tendinopathy

2. Bone pathologies

2.1 delayed healing/non-union 2.2 stress fracture

2.3 Osgood–Schlatter disease 2.4 medial tibial stress syndrome 2.5 bone marrow oedema 2.6 avascular necrosis 2.7 osteochondritis dissecans

3. Muscle pathologies

3.1 myofascial pain

3.2 muscle strain without discontinuity

4. Joint pathologies

5. Management of spasticity (13*,14*).

1. Clinical Application in Tendinopathies, Fasciopathy and Soft Tissue Pathologies

The most frequently studied

application of ESWT is of chronic tendinopathies and plantar fasciitis. Both focused and radial ESWT have proven clinical efficacy. Combining forms of focused and radial ESWT in clinical practice may be an effective option, targeting different anatomical structures within a given musculoskeletal condition (8*,11*,15,16,17*).

It is recommended that treatment should be performed without the use of anaesthetics. Clinical focusing – that being described as treatment directed over the area of maximal pain –should be used to optimise treatment outcomes and guide application from primary to secondary injury sites. ESWT should not only be applied to the primary site of tendon pathology but should include the muscle–tendon–bone unit thus addressing soft tissue impairments that could be contributing to the condition. For example, midportion Achilles tendinopathy treatment should include direct application over the painful portion of the tendon as well as exploration of painful sites in the soleus, gastrocnemius, myotendinous junction and the calcaneal enthesis. An upper limit in total treatment application has not been established, thus identifying and treating secondary injury sites can also be performed during a single treatment session. Bear in mind that ESWT can be painful and this should be accounted for during treatment and when counselling patients (8*).

1.1 Rotator Cuff Tendinopathy (Calcific and Non-Calcific)

l A recent Cochrane review and meta-analysis of over 32 clinical trials comparing ESWT to placebo, compared high-dose ESWT to low-dose ESWT or compared ESWT with various other interventions for treatment of rotator cuff disease (calcific and non-calcific tendinopathy) concluded that (i) ESWT compared with placebo at 3 months showed improvements in pain and function; however, (ii) these measures did not meet the minimum clinically important difference in the ESWT group (18*). Wide clinical diversity and varying treatment protocols make comparison

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challenging and question whether some trials tested subtherapeutic doses, possibly underestimating any potential benefits.

l A recent study showed significantly greater improvement in pain and function in the focused (electromagnetic) ESWT group (four sessions, EFD 0.09±0.018mJ·mm2, impulse #3000) to radial ESWT (four sessions, EFD 4±0.35 bar, impulse #3000) at 24 and 48 weeks, despite both groups improving from baseline (12*).


Positioning the shoulder in hyperextension and internal rotation during focused ESWT treatment (three weekly sessions, EFD 0.22mJ·mm2, impulse #1200) resulted in significantly more reabsorption of calcific deposits. More studies are needed to determine the use of ESWT in reabsorption of calcific deposits, to see if the size, density and location of the calcific deposit matter and whether the appearance of calcific deposits on imaging is of clinical relevance (4*).

l ESWT appears to be safe with minimal adverse events, although the optimum treatment parameters are not known for rotator cuff tendinopathy.

1.2. Lateral Elbow Epicondylopathy (4*)

l Studies show mixed treatment efficacy.

l Studies comparing ESWT to placebo, ultrasound, laser and lower-dose ESWT have shown improvements in pain and grip strength in the short term (1 to 3 months), but no difference in overall function.

l ESWT over the lateral epicondyle is not always tolerated due to pain. It is recommended that energy levels be adjusted to maintain a tolerable pain level. The EFD and frequency can be slowly titrated up as tolerated. One can consider use of a softer applicator, such as a plastic tip or silicon tip for radial ESWT.

1.3. Greater Trochanteric Pain Syndrome (GTPS) (4*)

l Both radial and focused ESWT may

be efficacious in treating GTPS.

l Radial ESWT (one session, four bars, impulse #2000) for GTPS has shown improved short-term (3 months) and long-term (12 months) outcomes compared with baseline, with 76% of athletes returning to sport within 1 week to 3 months.

l Similarly, when compared to corticosteroid injection radial ESWT (three sessions, three bars, impulse #2000) showed greater long-term (15 months) efficacy.

l Studies using focused ESWT (three weekly sessions, EFD 0.20mJ·mm2, impulse #2000; or three weekly sessions, EFD 0.15mJ·mm2, impulse #1800) resulted in improved pain and function at 2 and 6 months.

l Considering the typical depth of the gluteal tendons (varying across patients), the use of high-energy focused ESWT may be preferred to achieve adequate EFD at the site of deeper penetration.

1.4. Proximal Hamstring Tendinopathy

l There are only a handful of randomised controlled trials on the use of ESWT to treat proximal hamstring tendinopathy; however, success has been reported.

l Cacchio et al. (19) compared conservative management [nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy, and an exercise programme] to radial ESWT (four weekly sessions, EFD 0.18mJ·mm2, impulse #2500) for the treatment of proximal hamstring tendinopathy in professional athletes. A significant improvement in pain and function was reported at 3 months in the ESWT group. Of the ESWT group 85%, compared to only 10% of the conservative group, reported at least a 50% reduction in pain. Dramatically, 80% of athletes treated with ESWT returned to their preinjury level of sports participation by 3 months, whereas 0% of those in the conservative treatment group

returned to sport at 3 months.

l Similarly, treatment of proximal hamstring tendinopathy in runners has shown radial ESWT (average, four sessions, EFD 2 to 5 bar) successful in 69% of cases achieving minimal clinically important difference in the measured functional outcome (20).

l As a result of the success of these clinical trials, the conditions used have become a well established ESWT protocol: four sessions of radial ESWT with EFD of 0.18mJ·mm2. However, more sessions can be performed if needed, and EFD can be adjusted according to the patient’s tolerance of the treatment.

1.5. Patellar Tendinopathy

l Studies have used focused and radial ESWT with varied protocols.

l A meta-analysis concluded that ESWT may be a superior alternative to other non-operative treatments (physical therapy, NSAIDs, exercise) in the short term and equal to patellar tenotomy surgery at up to 24 months (21).

l Cheng et al. (22) performed a randomised controlled trial in athletes with patellar tendinopathy, comparing radial ESWT (16 weekly sessions, EFD 1.5 to 3 bar, impulse #2000) to a control group (who received physical therapy modalities such as acupuncture, ultrasonic wave and microwave therapy) and showed improved pain and strength in both treatment groups at 16 weeks.

l ESWT is an effective non-operative treatment for patellar tendinopathy.

l ESWT may be used safely during the competitive season for athletes with patellar tendinopathy with more immediate gains in pain relief and function (4*).

1.6. Achilles Tendinopathy

l For midportion Achilles


exercises and ESWT added in conjunction to this (27*).

l ESWT may allow for short-term pain relief permitting the patient to better tolerate an eccentric loading programme.

1.7. Plantar Fasciopathy

l The greatest amount of evidence supports ESWT use for this indication.

l Several recent meta-analyses show the superiority of a variety of ESWT protocols to placebo and other treatments (ultrasound, lowlevel laser, pulsed radiofrequency treatment, and corticosteroid injections) (28,29,30*).

l ESWT may be more efficacious at higher intensity (EFD >0.36mJ·mm2) in the short term (0–6 weeks) (4*).

Radial ESWT has been shown to be effective in treatment of overuse tendon injuries including distal biceps tendinopathy and tibialis posterior tendinopathy. The limited number of studies on these ‘other’ tendinopathies show promising results using radial ESWT for reducing pain and improving function in the short term. Combining it with rehabilitation, for example a progressive intrinsic foot muscle exercise regimen for tibialis posterior tendinopathy, has shown significant improvement in function (31).

2. Clinical Application for Bone Stress Injuries, Delayed Union and Avascular Necrosis

Application of high-energy ESWT is required to treat bone-related conditions, as the mechanism to facilitate bone remodelling requires upregulation of localised nitrous oxide to promote angiogenesis (8*). The use of focused ESWT to achieve higher EFD is recommended to target bone-related conditions. This can be accomplished through combining clinical focusing, using existing

imaging results (eg. X-rays or scans) or ultrasound-guided application to visualise underlying anatomy and neurovascular structures (8*).

3. Clinical Application for Muscle Pathologies As a non-invasive and safe modality,


chronic lower back pain (37*,38*). Although the use of ESWT for pain management is well established, future research may be able to identify additional benefits in these areas, and to establish the long-term advantages 19

and after treatments.

l ESWT can be given concurrently with other treatment interventions (4*).

The International Society for Medical Shockwave Treatment (ISMST), has compiled a list of contraindications to ESWT:

l Absolute contraindications (all energy treatments)

l active infection (ie. osteomyelitis); l malignant tumour (focused shockwave); and l pregnancy.

l Relative contraindications (highenergy treatments)

l brain or nerve in treatment focus;

l lung or pleura in treatment focus;

l significant coagulopathy; and

l epiphyseal plate in treatment focus.

l Important considerations

l cardiac pacemakers or other implantable devices;

l current NSAID use;

l current anticoagulation use; and

l recent corticosteroid injections (13*).


ESWT is a safe treatment option for a variety of musculoskeletal conditions. Different physiological mechanisms underpinning ESWT treatment may individually or collectively play a role contributing to the regenerative processes and benefiting a diversity of physical problems. Various protocols have shown efficacy in reducing pain and improving function but no single optimal ESWT protocol has been identified. Across studies and body regions, ESWT appears to be most efficacious in the short term. ESWT is not a substitute for other physical therapy modalities but should be added as a complimentary supplement within a rehabilitation protocol; the goal being to achieve long-term benefits.


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l In your experience of treating musculoskeletal pathologies with ESWT, which responded best to this treatment and was it alone or in combination with standard physical therapy?

l What are your greatest complaints or concerns from patients when using ESWT and how do you manage them?

l If you are interested in beginning to use ESWT, which pathologies would you start with and why? How would you decide what treatment protocol to use?


l Shockwave Therapy Content Marketing Campaign for Physical Therapists


l Shockwaves are thought to have a mechanical (mechano-transduction) and cellular effect that enhances tissue regeneration, healing and alters pain signalling.

l ESWT is a non-invasive treatment option with minimal side effects that may allow an individual to continue participating in their sport or activity, pain permitting, while receiving a course of treatment.

l ESWT may be preferable to more-invasive treatment options.

l There are numerous indications for treatment including tendon and bone pathologies, spasticity, joint and muscle injuries.

l ESWT is proven to reduce pain in the short term.

l ESWT should be used as a supplement to physical therapy treatment and rehabilitation and not as a substitute.

l Research has shown better clinical outcomes when ESWT is incorporated into an eccentric loading programme (for Achilles tendinopathy) or when combined with standard therapy (for example manual therapy, exercise therapy, cryotherapy, dry needling, or ultrasound) for musculoskeletal conditions.

l ESWT may be unpleasant but tolerable, as pain is experienced during and/ or after treatment, thus counselling a patient about their treatment and expectations is critical.

l The energy flux density (EFD) can be decreased if patients are unable to tolerate higher energy levels due to pain, and titrate up over subsequent treatments.

l Across the varied musculoskeletal conditions, optimal treatment parameters and protocols for ESWT are yet to be fully established.

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.


Moving Back To Basics

Low back pain (LBP) affects many people and can be hard to treat. If LBP becomes chronic, psychological factors, such as fear-avoidance beliefs and catastrophising, can also become involved. There is an almost overwhelming amount of research about LBP and how best to treat it. This article discusses the evidence for and against different approaches and will allow you to make individually-tailored decisions for the best

If alterations in the periphery (such as increased movement asymmetry, decreased variability, reduced movement speed, increased muscle co-contraction as well as decreased back muscle endurance, strength and mobility) are compensatory rather than causative, then treatment needs to focus on new approaches. For example, these can include strategies to retrain the cortical function, alter patients’ fears and beliefs, and incorporate a biopsychosocial model

The relationship between changes in physical performance as a consequence of exercise therapy and subsequent changes in clinical outcome has been reported as tenuous at best. It is conceivable that exercise therapy may elicit other changes that may be responsible for the improvements in pain and

improvements in self-efficacy; coping strategies and fear-

modification of motor control

changes in cortical organisation; and simply a positive relationship between patient and therapist (1).

Co-Kinetic Journal 2022;94(October):22-27

This article aims to review the evidence available regarding different exercise types for LBP and question whether evidence exists for the philosophy of ‘exercise that people enjoy and is easy for them to do will probably get done and hence have a positive effect’.

Comparing Exercise Types

1. Stabilisation or

Core Stability Exercises

It is well documented that there is dysfunction in both the feed-forward and the voluntary activation of the deep-lying trunk muscles in recurrent and/or chronic LBP. Studies have shown that, in comparison to healthy controls, patients with LBP have a delayed onset of activation, particularly for the transversus abdominis (TrA) muscle during rapid movements of the arm or leg. This is an involuntary ‘anticipatory’ function of the TrA that is compromised. Not only this, but the ability to voluntarily activate the TrA during standardised exercises can be deficient in patients with chronic LBP. Specific spine stabilisation exercises, aimed at restoring these aspects of deep trunk muscle function have become popularised over the years, based on the hypothesis that these dysfunctions may pose a threat to spine stability and perhaps predispose to continuing or future episodes of pain.

Panjabi proposed the well-known model of spinal stability consisting of three subsystems: the passive subsystem (which includes bone, ligament and joint capsule), the active subsystem (which includes muscle and tendon), and the neural subsystem (which consists of the central nervous system and peripheral nervous system) (2). Control of spinal movement requires the three subsystems to work harmoniously together. Thus, core stability exercises should consider the motor and sensory components of the exercise and how they relate to these systems to promote optimal spinal stability (3). Core stability training should progress to include more intricate static, dynamic and functional exercises that involve coordinated contraction of local and superficial spinal muscles. Many studies and systematic reviews have been

published showing the importance of core stability exercises in the rehabilitation of patients with LBP.

Core stability training has a powerful theoretical foundation. It would be conceivable therefore that stabilisation exercises are superior to other forms of therapy for LBP patients. Studies have shown that stabilisation (or core) exercises are superior to usual medical care and education (or ‘general practitioner treatment’) (4*), but not to other forms of physical therapy/ exercise – there is limited evidence for any additional effect when stabilisation exercises are added to conventional physiotherapy programmes (4*,5,6,7*).

In comparison to general exercise (general trunk strengthening without a focus on maintaining a neutral spine, stretching and aerobic activities), core stability exercise may be more effective in relieving pain and improving back-specific function for patients with chronic LBP in the short term. This has been shown in studies where improvements in proprioception and balance follow a core strengthening programme (8*,9,10*,11*) However, when core stability exercises are compared to other exercise interventions both showed improvements in proprioception and balance (12*,13). No significant differences are observed between core stability exercise and general exercise in pain and functional status in the long term (14*).

It is not surprising that core stability exercises demonstrate significant improvements in the percentage change of muscle thickness on both sides of the TrA and lumbar multifidus (LM) (11*). A recent randomised clinical trial compared the McKenzie method of exercises with motor control exercises and found that both types of exercises similarly improved abdominal muscle thickness (15).

Stability exercises may significantly increase the ability to voluntarily activate TrA after therapy; however, neither the TrA-contraction ratio (TrA thickness

contracted/TrA thickness at rest using ultrasound) recorded before treatment nor its improvement following treatment bore any significant relationship to clinical outcomes. Similarly, TrA anticipatory activation for rapid movements showed a nonsignificant effect on clinical outcomes following therapy (5).

There appears to be no consensus agreement that core stability exercise is superior to general exercise for chronic LBP. Seeing as positive effects are shown with different exercise forms (14*,16*), the application and underlying rationale for the use of stabilisation exercises are not endorsed unreservedly by all. Statistically significant differences in deep trunk muscle recruitment or activity levels between groups of chronic LBP patients and controls may be challenging to quantify, as is the diagnostic accuracy. More recent work has questioned the small but statistically significant group differences as being rather low and clinically non-relevant. There is also a paucity in the data directly correlating positive outcomes following a programme of stabilisation exercises contingent on improvements in deep trunk muscle function (5). Regardless of improvements in core muscle thickness or function with stability exercises, they are not superior to other exercise types in clinical outcomes such as pain, functional disability and fear-avoidance (11*,16*,17*,18).

As has been suggested for other types of exercise or physical therapy, it is conceivable that the mechanism of action for this treatment does not concern trunk muscle function or segmental stabilisation per se. A high dose of most exercise treatments appears to reduce pain and functional limitation outcomes more than a low dose, and the addition of cointerventions appears to improve the effectiveness of most exercise types for pain and functional limitation outcomes (17*). The positive influence of the


therapy may reside in improvements in self-efficacy, coping strategies, reduced catastrophising, fear-avoidance, changes in cortical organisation or simply a positive therapist–patient interaction/relationship (5,6,7*,19*,20*,21*,22*,23*).

Research has shown it may be difficult to attribute, with any confidence, the therapeutic results of core-based stabilisation exercises associated with improved or specific effects on abdominal muscle function (5). Likewise, a systematic review with meta-analysis concluded that “There is strong evidence stabilisation exercises are not more effective than any other form of active exercise in the long term” (24*). Results from the metaanalysis indicated a trend favouring core stability exercises which were not regarded as clinically significant, as any reduction in favour of stabilisation exercises fell below the minimal clinical important difference levels. Robust data from this meta-analysis considers that stabilisation exercises offer no benefit over alternative forms of exercises in the long term (24*). Outcomes from studies have found that there is a trend of worse fearavoidance belief questionnaire (FABQ) scores with stabilisation exercises, compared with stationary bikes, sling exercises and general exercises. The rehabilitation strategy surrounding stabilisation exercises has been

challenged with the suggestion that it could encourage unhealthy thoughts and beliefs about pain and movement (25). This will be discussed further towards the end of the article.

2. Motor Control Exercises

Motor control exercise (MCE) is founded on the principles of motor learning to integrate control and coordination of the spine muscles for functional activities (Video 1). The basis on which MCE may work follows the principles of spinal stability (2,3,6). Exercise should be individualised and tailored upon initial assessment of each patient’s posture, muscle activation and coordination. Clinical assessment of this can be challenging as laboratory-based biomechanical and electromyographic measurements are traditionally used in motor control studies.

Muscles having poor control (commonly the deep trunk muscles including LM and TrA), may benefit from MCE as well as overactive muscles (commonly the large external trunk muscles including rectus abdominis and erector spinae muscles). The premise behind the MCE strategy is the assumption that motor control patterns are maladaptive, and that clinical benefit will be derived from ‘correction’. Very low to moderate quality evidence shows that MCE is no more effective that other exercise types in reducing pain and disability in LBP patients (26*,27*).

3. Pilates

A popular exercise method touted to resolve chronic back pain is Pilates. Research showed that Pilates (specific trunk exercise), in comparison to a stationary bike programme, produced significant improvement in pain and disability at 8 weeks. FABQ scores were reduced in both groups. The results indicated that at 6 months, an important time point for assessing chronic pain, there were no between-

group differences; both exercise programmes were effective in reducing pain, disability and catastrophising in the long term. If a patient with LBP adheres to either specific trunk exercises such as Pilates or a general exercise such as stationary cycling, it is reasonable to think that similar improvements will be achieved (28).

Interestingly the Pilates group was performing significantly better than the stationary bike group initially, but not at the 6-month follow-up. The short-term benefits may be due to patients’ expectations being met (by receiving perceived relevant exercises), which in turn could activate the reward analgesia system (28).

4. Walking Programme

Conventional biomedical thinking may have you believe that a specific intervention, owing to its targeted nature, should outperform a more general exercise programme and not just a bit but significantly. When specific back strengthening exercises were compared to a walking programme (both performed twice weekly for 6 weeks), both groups improved. The walking programme was found to be as effective as the specific back strengthening programme for chronic LBP. All participants were sedentary at the start of the study, so possibly the take-home message is that physical activity is the most important factor, not necessarily the specifics of the activity (29).

5. Loading or Strength and Resistance Exercises

A study by Aasa et al. directly compared low-load motor control (LMC) exercises with high-load lifting (HLL) in back pain patients (30*). Both exercise groups progressed over an 8-week period; the LMC group incorporated more dynamic and functional activities while maintaining a neutral spine, whereas the HLL group performed a deadlift with increasing weight. Both interventions resulted in significant within-group improvements in pain intensity, strength and endurance. Interestingly the LMC group showed significantly greater improvement in functional scores, although there were no

Video 1. Motor Control Patterns in Low Back Pain (Courtesy of YouTube user Physiotutors)
Co-Kinetic Journal 2022;94(October):22-27

between-group differences in pain, strength and endurance tests. Thus, LMC intervention may result in superior outcomes in activity and movement control compared to an HLL intervention, but not in pain intensity, strength or endurance (30*).

Although receiving two quite different exercise programmes, both groups made improvements. Interestingly, both groups received pain education – addressing a psychosocial component that may have balanced the playing fields. It may also be interpreted that the LMC group had greater movement variety in their activities compared to the HLL deadlift. There is data, that will be discussed later in this article, to suggest reduced variability may be a factor contributing to LBP, thus the LMC exercises may have had a positive effect on this underlying issue (30*).

Both strength/resistance exercise and coordination/stabilisation exercise programmes have a small but significant effect on LBP. A greater effect size has been shown in exercise programmes that incorporate wholebody strength/resistance activities. The evidence fails to conclusively show the superiority of one exercise type over the other (31). This suggests, therefore, that any exercise programme that is adhered to is probably the most effective (16*,17*).

6. Deconditioning and Reconditioning Exercises

This is a case of the chicken or the egg – which came first? Consensus is lacking on firstly, an initial decline in fitness and subsequent development of chronic LBP; secondly, development of chronic LBP resulting in subsequent deconditioning; and thirdly, the impact of restoration of physical activity and aerobic fitness in terms of recovery from chronic LBP. There is minimal evidence that chronic LBP patients suffer from disuse and physical deconditioning, before or after the onset of acute or chronic LBP (32,33). The relation between the level of activity and back pain may in fact be a U-shaped curve. Both inactivity or sedentary lifestyle and excessive activities (physically strenuous back activities or sports) present an

increased risk for back pain (34).

7. High-Intensity Interval Training

High-intensity interval training (HIIT) is one of the most popular fitness trends worldwide, involving short bursts of very intense activity interspersed with short periods of rest or low-intensity exercises. HIIT offers an alternative to moderate-intensity continuous training (MICT). Whereas continuous exercise at high intensity leads to exhaustion quickly, alternating bursts of high and low intensity (or rest) allows patients to easily achieve high-intensity levels. HIIT is also a time-efficient form of exercise that may overcome motivational barriers for some patients (35*).

A study comparing HIIT to MICT for chronic LBP proved it to be a feasible, well-tolerated, and effective therapeutic modality. It showed greater improvements in disability and exercise capacity than MICT. The HIIT protocol consisted of bouts of cardiorespiratory training using a cycle ergometer, general resistance training exercises and core muscle training (36*); essentially a combination of multiple exercise types discussed above.

In a further study using HIIT protocols on chronic LBP patients, participants were randomly assigned to one of four groups performing high-intensity cardiorespiratory interval training coupled with (i) general resistance training; (ii) core strength training; (iii) combined general resistance and a core strength programme; or (iv) mobility exercises, which involved six exercises aimed to improve the mobility of the trunk and hip complex. Results showed that all four groups had clinically relevant improvements, which suggests that HIIT can be combined with other modalities when setting up exercise therapy for chronic LBP (37*).

Postural and Movement Characteristics or Deficits

A common belief held by clinicians is that identifying and correcting movement or postural aberrations can result in improved pain and activity. In order to ‘normalise’ dysfunctional movement, clinicians would need an empirical basis for (i) differentiating between normal and dysfunctional

movement, and (ii) determining whether correction of the dysfunctional movement might reduce pain and activity limitation. And here lies the problem with excessive heterogeneity across studies.

A systematic review by Laird et al. assessed 43 studies of lumbopelvic kinematics in patients with and without back pain (38*). In comparison to those not in pain, reduced proprioception, slower movement and reduced range of motion (lumbar flexion, lateral flexion and rotation) were common across back pain patients. The implications of reduced proprioception are that people with LBP are less ‘movement-aware’ with potentially reduced postural control. Key questions remain, such as Are these deficits a result of or a cause of LBP? And, potentially, Were these deficits present before the development of LBP? Structural factors including the size of the lumbar lordosis, pelvic tilt, leg-length discrepancy, and the length of abdominal, iliopsoas and hamstring muscles are not associated with the occurrence of LBP (39*).

Research has shown that patients with LBP experience 26% greater spine compression and 75% greater lateral shear (normalised to moment) than asymptomatic individuals during controlled exertions. The increased spinal loading resulted from muscle coactivation measured across 10 muscles using electromyography data. When permitted to move freely, the patients with LBP compensated kinematically in an attempt to minimise external moment exposure (40). Likewise, fear of movement, kinesiophobia, is associated with greater trunk stiffness in LBP patients (41*). Therefore patients with LBP have greater muscle activation and cocontraction with reduced lumbopelvic movement. This is reasonable seeing as the muscular response to pain or the threat of pain is protective in nature, aiming to minimise movement (42).

So, one might question whether exercises that promote co-contraction and increased core stiffness could potentially perpetuate the problem.

As with the pelvic floor, it has been shown that hypertonic muscles (more common than initially perceived), contribute to pelvic pain and dysfunction in the area. Relaxation and lengthening, rather than generic Kegel strengthening is a treatment goal for some of these patients. Similarly ‘turning off’ some muscles to allow for freedom of movement may be necessary for LBP patients.

Reduced movement may not be due to weakness but rather increased activation of a muscle, stiffening the joint and restricting movement. Thus freedom of movement, both physically and psychologically, should be a goal during treatment (Video 2).

Research shows that LBP individuals present with reduced gait speed and reduced stride length compared to individuals without back pain. It is possible that individuals with LBP use a strategy of slower walking velocity and slightly reduced stride length to minimise the kinematic and kinetic demands of walking. Strong evidence highlights altered phase relations between motion in the pelvis

and thorax during walking in individuals with persistent LBP. The pattern of coordination, or relative motion, between the upper trunk and pelvis in the axial plane is speed-dependent in healthy controls. Becoming more antiphase as speed increases. Contrary to this, LBP individuals exhibit greater in-phase movement patterns. There is an inability to dissociate the trunk and pelvis. During fast walking, anti-phase coordination helps to generate elastic recoil between the thorax and the pelvis. This may explain why individuals with LBP, presenting with reduced antiphase coordination, walk slower and with a shorter stride length (43*).

Individuals with LBP also have greater lumbar paraspinal activation during walking. Over time, this increased activation in individuals with LBP may contribute to recurrence due to increased compressive spinal loading. Increased paraspinal activation may also be the cause of the reduced anti-phase coordination as a result of increased axial stiffness limiting dissociation of motion between the upper trunk and the pelvis (43*).

Decreasing trunk stiffness may automatically increase movement variability in LBP patients. Focusing on decreasing stiffness through more relaxed movements across a variety of tasks or activities, such as gait, could be a treatment strategy for LBP sufferers.

Final Thoughts

Exercise therapy has been shown to alter a number of psychological factors correlating with the change in self-rated disability. It is impossible to say whether the psychological changes followed the improvement in symptoms and function after exercise therapy or vice versa. Even in cases where cognitive-behavioural therapy has not been addressed, physical activity has decreased the level of pain catastrophising. This may be due to ‘enforced’ exposure to activities that challenge the notion of movement being a threat, allowing the patient to enjoy the positive experience of completing the given exercises without undue harm (5).

There is an argument that performing (any) exercise is more

important than the type or the targeted physical aspect of the exercise. The biological mechanisms explaining the positive effects of exercise therapy are not yet fully understood. Improvements in clinical outcomes do not correlate to local (muscle or joint strength, length or endurance) changes. Other explanations that the derived benefit is from more central effects include:

1. perhaps a correction of a distorted ‘body schema’;

2. altered cortical representation of the back;

3. modification of motor control patterns as a consequence of a reweighting of sensory input; and

4. a positive therapist–patient interaction/relationship (44*).

Studies have reported a correlation between psychological status and LBP or pain tolerance. However, the efficacy of treatments that solely focus on psychological factors has been shown to be small (45*). In addition to providing physical benefits, exercise therapy seems to positively influence psychological variables such as fearavoidance beliefs, catastrophising and self-efficacy regarding pain control. This may result from patients not receiving harm while completing exercises, regaining trust and confidence in their back function, thereby adjusting irrational thoughts and beliefs about their back pain (44*).

If a treatment is effective, then the establishment of its active ingredient is immaterial. Basically, if an exercise activity improves a patient’s clinical outcome then don’t over-think the biomedical reasoning behind it. Accepting that chronic LBP may be a problem of cortical reorganisation and degeneration, it is also possible that exercise therapy may have served to normalise this. There appears to be a significant dose–effect relationship between adherence to the exercise and outcome. Thus choosing an exercise that is relevant, enjoyable, accessible, cost-effective and preferred by the patient will facilitate adherence to therapy.

As therapists, we should be aware of the potential danger of applying pain-contingent stabilisation exercises

Video 3. The BEST Exercise for Low Back Pain according to Research (Courtesy of YouTube user Physiotutors) Video 2. Graded Exposure Exercises for Low Back Pain (Courtesy of YouTube user Physiotutors)
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only. Focusing on nothing else but stabilisation exercises contradicts the current understanding of pain and neuromuscular interactions, and thus does not comply with a biopsychosocial approach to treatment. Stabilisation exercises prescribed to patients who have a moderate or high fear of movement might trigger or exacerbate their kinesiophobia (eg. “I have to keep my back always stable and I am therefore not allowed to move my back”) and catastrophic thoughts (eg. “If I do not continuously activate my stabilisation muscles, my back will be prone to severe injuries”). Stabilisation exercises can be integrated with other exercise types and in a biopsychosocial treatment programme, comprising various components such as stress management, education and activity self-management (23*,25).

Exercise therapy should be integrated into a patient-tailored biopsychosocial rehabilitation programme rather than applied as a stand-alone treatment (eg. a timecontingent approach to exercise therapy should be applied). There is consensus for individualised, supervised exercise based on patient presentation, goals and preference that is perceived as safe and non-threatening to avoid fostering unhelpful associations between physical activity and pain (46,47). Thus, education should play a key role, with supervised exercise and behavioural therapy as other first-line therapeutic options (48). Interventions such as supervised or individualised exercise therapy and self-management techniques enhance exercise adherence and improve self-efficacy, which is one of the main predictors of treatment outcomes for patients with chronic pain. It is unlikely that one kind of exercise training is the single best approach to treating chronic LBP. Studies provide evidence that ‘active therapies’ are the most effective, including Pilates, resistance, stabilisation/motor control and aerobic exercise training, where the patient is guided and actively encouraged to move and exercise in a progressive fashion (Video 3) (16*,47). These modes of exercise training also appear

to be more effective than therapist hands-on and hands-off treatments (49).

Indeed, if the main aim of exercise therapy in chronic LBP is to get patients moving again and be able to confront their fears about physical activity and movement, then the method used to do this may be immaterial. This has a fortuitous side-effect that it would open up the array of potential options for the type of exercise to be carried out, allowing consideration of the all-important issues of cost, access to facilities and patient preference. The focus should be placed on the human being doing the exercise rather than just their back!


Owing to space limitations in the print version, the references that accompany this article are available at the following link at the following link


l What do you believe is a key underlying element of a successful exercise programme in LBP patients?

l What exercises do you traditionally use for LBP, and why?

l Would you allow your LBP patients to choose their preferred exercise or activity?



l There are many different types of exercise that have a positive effect on LBP.

l No one exercise type is superior to another in clinical outcomes.

l Positive clinical effects from exercise for LBP are not directly attributed to physiological changes in muscle thickness, strength, mobility or endurance.

l Stabilisation exercises that re-enforce a patient’s beliefs in their pain, ‘instability,’ and catastrophising will negatively impact their recovery.

l Deconditioning is not clearly associated with LBP.

l Increased trunk stiffness, decreased ROM and speed of lumbar movement are associated with LBP.

l Kinematic and intramuscular reduction in variability is associated with LBP.

l An exercise or physical activity that allows patients to safely confront their movement fears and anxieties will be most beneficial.

l There is a significant dose–effect relationship between adherence to the exercises and positive outcomes.

l Choosing an exercise that is relevant, enjoyable, accessible, cost-effective and a patient preference will facilitate adherence to therapy.

l Consider a rehabilitation programme combining different exercise variables (high and low load) and different exercise types giving greater variability and freedom of movement.


l Classification Systems: A Review of Low Back Pain Care [Article]

l Low Back Pain During Pregnancy: Physiological versus Pathological Back Pain [Article]

l Low Back Pain: The 10 Minute Assessment [Article]

l Back Pain Patient Information Resources

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.

Kathryn Thomas BSc Physio, MPhil


Low Back Pain: Moving Back To Basics

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7. Mohseni-Bandpei MA, Rahmani N, Behtash H et al. The effect of pelvic floor muscle exercise on women with chronic non-specific low back pain. Journal of Bodywork and Movement Therapies 2011;15:75–81

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The effects of core program exercise on balance in patients with chronic low back pain. Journal of Korean Physical Therapy Science 2018;25:1–10 Open access

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10. Puntumetakul R, Chalermsan R, Hlaing SS et al. The effect of core stabilization exercise on lumbar joint position sense in patients with subacute non-specific low back pain: a randomized controlled trial. Journal of Physical Therapy Science 2018;30:1390–1395 Open access

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versus general exercise for chronic low back pain. PLoS ONE 2012;7:e52082 Open access

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An Integrated Approach to Managing Breast Cancer Care

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

For a long time, treatment of cancer was purely medical. Now, however, there is more understanding that treating the person holistically, involving support with diet advice, physical activity and massage, in addition to the medical care can help the patient to have a more positive outcome. This integrative approach to cancer care is discussed in this article and will allow you to better understand the role of the oncology massage therapist. Read this article online

What does ‘integrated care’ for breast cancer look like for a health practitioner? Whether you are a counsellor, movement or soft tissue therapist, it is now clearly evident that an integrative approach to cancer care can achieve better results.

In the UK, several groups are emerging that are adopting this model of treatment with great success. In particular, the British Society of Integrative Oncology (BSIO), led by a group of conventional medical practitioners, is recognising that as a collective group there is great value to be found in a diverse approach applied to the treatment of cancer.

“BSIO focuses on nutritional, lifestyle and complementary approaches that have sufficient evidence of safety and efficacy to be integrated into care alongside conventional therapies or where the research looks promising” (1*).

The key to its success is the use of several therapies working alongside each other to support the diverse systems that make us human, this includes mental wellbeing, movement and numerous biological mechanisms. As a clinical oncology massage therapist, I have witnessed the importance of modifying the treatment I offer to include a holistic approach, addressing the individual needs of the client, and working within a team structure. Unfortunately clients may not tell their oncologist that they are receiving complementary services, up to 86% do not communicate this information (2*,3*). The resistance to sharing this information can have

numerous negative effects: firstly it can interfere with treatment plans, and secondly there is the potential for a lack of recognition regarding the value of complementary therapies. I propose that one of the reasons for not sharing is the fear of a negative response a patient might receive from the medical team. Unfortunately, this dismissive attitude towards complementary and alternative medicine (CAM) is all too common because there is a lack of understanding about the importance of a holistic approach. Fortunately, this appears to be slowly changing.

What’s in a Name?

This brings me onto the subject of how we market ourselves. Historically, we prefaced the word ‘therapy’ with the word ‘alternative’ which has had a negative impact both in our ability to be part of a team approach and the outcome of our clients’ return to health. The descriptor ‘alternative’ has always felt like an ‘instead of’ treatment – separate and divisive – and there is a real danger in this model as evidence demonstrates that by using an alternative option in lieu of conventional treatment there is a decrease in curable cancer survival rates (4*).

We then progressed to referencing our profession as a complementary service, by definition ‘combining in such a way as to enhance or emphasise the qualities of each other or another’, signalling an intention that encourages

cooperation with other modalities. For obvious reasons this is a much more positive term and builds bridges.

Currently we are trending towards an integrative model both from the perspectives of conventional medical practitioners and CAM. Slowly, the professionals within the healthcare system are supporting a patient-centred approach which includes looking at lifestyle and other modalities. We see this in the format of social prescribing instead of handing out drugs or implementing surgical procedures as a first choice. Conventional medicine is now taking a closer look at lifestyle and starting with recommendations based on this.

True or False?

There are numerous misconceptions about what oncology massage is and is not. The biggest myth that I have to constantly correct is that massage will spread the cancer. For the most part this is not true (5*), but there are protocols that need to be implemented to ensure the session is safe for the client. This is complex and appropriate training is required in order to be able to deliver an effective massage that actually supports and/or enhances the healing process without interfering with it (6*).

Another misconception is that oncology massage is a lighter, softer variant that only addresses the superficial tissue. This might be true under some circumstances but if you

Co-Kinetic Journal 2022;94(October):28-3028

understand what you’re trying to achieve and how your touch can affect the body from a global perspective, the potential to make positive changes is open to the therapist and depth is less of an issue. However, I did come across a question in a forum about massaging a client near end of life where one of the responses was “Give them what they want, they’re dying so why should depth matter?”. OK, some of you might agree, but please consider this: if you are too aggressive, if your session is too long, or you’re working in an area of the body that is inappropriate, your client will suffer – it will make their passing harder as their body reacts to the lack of skill in your touch.

Our skill set is the ability to address our clients’ needs: needs, from their physical to emotional wellbeing. A significant part of what we do is to spend time listening to a client’s story as well as manually helping to reduce cancer-related symptoms such as fatigue, pain, nausea and psychological distress (7,8,9*).

Breast Cancer: A Case Study

According to the organisation Breast Cancer Now (https://, one in seven women in the UK will develop breast cancer at some point in their lifetime and 80% of them will be women over the age of 50. Remember though, this form of cancer is not exclusive to women and, although rare, can affect men as well.

Receiving a diagnosis of cancer can be overwhelming and scary. It is important that a client feels listened to, hence the first session is often longer as I take a detailed case history. By the time they come to me for an oncology massage session, they’ve usually had a bit of time to digest the news and have started treatment (although be aware that this is not always the case, and is the reason why you need to know what you can do at different stages of diagnosis and treatment).

Depending on the patient’s type of cancer, planned treatment and general health, I will devise a session that will meet their needs based on the above conditions. Not all techniques are suitable, the most important

modification being the speed at which we work, it will often be slower and more mindful, allowing our handson skills to respond appropriately to what we feel. Building trust is vital, pace matters, gentleness and eye contact matters; patients move from one appointment to another, often not understanding what is happening to them, therefore being in an environment that encourages them to slow down and take a deep breath is so important.

As there are different types of breast cancer, there are different types of treatment – all with their own side effects. With regard to chemotherapy we have to be able to consider and navigate the following symptoms:

l bone health issues;

l breast asymmetry;

l secondary surgical sites resulting from reconstruction;

l early menopause;

l mental distress and depression; l fatigue; l insomni; l infertility;

l joint and muscle pain;

l hot flushes;

l vaginal dryness;

l feeling like your body is a stranger; l weight gain; l hair falling out;

l problems with memory and concentration;

l lymphoedema; l neuropathy; l chronic pain;

l new cancer caused by the chemotherapy;

l cardiac issues from the chemotherapy medications; and l death.

This is quite a long list of side effects and considerations, all of which need to be managed.

Lifestyle: Dealing with the Elephant in the Room

We look at different ways in which we can empower our clients to feel more hopeful, and help them to manage their stress levels by choosing from a variety of tools such as breath work, self-massage and encouraging them to move more.

Movement is a key factor in both

cancer prevention and return to health. This does not mean they have to go to the gym and put in an hour’s session 3–5 times a week; instead it can be as simple as going for a walk around the block 15 minutes after dinner. My sister who had colon cancer made sure she walked down to the end of her block every day, whether she felt like it or not, yet afterwards she always felt better for it.

Exercise has been shown to decrease the recurrence of cancer, it is also top of the list for prevention (10*). It reduces the risk of recurrence of breast, colon and prostate cancers by 20% to 40%.

It’s important for survivors to know that exercise is the best way to treat cancer-related fatigue because as strength and fitness improve, it becomes easier to do activities that are meaningful and important. Exercise also improves sleep and bone health. Fortunately, those who have breast cancer-related lymphedema can do both aerobic and resistance exercise without making the condition worse.

Move more and sit less.

Eat what you Want: Truth or Fantasy?

I often hear clients coming to me having been told they can eat what they want. The reasoning behind this piece of advice is to prevent them from losing too much weight from the chemotherapy treatment; thus, they are told to eat high calorie foods to maintain their weight. The idea that you can eat a tub of ice-cream in one go isn’t OK. The impact that the sugar will have on insulin levels, inflammation and the gut microbiome is enormous – simply put, it will have a negative effect on the immune system.

A book called The Cancer-Fighting Kitchen really promotes the importance of eating a nutrient-dense diet to support a cancer client’s chances of getting the most out of their food and therefore support their return to health (11). (Unfortunately, I have not had a chance to try out any of the recipes, but they do look and sound good).

In the Foreword to that book, Keith Block (MD, medical director of the Block Center for Integrative Cancer Treatment, and director of integrative medical


education at University of Illinois College of Medicine, IL, USA) explains the importance of a diet that promotes good health:

“For example breast cancer patients who keep their insulin levels under control, a factor most often associated with diet and lifestyle, cut their risk of cancer recurrence in half, and decreases cancer mortality by two-thirds. It’s also well known that decreasing inflammation can help reduce cancer growth, boost treatment efficacy, and diminish side effects. We know that refined flours and sugars, most fast food, and soda pop, increase the enzymes that promote inflammatory cascades. Therefore, I encourage patients to avoid these pro-inflammatory foods and increase ingredients that have anti-inflammatory properties” (11).

Our goal as an oncology massage therapist is to assist our clients to live better, feel better, to help them have better outcomes and to be able to navigate this life-threatening journey as they return to health or receive end-oflife care.

Further Resources

l Blogs: Susan Findlay

l Video library: Susan Findlay

l Podcast: Dr Rupy Aujla on The Doctor’s Kitchen

l Podcast: Dr Rangan Chatterjee, Feel Better, Live More

l Book: Penny J, Sturgeon RL. Oncology massage: an integrative approach to cancer care. Handspring Publishing 2021 ISBN 978-1912085750

l Book: Thomas R. Keep healthy after cancer: lifestyle facts to help you live stronger for longer. Health Education Publications 2019 ISBN 978-0955821257

l Book: Peat P. The cancer revolution: integrative medicine – the future of cancer care. Win-Win Health Intelligence Ltd 2016. ISBN 978-


l Book: MacDonald G. Medicine hands: massage therapy for people with cancer. Findhorn Press 2014 ISBN 978-1844096398


1. The role of BSIO [website]. British Society for Integrative Oncology

2. Mao JJ, Palmer CS, Healy KE et al. Complementary and alternative medicine use among cancer survivors: a populationbased study. Journal of Cancer Survivorship 2011;5:8–17 Open access

3. Latte-Naor S, Sidlow R, Sun I. et al. Influence of family on expected benefits of complementary and alternative medicine (CAM) in cancer patients. Supportive Care in Cancer 2018;26:2063–2069 Open access

4. Johnson SB, Park HS, Gross CP et al. Complementary medicine, refusal of conventional cancer therapy, and survival among patients with curable cancers. JAMA Oncology 2018;4:1375–1381 Open access

5. Sifontes V. Oncology massage rehabilitation. Part I: newest scientific data, commonly used cancer treatments and their side effects. Journal of Massage Science 2019;1 Open access

6. Greenlee H, Balneaves LG, Carlson LE et al. Clinical practice guidelines on the use of integrative therapies as supportive care in patients treated for breast cancer. Journal of the National Cancer Institute Monographs 2014;2014:346–358 Open access

7. National Comprehensive Cancer Network (NCCN) guidelines for supportive care. Cancer-related fatigue, version 2. NCCN 2022; Version 2

8. NCCN guidelines for supportive care. Adult cancer pain, version 2. NCCN 2022; version 2

9. Cassileth BR, Vickers AJ. Massage therapy for symptom control: outcome study at a major cancer center. Journal of Pain and Symptom Management 2004;28:244–249 Open access

10. Schwartz AL. Exercise may help prevent cancer or its recurrence. Cure 2020;19(4):61–62 Open access

11. Katz R, Edelson M. The cancer-fighting kitchen: nourishing, big-flavor recipes for cancer treatment and recovery. Celestial Arts 2009. ISBN 978-1587613449. View on

Related Content

l Oncology Massage: The Lymphatic System [Article]

l Cancer, Exercise and Massage [Article]

Key Points

l An integrative approach to cancer care can achieve better results.

l Integrated cancer care is patient-centred and involves a combination of conventional, nutritional, lifestyle and complementary medicine to improve wellbeing.

l The term complementary care conveys a sense of cooperation with other care modalities.

l Cancer is not usually a contraindication to massage; however, adaptations do need to be made.

l Appropriate training is needed to be able to provide effective, supportive massage for cancer patients.

l Cancer massage does not necessarily need to be lighter but you do need to understand your client’s needs.

l Oncology massage is usually slower and more mindful.

l Building trust with the patient is even more important than usual.

l Cancer treatments differ according to the type of cancer and side effects of treatment need to be understood.

l Physical activity, tailored to the patient, is beneficial.


l If oncology massage is something that you would like to do, what do you need to be aware of or do before you start this service?

l If you provide oncology massage, how do you modify your practice for cancer patients?

l Discuss who you would need to communicate with (and how) if you want to provide oncology massage as part of an integrated care approach. For instance, who are the other members of the care team?


Susan Findlay BSc RGN, Dip SMRT, MSMA, MCNHC, MLCSP, Director NLSSM, is director of the North London School of Sports Massage, where she is a sport and remedial massage therapist and lecturer. Susan’s experiences as a ballet dancer, gymnast, personal trainer, and nurse have allowed her to develop both an applied and a clinical understanding of human movement, physical activity, anatomy, and physiology. Susan is the co-founder of the Institute of Sport and Remedial Massage. She also serves as chair of communications on the General Council of Massage Therapies and as an educational advisor to the Sport Massage Association. In her free time, Susan enjoys motorbiking, cycling, and yoga.




Facebook: SusanFindlayUK/


Co-Kinetic Journal 2022;94(October):28-30


Benefits of Massage for Patients with Breast Cancer

As is the case with the general population, breast cancer patients and survivors can take advantage of the many benefits of massage. Despite lingering fears among some people that massage may be harmful and spread cancer, there is no scientific evidence that this is the case. On the contrary, studies have shown that massage is safe, and hugely beneficial even in patients undergoing chemotherapy. The goal of massage therapy in oncology is to aid the patient to live better, feel better, improve their outcomes and be able to better navigate this life-threatening journey.

The benefits of massage for patients with breast cancer include:

1 Decreased anxiety and stress. Although increased levels of stress and anxiety may be beneficial in a fight or flight type situation, prolonged higher levels of anxiety (for example over weeks or months of treatment) can have a negative effect on your body. Stress increases cortisol levels, which in turn can weaken your immune system. Massage is proven to reduce cortisol levels and increase the release of serotonin – a happy hormone. Managing your stress levels will not only benefit your body during treatment and recovery but also your mind and emotions allowing you to better cope with your situation.

2 Improved mood. Depression is common among breast cancer patients, ranging from an occurrence of 25% to as high as 46%. Depression can negatively impact your quality of life, relationships, work and recreational environment and impact your ability to cope during treatment and recovery. Massage has been found to be effective in combating depression in breast cancer patients, by increasing serotonin,

dopamine, endorphins and oxytocin – those happy hormones. These hormones also promote better quality sleep, which in turn helps to improve mood and reduce depression.

3 Reduce fatigue. Fatigue is one of the most common side effects of cancer treatment. Depression and anxiety fuel those feelings of lethargy and fatigue. Massage is proven to improve fatigue by stimulating blood flow and oxygen around the body as well as releasing those ‘feel-good’ hormones.

4 Better immune function. Massage therapy has been shown to increase both natural killer cells and lymphocytes, which are white cells that are crucial to the immune system. This benefit may be particularly valuable to breast cancer patients and survivors. Natural killer cells are part of our innate immune system and help to control several types of tumours and microbial infections by limiting their spread and subsequent tissue damage.

5 Pain relief. Pain is a symptom present not only following surgery but can also be a chronic (longterm) issue for breast cancer survivors. Nerve and tissue damage can be the product of some cancer treatments, resulting in pain. Massage is proven to reduce pain by increasing endorphins, which are natural pain-relieving hormones.

6 Relaxation. This may seem like a superficial or flippant benefit compared with the many more urgent issues you may be dealing with when living with cancer. Dealing with a breast cancer diagnosis, anxiety, stress, depression, side effects from treatments, reduced activity as a result of treatment and fatigue and muscle tension all give you permission to selflessly enjoy the benefit of relaxation from massage. Relaxation is

‘medicine’ for your physical and mental health.

7 Nausea reduction in chemotherapy patients. Nausea is a common and major side effect of chemotherapy; however, research has shown that regular massage for short periods (20 minutes) during this time can significantly reduce the nausea effect.

There are different massage techniques that can be used. Some treatments may involve deeper myofascial massage techniques and stretching to restore full movement in your shoulder following mastectomy. Gentle lymphatic massage may facilitate drainage and reduce swelling in the arm. The warm touch of the hand triggers the healing process on many different levels: reducing fear, and acknowledging the scar. This can facilitate a re-connection to your body, creating a sense of calm, experiencing a feeling of being ‘whole’ again, possibly leading to outcomes including post-surgical body-image acceptance, a return of sensuality and even overcoming intimacy issues.

Massage promotes deep restoration and relaxation. The emphasis on an oncology massage session is placed on being fully present with your needs, allowing you to feel safe and nurtured and offering you a place to simply ‘be’. Studies have shown that interventions to reduce a patient’s psychological stress level may improve wound repair and recovery. Massage, of course, is well-established as a stress-relieving therapy. Other ways of boosting your feel-good hormones include getting outside in the sun, doing some exercise, laughing with a friend, listening to music, meditation or mindfulness, deep-breathing exercises and good quality sleep.

The information contained in this article is intended as general guidance and information only and should not be relied upon as a basis for planning individual medical care or as a substitute for specialist medical advice in each individual case. ©Co-Kinetic 2022


Exercise and Breast Cancer

Itis a well-known fact that physical activity has multiple benefits for people, young and old, not just for their physical health but their mental wellbeing too. This is no different for people who’ve been diagnosed with, or are being treated for, or are recovering from, breast cancer. From reducing fatigue to helping regain a sense of control and normalcy in their life, being active in some way will help you along this journey.

Movement is a key factor in both cancer prevention and returning to health. It doesn’t have to involve a gym membership or fancy equipment to be active, it can be as simple as going for a walk around the block for 15 minutes after dinner. There are many ways to make physical activity an enjoyable part of everyday life. Exercise has been shown to decrease the recurrence of cancer – from breast, colon and prostate cancers. It also decreases the risk of recurrence by 20–40%. Cancer-related fatigue is best treated with exercise: as strength and fitness improve, it becomes easier to do activities that are meaningful and important to you. Exercise also improves sleep and bone health. Before starting any type of

activity, talk to your specialist team, doctor or physical therapist. You may need to build this up slowly, monitoring how your body responds to the activity, as this may have changed since surgery or treatment.


Regular physical activity can help maintain or improve your health during and after treatment.

Exercise can do many wonderful things for you; below are some examples.

l Help you to avoid or reduce some side effects of cancer treatment, such as fatigue, weight gain, osteoporosis (common with ageing and as a side effect from some medication) and lymphoedema. Yes, it may seem absurd or a contradiction to think that at a time when your body and mind are exhausted from your daily challenges with breast cancer that more physical activity would actually counter the fatigue – but it’s true it does!

l Improve your long-term health, which reduces the risk of heart attack and stroke, and exercise may reduce the risk of cancer coming back.

l Help your mental wellbeing by reducing anxiety, stress, and depression and improving your mood. Exercise is shown to stimulate the release of endorphins. These are feel-good, happy hormones that help combat stress, anxiety and depression. Endorphins also promote better quality sleep, which in turn supports a more positive mindset. Exercise can reduce cortisol levels (a hormone often elevated during anxious and stressful times), which can have negative effects on your immune function.

l Prevent or reduce the loss of muscle tone and general fitness that can happen during and after treatment. Muscle strength helps support movement and joints and may help minimise pain which can develop from lack of use and muscle wasting.


Generally, people who’ve had a breast cancer diagnosis are recommended to do the same amount of physical activity as


the general population. This is obviously up to the individual and where they are in their journey through breast cancer treatment, as well as what level of activity they did before diagnosis. No one expects you to run a marathon unless that’s what you did on a regular basis before! Don’t be overwhelmed with expectations, doing anything is better than nothing, so start where you can and work from there.

International health guidelines suggest that adults should do at least 150 minutes of moderate aerobic activity such as brisk walking (or 75 minutes of vigorous activity such as running) every week. They should also do muscle-strengthening activities at least two days a week.

Some treatments for breast cancer can make you feel very tired or unwell. If this is how you’re feeling at the moment, don’t worry about how much exercise you do. Even a small amount of activity will have benefits. Doing too much too quickly may set you back for days. If you struggle to do 150 minutes a week, start by trying to reduce the time you spend sitting down or being inactive and gradually increase this over time, from doing more daily chores at home or in the garden to simply walking down the street and back up again, before heading off around the block.

If you’ve just had breast surgery, check with your treatment team when you can


start exercising and what type of activity would be best for you.


As mentioned, this may depend on where you are or where you were. It’s best to start slowly with an activity that you enjoy and gradually build up the amount you do. Enjoying what you do is more important than the activity itself. Enjoyment will help you stick with it and improve your mental outlook too.

For example, if you enjoy walking, start walking a short distance regularly. If you’re managing this easily, gradually build up the distance, the number of times a day you walk, or the speed at which you walk. If the walk includes joining friends and sharing their company and support that’s all the better.

Setting realistic goals, keeping a record of how much activity you do and sharing your progress with other people may help you stay motivated. This will help on those days when you feel overwhelmed and deflated with the challenge that lies ahead.

Exercise can be prescribed by a healthcare professional, physical therapist or personal trainer. It can be something to do alone or in a group, such as Pilates, yoga or a dance class. It can include golf, cycling, swimming or a multitude of other sports – not just walking or running. If you

are unsure, chat to your doctor and medical team for guidance.

Starting a Walking Programme

Walking is a safe, inexpensive and great aerobic workout. Walking is also a gentle way to begin an exercise programme. When you walk, your arms move gently. Gentle arm movements are best. Keep the following in mind:

l Wear comfortable shoes.

l Be aware of your posture and breathing.

l Begin your walk well hydrated and drink fluids during and after.

l Warm-up by beginning your walk at a somewhat slower pace.

l Cool down by ending your walk at a somewhat slower pace.

l Start at a level that is safe and realistic for you, and gradually build up your duration and intensity.


There are many ways to include exercise in your daily routine, such as:

l energetic housework or gardening;

l parking your car a little further away from the shops or work and walking the rest of the way;

l getting off the bus a stop earlier than you need to and walk the rest of the way;

l using the stairs instead of taking the lift; and

l sitting less and standing more, for example, you could walk around when talking on the phone.

should not be relied upon as a

individual case. ©Co-Kinetic 2022


PRODUCED BY: TIME-SAVING RESOURCES FOR PHYSICAL AND MANUAL THERAPISTS The information contained in this article is intended as general guidance and information only and
basis for
individual medical care or as a substitute for specialist medical advice in each

How to Use Content to Make Your Business More

Findable on the Web

Once you’ve created a website for your clinic or business, it might be tempting to sit back and think “Job done!” and then wait for the patients to arrive. However, things are never quite that easy. You won’t be the only businesses in your area, all trying to attract the same clients. To boost your chances of being the one to succeed, you need to make it easy for people to find you. This involves playing nicely with the search engines, so that when somebody does a search in Google (for example), it’s your website that appears at, or at least near, the top of the list. This article takes you through some easy things to do with your website content that will boost your rankings in the all-important search engine results. Read this article online

Most people are probably aware that creating content for their website can help them to improve their search engine rankings (findability), but are less aware about how or why this works, or how to achieve it. In this article we’ll explore how to use content to improve your SEO (search engine optimisation), and how to structure your content to help your website to rank higher and increase the chances of it being found by people looking for the services you offer.

Content Types

There are two key areas where you can use content to impact your search engine rankings, the first being ‘condition pages’ in which you discuss individual conditions that you can treat, and the second is your blog area. The two types of content are similar but at the same time different.

Condition Pages

Condition pages tend to cover the key issues you can treat and tend to be relatively generic. You might have a page dedicated to back pain, arthritis, falls and fractures, chronic pain, and so on. The Chartered Society of Physiotherapy, the main membership organisation for physiotherapists in the UK, has an excellent ‘Conditions’ section ( conditions).

Good condition page content gives you a big SEO advantage. Many ‘condition-related searches’ will return local results, boosting your opportunity to rank highly in the list of results for anyone searching for that condition in your area.

For example, a simple Google search for ‘back pain’ will typically return a map with the top three local results. Adding a location to the search – eg. back pain Brighton – will only return local therapists, as will other local ‘trigger words’ such as clinic and specialist. By creating good content for your condition pages, you’re far more likely to appear in these searches –especially as many of your competitors won’t have taken the time to do the same.

Condition pages are also great for conversion – changing ‘prospects’

Co-Kinetic Journal 2022;94(October):34-38

(prospective customers) into paying clients. They provide valuable information, show users that you know what you’re talking about, and that you care enough to provide advice and share your knowledge, thereby building a sense of reciprocity (the desire to give back), which is an excellent prospect-to-customer conversion strategy.

Blog Posts

Condition pages are by their nature quite general. You will explain the condition, how it’s treated, your approach to treatment and how to access your services. Blog posts, on the other hand, allow you to really get into detail and give some concrete advice on one particular thing, providing interesting and useful advice to the reader. For example, you might write about how to set up your workstation or driving position to avoid back problems; the best stretches to do before a run; the use of heat or cold in treating a certain condition; and so on. Also, whereas a condition page is done once and then stays the same, you can keep on creating fresh content and adding to your blog.

Having good blog posts that expand on your condition pages, giving useful advice and linking to and from the pages which relate to that condition (eg. your back pain page will have links to back-pain-related blog posts and vice versa), vastly increases the usefulness of your site to the local searcher looking for treatment for that condition. They also help to demonstrate expertise, all of which Google loves. Google will see your site as a repository of useful information on that condition, making you more likely to rank more highly on the search engine results pages.

Fresh blog posts also give you great information to share on social media, both on your own page and on related pages (eg. sharing a post on running on other running pages). You can also send links to your blog posts to your email list, helping you to stay in touch with your prospects and offering value to people interested in your services.

Blog posts are also essential for helping you to build inbound links to

your site (these are also often referred to as backlinks). For example, if you have a useful post on plantar fasciitis, you might ask local running clubs to link to it from their website, and these inbound links, directing into your site from another site, will in turn boost your SEO.

So what’s the downside? Well there are a couple. The first is that writing regular blog content does take time and if it’s not something you enjoy doing, it becomes a chore that very often falls by the wayside.

The second issue is that your blog content requires clinical expertise, something that’s hard to find in a general marketing agency. Accuracy and quality is critical for establishing authority and reputation, so it’s important to source your blog posts from someone who can deliver that level of knowledge.

It’s worth mentioning that CoKinetic provides regular pre-written and peer-reviewed blog content under their Clinic Growth subscription. If you can see a couple of patients in the time you would otherwise be writing a blog post, then using that subscription would give you a good return on your investment.

Using Content to Convert Visitors

So far so good. You have great condition pages and interesting blog posts, all of which are increasing your visibility on Google and the other

search engines and bringing traffic to your site. We now need to stimulate your visitors to take action once they get there, otherwise they’re just passive viewers that may never convert into either a prospect or a paying customer.


To do this you need to add ‘calls to action’ or CTAs on your pages, which invite and motivate the user into taking action. This could be as simple as a ‘contact us’ button, or a ‘book an appointment’ link, maybe with some text about your friendly and professional service and how easy it is to book an appointment online.

However, many people looking at our content won’t necessarily be looking to book or contact us immediately. They might just be looking for helpful information, or researching treatment options but are not yet ‘ready to buy’. Which means that wherever
Sportsinjury 20000 10000 0 25000 15000 5000 Backpain ArthritisFibromyalgiaScoliosis SciaticaNeckpainKneepainOsteoporosisPlantarfasciitisShoulderpainFrozenshoulderCarpaltunnelTenniselbow Figure 1: Local Searches per Month, UK

possible, we want to collect those users’ contact details so we can connect with them on an ongoing basis via our email list, to keep encouraging them to make contact and be first in their minds when they do decide to book treatment (a process often referred to as nurturing).

To do this we need a ‘lead magnet’ – something we can give away for free to encourage someone to join our mailing list. This could be a free guide, factsheets, infographics, checklists or any other downloadable resource. It’s worth putting some effort in here – the

HeatStanding NightMassage

more valuable your lead magnet is to the user, the more people you will convert (ie. the more email addresses you will collect) and the more likely they will be to stay on your mailing list, especially if you follow up the lead magnet download with a series of informational emails that continue to provide further value. You will also need an email-lead collection form or widget that collects that email address for you and adds it to your email list.

This is another service that Co-Kinetic provides under both the Social Media and the Clinic Growth subscriptions.

What Topics Should You Write About?

If we’re going to create content in order to attract people searching on the search engines, it’s a big help if we know exactly what people are searching for. For example as you can see from the bar chart (Fig. 1), sports injury gets twice as much local traffic as back pain, and ten times as much as neck pain or sciatica, so sports injuries is definitely something you need to be publishing content around.

Once we start writing about a particular condition – either for a condition page or blog post – we also want to know what people are searching for within that particular term. For example, the single most popular search term associated with ‘back pain’ is ‘pregnancy’ (Fig. 2).

Knowing this data allows us to create content which targets the searches that people are making in real life, and that addresses their real questions and concerns. You can get all of this data from The Manual Therapy SEO Reference Guide. You can buy the book from Amazon, or download the free digital version from the Market Your Clinic Online website, along with a series of emails to show you how to use the data (https://www.

Optimising Your Content for SEO

If we’re creating content for SEO, it’s important to know how to make our page attractive to Google (the same principles apply to the other search engines). Search engines have several rules that it helps to follow to ensure our content ranks well for whatever search phrase we’re targeting.

Calls to Action

We discussed the importance of CTAs in conversion, but it’s also important for SEO. Google is more likely to rank you highly for ‘back pain’, for example, if you have links for the user to book an appointment for their back pain, or links to other downloadable resources that will help them. So remember those calls to action and lead magnets.

Biographical Information and Qualifications

Since 2018 Google has been rating medical and financial websites on Expertise, Authority and Trust, or E-A-T for short.

Google uses artificial intelligence (AI) to ‘read’ your website. When it discovers that you’re giving medical advice it will look to verify that you are qualified to give advice on that particular subject, to avoid people getting important advice from people who don’t know what they’re talking about.

To make sure that Google can see that you’re qualified to give medical advice, it’s important to set up a profile page for yourself listing your titles, qualifications and experience, with links to your professional bodies and registrations. Then create an author


Co-Kinetic Journal
PregnancyExercisesMattressSleepingpositionStretchesFemale PeriodSittingWalking YogaBestchair

box on your blog posts that provides a quick summary of this information, and link it back to your profile page.

Google also likes to see that information is up-to-date, so it’s a good idea to review your content on an annual basis and state ‘this information was last reviewed on (date) by (name and title)’, again with a link to your profile page.

Structure Your Page Well

Pages with dense chunks of text, without breaks in that text, are hard to read. Breaking up your text using subheadings is important for the reader, and also for Google.

Google will gauge what your page is about based on the hierarchy of headings, subheadings, and body text. Your headings should give both Google and the reader a good idea of the content of your page and the topics it covers, before getting down into the text itself. So make sure your page is well-structured, and that important keywords are contained in headings as well as in your main text.

At the same time, you mustn’t overdo it. If you put exactly the same key phrase into every (sub)heading, Google will judge that your priority is to rank, rather than to convey useful and broad information about

the subject. There are tools such as Yoast for WordPress that will help you strike the right balance.

Internal and Outbound Links Google likes webpages which are a hub of information, so that the user can quickly jump to any other resources they might find useful.

This begins with internal linking, ie. linking your own pages to other pages on your own website. A condition page might link to your booking page, practitioner profile page, clinic page, and any blog posts that are pertinent to that condition.

However, you should also link out from your page to other highauthority sources, such as the NHS (if you’re UK based), WebMD, Mayo Clinic, and so on. You can do this with a ‘useful resources’ section, and by simply referencing your text. For example, if you say that ibuprofen can help reduce swelling, you might link to the NHS page on ibuprofen.

Aim to include at least 10–15 outbound links in your text. It shows Google that you’re giving the user more useful information, that you’re referencing your claims with highauthority sources, and that you’re

‘plugged in’ to the wider wealth of healthcare knowledge and aren’t living in a bubble.

Include Images

Articles with images are far easier to digest than those that are all text. Break up your content with relevant images, and caption them so that the reader scanning through the page can get an idea of what the text is about from the image and caption.

Google also knows that pages with images are more appealing than those without, and that image captions are one of the first things the user will read. Be sure to include your keywords in some of your image captions.

Keep it Simple

Remember that your pages will be ENTREPRENEUR THERAPIST 37

aimed at the layperson rather than the medical professional. If you’re writing about a particular condition, start off by explaining what that condition is, what the symptoms are and the different ways it’s treated before going into any more detail. Keep the language light and accessible, write as succinctly as you can, and explain any medical terms the average reader might not understand. Co-Kinetic for example writes the patient-facing content they create for practitioners, to meet Plain English standards (

Build Links

In many ways, Google is a popularity contest. If the algorithm judges two pages to be equally useful to the user’s search, it’s the one with the most relevant inbound links (people who link to you) that will rank higher. You should aim to build a repository of useful and interesting information that other websites will find it useful to link to, and reach out to them to do so. Content creators and link builders are employed in SEO agencies for the purpose of building links in exactly this way.

Do some research to identify local organisations for whom you could create content they would find useful. For example, if you have local elderly groups or community centres with actively maintained websites or blogs, you could write a blog post on osteoarthritis treatment and reach out asking them to link to it, perhaps with the offer of a free telephone consultation or a discount on their first treatment.

You might also consider sponsoring local groups or events, or offering something like a free hour of

your time giving advice at a running club in exchange for a link from their blog. You can also mix up your expert content with blog posts featuring local sports clubs, gyms or any other relevant groups, explaining what they do and how to get in touch. Don’t be afraid to reach out to them beforehand and ensure that they link to the article in exchange for you publishing it.


Content marketing is a long-term strategy. Focus on creating content that will give value to the reader, and follow the guide above to ensure that Google will consider it worthy of ranking. Make sure you include CTAs, and a valuable lead magnet for future marketing. Reach out to groups who may find it useful, and ask for a link when you’re offering value to any other group or organisation.

In the early days you may not immediately see a return on your efforts. However, the difference in the long run of having a wide repository of useful and SEO-optimised content is impossible to underestimate, and will set you head and shoulders above your competitors.

SEO Checklist

Before you publish any content, make sure your key words and phrases appear in the following places on your page. You can find more information online, or speak to a web developer or SEO specialist to check that everything is in the right place.

l URL (page address)

l Title tag (sometimes called SEO Title)

l H1 tag (normally the on-screen page title)

l Meta description (sometimes called SEO Description)

l H2–H6 tags (tags for different levels of subheadings)

l Image captions

l Image alt tags

l Ensure you include at least 10–15 outbound links, and links to your own pages and blog posts

Related Content:

l 5 Things You Can Do in Less Than An Hour To Increase Your Google Search Profile and Get New Clients [How To Guide] Optimising Your Physical Therapy Website to Generate New Leads and Get New Clients

How to Get More Patients Without Being Salesy [Article]

How to Power-Up Your Email List: A Start Up Guide to Facebook Advertising for Physical Therapists [Article]


Further Resources

l Visit to:

l download a free copy of the Manual Therapy SEO Reference Guide

l book a free web review

l read more of Chris’s content.

l The top 10 Google ranking factors for 2022 (+how to optimize for them) [website]

l How to rank higher on Google: 17 strategies for 2022 [website].

McCormick K. 2022

Chris Dann is the founder of Market Your Clinic Online and is unreasonably passionate about digital healthcare marketing. He builds websites, carries out SEO optimisation, has written for Osteopathy Today, works with Physio First and Co-Kinetic and is the author of the Manual Therapy SEO Reference Guide. When not promoting clinics, he enjoys the gym, modern art, playing guitar and eating hamburgers.




Facebook: marketyourcliniconline

38 Co-Kinetic Journal 2022;94(October):34-38 ENTREPRENEUR THERAPIST


In this article we look at some of the key factors that impact your marketing success, including the importance of building an audience and the value of investing in developing trust and engagement with that audience. We discuss strategies for turning a cold audience into a warm one, how to boost your open and click rates on your nurture emails, making sure you’re doing the right marketing activities at the right time, and the benefits of focusing on a niche to help you optimise the financial return on your patient-facing time and build a more stable and sustainable business. Read this article online


What do Coldplay, JK Rowling, The Kardashians, Meryl Streep, Cristiano Ronaldo and Donald Trump have in common (apart from being rich that is)?

The answer: each one has an audience that hangs off their every word – audiences that will buy their songs and their books, watch their films, follow them on social media, go to their matches and (even though it’s almost unfathomable) vote for them!

Everyone Needs an Audience

It doesn’t matter whether you’re a celebrity, a huge global brand, a niche ‘save the environment’ product or a physical therapy business – each one must have an audience if it’s to be successful.

Without one, you have no buyers and you have no commercial leverage.

The stronger, more faithful and more passionate your audience, the greater your ability to generate revenue.

Footballer Cristiano Ronaldo is currently considered to be the top social media influencer today. In 2016, he became only the third athlete in history to sign a lifetime deal with Nike. In February 2021, he became the first person in the world to surpass 500 million followers across all the social networks, and by February 2022 he had nearly 600 million!

The simple fact is: money follows an audience.

It’s therefore no surprise that Ronaldo was ranked third on Forbes’ 2021 list of the highest paid athletes in the world, with earnings of £87m –£36m of which was accrued through off-field ventures – and that’s in just

one year!

His influence on any single product he’s associated with will result in sales for that business that are almost unimaginable to those of us running small or even medium sized businesses, and he barely needs to lift a finger to make it happen.

That’s what having a passionate, trusting audience can achieve – and the principle is no different for your physical or manual therapy business. You may only have 600 rather than 600 million followers, but if they trust and believe in you, they will buy from you.

So this begs the questions, why do so many physical therapists: (a) neglect their email lists; and (b) fail to invest in growing their email lists?

Because as a physical or manual therapist, this is YOUR prospective audience and how else are you going to drum up business as quickly and easily as you can by sending out one (or two) simple emails?

John Henrik Clarke (African-American historian and professor) ENTREPRENEUR THERAPIST

Learning a New Skill Doesn’t Happen Overnight

To come back to Ronaldo: OK, he has an exceptional gift on the football pitch, but he didn’t just wake up one morning with 600 million followers; he’s grown that following over time by training hard, performing consistently well/brilliantly on the football pitch, and being the kind of person that people of all ages and nationalities admire and aspire to be.

We all know that anything worth achieving requires commitment, practice and application – it doesn’t matter whether it’s following a rehabilitation programme, learning to play a sport or a musical instrument, or speaking a new language.

Gaining a new skill, whatever it is, requires the same steps – learn to do the basics well and then build on those basic skills through regular, consistent practice and experimentation.

Unsurprisingly, it’s the second stage where most people fall down – let’s face it, it’s frustrating not being good at something (and quickly), and we live in an age of speed, where we increasingly seek instant gratification.

Exactly the same goes for marketing, which is why those quick-fix marketing hacks that most of us have undoubtedly tried at one time or another (or possibly on multiple occasions) don’t work. Because people (a) don’t know the basics, and (b) even if they do, they don’t practise them.

Thankfully, it’s not difficult to learn the basics. If you don’t know what you need to be doing, watch my webinar: Discover the 20% of Marketing Activities that Will Give You 80% of Your Marketing Results (

Slow but Steady Wins the Race

Good marketing, done well, is all about building relationships with your target customer base (and you really do need

a clear target audience or two, more on that shortly) and this takes time. Sure, you can (and absolutely should) start straight away, but the depth and strength of those relationships, and their ultimate impact on your business, will build over time if consistently nurtured.

For the nay-sayers muttering bah humbug into their cups of coffee, sure, you guys go ahead and rely on running discounts and promotions all day long to bring in new customers if you really want to. In fact, knock yourself out because that would quite literally be more constructive!

All you’re doing long term is damaging your reputation, eating away at your credibility and authority and destroying all the hard work you’ve put into becoming the high-quality practitioner you’ve trained to be. After all, if you’re REALLY that good, you certainly shouldn’t have to hustle for appointments, at least certainly not once your business is up and established.

If this is your approach, it also really shouldn’t come as a surprise to you that most of your marketing efforts and investments fail, because you haven’t taken time to build relationships.

Until we acknowledge that marketing is a skill, just like learning a new sport, or learning to manage your finances, that business will always struggle to thrive; in fact, under difficult circumstances like recessions it will mostly likely struggle just to survive.

Turning Up the Audience Temperature

Hopefully by now you can see that having a growing audience to whom you’re consistently offering added value, and in turn, building and strengthening the relationship between those people and your business, gives you commercial leverage.

It gives you the opportunity to

launch a clinic membership plan, get sign-ups for an education workshop, sell vouchers, encourage customer testimonials, introduce a referrals plan, subscribe to customer interest groups, or deliver a customer loyalty programme. Whatever initiative you decide on, by building up your email list, and earning the trust of the people on your list, you can harness them to take action whenever the time is right.

Asking a warm, nurtured, trusting audience to take action, compared to a cold email list that you’ve neglected for months or even years, and who you only ever email when you want them to buy something from you, will unsurprisingly result in very different outcomes.

Why Is Email The Chosen Strategy?

Email is a perfect communication channel for the main reason that it is completely scalable. This means there’s no extra work/time/or significant additional cost in writing one email and sending it to 10 people, compared to 1,000 or even 10,000 people – assuming you’re using a proper email marketing platform (which you absolutely should).

Texts incur SMS charges, letters incur postage costs, picking up the phone costs time and using your social media channels is no good because only 3–4% of your followers will see your post.

Email can be made personal at scale and the change in the monthly subscription cost for a growing audience is usually very small.

But My Low ‘Open Rates’ Means Nobody Will Read My Message

To put it bluntly, open rates are only low when there is a history of sending low-quality, low-value emails. If, instead of always sending ‘clinic news’ that’s basically just a low-quality piece of PR with absolutely no value to the reader, you focused on sending regular genuinely helpful, value-adding emails with solely your customer in mind, instead of plugging your own business, your open rates would start to increase. The sooner you start doing this, the quicker your open rates will start to rise.

Adam Carolla (Guinness-World-Record-breaking talk show host)
40 Co-Kinetic Journal 2022;94(October):39-43

Combine that with demonstrating consistency (one of the 7 principles of persuasion) and sending those emails at regular intervals (eg. once or twice a month) and regularly culling readers who haven’t opened your last 10 emails, for example, will result in a significant increase in your email open rates.

Cleaning your email list of inactive people also helps improve email deliverability, meaning more emails find their way into inboxes instead of the spam folder, which in turn results in a better chance of the email being read, and consequently higher open rates.

The reason why most people don’t want to cull their inactive readers is because they’re not investing in growing their email lists with new readers and they perceive that a smaller email list means they’re less successful. However, the truth is that email list size is a vanity measure; the true test of an email list is the open (and click) rates.

Look at the numbers shown in Table 1.

If you had an engaged email list of 1,250 people who you’d nurtured by focusing on sending value-adding, non-promotional emails to, and regularly achieved 60% open rates (which is perfectly achievable – I can prove it), this would be equal in reader numbers to double the audience with half the open rate. In fact, it’s not far off a list that’s 4 times the size with an open rate of 20%.

Plus, if you look at ‘take-up’ for whatever offer you’re pitching, from the smaller, warmer, more engaged audience, it will far outstrip the take-up from the bigger, colder, less engaged audience.

Here’s the equation for a perfect email strategy:

Regular value-adding email nurture plan + investing in growing your email list + diligent email list cleaning = healthy, engaged, trusting, responsive audience.

But I Hate Unsubscribes

I hear this soooo often and I do get it. I also hate seeing people unsubscribe as much as anyone, it feels like a personal affront, especially when our businesses

Table 1: The true test of a successful email list is not the number of contacts but the email ‘open rate’

No. of email contacts Open rate (%) No. of readers

Scenario 1 5,000 20 = 1,000

Scenario 2 2,500 30 = 750

Scenario 3 1,250 60 = 750

are very much about us. But the truth is, those people were NEVER going to become a customer. And if they had, they most probably wouldn’t have been the kind of customer you wanted. Better that they get out quickly, than linger and continue to damage your open rates and your email deliverability – so let them go, safe in the knowledge your email list will be healthier for it.

Quality trumps quantity every time when it comes to email readers.

Bigger is Not Necessarily Better

If you’re Coldplay or JK Rowling, sure, the more the merrier. Their ‘products’ are scalable. In other words, it doesn’t take Coldplay any more work to play to 100,000 people than it does to 10,000.

Or in JK Rowling’s case, while there is a run-on cost impact to producing more books, it’s very, very small relative to the cost of getting the first copy of that book printed, meaning the profit is high. And then there are the upsells – it means one more fan, who will most likely watch all 8 films, buy some merchandise and visit Harry Potter World (which is awesome by the way!).

In the case of physical therapy, what you sell is not scalable because you don’t have infinite amounts of time, just the hours in your day/week/ year. This means that you need to maximise the financial value of your time.

Even if you introduce more therapists into the practice, you’re still working with limited time for each therapist so your profit will always be limited based on the time available.

This, incidentally, is exactly why I encouraged people to start

building scalable revenue streams into their businesses during the Covid lockdowns. The idea is to create something for one person, that can be delivered to 100 or even 1,000 people without causing significant additional work. If you can also turn that into an ongoing content offer delivered over time through a subscription, it means you generate recurring revenue, adding a stable stream of revenue to your cashflow.

I go into this in more detailed in my article entitled, ‘Membership Magic: Building Recurring Revenues into Your Physical Therapy Business’ (see the Further Resources box).

Becoming a Specialist

So, how do you maximise the financial return on your time? Easy: you specialise.

I recently watched an excellent webinar by New York Times bestselling author and health practice success mentor, Yuri Elkaim, mainly because I love learning the different ways that my fellow health professional business mentors can help you to maximise your professional potential.

Yuri’s specialism is helping people to create online coaching businesses, giving the owners more freedom, flexibility and scalability. If I was a health professional, I’d sign up to his programme – to me it makes a LOT of sense. But if you’re committed to the face-to-face/hands-on delivery of your service, Yuri’s approach doesn’t work (but that’s not to say you couldn’t incorporate a bit of both).

The downside of hands-on delivery (as we’ve discussed) is scalability, and that’s the restriction that Yuri’s coaching ENTREPRENEUR THERAPIST

The webinar works through Yuri’s 5 laws of client attraction. His first law is that everyone wants a specialist. If you have a problem with your eyes, you go to an optometrist not a GP. If you have a leaking pipe, you go to a plumber not a building contractor. And my personal favourite, if you’re seeking a top-notch pizza, you go to a pizza restaurant not a buffet.

His point is that if you try to help everyone, you end up helping no one.

Trying to help everyone means that:

1 your message is diluted;

2 you can’t streamline delivery if the audience is too wide; and

3 it is pretty much impossible to scale your business.

He suggests that in deciding what specialist you might become, you ask yourself the following questions:

l Who or what condition have I historically had the most success with?

example of someone who needs to lose 500lbs (~225kg) and lives a static life versus someone who just wants to lose 20lbs (~9kg) and is already active. The latter is going to be a much easier and more enjoyable client to work with, because although the larger person needs your help the most, in terms of motivation they would want your help the least.

This doesn’t mean you have to turn away the people who come to you with general issues, it means that you focus your marketing on attracting new clients under your specific target audience.

How Does Specialising Affect Your Marketing?

Having a clear target audience means you can focus the marketing investments that you make on a very specific group of people.

For example, offering a very specific lead magnet that provides advice for one or more of the most pressing problems facing your target audience – and promoting this to groups which may include your desired target audience – will help you start to build your email list.

Then follow this by putting in place a simple marketing funnel (in its simplest form, an email sequence)

designed to nurture and build trust with this audience, before offering your audience targeted ‘next step’ opportunities to encourage them into becoming a paying customer. These opportunities might be a webinar, a face-to-face workshop or a group meeting. At that event, offer your target audience a targeted and unique opportunity to buy into something you

One MAJOR benefit of becoming a specialist is that if people have that specific ‘problem’ that you solve, you will be that go-to professional, meaning not only will you be more sought-after but you can also afford to charge more for your time.

Combine this with some sort of scalable revenue stream (such as a subscription-based online community, where you could provide regular new content and resources, online support/ webinars/FAQ sessions, guest speaker interviews, updates on treatments/ therapies, etc.) relating to your specialist topic and you’ll be well on your way to optimising the financial value of your time.

And if you run a multi-therapist clinic, then ideally each therapist would focus on a different specialism.

The Cost of Living Crisis

In the UK and Europe at least, physical and manual therapists are for the second time in two years, facing a seriously difficult and challenging time, brought about primarily by the rapid and dramatic increases in costs of just about everything, but specifically energy, as a result of the invasion of Ukraine by Russia.

As if Covid wasn’t hard enough, this cost of living crisis will further reduce the money available for spending on anything other essentials, such as heat, light and food.

This means that, as small businesses, we’re going to need to think outside the box when it comes to surviving this next crisis. Afterall, clinics where people are stripping down to their bare skin can hardly turn down the heating, and that’s without taking into account the increasing costs on just about everything we purchase for our businesses.

I cover this in more detail in my

42 Co-Kinetic Journal 2022;94(October):39-43

next article, ‘Recession-Tackling Tools and Strategies’ (https://bit. ly/3QKHpW5).

There are three topics that we have covered in this article that will be even more pertinent and critical as the pressures on our costs of living (and running a business) grow:



Having a specialism that covers a need that is urgent and prevalent offers many advantages when money is tight.

Having an engaged and trusting email audience primed and ready will make a big difference to the success of every marketing campaign you run.

significantly impact the success of your marketing campaigns and that in turn is governed by the regularity and consistency of your marketing efforts.

Key Points

l Every business needs a trusting and nurtured audience to be successful.


The sooner you get an active target-audience-building campaign running, the more help it will be to you in the coming months.

Growing a target audience and sending regular value-adding nurture emails are two of the most fundamental marketing basics that every single business, whatever its size or success, should be heavily committed to for all the reasons we’ve outlined above. Furthermore, identifying a specialism and building a target audience for this specialism, will help you to maximise the financial return on your time and give your business considerably greater security over the coming months.

Further Resources

l Membership Magic: How You Can Build Recurring Revenues into Your Physical Therapy Business [Article]

l Marketing is a skill that needs to be learnt and practised regularly in order to achieve success.

l Email is the most scalable, cost-effective channel for communicating with your audience on a regular basis.

l Sending regular and consistent emails is key to turning cold leads into warm ones.

l Audience temperature has a significant impact on the success of your marketing.

l 90% of your customer emails should focus on adding value (ie. nothing promotional).

l Use paid social media to promote lead magnets behind email-lead collection forms to grow your email list with your target audience.

l Open and click rates are much more important than email list size.

l Keep your email list health good by regularly deleting or archiving people who haven’t opened your emails for the last 6–12 months. Becoming a specialist in a niche helps you to maximise the financial return on your time.


Tor Davies began her professional life training as a physiotherapist at Addenbrookes Hospital, Cambridge, UK. She went on to complete a BSc in Sport & Exercise Science at the University of Birmingham while also achieving a WTA international tennis ranking. After graduation she worked in marketing with a London agency and then moved into medical journalism where her passion for publishing was born. At 27 she established sportEX medicine, a quarterly journal for physical and manual therapists. With a passion for technology as well as publishing, Tor’s leadership grew sportEX into the Co-Kinetic journal and website which included a more collaborative, royalty-based form of publishing as well as a wider content remit. Tor’s focus is on providing resources to help therapists develop their professional authority and brand, and grow their own businesses while working more efficiently and effectively, a topic that she speaks regularly on at global conferences.

Join us on Facebook: Connect with Tor:


Recession-Tackling Tools and Strategies

The fact that we are talking about how to survive recession for the second time in two years is a timely reminder that we must not take our clients or our businesses for granted. This article describes the key aspects of your business to think about and some simple marketing plans to put in place that will help you to win customers and survive this current storm in the best financial shape possible. Read this article online

On the one hand it’s a bit gutting to have to be talking about weathering another business-threatening storm after the chaos of Covid, on the other hand, however, if you put good processes in place from the lessons learnt during that time you’ll already be in a much better place than most.

If there’s one lesson that everyone hopefully learnt from Covid, it’s that your relationships with your existing customers are the anchor for every small business in a storm. We come back to it time and time again.

What’s key to building relationships with your customers?

A good marketing plan. This is because the central pillar to good marketing is all about building and strengthening relationships with (a) new prospects and (b) existing customers.

When it boils down to the basics,

there are four cornerstones to every business, regardless of whether we’re in times of prosperity, crisis or recession:

1. relationships

2. services and products

3. marketing and sales

4. business management and finance.

So let’s look at what we can do under each of those four cornerstones, to add ballast to our businesses.


Relationships become absolutely fundamental during challenging times. There’s an African proverb that is particularly appropriate here:

“If you want to go fast, go alone; if you want to go far, go together.”

Existing Customers

During a recession your existing clients will be your most precious assets, so treat them well and keep them happy. Look for low-cost strategies to improve customer service and stay in regular touch with them. Give them tools that help them to make their lives better/happier/easier, free educational workshops are brilliant in this context.

Treat your customers in the way they want you to treat them and by saying ‘thank you’ in memorable ways that support your brand. Think ‘under-promise, over-deliver’. Look for opportunities where you can add value and demonstrate your appreciation for

their loyalty.

You could offer them a clinic membership programme where in exchange for a regular financial commitment, you offer them a 10–15% discount on their treatments along with other added-value benefits.

Actively invest in their wellbeing. A really good way to do this is to put a regular nurture email programme in place. Send them high-value (non-promotional) content that demonstrates your commitment to them and include links to useful resources, such as patient leaflets. You can use health awareness events, national or international sports events or seasonal events as a structure to base your emails on.

Can you team up with local businesses to offer added-value ‘treats’ and benefits? More on that shortly.

Reconnect with Past Customers

Cultivate your relationships with your past clients before the crisis hits. The easiest way to keep in touch with past customers, is to include them in your nurture email programme that by now you’re hopefully sending to existing customers.

If you don’t have an email address for your past customers, why not send them a printed newsletter (we have more than 50 newsletters covering a whole range of different clinical topics) and post it to them with a simple message on a letterhead explaining the relevance of the newsletter. You

Co-Kinetic Journal 2022;94(October):44-4744

could do this once a quarter, just to stay in contact and give them incentives to give you their email address so you can send them digitally in future. For example:.

Hi [Past Customer]

As it’s Breast Cancer Awareness Month in October, we’ve enclosed a short leaflet with some information we hope is useful. If you’d like to share this with a friend or a member of your family, we can also provide you with a digital copy, just give us a call or drop us an email.

With warm wishes

[Your name at Your Clinic Name]

New Customer Prospects

As you will probably know by now, one of the essential steady-state marketing activities that I recommend every business should do – without exception – is to be building an email list of prospective new customers. The best way of doing this is by offering helpful information on relevant topics to the services you provide, in exchange for an email address, and promoting these ‘lead magnets’ to prospects living locally to your business, using paid social media.

Then add these people to your regular nurture emails that you are sending to existing and past customers, so that you start to build trust, establish authority and strengthen your relationship with these prospects. This means that when you have something to offer them in future, their relationship with you will be much more trusting than if they are just a cold, unnurtured email lead.

Partnerships with Local Businesses

Could you strike a deal with a local café and give them a voucher for a free coffee or smoothie? Or even just a discount voucher on purchase.

It doesn’t really matter what the business is that you partner with. Obviously it makes sense if they can offer complementary services to the ones you provide, so those sorts of partners are definitely worth seeking out. They might include local personal trainers, yoga teachers, Pilates


instructors, sports coaches – people with clients who are more likely to have issues that you can help with. Make time to meet them for a coffee or a beer so you actually get to know them, and they you.

But at the end of the day, everyone uses their local shops, so if each week or month, you can provide an nice little added-value benefit for another local business, it’s a perk for your customer, and a boost for that local business. It doesn’t matter if it’s a butcher, wine shop, deli, bakery, or restaurant, anything goes.

Make sure the partnership goes both ways. Provide your partners with something physical, like a discount card or postcard detailing your offer. That way the customer will bring it with them and you know which businesses and promotions are working best.

The artwork platform Canva has loads of discount card templates that you can adapt and order for printing. Here are the results for a search I did for discount cards.

The best partnerships are ones that add good value to the recipient, with little to no cost to you. During a recession every business will struggle, and people will be much more open to collaborations and partnerships than they might during the good times, so use this opportunity to build strength into your business in the long term.

Your Services and Products

Now is a good time to take a hard look at the services you’re offering and the way in which you offer them.

Redefine the ‘Need’ Recession or not, a need will always be a need and your customers will still have them. Look for ways you can meet this need. Sharpen your focus. Do you need to cut back services that aren’t profitable, or innovate with new services? Really dig deep into what your clients really want. Talk to your existing customers and ask them what

they want – is there something you can offer that you haven’t thought of yet?


In my article ‘The Business of Audiences in Physical Therapy (, we discuss the benefits of specialising or focusing on a niche audience, the argument being that no one wants a generalist.

We use the analogy that if you want a really great pizza, you don’t go to a buffet, you go to a genuine Italian pizza restaurant. If someone has chronic, persistent back pain, they want THE ‘goto’ person for persistent back pain.

Research your competitors, see what they’re doing and find your own niche.

Provide products and services that they’re not providing. In deciding what specialist you might become, you could ask yourself the following questions:

l Who or what condition have I historically had the most success with?

l If I only got paid AFTER getting a result for my client, who would be the BEST client for me to work with?

l Who is dealing with a ‘bleeding neck’ problem instead of just a stubbed toe? That is, pick an urgent-need issue.

l Who would be energising and a joy to work with? Who do you want to spend your time with?

This doesn’t mean you have to turn away the people who come to you with general issues, it just means that you focus your marketing on attracting new clients under your specific target audience.

Taking this


Marketing in

approach has the benefit of reducing price-sensitivity. People are going to be less worried about what it costs if they’ve got THE best person dealing with their issue and that’s a definite benefit during a recession.

Diversify Revenue Streams Memberships

I strongly advocated for this approach during Covid, and even built the technology into the Co-Kinetic system to help you manage recurring revenue subscription plans.

If you become the go-to person for persistent chronic back pain, why not create a subscription-based membership community? Facebook provides a membership platform for

a subscription product that people can buy (you can do this through Co-Kinetic) and then deliver regular content to that community.

That content could come in the form of live video presentations or FAQ sessions, it could be resources that you share, updates on new research, links to interviews on YouTube or stretches that are useful to reduce pain – the point is that with your established expertise, you’re leading the group and curating the content.

The great thing about a community, is that it can also become self-supporting, particularly if you encourage group engagement and sharing. People also benefit from a sense of belonging and being part of a group who truly understand their ‘pain’.

People suffering with chronic conditions can benefit greatly from groups like this. Some ideas that spring to mind other than chronic back pain might be long-Covid, arthritisbased conditions, ME/CFS and the menopause. Use paid social media ads to target local audiences who may be interested.

The other less-known benefit about providing a subscription-based offer is that it builds greater customer loyalty and helps with retention.


Don’t miss the opportunities to sell vouchers – particularly in the run up to Christmas, New Year, Valentine’s Day, Mother’s/Father’s Day. The big benefit of vouchers is that you get the cash upfront which can be a life saver when your cashflow is looking a bit peaky.

And everyone expects people to sell vouchers around these times, so you’re not damaging your reputation.

Again we’ve built a simple voucher system into the Co-Kinetic system and also provide you with therapy-themed content including social media and posters, to help you promote your campaigns.

Partnerships and Strategic Alliances

Can you team up with another local business to offer some kind of ‘package’ or ‘bundle’? Look at which other businesses or professionals can provide services or products that complement a service you provide.

Talk to your customers: do they have friends or colleagues running local businesses who might be open to a collaboration? This is a win–win because then you’re effectively supporting your clients, by supporting the people who are important to them.

I currently live in Wimbledon which hosts the internationally renowned Wimbledon Tennis Championships. As a result, more than half a million people flood into Wimbledon over a 14-day period.

And yet I didn’t see one single shop offering any kind of ‘Wimbledon special’ offer. Literally hundreds of thousands of people walked past a high-end butcher, wine shop and cheese delicatessen (all of which I know would like more business). It would have been so easy for those three businesses to have collaborated by offering a picnic package or hamper, or even just for the butcher to sell their amazing sausage rolls outside their shop to people with a 10–15- minute walk to the entry gates.

There is an almost unbelievable lack of imagination around what is an absolute gift horse to any local business community. Come on people, it’s not difficult! It doesn’t have to be the most perfect offer right off the bat; try something, if it works, great, do more of it. If it doesn’t, try something different and eventually you’ll hit on something that works really well for you.

Marketing and Sales

The absolute worst thing you can do in the run up to, or during a recession, is

Co-Kinetic Journal 2022;94(October):44-4746
a Recession 1. Don’t scale back on marketing – if anything, you need to be doing more. 2. Stay top of mind with your customers during these periods with: a. consistent email marketing b. updating blog posts c. consistent social media posts d. updated website. 3. Increase your local visibility with: a. SEO + blog posts b. local media c. local discussion forums. 4. Maximise your chance of conversion with testimonials and social proofing. 5. Be effective – don’t waste time and money on things that don’t work.

to scale back your marketing. You need to do exactly the opposite. You need to do MORE marketing in a recession, particularly if you need to attract new clients, because they’ll be harder to acquire.

Marketing underpins everything we’ve talked about in the article above. It’s your marketing that will help you build relationships with new prospects, strengthen relationships with your existing customers and help you reengage with your past customers.

You need to stay ‘top of mind’ with these people through consistent valueadding email marketing, the writing of blog posts, a consistent social media presence and keeping your website updated.

It’s your marketing that will help you specialise and build new, targeted audiences through blog posts, paid social media promotions and the use of lead magnets and email-lead collection pages.

You should pay particular attention to increasing your local visibility by publishing regular blog posts accompanied by search engine optimisation (SEO). And you need to maximise the chances of a prospect becoming a customer by growing your portfolio of customer testimonials, reviews and social proofing.

And most importantly, you need to focus on the elements that will move the needle for your business, and don’t waste valuable time and money doing activities that don’t work.

Business Administration and Finances

The last of the recession-tackling tools and strategies revolve around managing your business both financially and administratively. I won’t go into each of these items individually as they should be self-explanatory but here are some things you can be implementing as part of your recession-proofing process.

l Improve customer retention/ customer lifetime value.

l Focus on delivering more of your high-value/profitability services.

l Know your costs and don’t be afraid to increase your prices.

l Cut costs that don’t help you achieve the objectives we’ve

outlined in this article.

l Automate everything you can.

l Actively manage your cashflow.

l Renegotiate deals with suppliers.

l Pay your debts promptly –it’s important to have good relationships with your suppliers and don’t let the debts stack up.

l Build a rainy day fund.

In Summary

As you will probably have realised by now, most of these recession-fighting tools are interconnected. If you identify and build a reputation in a specialist niche and become the go-to person for [insert your specialism], then people will be much less price-sensitive when it comes to booking appointments with you and you can charge fairly for your services instead of having to pricematch with local competitors.

In order to build that go-to reputation you need to be actively marketing and promoting your expertise, delivering workshops, writing articles for local media outlets, publishing SEO-optimised content on your blog, and sharing value-based content through your emails and social media pages.

To ensure that you keep your current customers coming back, you need to up the ante when it comes to keeping them happy and building loyalty. That can happen easily through a consistent value-adding email marketing plan and the strategies we’ve discussed above about adding value. This in turn impacts your customer retention.

The healthier and more active your email marketing strategy and audiencebuilding campaigns, the better you’ll be able to promote your partner offers, and the stronger those relationships will become as a result.

Everything is connected to, and underpinned by, your marketing. The minute you start fading into the background, is the minute that your business will start to shrink, and collapse will only be a matter of time.

Related Content:

l Turning Prospects into Paying Clients: Building and Implementing a 12-Month Marketing and Sales Plan

l The Challenges Facing Physical Therapy Businesses in 2022 and Beyond – and What To Do About Them [Article]

l Being Seen, Being Found, Being Heard [Article]

l The 20% of Marketing Activities that Will Give You 80% of Your Marketing Results [Webinar]

Key Points

l Actively invest in the wellbeing of your existing customers.

l Cultivate your relationship with past customers.

l Use email lead magnets to grow your email list of prospective customers.

l Speak to your clients to find out what they want.

l Become a specialist in a particular issue – this helps reduce price-sensitivity.

l Set up different revenue streams with community memberships, vouchers and partnerships.

l Do more value-added marketing in a recession, not less.

l Streamline your business administration and costs.


Tor Davies began her professional life training as a physiotherapist at Addenbrookes Hospital, Cambridge, UK. She went on to complete a BSc in Sport & Exercise Science at the University of Birmingham while also achieving a WTA international tennis ranking. After graduation she worked in marketing with a London agency and then moved into medical journalism where her passion for publishing was born. At 27 she established sportEX medicine, a quarterly journal for physical and manual therapists. With a passion for technology as well as publishing, Tor’s leadership grew sportEX into the Co-Kinetic journal and website which included a more collaborative, royalty-based form of publishing as well as a wider content remit. Tor’s focus is on providing resources to help therapists develop their professional authority and brand, and grow their own businesses while working more efficiently and effectively, a topic that she speaks regularly on at global conferences.

Join us on Facebook: Connect with Tor:



Subject: A Small Favour...


Great to see you the other day and thanks again for choosing [BUSINESS NAME]. We really hope the treatment we’ve provided is making a positive difference for you.

If so, we were wondering if we could ask a small favour?

A few words from you could make a massive difference to how new customers find us - and whether they choose to use us. Which obviously makes a massive difference to our business in the long run.

So if you have a couple of minutes spare, we’d really appreciate it if you could leave us a quick Google Review. If you’re happy to do this, just follow this link [insert link] to our Google Business page and add your comments to the reviews section.

Thanks so much for your support, we really appreciate it.


You can download a Word file containing the text for these emails using the button below


Subject: Why Your Words Matter to Us


Quick question – do you remember how you first heard about us?

If you’re like the majority of people we ask, it was word of mouth. Makes sense. When you’re trusting someone to take care of your health, there’s nothing like a personal recommendation to reassure you.

But those who don’t have a friend or family member on our books have to rely on the lottery of a Google search. So many options, so difficult to choose.

One thing could make that process a little bit easier is a simple Google review from past or current clients. A little personal touch in the jungle of the internet.

So we were wondering if you’d have a couple of minutes spare to leave a quick review of [BUSINESS NAME].

You’d really be doing us a favour – and hopefully your review will help other people get the treatment that will benefit them as well.

If you’re happy to do this, just click the link here and add your comments to the reviews section. Thanks so much. We really appreciate it (and we’re sure others will too!)


Co-Kinetic Journal 2022;93(July):48-5148

Ready-to-Use Templates for Requesting Customer Reviews

Nine out of ten people read reviews online before making a purchase (1). Eight out of ten people trust online reviews as much as personal recommendations (1). Google is the most popular review platform with 6 out of 10 people using it to read reviews (1). Your response matters – 97% of people who read reviews also read the business’ response (1). Reviews also impact Google search results (2). Google trusts the power of word-of-mouth marketing. It factors in the quantity and quality of reviews to evaluate the search position. When you enter a local search term into Google (like “sports physio”), three main factors will affect the ranking of each site displayed: Relevance; Distance; Prominence. Reviews fall into the category of prominence. A sports physio with many highly rated reviews is likely to outrank a closer local competitor if they have fewer, less positive ratings and reviews. With all this in mind we’ve put together some practical resources to help you to encourage customer reviews. Read this article online

Subject: We hate doing this...


We’ll get straight to the point, ‘cos we hate asking for favours. (We’d much rather be the ones helping others out!)

But do you think you’d have a couple of minutes to leave us a quick Google Review? We’re looking at ways help new customers find our services, and our marketing people tell us these reviews make all the difference when it comes to reassuring people they’ve found the right physical therapist for them.

So if you’ve anything positive you could share – even just a one-liner would be great – we’d be extremely grateful. Just follow this link [insert your link] and add your comments to the reviews section.

Thanks so much for your continued support, [BUSINESS OWNER NAME].

Here are three email templates you can use to encourage people to write reviews. Ideally you would drop some or all of this copy into a post-appointment follow-up email. Even better if you include a link to a relevant resource, like one of the Co-Kinetic advice leaflets that you think may be helpful –it could be related to the issue you’re treating, or it could be unrelated, but perhaps something health-related that cropped up in discussion during the appointment. That simple gesture of support helps to build a sense of reciprocity (a desire to give back) ENTREPRENUER THERAPIST

5 Ways to Support Your Local Business Poster and Postcard

Every local business should display one of these posters on their wall!

Simply click on the link below which will take you to the poster (or postcard) and add your logo and contact details.

Then either order your poster via Canva (best quality, the print button is top right) or print it off to use in your clinic.

All of the downloadable posters come in a variety of sizes (A4-A1), allowing you to print to whichever size you need!

The service is available through Canva (and it’s international). To give you an idea of cost, in the UK an A3 poster costs just £13 or an A2 poster costs £18.

Access the poster here

Or you can find the postcard here

We’ve written and designed an A4 leaflet and postcard which you can add your own review links to (see middle section) along with your logo and contact details and then display on your front desk or give to people when they settle up for their visit.

Again you can either print this out yourself or order them through Canva (in the UK 50 letterheads cost £30 at the time of writing). Again this service is available internationally.

You can find the A4 leaflet here

There’s also a postcard version here

Brand and print yourself, or order this poster for printing through Canva, at the following link


Ben Martin, Co-Kinetic Copywriter

Ben has worked as a writing lecturer at the University of Swansea, South Wales, a landscape gardener in the Eden that is New Zealand and an ambassador for the English language in Japan. (He also apparently been the lead guitarist in a wedding band and can still do a mean Billie Jean on request!). Ben crafts the words we produce for you in our content marketing campaigns, into vibrant, engaging sentences to help you draw your customers in and build trust. He writes the blog posts, nurture emails, social media posts, email sign-up pages and animations that we include across all those campaigns. He’s based in Swansea, South Wales, works for clients from all over the UK as well as New Zealand, Australia and the U.S.

50 Co-Kinetic Journal 2022;93(July):48-50
Customer Review Request Leaflet and Postcard Customer Review Poster Article References 1. 10 Online Review Statistics 2021 2. Just How Much Do Google Reviews Impact Your SEO Ranking? Further Resources l Timeless Testimonials: The Power of Reviews [Article] l Sales is Not About Selling But About Building Trust [Article]

Scan the QR code below to rebrand, print or order A1A4 sized


We’ve gone NAKED!

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

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)

The old polybag, while a step in the right direction, only breaks down in open air. If it finds its way into landfill much of its environmental value is lost.

For other enquiries: Email:

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