Co-Kinetic Journal Issue 96 - April 2023

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Feel confused or overwhelmed by social media

Get little or no engagement from your social media posts

Have no idea what you should be doing but...

Know you’re spending way too much time and getting zero ROI from your efforts


Why getting engagement on your posts is so hard and ways to overcome that

How to build a dynamic social media profile that demonstrates expertise and relevancy, as well as delivers value to your social media followers

How to use our ENGAGED content formula to create the right kind of professional content that attracts the attention of the all-important platform algorithms

Ways in which you can nurture and ‘massage’ these algorithms to increase exposure to your content, in turn increasing engagement and followers

The two sides of the social media coin, without which your social efforts will always fail

Course Presenter Tor Davies

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

Don’t know how to build an audience, or promote your business through social media without being salesy

Feel like your social media efforts are mostly a complete waste of time

...then this is the course for you.

Using proactive and reactive engagement to build targeted audiences

How to use paid social effectively

FAQs around what networks to post to (and why), when and how often

And finally how to generate new clients using social media.

This is a four module course with a heavy emphasis in module 3 and 4 on practical application so you can walk away and create a social media presence that not only you can be proud of but which engages, adds value, entertains and educates your followers.

Be the first to hear when the course launches by registering your interest at the following link



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APRIL 2023 ISSUE 96 ISSN 2397-138X is published by Centor Publishing Ltd 88 Nelson Road Wimbledon, SW19 1HX, UK






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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.

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Ji YX, Xie YJ, Zhou XZ et al. medRxiv 2023;doi:

This is a meta-analysis pooling the findings of 45 trials with 42,319 patients using outcomes of pain intensity or functional improvement following a diagnosis of patellofemoral pain. The results showed that all included treatments were superior to a wait-and-see approach. They were:

l PNF + exercise;

l whole body exercise;

l hip-and knee-focused exercise therapy;

l foot orthoses + exercise;

l hip exercise;

l knee brace + exercise;

l gait retraining exercise;

l knee exercise;

l knee arthroscopy + exercise;

l target exercise;

l kinescoping + exercise;

l education + exercise;

l feedback exercise.

Exercise therapy with education was better than exercise alone in alleviating pain intensity.

Co-Kinetic comment

You should be able to find a treatment that suits your patient in that list. The key is making sure that exercise is included.

INJURIES IN PHYSICAL EDUCATION TEACHER STUDENTS: DIFFERENCES BETWEEN SEX, CURRICULUM YEAR, SETTING, AND SPORTS. Barendrecht M, Barten CC, van Mechelen W et al. Translational Sports Medicine 2023;2023:8643402

This study examines the injuries occurring in Physical Education Teacher Education students. Data


PHYSIOLOGICAL AND NEUROPHYSIOLOGICAL EFFECTS OF SPORTS MASSAGE ON THE ATHLETES’ PERFORMANCE: A REVIEW STUDY. Shamsi H, Okhovatian F, Kalantari KK. Scientific Journal of Rehabilitation Medicine 2022;11(5):680–691 (in Persian)

This review study aimed to investigate the neurophysiological and physiological effects of sports massage on athletes’ performance and to find out the clinical beliefs of sports physiotherapists regarding the effects of sports massage on sports injuries and whether such beliefs were supported by scientific evidence of not.

A search of Google Scholar, ScienceDirect and PubMed was conducted from 1975 to 2020 for papers in English using the keywords ’sports massage’, ‘sports injuries’, ‘physiological mechanisms’, ‘neurophysiological mechanisms’ and ‘performance of athletes’. The results were whittled down to 14 clinical trial studies and 1 case review. The conclusions drawn were that the existing studies were heterogeneous in that they reported the effects of massage on different factors and with contradictory results, and that the effects on athletes’ performance are more due to psychological rather than clinical effects.

Co-Kinetic comment

No surprises here. Sadly, too much massage research tends to be of low quality and this paper does not buck the trend. There is no table listing the papers they are discussing and the majority of the 21 listed references are so ancient they are written on papyrus. Come on people, massage deserves better.

was collected from 2899 students (male n=1947; female n=952) over a 14-year period. Forty-three percent of all students (54.9% of females and 37.2% of males) reported a total of 2129 injuries (1st year 56.4%; 2nd year 28.2%; 3rd year 15.5%). The most prevalent sudden-onset injury locations (63.4% of all injuries) were the ankle (32.5%) and knee (16.6%). The most prevalent gradual onset injuries were the lower

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leg (27.8%) and knee (25.2%). Joint/ ligament injuries (45.8%) and muscle/ tendon injuries (23.4%) were the most prevalent injury types. Proportions for injury locations and injury types differed significantly between curriculum years. Injury prevalence per setting and sport differed significantly between the sexes. Injury locations differed significantly between sports and between the sexes per sport.

The conclusion to this study is that there needs to be more injury prevention measures applied to PE students. To be fair to them, as they progress through the years they get fewer injuries, which might mean that their training in injury prevention is working. The big question is what happens when they qualify and start teaching? Are their own student teachers getting hurt in the same numbers? Can we have a follow-up study, please?


Journal Watch

The objective of this study was to the compare the efficacy of the Graston technique versus soft tissue release on patients with myofascial neck pain syndrome. In a pre-test/post-test RCT, 60 participants with ages ranging from 25 to 40 years were assigned to 3 groups. Group A (n =20) received Graston technique plus conventional treatment. Group B (n =20) received soft tissue release plus conventional treatment. Group C (n =20) received traditional treatment only.

The Graston technique was instrument-assisted soft tissue massage performed at 30–60° for 40–120s on each side till redness arises, followed by cold packs to reduce the redness. The soft tissue release involved the therapist putting one hand on the patient’s chest, so the palm touched the collarbone, and the fingers pointed toward the patient’s elbow on the same side. The other hand was placed beneath the patient’s jaw, using it as a handle and pointing the fingers toward the top of the patient’s head. A release was then made in three dimensions. The process was carried out for at least 5min. The standard treatment consisted


of ultrasound, hot packs and TENS, plus proprioceptive and isometric neck exercises. There were 3 sessions a week for 4 weeks. Outcome measures were cervical pain intensity using analogue visual scale, daily activities using a neck disability score, range of motion using an inclinometer, and tenderness using a pressure algometer pre-and posttreatment.

The results showed that there was a significant difference between the Graston technique and soft tissue release. Both were more successful than the control group in pain relief, functional

impairment, and range of motion, with the Graston approach having a more beneficial impact.

Co-Kinetic comment

This is one of those papers where you want to go back and ask the authors what on earth they were thinking. For a start the interventions are cumbersome. The standard treatment alone is a case of throwing everything at the problem with the two interventions being tested as a bit of an afterthought, the descriptions of those interventions are not detailed enough to be repeated, and finally the results were obtained immediately after the intervention. How hard would it have been to include a longer term follow-up?

The purpose of the study was to compare the effects of instrumentassisted soft tissue mobilisation (IASTM) and myofascial release technique (MFR), to improve pain and mobility among patients with chronic heel pain. Sixty-six participants recruited via a convenience sample, and 33 were allocated to each treatment group, both of which were treated for 3 sessions per week for 4 weeks. Pre- and post-treatment readings were measured on the numeric pain rating scale (NPRS) and foot and ankle index (FADI).

Both groups were treated with cold packs for 7 to 10min to reduce fascia pain. The IASTM group were


treated for 7 to 10min using a GT 4 instrument. A small amount of lubricant was applied and the medial and lateral part of gastrocnemius and both sides of the Achilles tendon were treated. For the other group, MFR was done by a physiotherapist using the knuckles of the dominant hand to apply broad strokes to release superficial restrictions. Strokes were applied at 45° in relation to the calf muscle. After that, small restrictions were located and then released, deeper massage was applied

using the thumb, followed by the calf muscles being shaken for 30s. In both groups NPRS and FADI improved, but there was greater improvement in the IASTM group.

Co-Kinetic comment

That both groups improved was great. The big question for clinicians is the balance between wear and tear on the thumbs against the cost of the gadgets. There are ways to protect your hands and ways to protect your bank balance, such as using the back of a dessert spoon!

Journal of Exercise and Sports Psychology 2022;17(6):441–444

This was a multicentre observational diagnostic study involving seven centres from six countries (Belgium, Brazil, Chile, the Netherlands, Portugal and Spain). All patients with a diagnosis of multiple ligament knee injuries (MLKI) who were surgically treated between January 2014 and December 2020 in the participating centres were eligible for inclusion. MLKIs were considered as injuries of at least two of the four main ligaments of the knee: anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL) and posterolateral corner (PLC). The PLC comprises the lateral collateral ligament (LCL), the popliteus tendon, and the popliteofibular ligament (PFL); injuries that involved at least one of these three structures were considered as lesions to the PLC.

Inclusion criteria were:

l skeletally mature patients;

l diagnosis of MLKI;

l surgical treatment by a knee surgeon with experience in MLKI; and

l MRI report of the knee before


OF MAGNETIC RESONANCE IMAGING IN THE DIAGNOSIS OF MULTIPLE LIGAMENT KNEE INJURIES: A MULTICENTRE STUDY OF 178 PATIENTS. SanchezMunoz E, Lozano Hernanz B, Zijl JAC et al. The American Journal of Sports Medicine 2023;51(2):429–436

surgery by an experienced musculoskeletal radiologist. Exclusion criteria were:

l previous lesion of the knee;

l previous surgery of the knee;

l concomitant fractures of the knee (except for bone avulsions associated with ligament lesions, such as arcuate fractures); and

l patients with incomplete data.

Detailed data on the knee injuries of 178 patients were gathered from MRI reports and surgical records. There were 127 male (71.3%) and 51 female (28.7%) patients. The mean age was 33.1± 11.9 years (range, 14–66 years). Highenergy trauma was the most usual mechanism of injury, which occurred in 90 patients (50.6%), followed by sports trauma in 69 patients (38.8%) and low-energy trauma in 15 patients (8.4%). A vascular injury was present in 5 patients (2.8%), which was not reported

in 34 patients (19.1%). Nerve injuries affected 17 patients (9.6%) and were not reported in 34 patients (19.1%).

The main finding of this study is that the diagnostic accuracy of MRI was highly varied for the different knee structures in MLKIs, with PLC, meniscal and chondral lesions showing a high risk of a misdiagnosis. The ACL was the structure with the best diagnostic accuracy. MRI was more reliable in detecting the absence of meniscal and chondral lesions than in identifying them. The diagnostic accuracy of MRI was mostly influenced by the severity of the lesion and by age or sex for some knee structures.

Co-Kinetic comment

What’s the old medical adage – ‘Treat the findings not the films’ ? Maybe, but it’s a bit sad that we have to get cut up to accurately find what is wrong.

PREVALENCE OF MUSCULOSKELETAL SPORTS INJURIES OF HEAD, NECK AND UPPER LIMB AMONG CRICKET PLAYERS. Umar MH, Batool S, Javaid HB et al. The Therapist (Journal of Therapies & Rehabilitation Sciences) 2022;3(2):6–9

A cross-sectional study was conducted in which convenience sampling was used and data collected from 180 players in Lahore. The players ranged from U14 to national level (mean age, 21.56). Of these, 60 were batsman, 60 were bowlers, 50 all-rounders and 10 were wicket keepers. Only 5 (2.8%) reported a head injury and the same number a neck injury. Of the batsman, 35 complained of shoulder pain, 5 were diagnosed with rotator cuff injury, 5 had tendinitis and 5 had shoulder dislocations. All of the bowlers and 25 of the all-rounders had had shoulder pain. Out of the 10 wicket keepers, 5 were diagnosed with rotator cuff injury.

Co-Kinetic comment

There is a great line in this paper, “Players who were on illegal drugs [were] excluded from this study”. Would anyone admit to that or is it so common in Pakistan that it’s a reasonable question to ask? The authors only give us a partial picture here. Clearly, cricket is bad for the shoulders but there is no information on whether there was pain in the non-bowling/ throwing arm or detail about the wicket keepers who in theory don’t do much throwing. If you have this information guys, publish a follow-up.

Co-Kinetic Journal 2023;96(April):4-11 6


A systematic search was conducted in the usual international electronic databases, such as Scopus, PubMed, Web of Science, and Persian electronic databases such as Iranmedex, and Scientific Information Database using keywords extracted from Medical Subject Headings such as ‘massage therapy’, ‘musculoskeletal manipulations’, ‘acute pains’, ‘burning pain’, and ‘burn’ from the earliest

content to 17 October, 2022. Stata version 14 software was used to perform the meta-analysis. The duration of the study was reported in five studies, with a mean of 42.40 weeks. The duration of the intervention was reported in seven studies with a mean of 22.86min. The results of the meta-analysis showed that using various types of massage therapy interventions significantly reduced pain intensity and anxiety in the intervention

groups compared with the control groups.

Co-Kinetic comment

Of the seven papers showing positive results, one used Shiatsu, two general massage with aromatic oils, two Swedish massage and two foot reflexology, which are wildly different techniques but they all work on pain and anxiety.


Evans DW. Chiropractic & Manual Therapies 2022;30(1):51 OPEN

This paper starts with the prevailing model of joint manipulation as proposed in 1976 by Raymond Sandoz, a French-Swiss chiropractor who was building on earlier work on cracking joints from 1947, “A passive, manual manoeuvre during which an articular element is suddenly carried beyond the usual, physiological limit of movement without however exceeding the boundaries of anatomical integrity”. It then goes on to explain why the model is fundamentally flawed. The application of peak force will move a

joint beyond the point of any resistance at the end of range with the possibility of causing damage to the capsule and ligaments.

The early research on ‘joint cracking’ that led to the development of this model is described in chronological order, alongside how this research was misinterpreted, which gave rise to the model’s flaw. A corrected model, first published by Evans and Breen in 2006, is then presented and explained. Unlike the flawed model, this corrected model makes predictions in line with all

available empirical data and additionally provides reassuring answers to critics: the bottom line being that cavitation should be achieved more easily when the joint is at or near to neutral.

Co-Kinetic comment

This is well worth a read if you are a clinician performing manipulations. It’s particularly good on the history of cavitation bubble research. The main title refers to the author complaining that his earlier paper has not had greater recognition. Given that his model is safer than the original he may have a point.

MANUAL THERAPY IN MUSCLE TENSION DYSPHONIA (MTD) FOR SINGERS – RECENT REVIEWS AND A CASE STUDY. Pani S, Chatterjee I, Kumar S. World Journal of ENT & Head-Neck Surgery 2022;3(4):14–18

This is a case study of a 34-year-old female classical singer complaining of voice fatigue and a ‘hoarse’ voice who was diagnosed with muscle tension dysphonia (MTD). MTD was originally coined in 1983, and describes difficulty making sounds when attempting to speak caused by increased muscle tension of the muscles surrounding the voice box (laryngeal and paralaryngeal muscles). One of the treatments for this involves kneading the laryngeal area without voicing in order to reduce hyperfunction of the muscles and improve the quality of voice. Direct massage was applied to the medial suprahyoid, around the hyoid bone thyrohyoid space, thyroid cartilage and larynx. During the palpation the patient was asked to sustain vowel sounds. It worked – she returned to a ‘normal’ voice.

Co-Kinetic comment

Unlike some of the other papers we report on today, this one does have enough information for a competent therapist to repeat the treatment. Sadly it’s a bit less clear on timings and number of sessions, other than to state that the treatment should take approximately 10min and can be repeated in one session. As part of the assessment process the authors used a computerised speech lab called Dr Speech. Their tag line is, “Everyone deserves a voice”. 10/10 to whoever dreamed that up.


This study aimed to develop an international expert consensus for the management of hamstring injuries (HSIs). A modified Delphi methodology and consensus process was used with an international expert panel, involving two rounds of online questionnaires and an intermediate round involving a consensus meeting. The questionnaire for the initial round of information gathering was sent to 46 international experts, and comprised open-ended questions covering decision-making domains in HSI. Thematic analysis of responses outlined key domains, which were evaluated by a smaller international subgroup (n =15), comprising clinical academic sports medicine physicians, physiotherapists and orthopaedic surgeons in a consensus meeting. After group discussion around each domain, a series of consensus statements were prepared, debated and refined. A questionnaire for round two was sent to 112 international hamstring experts to vote on these statements and determine level of agreement. Consensus threshold was set a priori at 70%. The main recommendations were individualised rehabilitation based on the athlete, sporting demands, involved muscle(s), and injury type and


severity. Early stage rehab should avoid high strain loads and rates. Loading is important but there was less consensus on optimum progression and dosage. This panel recommends rehab progress based on capacity and symptoms, with pain thresholds dependent on activity, except pain-free criteria supported for sprinting. Experts focus on the demands and capacity required for match play when deciding the rehabilitation

Co-Kinetic comment

end-goal and and timing of return-to-sport (RTS). Additional research is required to determine the optimal load dose, timing and criteria for HSI rehabilitation and the monitoring and testing metrics to determine safe rapid progression in rehabilitation and safe RTS. Further research would benefit the optimisation of prescription of running and sprinting, the application of adjuncts in rehabilitation, and treatment of kinetic chain HSI factors.

This paper starts by saying, “Hamstring injuries are the most common athletic injury in running and pivoting sports, but despite large amounts of research, injury rates have not declined in the last 2 decades” so we must be missing a trick somewhere. The people making these recommendations are a body of over 100 international experts but sadly the consensus is rarely 100%, so the paper helpfully includes the percentage who do agree after each recommendation.

Part 1 of the series recommends HSI classification systems evolve to integrate imaging and clinical parameters around: individual muscles, injury mechanism, sporting demand, functional criteria and patient-reported outcome measures. Part 2 is about indications for surgery and recommends the knife if there is gapping at the zone of tendinous injury and loss of tension, symptomatic displaced bony avulsions and proximal free tendon injuries with functional compromise refractory to non-operative treatment. Other important considerations for operative intervention included the demands of the athlete/patient and the expected functional outcome based on the anatomy of the injury; the risk of functional loss/performance deficit with non-operative management; and the capacity to restore anatomy and function. Consensus was not reached within the whole group but was agreed by surgeons in the cohort. The consensus group did not support the use of corticosteroids or endoscopic surgery without further evidence.


In this cross-over study, 19 male and female competitive swimmers aged between 12 and 20 years old were subjected to three 12min interventions performed over a week, which they completed between their resistance and swim training. After the intervention week, perceptive (well-being, heaviness, tiredness, discomfort, and pain), performance (sprint time, FINA points, and stroke characteristics), and functional (flexibility, squat jump, bench press, proprioception) outcomes were measured, in addition to athlete beliefs and preferences. The interventions were (i) 12min of

superficial massage; or (ii) deep massage both of which were by trained physiotherapists on the arms, back and anterior thigh with sliding movements controlled by metronome; and (iii) a control group of a 12min rest period in which the subjects were free to sit, stand, or walk by the pool to simulate the actual training scenario, but were instructed not to enter the water or engage in physical activity.

also maintained perceptions of wellbeing, whereas the control group got worse throughout the week. However, there was evidence of worsening of the perceptions of heaviness and pain at the main stages of the swim training for the massage groups and neither had an effect over sprint and functional performance.

Co-Kinetic comment

This is a well-presented work. The

OPEN training regime is shown as a diagram and the massage protocol is also shown using a body diagram to indicate stroke direction. It’s less clear on how they distinguish between superficial and deep strokes but that is an issue in massage research that is rarely – if ever –addressed. The results suggest that the swimmers didn’t improve their performance with massage but they felt better for it.

Co-Kinetic Journal 2023;96(April):4-11

EFFECT OF NONINVASIVE STATIC HUMAN DATA ON MAXIMUM DATA IN EXERCISE. Wu Y, Sun Y. International Journal of Environmental Research and Public Health 2023;20(2):1612

The basic premise of this study is that obtained maximum data in exercise (Max-Ex), including maximum heart rate (HRmax), peak oxygen uptake (VO2pk), maximum power, etc, are frequently used for a variety of reasons, such as the determination of exercise intensity, the measurement of an athlete’s performance, assessment of recovery from disease, and so on.

However, very often this choice does not take into account the targeted individual. So, this study looked to determine variations in Max-Ex, according to the non-invasive static human data (Non-In data). There were more than 40 dimensions of Non-In data including anthropometric and demographic data (eg. height, weight and BMI); physical fitness levels (eg. grip

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strength, reaction times, sit and reach length); and body composition (eg. body fat percentage, water content and muscle bulk).

Sixty-one participants (32M, 29F) were recruited and underwent an incremental graded exercise test (GXT). The two data sets of Max-Ex and NonIn were correlated. The results showed a significant relationship between body composition and Max-Ex. Of the 41 types of Non-In data collected in communities, the body composition generally showed high correlation. The muscle-related body composition data had a greater effect on power, and the fat-related ones had a greater effect on HR max and VO2pk. For some types of Max-Ex, the older and younger ones showed specific differences.

This study comes from the Chinese Institute of Intelligent Machines. That doesn’t sound scary at all does it? It gives some quantifiable data to back up what should be obvious: there is no ‘one size fits all’ when it comes to exercise prescription.


Sugino Y, Yoshimura I, Hagio T et al. Foot and Ankle Surgery 2023:S1268–7731(23)00004-8

This study consisted of 14 subjects [8 men, 6 women; mean age of 30.9±4.8 years (range, 25–41 year)] with no history of plantar fascia (PF) disorders or painful episodes. All participants performed a sustained PF-specific stretch (sPFSS) on one foot and intermittent stretching (iPFSS) on the other foot. Force was applied distal to the metatarsophalangeal joints on the evaluated foot, pulling the toes upward toward the proximal side until a stretch was felt in the PF. Two weeks later, all participants performed sustained Achilles tendon stretching (sATS) on one foot and intermittent stretching (iATS) on the other foot. Sustained stretching was performed for 3min at a time. Intermittent stretching was performed 10 times for 10s each with an interval of 10s between stretches.

Shear wave elastography (SWE) measurements were performed immediately after each stretching. SWE is a non-invasive method for real-time visualisation of soft tissue viscoelastic properties. It allows for reproducible, quantitative evaluation of tendons and muscles despite limitations in the size, shape and depth of the region of interest.

The results showed that there was a difference in the PF elasticity pre- and post-tests for both stretching methods, although there was no significant difference between the types.

Co-Kinetic comment

If you are interested in this, there are photos in the paper which make it much clearer than the written text does.



The Open Orthopaedics Journal 2022;16: e187432502211210

This paper presents the results of an 18-question electronic survey sent to Athletic Trainers (ATs) in the USA about their use of portable, home-use ultrasound machines, known as sustained acoustic medicine (SAM). The survey included both qualitative and quantitative questions. In addition, a panel discussion about SAM effectiveness with expert ATs was held. Survey respondents (n =97) and panellists (n =142) included ATs from all National Athletic Trainers Association districts. SAM was primarily used for musculoskeletal injuries (83.9%) with a focus on healing tendons and ligaments (87.3%). SAM treatment was also used on joints (44.8%), large muscle groups (43.7%), and bone (41.4%). SAM provided clinical improvement in under 2 weeks (68.9%,) and a 50% reduction in pain medication (63%). In addition, patients were highly receptive to treatment (87.3%), and ATs had a high level of confidence for improved function and returned to work after 30 days of SAM use (81.2%).

Co-Kinetic comment

If you are new to the SAM devices, you are not alone. Imagine a TENS machine but using ultrasound rather than electric current. They transmit a low intensity, long duration ultrasound treatment at 1.3W (0.65W/applicator) for up to 4h. They cost between $4000 and $6000. If you want to know more seek out ‘Sustained acoustic medicine: a novel long duration approach to biomodulation utilizing low intensity therapeutic ultrasound’ by Langer MD, Lewis Jr GK in Proceedings of SPIE–The International Society for Optical Engineering 2015;9467:946701 (


This is a case study of a 43-year-old woman who presented with a history of sudden-onset dizziness, dysarthria, nausea/ vomiting, tinnitus and imbalance. Two days before her presentation, she experienced a new-onset moderate- to severe-intensity headache along with neck pain. The patient mentioned a first-time use of a home massage device 3 weeks before the headache onset. After investigations, the patient was diagnosed with vertebral artery dissection (VAD), and treatment was initiated. She was discharged in a stable condition.

Co-Kinetic comment

These devices are becoming increasingly popular, but they are not without risk. Hire a properly trained massage therapist instead.


To examine the extent of sportrelated spinal cord injury (SCI) in China, individuals admitted to the China Rehabilitation Research Centre (CRRC) between January 1, 2013 and December 31, 2019 suffering with injuries of the vertebral column with spinal cord lesions resulting from sport-related accidents were included in the study.

Of the 2448 individuals evaluated, 164 (6.7%) had sport-related SCIs. The mean age was 15.23 (±13.83) years old. Most were female (male:female ratio, 0.47:1) and aged between 4 and 70 years. Dancing was the leading cause of sport-related SCIs, accounting for 58.6% of the injuries. This was followed by water sports (14.7%) and taekwondo (4.2%). The highest proportion of individuals with SCIs was in the 4–11-year-old age group at 61.7%, and when combined with the 12–29-year-old group, accounted for 83.0% of the total SCIs. Of the 96 individuals who had dance-related SCIs, 89 (92.7%) had thoracic SCI. All individuals were female, and 85.4% of them were aged between 4 and


7 years. Of these, 42 had injured segments in T9–11. Further, 90 (93.8%) and 6 (6.2%) individuals had SCIs due to performing the bridge and handstands during practice, respectively.

For the injured water sports patients (n =24), 13 (54.2%) were injured hitting the bottom of the pool after diving; 5 (20.8%) from falling into the pool; 2 (8.3%) from being hit by waves on the beach; the other 4 patients were injured due to water skiing, jet ski accident, breaststroke training, and swimming with neck degeneration. Most of the individuals with water-sport-related SCI were men, and 75% were younger than 32 years old. Further, most of the individuals had a cervical SCI, with 18 (75.0%) having injured segments in C4–6.

There were 7 injured martial artists and 3 of those had been doing a bridge, similar to the dancers. Of the 6 climbers, 3 fell down a mountain. All 6 trampolinists fell headfirst while bouncing and all had C-spine injury.


This study examined the incidence and severity of adverse events (AEs) involving patients receiving chiropractic spinal manipulative therapy (SMT), with the hypothesis that <1 per 100,000 SMT sessions results in a grade ≥3 (severe) AE. A secondary objective was to examine independent predictors of grade ≥3 AEs. Patients with SMT-related AEs from January 2017 through August 2022 across 30 chiropractic clinics in Hong Kong. AE data were extracted from a complaint log, including solicited patient surveys, complaints and clinician reports, and corroborated by medical records. AEs were independently graded 1–5 based on severity (1, mild; 2, moderate; 3, severe; 4, life-threatening; and 5, death). Among 960,140 SMT sessions for 54,846 patients, 39 AEs were identified, two were grade 3 (both of which were rib fractures occurring in women age >60 with osteoporosis) and none were grade ≥4, yielding an incidence of grade ≥3 AEs of 0.21 per 100,000 SMT sessions. There were no AEs related to stroke or cauda equina syndrome. The sample size was insufficient to identify predictors of grade ≥3 AEs using multiple logistic regression. In this study, severe SMT-related AEs were reassuringly very rare.

Co-Kinetic comment

Rib fractures!! Is not screening for dangers one of the purposes of taking a patient history? Stick to: Can I hurt you? Can you hurt me? and if in doubt don’t do it.

Another 5 fell off a horizontal bar and 5 were doing aerobics. The most common injured segment was C4–5. Of the 3 air sports participants, 1 was paragliding, 1 skydiving and 1 had a high-altitude crash in a hot air balloon. There were also a couple of horse riders, 2 motorcyclists and a gymnast doing the dreaded bridge.

Co-Kinetic comment

Although this is a Chinese study it starts with a round-up of sport-related SCIs from around the world and the disturbing fact is that they are on the increase. In New Zealand, the proportion of sport-related SCI increased from 11.0% in 1993 to 22.0% in 2020, and in Canada from 9.3% in 2004 to 17.9% in 2012. The highest SCI figure was from Russia at 32.9% and the lowest in Nigeria at 1.7%. They are rising in China as well. The number of ways that humans can break themselves while engaged in an activity that is supposed to improve their health is truly frightening. What is worse is that so many of these incredibly active sporting individuals were so young and sadly the study reports that most of their injuries were measured on the high end of the American Spinal Injury Association Impairment Scale with little hope for improvement in their condition as there is currently no effective treatment for SCI.


This systematic review aimed to compare the effects of exercise in outdoor environments versus indoor environments on psychological health, physical health, and physical activity behaviour. The ‘usual suspect’ databases were searched for randomised and non-randomised trials that compared multiple bouts of exercise in outdoor versus indoor environments, and that assessed at least one outcome related to physical health, psychological health, or physical activity behaviour. This identified 10 eligible trials, including 7 RCTs, and a total of 343 participants. Participant demographics, exercise protocols and outcomes varied widely. In the 10 eligible studies, a total of 99 comparisons were made between outdoor and indoor exercise; all 25 statistically significant comparisons favoured outdoor exercise. Interpretation of findings was hindered by an overall high risk of bias, unclear reporting, and high outcome heterogeneity. There is limited evidence for added health or behaviour benefits of outdoor exercise versus indoor exercise.

Co-Kinetic comment

In or out, shake it all about. It’s slightly better outside but one wonders how many of the outdoor types are willing to risk a dark February night on the streets of a wet and windy British city?

Co-Kinetic Journal 2023;96(April):4-11 10


The term ‘temporomandibular disorder’ is a catch-all name used for pain and dysfunction at the temporomandibular joint. Manual therapy or exercise therapy has proven to be an effective measure for pain relief. The purpose of this study was to compare the effectiveness of manual therapy and exercise therapy in temporomandibular disorders. A convenience sample of 24 patients aged between 18 and 55 years were involved in the study. They were randomly assigned to either a manual therapy group or an exercise therapy group. They received 3 sessions of treatment per week for 6 weeks. The participants were assessed before

The aim of this study was to investigate the effects of manual therapy on pain intensity, maximum mouth opening (MMO) and disability. Searches were conducted in six databases for RCTs. Twenty trials met the eligibility criteria and were included. For pain intensity, highand moderate-quality evidence demonstrated the additional effects of manual therapy at short- and long-term. For MMO, moderate- to

The International Olympic Committee (IOC) recently released a sports-generic consensus statement outlining methods for recording and reporting epidemiological data on injury and illness in sport and encouraged the development of sportspecific extensions.

The Fédération

Internationale de Football Association (FIFA) Medical Scientific Advisory Board established a panel of 16 football medicine and/or science

and after the intervention through the numeric pain rating scale (NPRS) for pain, patient-specific functional scale (PSFS) for function, Fonesca amnestic index (FAI) for the severity of condition, and millimetre mouth opening (MMO) for ranges. The manual therapy group showed a statistically significant difference in pre- and post-treatment NPRS, PSFS, FAI and MMO scores.

Co-Kinetic comment

Sadly neither intervention is described in sufficient detail to recreate what was done. The manual therapy was described as mobilisation with movement, soft-tissue mobilisation, myofascial release, muscle energy techniques and active isolated stretching. The exercise therapy was described as Racabado exercises, isometric exercises, strengthening exercises, resistive exercises, and stretching exercise. We need more than this.


high-quality evidence was found in favour of manual therapy alone and its additional effects at short- and long-term. Moderatequality evidence demonstrated an additional effect of manual therapy for disability.

Co-Kinetic comment

TMJ studies are like London buses. You wait ages for one and then two come along at the same time. As in the other TMJ paper, manual therapy comes out strongly, but there are few specific details which don’t help busy clinicians much. To obtain the results the authors screened titles and abstracts of 3630 papers. Is there too much research out there?


experts, two players and one coach. With a foundation in the IOC consensus statement, the panel performed literature reviews on each included subtopic and came up with a football extension to the basic IOC model.

The main amendments from the IOC consensus statement were to use football-specific terminology, to define return-to-football after a

health problem, to categorise the severity of a health problem in more detail, and to define match and peri-match exposures. The paper includes a table of the relevant terminology.

Co-Kinetic comment

One of the big complaints from researchers trying to do metaanalysis of data in our industry is the lack of consensus in data collection, which makes it difficult to pool results. This may help in the injury reporting field and, by extension, injury prevention. If you work in football and collect injury data, this paper is a must-read. It’s open access so easy to obtain. Both the IOC and FIFA can get bad press at times but, despite questions over their politics and finance, their medical departments regularly come up with good stuff. They do take their time though – this 2020 statement was not published until January 2023. 11 OPEN

Move it or Lose it How Exercise Can Help Combat Arthritis

Reduces joint pain: Exercise helps to strengthen the muscles surrounding the joints, which can help to reduce joint pain and stiffness.

Improves mood: Exercise improves mood and reduces symptoms of anxiety and depression, which is common in people with arthritis.

Boosts cardiovascular health: Exercise increases heart rate, blood circulation, and oxygen uptake, reducing the risk of heart disease and stroke.

Maintains a healthy weight: This is important as excess weight can put extra strain on the joints and make symptoms worse.

Improves joint function: It also promotes flexibility and range of motion, making it easier to move the affected joints and perform daily activities.

Reduces the risk of co-morbidities: Exercise reduces the risk of developing co-morbidities such as diabetes, hypertension, and obesity.

It is important to note that exercise should be tailored to the individual’s abilities and specific type of arthritis, and that a doctor or physical therapist should be consulted before starting any exercise programme.

Lovingly produced by 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 2023 Scan this QR code to add your own branding and print your own copy through Canva

About Arthritis The Truth Debunking Common Myths

Exercise makes arthritis worse.

Regular exercise actually helps improve joint mobility, reduce pain and increase overall fitness.

Painful joints is a symptom of arthritis, but doesn’t always mean damage is being caused. Pain may be due to inflammation or irritation, which can occur without damage to the joint itself.

There is nothing you can do to prevent or treat arthritis.

While there’s no cure for arthritis, there are many treatments and lifestyle changes that can help.

Arthritis only affects the elderly.

Arthritis can affect people of all ages, including children.

Arthritis is a normal part of aging.

Arthritis is not an inevitable part of aging, many people can live their entire lives without developing it.

Arthritis is always painful.

While pain is a common symptom of arthritis, not everyone experiences it.

Lovingly produced by 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 2023 Scan this QR code to add your own branding and print your own copy through Canva
Painful joints means the joints are being damaged.

Physical Therapy Intervention for Patients with Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a relatively common disease affecting approximately 1% of adults. It is a chronic, systemic autoimmune disease that affects the joints of the hands, wrists, shoulders, elbows, knees, ankles and feet. RA can present with a range of symptoms, including joint swelling, chronic pain, stiffness, restricted or limited joint range of motion and fatigue. Other body systems can also be affected, such as the cardiovascular and respiratory systems. Together, the symptoms can result in the individual being limited in (i) daily activities (including self-care and performing household activities) and (ii) social participation (work and leisure activities) (1*).

The past decades have resulted in advancements in medical treatment, and a variety of effective disease-modifying antirheumatic drugs (DMARDs) are now available. The range of options includes (i) conventional synthetic DMARDs (eg. methotrexate), (ii) targeted synthetic DMARDs (eg. Janus kinase inhibitors), and (iii) biological DMARDs (monoclonal antibodies targeting tumour necrosis factor or other inflammation-causing molecules). Early and aggressive treatment, targeting remission and tight symptom control, appears to provide the best results. However, despite this, many patients still have persisting or recurring disease, with or without joint damage. Additionally, there is increasing evidence showing that patients with

Rheumatoid arthritis (RA) is a relatively common, systemic, autoimmune disease affecting approximately 1% of adults. Symptoms typically occur in joints in the limbs, but RA can also affect the cardiovascular and respiratory systems. Although medication for RA has advanced, education and physical therapy remain crucial in good management of the disease. This article summarises how to assess and categorise patients with RA, which then allows the therapist to provide an appropriate and individually tailored exercise and activity plan for maximum benefit to their patients. Read this article online

inflammatory joint diseases are at an increased risk of cardiovascular disease (2*). According to the latest insights from research and clinical practice, physical therapy is a crucial element in the management of RA (1*,3*), and the cornerstone of this treatment is exercise therapy and education. Therapists need to empower their patients towards self-management, making treatment effective (and also cost-effective) in the long term. This article will highlight the current recommendations for diagnosing and treating patients with RA by physical therapists.

1. Assessment of a Patient with RA

The recommendations for assessment are based on ‘best practice’, ie. expert opinion. The World Health Organization’s International Classification of Functioning,

Disability and Health (ICF) Core

Set for RA provides the basis for a comprehensive assessment (4*). The ICF conceptualises a person’s level of functioning as a dynamic interaction between their health condition, environmental factors and personal factors. It is a biopsychosocial model of disability, based on an integration of the social and medical models of disability. It represents the typical spectrum in the functioning of RA patients with a selection of 96 categories over four components: (a) Body Functions, (b) Body Structures, (c) Activities and Participation, and (d) Environmental Factors (5). The Core Set can be further supplemented with a few factors relevant to physical therapy practice. Patient assessment requires careful history taking, the identification of red and yellow flags, and physical examination.

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

Co-Kinetic Journal 2023;96(April):14-24 14

1.1. History Taking

History taking should include:

l an inventory of the patient’s health and impact on daily life;

l information on the course of the disease; and

l previous and current medical treatment.

Table 1 presents examples of suggested or relevant questions when taking a patient’s history. The questions can be adapted to suit the therapist’s communication style and the patient’s communication level.

Identifying red and/or yellow flags is crucial during history taking. Yellow flags indicate psychosocial risk factors for poorer prognosis and red flags are indicators of severe pathology that may require additional medical evaluation. It is, therefore, vital that before and during treatment red flags (for example, signs of infection and neurological complications) are identified and patients are referred on immediately.

Red flags for RA include:

l unwanted weight loss >5kg per month (possible sign of malignancy);

l excessive night sweating (possible sign of infection or malignancy);

l warm and swollen (red) joints (possible signs of infectious inflammatory process of the joint, bacterial arthritis);

l fever or general malaise in the use of biologicals (possible signs of infectious inflammatory process);

l neck pain or pain in the back of the head, with or without ‘jumping’ legs, and/or a feeling of sand in the hands (possible signs of myeloma compression due to instability of the cervical spine with (sub)luxation of the first or second cervical vertebra);

l motor (paresis or paralysis) and/ or sensory (sensory impairment) symptoms (possible signs of polyneuropathy, mono neuritis or vasculitis);

l acute flaring of RA or sudden increase in symptoms (possible signs of active disease);

l sudden local motor failure (possible sign of tendon rupture of, for example, the extensor digitorum communis/indices muscle, the

extensor pollicis longus muscle or the biceps brachii muscle); and

l severe pain in the back, whether or not after falling (possibly a vertebral fracture in case of osteoporosis after prolonged corticosteroid use) (1*).

1.2. Physical Examination

The physical examination should involve:

l examining and documenting the patient’s current disease activity (extent and severity of joint pain, swelling and limited joint range of motion);

l noting structural joint damage and deformities;

l assessing general exercise tolerance; and

l assessing muscle function.

All the joints (not only the peripheral joints) and peri-articular structures that can be affected by RA must be assessed, including the cervical spine and jaw. Assessments should not be limited to the symptomatic joints alone. Some joints in which symptoms are latent may only have subtle


swelling or a limited range of motion – these too should be assessed during the physical examination (6). Detailed assessment points are available in Table 2.

The measurement instruments shown in Figure 1 should be used by physical therapists to support the diagnosis and evaluation when treating patients with RA (1*).

2. Treatment of Patients with RA

The literature emphasises the importance of physical therapy in two main areas of RA management. Firstly, RA patients should have access to

Rheumatoid arthritis (RA) measurement tools

Body structures and functions

Recommended: NRS pain and fatigue, BORG scale 6–20

Optional: 1RM submax test, HHD


Recommended: HAQ, PSC, 6-minute walk test

Optional: Quick DASH, accelero meter/step counter, MET-method


Recommended: PSK

Optional: WPAI

External factors

Personal factors

DASH, disability of arm, shoulder and hand questionnaire; HAQ, health assessment questionnaire disability index; HHD, hand-held dynamometer; MET, metabolic equivalent of task; NRS, numerical rating scale; PSC, patient-specific complaint instrument; PSC/PSK, patient-specific functional scale; RM, repetition maximum; WPAI, work productivity and activity impairment.

Figure 1: Measurement tools for RA assessment Reproduced with permission from Peter WF, Swart NM, Meerhoff GA, Fliet Vlieland TPM. Clinical practice guideline for physical therapist management of people with rheumatoid arthritis. Physical Therapy 2021;101(8):pzab127 (1*), revision of the 2008 Royal Dutch Society of Physical Therapy guideline


Table 1: Relevant questions for history taking in patients with RA Reproduced with permission from Peter WF, Swart NM, Meerhoff GA, Fliet Vlieland TPM. Clinical practice guideline for physical therapist management of people with rheumatoid arthritis. Physical Therapy 2021;101(8):pzab127 (1*), revision of the 2008 Royal Dutch Society of Physical Therapy guideline

History-taking items

Relevant questions



l What is the patient’s need for assistance? (PSC)

l What are the expectations regarding physical or exercise therapy?

l What are the expectations regarding the progression of the symptoms?

Functions and anatomical characteristics

l Is there pain in 1 or more joints? (NPRS)

l What is the location of the pain (which joints)?

l Is the pain related to exertion?

l What is the progression of the pain in the morning, afternoon, evening, or night time?

l Is there inexplicable, persistent severe pain and/or inflammatory symptoms in 1 or more joints? (potential red flag)

l Is there morning stiffness and/or start-up stiffness? If so, for how long?

l Is there swelling of 1 or more joints? If so, which joints?

l Is there limited range of motion and/or stiffness in 1 or more joints? If so, which joints?

l Is there fatigue? (NRS fatigue)

l Is there reduced muscle strength? If so, where and during which activities?

l Is there decreased endurance?

l Are there skin problems (ulcers) or nail fold infarcts that may be associated with RA?

l Are there problems when chewing or swallowing?

l Is there dry mouth and/or dry eyes, for example as a result of Sjögren’s syndrome?

l Is there high blood pressure? (cardiovascular risk factor)

l Is there high cholesterol? (cardiovascular risk factor)

l Is there neck pain and/or pain in the back of the head, in combination with paraesthesia and/or dysesthesia, motor deficit, ‘twitching’ legs, and/or a sandy feeling in the hands? (neurological symptoms that could indicate a red flag)

l Are there sensory disorders? (potential red flags)

l Are there balance problems? (potential red flags)

l Are there sleep problems?

l Is there a sudden increase of symptoms or an acute RA flare-up? (potential red flag)

l Is there severe back pain, possibly after a fall? [potential red flag with osteoporosis and (long-term) corticosteroid use]

l Are there signs of infection somewhere other than in the joints, possibly accompanied by fever and/or general malaise? (potential red flag with the use of biologicals)

Activities (PSC)

Activities (PSC)

l Are there limitations to performing activities of daily living and/or functions such as:

l changing posture (eg. turning around in bed, getting up from bed, sitting down)

l self-care, such as getting dressed and undressed, showering, combing hair (optional measurement instrument for arm and hand function; Quick-DASH)

l walking (at home or outside), climbing stairs

l picking up items from the ground

l writing or other fine motor activities

l eating and/or drinking

l cycling, driving a car, or using public transportation

l sexual activities

l Does the patient meet the Physical Activity Guidelines?

l If so, with which activities and for how many minutes per week?

l If not, what is the most important impeding factor?

l Which degree of physical activity is achieved? With which activities and for how many minutes per week? (optional measurement instrument: accelerometer/pedometer or the MET method)

Co-Kinetic Journal 2023;96(April):14-24 16

History-taking items


Relevant questions

l What is the family situation? (to assess the daily exertion compared to the capacity)

l Are there limitations resulting from the symptoms in:

l relationships and/or social contacts?

l paid or volunteer work? (optional measurement instrument: WPAI)

l free time, eg. when playing sports or engaging in hobbies?

l quality of life (optional measurement instrument: RAQoL)

External factors

l Is there a family history of RA?

l Is there a family history of cardiovascular disease?

l How do the people surrounding the patient (partner, family, friends, co-workers) respond to the symptoms?

l What is the patient’s living situation? Are there stairs in the house and how does the patient do climbing these stairs?

l Does the patient use medication? If so, which ones? What is the effect of the medication? Are there side effects? If so, which ones?

l Has the patient previously undergone physical or exercise therapy for RA? If so, what was the result?

l Other than the rheumatologist, is there another medical specialist or other healthcare provider involved with the patient for treating the RA or related co-morbidity?

l Does the patient use modifications, aids, or facilities for activities of daily living or household tasks? How about at work or during sport or leisure activities?

l Does the patient use a walking aid? If so, what is the effect?

l Does the patient use an aid to perform activities? (standing support, stand-up chair, wheeled stool, knee support)? If so, what is the effect?

l Has any surgery been performed in the past (for example, joint replacement surgery or tendon surgery)? If so, how long ago did this take place and how did the recovery progress?

Personal factors

l What are the patient’s views regarding exercise?

l How does the patient handle the complaints in his/her daily life?

l What measures has the patient undertaken to influence his/her complaints, such as resting/exercise, and are these helping?

l Presence of the following conditions:

l Co-morbidity? If so, which ones? Does this influence the patient’s functional movement and/or exercise capacity?

l Overweight? (cardiovascular risk factor)

l Smoking? If so, how much does the patient smoke? (cardiovascular risk factor)

l Facilitating or inhibiting factors towards exercise? If so, which ones?

l A need for information about RA and the treatment?

l Fear, for example of falling?

DASH, disability of arm, shoulder and hand questionnaire; MET, metabolic equivalent of tasks; NPRS, numeric pain rating scale; NRS fatigue, fatigue numeric rating scale; PSC, patient-specific complaint; RAQoL, rheumatoid arthritis-specific quality of life questionnaire; WPAI, work productivity and activity impairment.

Table 1

Table 2: Relevant points of attention during the physical examination of patients with RA Reproduced with permission from Peter WF, Swart NM, Meerhoff GA, Fliet Vlieland TPM. Clinical practice guideline for physical therapist management of people with rheumatoid arthritis. Physical Therapy 2021;101(8):pzab127 (1*), revision of the 2008 Royal Dutch Society of Physical Therapy guideline

Where is the pain reported (which joints)? During which movement(s) does the pain occur in the respective joints?

Is there any swelling of the respective joints? If so, which joint(s) and to which degree (slight, moderate, or severe). Is the swelling diffuse or localised?

Are there changes in position or deformities of the joint(s), in particular the hands, wrists, or feet?

Is there any swelling of the joints or surrounding structures (eg. tendons, bursae)?

Is there any temperature increase of the joint(s)?

Is palpation painful?

Are there changes in position or deformities of the joint(s), in particular the hands, wrists, or feet?

Active movement examination:

l determination of the range of motion of all joints of the upper and lower extremities and of the cervical spine in all directions;

l assessment of the combined shoulder and elbow function by having the patient perform several combined movements (eg. the hair combing movement).

Passive movement examination of the joints with limited range of motion that was determined during the active movement examination.


l the muscle weakness and muscle endurance of the upper and lower extremities;

l the active and passive stability, muscle length and proprioception;

l the static and dynamic balance;

l the sensitivity of primarily the upper extremities (potential red flag);

l the hand function (movement examination), but also coordination, gripping function, and the functioning of the flexor and extensor tendons in the hand (including tendon gliding);

l the physical functioning [(6MWT) is a supporting functional test to estimate the physical functioning and to use as a baseline measurement for the treatment];

l the aerobic capacity [eg. with the help of the Borg scale (6–20) or the heart rate].


6MWT, six-minute walk test.

Assessment of:

l the gait pattern; such as heel strike, ankle function, knee function (is there, for example, a flexion contracture?) and hip function (is there, for example, a Trendelenburg sign?), trunk rotation, and arm function;

l the quality of movement during functional activities, such as standing, getting up and sitting down, bending, transfers, getting (un)dressed, walking up/down stairs, reaching and gripping, picking something up from the floor, and writing;

l specific activities that are restricted during work, sports, or other leisure activities;

l use of aids;

l performance of other specific activities where symptoms are reported.

Co-Kinetic Journal 2023;96(April):14-24 18 General Activities (PSC) Functions and anatomical characteristics Inspection Palpation Functional examination Inspection
Examination area Examination component Points of attention

Table 3: Patient profiles for physical therapy in patients with RA Reproduced with permission from Peter WF, Swart NM, Meerhoff GA, Fliet Vlieland TPM. Clinical practice guideline for physical therapist management of people with rheumatoid arthritis. Physical Therapy 2021;101(8):pzab127 (1*), revision of the 2008 Royal Dutch Society of Physical Therapy guideline

Patient profile Description


l A need for information, advice, instruction and practical tools when exercising and (again) moving and/or;

l A need for more insight into the disease, the symptoms and course of RA, and the consequences for physical functioning and social participation and/or;

l A need for information about the physical therapists or remedial therapeutic treatment options and the own role in them and/or;

l A need for information about the possible health effects of appropriate exercises and an active lifestyle and the own role therein and/or;

l A need for information about the practical possibilities of participating independently or with the help of others (eg. informal carers, care providers other than physical therapists or remedial therapists, sports/fitness instructors, etc) in the regular or adapted range of sports and exercise activities to obtain and maintain sufficient physical activity and/or;

l A request for help that relates to aspects such as: limitations in self-regulation skills related to physical activity, or the availability of exercise options and social support.

l A request for help in the area of RA-related complaints, and related disorders and limitations in daily activities and/or social participation, which cannot be solved by short-term information, advice, and instruction alone and/or;

l A need for more and longer guidance to be able to carry out an exercise programme independently and to obtain and maintain sufficient physical activity.

l Restriction(s) in basic daily activities and social participation as a result of which the patient is not able to independently obtain or maintain an adequate level of functioning and/or;

l A high disease activity based on the clinical picture that cannot be regulated adequately with medication and/or;

l Serious joint damage and/or;

l Serious joint deformations and/or;

l Presence of risk factors for delayed recovery that hinder the implementation of remedial therapy (eg. co-morbidity) and/or;

l Presence of psychosocial factors (yellow flags) in combination with inadequate pain coping.

evidence-based non-pharmacological treatment, and secondly that people with RA should understand the importance of and benefit of exercise and physical activity in managing their disease. That exercise or activity should be advised appropriately for the individual. Patients may need support regarding their RA-related problems and ensuing limitations in daily activities/sports/social participation. Similarly, if a patient is unable to achieve or maintain an adequate level of exercise or physical activity, physical therapy guidance would be deemed necessary (7*,8).

Depending on the assessment findings and consideration of red flags, physical exercise may be regarded as an absolute contraindication for worsening symptoms. In this case, modification of exercise therapy prescription and physical therapy treatment may be necessary. To assist in this, the literature suggests classifying patients with RA into one of three treatment profiles. These profiles are based on the patient’s needs, requirements for guidance and supervision, the complexity and severity of problems, limited selfmanagement skills and co-morbidities

or complications. The profiles are expanded on in Table 3.

2.1. Education

The goal of treating a patient with RA is to achieve effective selfmanagement. Information and advice should be customised to support their needs and to optimise their health and wellbeing. Key points are to (i) emphasise the importance of exercise and a healthy lifestyle (including decreasing stress and fatigue and the way this lifestyle can be achieved and maintained), and (ii) provide treatment options.

19 PHYSICAL THERAPY General 1 Need for information, advice, and instructions for mainly independently performed exercises Need for information, advice, instruction, and exercise therapy with brief physical therapy guidance 2 Need for information, advice, instruction, and exercise therapy with intensive and/or long-term supervision of a physical therapist 3

Table 4: FITT factors for exercise therapy in patients with RA Reproduced with permission from Peter WF, Swart NM, Meerhoff GA, Fliet Vlieland TPM. Clinical practice guideline for physical therapist management of people with rheumatoid arthritis. Physical Therapy 2021;101(8):pzab127 (1*), revision of the 2008 Royal Dutch Society of Physical Therapy guideline

Factors for exercise therapy

Frequency Intensity Type

Patient goals

Aim that the patient preferably performs daily, but at least 2 days/week (for muscle strengthening/functional exercises) to at least 5 days/week at least 30min at a time (for aerobic exercises).

Start with 1 to 2× weekly guided exercise therapy, supplemented with independently performed exercises and complete the guidance during the treatment period.

Aim for the following minimum intensity for muscle strength and aerobic training.

l Muscle strength training:

60–80% of 1 repetition maximum (1RM) (≈Borg score 14–17) [or 50–60% of 1RM (≈Borg score 12–13) for people not accustomed to strength training] with 2 to 4 sets of 8 to 15 repetitions with 30–60s rest between sets.

l Aerobic training:

>60% of maximum heart rate (≈Borg score 14–17) [or 40–60% of maximum heart rate (≈Borg score 12–13) for people not used to aerobic training]. Ensure a gradual build-up in intensity during the programme and follow the training principles.

Offer a combination of the following.

Muscle strength training:

l Choose exercises primarily aimed at the large muscle groups around the knee and hip joint (especially knee extensors, hip abductors, and knee flexors).

l Have these exercises performed on both legs (for hip and knee osteoarthritis, both for unilateral and bilateral arthritis).

l Choose both functional exercises with your own body weight and exercises with devices. Exercises with high mechanical knee load (eg. ‘leg extension device’) should preferably be avoided in case of knee osteoarthritis and after joint replacement surgery of the knee.

Aerobic training:

l Choose activities with relatively low joint load, such as walking, cycling, swimming, rowing, or cross-trainer.

Functional training:

l Choose (parts of) activities that are hindered in the patient’s daily life (eg. walking, climbing stairs, sitting down and getting up from a chair, lifting or packing large or small objects) by exercising (parts of) these activities.

l Consider offering specific balance and/or coordination/neuromuscular training in addition to exercise therapy if there are disturbances in balance and/or coordination/neuromuscular control that interfere with the patient’s functioning.

l Consider offering (active) range-of-motion or muscle stretching exercises in addition to the exercise therapy if there are muscle shortening and/or reversible mobility limitations of the joint that interfere with the patient’s functioning.

Patient education is proven to provide a small but positive effect on self-reported pain, fatigue, activity limitations, and physical activity. Education should support the patient in disease understanding, in how best to be physically active yet

distribute their energy over the day and/or week. RA patients should be able to acknowledge that there may be barriers to exercise and physical activity. A lack of education on this may result in a lack of social support, pain, fatigue or fear that exercise may

damage their joints.

Patients therefore need to be educated that individually tailored exercise and/or physical activity has a beneficial effect on muscle strength, aerobic capacity, daily functioning, disease activity and mental health; and that being physically active has protective benefits that are particularly important for RA patients who have an increased risk of cardiovascular disease (7*,8,9*,10*).

Therefore education by the physical therapist should provide:

Co-Kinetic Journal 2023;96(April):14-24 20

Table 4

Factors for exercise therapy


Patient goals

l Aim for a treatment period between 3 and 6 months, supplemented by 1 or more follow-up sessions after completion of this treatment period to encourage compliance.

l Encourage the patient to continue practising independently after the treatment period.

General points of attention

l Offer exercise therapy in combination with instructions for independently performed exercises or activities to promote physical activity. Observe the Health Council of the Netherlands Movement Guidelines.

l In the case of RA, accompany and motivate the patient when moving with specific barriers such as pain, stiffness, fatigue and fear of worsening the disease.

l In patients with hand problems, consider a specific exercise programme for the hand. The patient can be referred to a physical therapist or remedial therapist or occupational therapist with specific expertise in the field of the (rheumatic) hand.

l Consider water-based exercise therapy in the initial phase of treatment if there are serious pain symptoms during exercise.

l Consider using the MET method (see measuring instruments) when estimating exercise capacity.

l Consider the use of e-health applications to support the patient in performing or continuing to perform exercises independently and/or to reduce the level of supervision.

l Consider offering group exercise therapy if little individual support is required.

Training principles for people with RA

l Precede the workout with a warm-up and finish with a cooling-down.

l Determine the starting intensity of the strength training and monitor the intensity during the treatment using the 1RM submaximal test.

l Determine the starting intensity of the aerobic training and monitor the intensity during treatment using heart rate and/or Borg score.

l Gradually increase the intensity of training to the maximum level possible for the patient.

l Reduce the intensity of the next workout if joint pain increases after the workout and persists for more than 2h.

l Start with a short period of 10min (or less if necessary) in aerobic exercises, in patients who are untrained and/or limited by joint pain and mobility.

l Offer alternative exercises using the same muscle groups and energy systems if the exercise leads to an increase in joint pain.

l When adjusting training intensity, use variation in sets and repetitions (in strength), intensity, duration of session or exercise, type of exercise, and rest rests and determine the adjustment in consultation with the patient.

FITT, frequency, intensity, type, and time frame; MET, metabolic equivalent of tasks; 1RM, 1 repetition maximum.

l information about the condition and strategies to reduce disability;

l instruction and advice regarding specific activities, for example, distributing load over multiple joints when lifting or carrying or using assistive devices;

l instruction and advice on patientspecific exercises and promoting an active lifestyle;

l support for the patient to choose the best physical activities to distribute their energy over the day/week (teach patients about pacing);

l understanding of the barriers for some exercise; and

l education regarding behavioural change – this is essential to ensure an ongoing commitment to an active lifestyle, and a sustained integration of exercise into their daily lives (Box 1) (8).

2.2. Exercise Therapy Recommendations for exercise therapy

in patients with RA are taken from guidelines on physical activity and arthritis as well as from systematic


reviews of randomised controlled trials (RCTs) (Table 4) (4*,7*,8).

Exercise therapy should be offered with instruction to ultimately perform activities independently. Motivation and support are necessary when moving RA patients through activities that carry specific barriers such as pain, fatigue, stiffness and fear of worsening the disease. In patients with hand problems, a specific hand exercise programme as well as referral to a remedial therapist or occupational therapist with specific expertise may be necessary. Waterbased exercise therapy in the initial phase of treatment or in those whose symptoms flare during exercise may be beneficial. Estimating exercise capacity can be challenging, thus considering

the use of the metabolic equivalent of task (MET) method may help. In order to progressively reduce supervision, ultimately having the patient perform their exercises independently, e-health/ telehealth or a group therapy class could be suggested.

According to the guidelines of the American College of Sports Medicine for patients with arthritis (7*), the intensity of muscle-strengthening exercises should be built up from 50–60% of the 1-repetition maximum to 60–80% of the 1-repetition maximum. The intensity of aerobic exercise should be built up from 40–60% of the maximum heart rate to more than 60% of the maximum heart rate (7*). This will clearly vary depending on the starting capacity of the patient and must be

Box 1: Principles of behavioural interventions based on theories of behavioural change Reproduced with permission from Peter WF, Swart NM, Meerhoff GA, Fliet Vlieland TPM. Clinical practice guideline for physical therapist management of people with rheumatoid arthritis. Physical Therapy 2021;101(8):pzab127 (1*), revision of the 2008 Royal Dutch Society of Physical Therapy guideline

✓ Take into account the phase of behavioural change in which the patient finds himself/herself.

✓ Formulate achievable goals in consultation with the patient.

✓ Provide good instructions that allow the patient to know and understand what he or she should or can do.

✓ Ensure that there is sufficient variation during the exercise sessions.

✓ Integrate individual exercises and physical activities into daily life and teach the patient to integrate individual exercises and physical activities into daily life to increase effectiveness.

✓ Make sure the patient becomes independent of the therapeutic support.

✓ Help the patient to prevent relapse into the old (inactive) movement behaviour.

✓ Inform the patient about progress and teach the patient to monitor this himself/herself.

✓ Involve the patient’s environment (partner, children, friends, etc.) to support the change in movement behaviour.

✓ Encourage confidence in the patient’s own abilities.

✓ Evaluate with the patient what is effective and what is not.

✓ Help the patient to continue to pursue their own goals.

✓ Teach the patient to deal with negative emotions and stress that can hinder the achievement of set goals.

adjusted regularly. It is important that the frequency of exercising does not decrease as the emphasis shifts from supervised to non-supervised exercise. Table 5 shows the exercise recommendations specific to the three patient groups.

It may be challenging to determine which exercise and physical activity plans should best be tailored to the individual patient when co-morbidities are present, as in ‘patient profile 3’. Co-morbidity occurs relatively frequently in patients with RA because of (complications of) the disease and/or medication use and/or independently of RA. Modified exercise therapy for such patients also requires specific knowledge and skills relating to the individual patient’s co-morbidities (11,12). The general rule of ‘unskilled is unauthorised’ would apply here. If the treating therapist has insufficient knowledge and skills regarding the patient’s co-morbidity, then the patient should be referred to another therapist.

2.3. Other Therapeutic Interventions and Passive Mobilisations

In patients with RA, evidence suggests you should not offer interventions including low-level laser therapy, electrostimulation (including transcutaneous electrical nerve stimulation), ultrasound, massage, thermotherapy, medical taping or dry needling. In addition to this, passive mobilisation of joints and muscles should preferably not be offered to patients with RA. This is based on a lack/absence of evidence or low-/poor-quality evidence.

Short-term passive mobilisation of an affected joint may be considered only as an exception to support exercise therapy to increase joint mobility in patients without active inflammation. Current evidence for this neither supports nor opposes the intervention. However, it is strongly

Co-Kinetic Journal 2023;96(April):14-24 22

Table 5: Specific Recommendations per patient profile Sourced from Peter WF, Swart NM, Meerhoff GA, Fliet Vlieland TPM. Clinical practice guideline for physical therapist management of people with rheumatoid arthritis. Physical Therapy 2021;101(8):pzab127 (1*), revision of the 2008 Royal Dutch Society of Physical Therapy guideline

Patient profile

General Profile 1

l Primary focus is education, advice and instruction

l Based on moderate effect of unsupervised exercise therapy on quality of life (QoL), physical functioning and a large effect on pain in patients with RA

l Small effect size on muscle strength, disease activity and positive effect on radiological damage

Exercise recommendations

l Ensure that exercises are aligned with the patient’s request for help

l Individually tailored exercise and physical activity plan should be developed, with limited supervision to monitor the appropriate performance

l Appropriate advice and instruction for patients to perform exercises on their own

l Maximum of 3–6 sessions over period of 3–6 months

l Treatments consecutively or spread over the time

l Re-evaluate every 8 weeks

Profile 2

l Primary focus is intermittent or short-term supervised exercise therapy

l Based on patients with RA receiving supervised exercise therapy having large effect size on QoL, muscle strength and mobility

l Moderate effect on physical functioning, aerobic capacity and pain

l Small positive effect on disease activity and radiological damage

Profile 3

l Patients have serious/progressive functional disability due to severe co-morbidities or complications

l Primary focus is intensified supervised exercise therapy

l No RCT on this patient group. Advice should be based on expert opinion

l Instructions for exercises to be done primarily independently and a concise period of supervision

l Individualised exercise and physical activity plan

l Independently performed home exercise programme

l Supplemented with supervised exercise therapy 2× week in initial phase

l Longstanding, supervised therapy

l Frequency, intensity, and duration of the exercise therapy will depend on patient’s health status

l i3-S model (11): a 3-step inventory of:

o relevant comorbid diseases

o contraindications and restrictions to exercise

o potential adaptations to exercise therapy

l Maintaining and possibly improving daily functioning and social participation is treatment goal

l Given the varying nature and severity of the problem, treatment goals are regularly adjusted or new treatment goals set

suggested that passive mobilisations of cervical problems should not be offered. These recommendations align with the use of treatment modalities in the Choose Wisely campaign of the American Physical Therapy Association (13*).

Final Words

The evidence discussed in this article comes from the latest physical therapy guidelines for the assessment and treatment of patients with RA (1*). These are based on scientific evidence and expert consensus, which show that the best outcomes from physical therapy treatment for RA patients include both active exercise therapy along with education, so that the patients understand why activity is important for managing their disease

and that it can be done safely and without causing further damage.


1. Peter WF, Swart NM, Meerhoff GA et al. Clinical practice guideline for physical therapist management of people with rheumatoid arthritis. Physical Therapy 2021;101(8):pzab127 Open access

2. Agca R, Heslinga SC, Rollefstad S et al. EULAR recommendations for cardiovascular disease risk management in patients with rheumatoid arthritis and other forms of inflammatory joint disorders: 2015/2016 update. Annals of the Rheumatic Diseases 2017;76:17–28 Open access

3. Combe B, Landewe R, Daien CI et al. 2016 update of the EULAR recommendations for the management of early arthritis. Annals of the Rheumatic Diseases 2017;76:948–59 Open access

4. Kirchberger I, Glaessel A, Stucki G et al. Validation of the comprehensive international classification of functioning, disability and health core set for rheumatoid arthritis: the perspective of physical therapists. Physical Therapy 2007;87:368–384 Open access

5. Bijlsma JWJ. EULAR textbook on rheumatic diseases. BMJ Publishing Group 2018. ISBN 978-0727918826. Buy from Amazon

6. Liguori G, American College of Sports Medicine. ACSM’s guidelines for exercise testing 23 PHYSICAL THERAPY

and prescription, 11th edn. Lippincott Williams and Wilkins 2021. ISBN 978-1975150198 (Print £33.34 Kindle £32.47). Buy from Amazon

7. Rausch Osthoff A-K, Niedermann K, Braun J et al. 2018 EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritis. Annals of the Rheumatic Diseases 2018;77:1251–1260 Open access

8. Stevens A, Köke A, van der Weijden T et al. The development of a patient-specific method for physiotherapy goal setting: a user-centered design. Disability and


Rehabilitation 2018;40:2048–2055

9. Zangi HA, Ndosi M, Adams J et al. EULAR recommendations for patient education for people with inflammatory arthritis. Annals of the Rheumatic Diseases 2015;74:954–962 Open access

10. Gwinnutt JM, Wieczorek M, Balanescu A et al. 2021 EULAR recommendations regarding lifestyle behaviours and work participation to prevent progression of rheumatic and musculoskeletal diseases. Annals of the Rheumatic Diseases 2023;82:48–56 Open access

11. Dekker J, de Rooij M, van der Leeden M. Exercise and comorbidity: the i3-S

l What are the key ‘comments’ during history taking, or findings on physical examination, that might indicate a sensitive patient susceptible to symptom flare-up with exercise therapy?

l Do you find the three patient profiles helpful in guiding treatment plans?

l How often do you encounter patients willing to work towards selfmanagement through exercise therapy versus those with a desire for greater support and passive interventions? How do you manage that from a psychosocial perspective?


l Despite recent advancements in pharmaceutical management, there is a substantial proportion of rheumatoid arthritis (RA) patients with persisting or recurring disease activity, with or without joint damage.

l Many individuals are limited in their daily activities, including self-care and performing household activities as well as social participation, work and leisure activities.

l The cornerstone of non-pharmacological treatment is exercise therapy and education.

l Patients need to be empowered towards self-management, making treatment effective but also cost-effective in the long term.

l A thorough history and examination, tailored towards physical therapy, is required to fully understand the biopsychosocial complexity of the disability and pain.

l RA patients should be classified into three treatment profiles based on their assessment.

l The profiles are based on patients’ needs, requirements for guidance and supervision, the complexity and severity of problems, limited selfmanagement skills and co-morbidities or complications.

l Patient education is proven to provide a small but positive effect on selfreported pain, fatigue, disease understanding, activity limitations and physical activity.

l Exercise therapy should follow the FITT (frequency, intensity, type, time) principles and progressively increase depending on the capacity of the patients and the irritability of their arthritis.

l Co-morbidity occurs frequently in patients with RA, thus modifications to exercise therapy may be required.

l Passive treatment interventions should play a subordinate role in managing patients with RA.

strategy for developing comorbidityrelated adaptations to exercise therapy. Disability and Rehabilitation 2016;38:905–909

12. van der Leeden M, Huijsmans RJ, Geleijn E, de Rooij M, Konings IR, Buffart LM, et al. Tailoring exercise interventions to comorbidities and treatment-induced adverse effects in patients with early stage breast cancer undergoing chemotherapy: a framework to support clinical decisions. Disability and Rehabilitation 2018;40:486–496

13. ‘Choosing Wisely’ app now available [website]. American Physical Therapy Association 2017


l Low Back Pain: Moving Back To Basics [Article]

l Pain Does Not Always Indicate Injury [Article]

l Rehabilitation adherence: is it time to prioritise?

l Gait retraining in medial osteoarthritis of the knee [Article]


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.


Co-Kinetic Journal 2023;96(April):14-24 24


‘If it hurts, rub it better’ is a course of action that has felt natural for probably as long as humans have existed. However, in these days of evidence-based therapy, we have to have clinical proof that a treatment works. If you are a regular reader of Co-Kinetic’s Journal Watch, you will know how difficult it is to find a good-quality study of massage, and massage seems to have fallen off the list of therapies for arthritis largely because of this. But we all know that absence of evidence is not evidence of absence. Reading this article, combined with knowing your arthritis patients, will help you to decide whether massage can be part of a treatment plan for those individuals. Read this article online


Of the different types of arthritis, osteoarthritis (OA) is the most common form affecting more than 300 million people worldwide. OA is the leading cause of disability in older adults, with the knee, hip and hands being the most commonly affected joints. Pathology may involve the whole joint, including cartilage degradation, bone remodelling, osteophyte formation and synovial inflammation. This leads to pain, stiffness, swelling and loss of normal joint function.

OA may span decades of a patient's life. During this time patients are likely to be treated with a range of pharmaceutical and nonpharmaceutical interventions, often in combination. Finding the right treatment for a patient may depend on the individual, the extent of their OA, and their socioeconomic situation. Some treatment recommendations are specific to a particular joint, whereas others are particular to a patient population (eg. those with erosive OA). Therapies recommended for the management of OA are shown in 'Figure 1. Recommended therapies for the management of osteoarthritis (OA)'

( in Kolasinski

et al. and are based on the strength of scientific evidence from randomised controlled clinical trials (1*).

Recommendations for OA treatment assume the appropriate application of physical, psychological, and/or pharmacologic therapies by an appropriate provider. For some patients at some time points, a single intervention may be adequate to control their symptoms; for others, multiple interventions may be used in sequence or in combination. These treatment options are listed in Figure 1 mentioned above and in 'Table 1. Recommendations for physical, psychosocial, and mind-body approaches for the management of osteoarthritis of the hand, knee, and hip' (, both in Kolasinski et al. (1*). What is evident is that massage therapy does not feature as a recommended treatment option in managing OA. In fact, in certain cases, the advice may be against the use of it in the management of OA.

Rheumatoid Arthritis

Rheumatoid arthritis (RA) is also common, affecting joints – especially of

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


the upper limbs (hands, wrist, elbow and shoulder). RA is defined as a systemic, idiopathic, inflammatory and autoimmune disease. It is three times more common in women than in men, most often affecting the 40–50-year age bracket. Symptoms of RA include chronic pain, swelling in the joints, loss of joint function, stiffness and often deformity. The joint inflammation, which leads to the symptoms listed above, can result in disability, psychosocial issues, mobility problems and a poor quality of life or poor sense of wellbeing.

Pharmacological interventions for RA include anti-inflammatory medications, anti-rheumatic medications, and analgesics. Longterm, frequent use of pharmaceutical medication and other invasive procedures (for example injections and joint replacements) for managing chronic pain can lead to further complications and stress. Complementary therapies have been reported to be useful, these may include (but not be limited to) exercise therapy, manual therapy, devices, hydrotherapy, acupuncture, education and massage. Evidence indicates that massage is a frequent complementary therapy used in the management of chronic conditions, especially chronic pain conditions (2,3*).

Likewise, the most recent guidelines published by Peter et al. for physical therapy management of RA stated that “the cornerstones of physical therapist treatment for people with RA are active exercise therapy in combination with education, whereas passive interventions play a subordinate role” (4*). They state that, based on systematic literature searches, the following non-active

exercise interventions are not recommended: electrotherapy (including transcutaneous electrical nerve stimulation), low-level laser therapy, ultrasound, massage (evidence absent), thermotherapy (evidence absent), medical taping (evidence absent), and dry needling (evidence absent). These recommendations align with the use of treatment modalities in the Choose Wisely campaign of the American Physical Therapy Association (4*,5*).

Studying the Effect of Massage

Massage therapy encompasses a number of techniques aimed at affecting muscle and other soft tissue. Clinical trials assessing massage efficacy have suffered from a high risk of bias, small sample sizes, and have not demonstrated significant benefits for arthritis outcomes. Massage may be more effective than non-active management but has not been shown to be superior to other recommended treatments (6). Studies often use massage in combination with other modalities which ‘muddies the water’ on its efficacy. It should be noted, however, that some studies have shown positive outcomes and minimal risk and the authors felt strongly that massage therapy was beneficial for symptom management (7*). However, based on the available evidence regarding OA and RA, there remains a conditional recommendation against the use of massage for the reduction of arthritis symptoms because of lowor moderate-quality evidence.

So Where Does that Leave Massage Therapy?

Therapeutic massage is a treatment that can be performed in a number of ways, with contrasting techniques. The modality can be offered to patients almost anywhere, requires no special equipment and has a low likelihood of any serious harm – making it easily accessible and affordable. Massage therapy itself can encompass many techniques, the type, pressure and time may depend on the patient’s needs or tolerance (3*).

As stated above, massage therapy has been the subject of hundreds of

clinical trials and dozens of systematic reviews, with varying results. Some outcomes show treatment efficacy in managing certain conditions or alleviating pain, whereas others have found massage not to be effective, or with unclear benefit to the patient. It can be difficult to interpret the breadth and depth of evidence, as various painful conditions may respond differently to therapeutic massage, and distinct types of massage involve unique approaches to manipulating muscles and soft tissue with varying results. There is a general bias in massage-based clinical trials, as providing a ‘placebo’ is challenging. Massage is often compared to other treatments or no treatment/ intervention or combined with other therapies, making it challenging to identify its relative efficacy.

When treating any patient, particularly one with a chronic condition (such as arthritis) where the relationship will be ongoing, the personal beliefs and preferences of the patient need to be considered, not to mention their socioeconomic situation. The choice of treatment will impact their physical, psychological, and mind–body response. In addition to pain and functional limitations arising from arthritis and/or comorbidities, symptoms including mood disorders, such as depression and anxiety, altered sleep, chronic widespread pain, and impaired coping skills may manifest (1*).

Thus, a multimodal treatment option, rather than a single modality (eg. medication or exercise or bracing or heat therapy), should be chosen to best address the patient’s needs. Measures aimed at improving mood, reducing stress, addressing insomnia, managing weight, and enhancing fitness may improve the patient's overall well-being. Indeed, interventions that have proven beneficial in the management of chronic pain may prove useful in managing arthritis (1*).

‘Figure 2. Evidence map of systematic reviews describing the effect of massage for pain’ ( in Miake-Lye et al. displays 49 systematic reviews of massage therapy (3*). The bubble label

Co-Kinetic Journal 2023;96(April):25-28

represents the pain indication in that review, and the bubble size denotes the number of primary studies included in the review specifically related to massage for pain. Each bubble was plotted according to the strength of the findings for massage for pain (y-axis,) and the effect massage had on pain (x-axis) (3*).

Although the map highlights gaps in the evidence as well as the lack of moderate- to high-strength clinical findings, a number of highquality systematic reviews reached low-strength findings that massage offers potential benefits for pain indications, and that massage can be beneficial across multiple conditions (3*). The effect of simple human touch, particularly in the alleviation of pain, is one of the oldest approaches to healing known to humankind (8*).

A pilot study of massage therapy for OA of the knee found that biweekly (two sessions per week for 4 weeks) rather than weekly (one session per week for 4 weeks) Swedish massage sessions of 1-hour resulted in significant improvements in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), for assessing pain, stiffness, and physical functional disability outcomes, compared to usual care (9*). Notably, the benefits persisted for up to 8 weeks following the cessation of massage. Despite these promising results, there were no data to determine whether the dose used in the pilot study was optimal (9*). As in so many clinical trials, the treatment protocol for massage is often one of 20–30 minutes once or twice weekly. Could the treatment dose be impacting the perceived ‘poor’ outcomes? Operationally, finding the optimal dose may be one of balancing the optimal and the practical – ie. producing the greatest ratio of desired effect compared to costs (in time, labour, and convenience) (7*).

Thus, the first formal dosefinding study of massage therapy was implemented (7*). The study investigated four different doses of tailored Swedish massage, varying both the time (30 versus 60 minutes per treatment) and frequency (once a week versus twice a week for the first month) to determine an optimal, practical

dose. Subjects receiving the 60-minute doses improved with highly clinically significant changes (44–50% change from baseline) in WOMAC scores. A dose-response curve based on WOMAC Global scores indicated an increasing improvement with a greater total dose (minutes) of massage, with a threshold effect at the 480-minute dose. Thus, patients in the groups receiving massage therapy treatment sessions of 60 minutes showed greater benefit and magnitude of change from baseline compared to usual care and the 30-minute massage treatment groups. The durability of the response in the improvement of OA symptoms and functions to massage treatment was also supported by treatment duration. The magnitude of the effect was greatest after 8 weeks of treatment. The persistence of improvement at 2 months and 4 months after treatment cessation indicated that the effects of massage go beyond immediate changes. This may involve longer-term shifts globally and/or locally at the joint. The mechanism for persistent benefit is not fully understood; however, it highlights an opportunity for periodic maintenance doses of massage to sustain the effects over time. It was recommended that 60-minute massage sessions should be advised over a 30-minute session because of the superiority in the results; however, a once-weekly session may suffice. This is a result of the time and cost constraints of a biweekly massage protocol (7*).

Massage therapy should be considered as a routine complementary, not alternative, part of an individualised, multimodal painmanagement plan (10). It may not remove the need for medication and may not be appropriate for everyone; however, massage may reduce the dependence on analgesic or opioid medication, which has negative long-term side effects on other bodily systems, as well as being addictive in nature (11*). A study has shown that Swedish massage can reduce the severity of arthritic joint pain immediately after each session and for 1 month after the intervention. In addition to pain reduction,

Swedish massage also reduced the consumption of painkiller medication (2).


Regardless of its origin or underlying disease manifestation, pain is an experience that is multidimensional. It may impact an individual physically, socially, mentally, emotionally and spiritually. As is often the case with arthritis, pain persists and worsens; it can interfere with daily activities, and significantly impair the performance of social responsibilities, sports, work and family life, thus negatively affecting the individual’s psychological health and quality of life.

Despite the many options available, some patients may continue to experience inadequate symptom control; others will experience adverse effects from the available interventions. Clinicians treating patients in these circumstances should choose alternative complementary interventions with a low risk of harm. Effective pain management thus requires therapies that treat the biomechanical pathophysiological component of the joint, the pain and its related sequela by addressing the whole patient through a holistic biopsychosocial model (12*). There are controversies in the interpretation of the evidence, particularly regarding ‘alternative’ treatments such as acupuncture and massage therapy. The ambiguity in treatment protocol, definitions, methodology and sample size has resulted in massage therapy falling away from the published guidelines for the management of arthritis. The process of updating treatment guidelines permits scrutiny of the state of the literature and identification of critical gaps in our knowledge about best practices. Future research may see massage being re-instated in the guidelines as we learn more about the complexity of humans and pain. Optimal management requires a comprehensive, multimodal approach to treating patients with arthritis. The ultimate goal is to share decisionmaking with patients to choose the safest and most effective treatment for that individual.


1. Kolasinski SL, Neogi T, Hochberg MC et al. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Arthritis & Rheumatology 2020;72:220–233 Open access

2. Sahraei F, Rahemi Z, Sadat Z et al. The effect of Swedish massage on pain in rheumatoid arthritis patients: a randomized controlled trial. Complementary Therapies in Clinical Practice 2022;46:101524

3. Miake-Lye IM, Mak S, Lee J et al. Massage for pain: an evidence map. Journal of Alternative and Complementary Medicine 2019;25:475–502 Open access

4. Peter WF, Swart NM, Meerhoff GA et al. Clinical practice guideline for physical therapist management of people with rheumatoid arthritis. Physical Therapy 2021;101(8):pzab127 Open access

5. 'Choosing Wisely' app now available [website]. American Physical Therapy Association 2017

6. Nelson NL, Churilla JR. Massage therapy

Key Points

for pain and function in patients with arthritis: a systematic review of randomized controlled trials. American Journal of Physical Medicine & Rehabilitation 2017;96:665–672

7. Perlman AI, Ali A, Njike VY et al. Massage therapy for osteoarthritis of the knee: a randomized dose-finding trial. PLoS One 2012;7:e30248 Open access

8. Jonas W, Schoomaker E, Berry K et al. A time for massage. Pain Medicine 2016;17:1389–1390 Open access

9. Perlman AI, Sabina A, Williams AL et al. Massage Therapy for Osteoarthritis of the Knee: A Randomized Controlled Trial. Archives of Internal Medicine

2006;166:2533 Open access

10. Wu Q, Zhao J, Guo W. Efficacy of massage therapy in improving outcomes in knee osteoarthritis: a systematic review and meta-analysis. Complementary Therapies in Clinical Practice 2022;46:101522

11. Buckenmaier C, Cambron J, Werner R et al. Massage therapy for pain—call to action. Pain Medicine 2016;17(7):1211–

l Finding the right treatment for a patient may depend on the individual, the extent of their arthritis, and their socioeconomic situation.

l Based on the strength of scientific evidence from randomised controlled clinical trials, non-pharmacological treatments highly recommended for managing osteoarthritis include exercise, weight loss, self-efficacy and selfmanagement, orthotics and bracing.

l The cornerstone of non-pharmacological physical therapy treatment for patients with rheumatoid arthritis includes exercise therapy, education and self-management strategies.

l Guidelines suggest against using passive modalities (including massage therapy) owing to a lack of or low-quality evidence relative to arthritis management.

l Clinical trials assessing massage efficacy have suffered from a high risk of bias, small sample sizes, ambiguity in methodology and have not demonstrated significant benefits for arthritis outcomes.

l Emerging evidence suggests that longer massage sessions (1 hour) offered biweekly significantly improve arthritis outcomes of pain, stiffness and function.

l It is suggested a ‘higher’ massage dose may provide more optimal outcomes in arthritis patients.

l Across a number of systematic reviews, massage therapy has been shown to be effective in managing pain.

l In addition to pain and functional limitations arising from arthritis and/or comorbidities, symptoms including mood disorders, such as depression and anxiety, altered sleep, chronic widespread pain, and impaired coping skills are often present.

l It can be argued that a multimodal treatment option should be considered for long-term holistic management, including complimentary therapies such as massage therapy.

l The ultimate goal may be shared decision-making with patients to choose an individualised treatment plan that is safe, effective and affordable to them.

1214 Open access

12. Crawford C, Boyd C, Paat CF et al. The impact of massage therapy on function in pain populations—a systematic review and meta-analysis of randomized controlled trials: part I, patients experiencing pain in the general population. Pain Medicine 2016;17(7):1353–

1375 Open access


l Have you found benefits in using massage therapy when managing patients with arthritis?

l Do you believe that using passive treatment modalities, such as massage, hinders the progression of patients towards self-efficacy and self-management of their chronic disease?

l Would you agree that there may be a dose-response to massage therapy potentially affecting its perceived long-term efficacy?


l Osteoarthritis of the Knee: A Practical Treatment Approach [Article]

l Efficacy of Manual Therapy for Chronic Musculoskeletal Pain [Article]

l Pain Does Not Always Indicate Injury [Article]


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.


Co-Kinetic Journal 2023;96(April):25-28 28

Creating Connections: The missing link to effective marketing

By reading this article, you’ll gain valuable insights into how to build a successful physical therapy business by making meaningful connections. We’ll take a deep dive into the three key objectives of a connected marketing strategy that will help you attract and retain paying customers. Additionally, we’ll explore the importance of having a trust-building nurture process in place to turn prospects into loyal clients. You’ll also discover what you need to do to streamline your customer journey, saving both time and money. In this article, we’ll explore in more detail how you can implement this business-growth strategy in practice. Reading this article will give you clarity about your marketing objectives and of the business value and importance of building connections with people both online and in your local community. Read this article online

There are lots of reasons why so much small business marketing fails, but there’s one particular reason which has spread so widely and so quickly, and for the most part gone unnoticed, and that’s the growing disconnection between: our marketing; our businesses and the services we provide; and our local communities.

Businesses need connections

Think back to how local trade began a few thousand years ago, when people started to produce more goods than they needed for their own consumption. This prompted people to start bartering goods with one another where for example, a farmer might trade some of his crops for a pot made by a local potter. This bartering system didn’t require money.

But, as societies became more complex, the need for a more organised system of trade emerged and this led to the development of market places, where people could buy and sell goods in a central location, hence the reason why market places are generally located in the middle of a town. The key to this whole trade system was face-to-face connections.

Humans need connections

We also now know how crucial connecting with others is for our physical, emotional and mental wellbeing.

Human beings are social creatures and most of us need at least some level of social interaction to feel a sense of belonging, support, and emotional fulfilment. Studies have shown that people who have strong social connections are happier, healthier, and more resilient than those who are isolated.

On the flip side, social isolation has been linked to a range of physical health problems, including increased risk of heart disease, stroke and premature death.

Social connections have also been linked to lower rates of depression, anxiety, and other mental health problems. Having people to talk to and share experiences with, can help us process our emotions and cope with stress.

Then there are the benefits that come from learning and growth as well as helping to facilitate social change through the connection with people who share our values and goals. In a nutshell, it’s communities and connections that help us to thrive as human beings.

Technology and connection

As technology has spread so rapidly through our lives, we’ve taken a huge step back from those face-to-face connections that have helped us and our businesses to thrive in the past.

On one hand, the internet has enabled people to connect with others beyond their immediate geographic area, and has provided access to all sorts of information and resources that may not be available locally, which is good for communities that are geographically isolated or marginalised.

But on the other hand, the internet has also been associated with a decline in the more traditional forms of community engagement, such as face-to-face interactions, involvement in local social organisations and community events, and this has weakened our sense of community, as we spend more time online and less time engaging with our local neighbourhoods and organisations.


Physical therapy and connection

Despite the advances in telehealth necessitated by Covid, a vast majority of physical and manual therapy services are still delivered within a local community setting and that’s a community that for the most part, we’ve lost touch with. The service we provide requires people to put themselves literally physically at our mercy, usually requiring the need for them to undress at least partially. This is a big ask for many people, which means gaining the trust of our prospective customers is one of the most important ingredients to our professional success.

In the old days (pre-1976), physiotherapists in the UK at least, had to rely on GP referrals as a source of new patients as they weren’t allowed to actually advertise their services. Can you even start to imagine that today? So it’s easy to understand why historically we’ve relied so heavily on word of mouth as our primary source of new patients.

But in 2023, there’s competition literally everywhere. Even 30 years ago, there might have only been one or two physiotherapists in a town and even rarer an osteopath or chiropractor, today there are probably 20 or 30 physical therapists within just a few miles of you, all of whom are similarly qualified to treat the same prospective patient.

Ironically, in 2023 we choose to hide behind websites and social media platforms as our main form of marketing –neither of which are very conducive to building connection or trust, especially not when it’s done as passively as we are currently doing it.

For most therapists the primary focus of their marketing efforts is to build a website. They might then graduate to publishing some usually poor quality, self-promotional content to their social networks and then just sit back and wait for the local community to start pouring through their doors, or take valuable time out of their busy days to engage with our newly published social media posts.

But why do we expect this to happen when we make absolutely ZERO effort to get that content in front of people? We seem, for some unknown reason, to think the adage ‘build it and they will come’, will apply.

There’s a quote I use quite often in talks and presentations, that illustrates this point well:

“Doing business without advertising, is like winking at a girl in the dark. You know what you’re doing, but nobody else does.”

You can build a website, and invest time in a great social media feed but unless you give people a reason to visit those assets, they’re never going to know they exist.

For your marketing to work, it needs to work as one joined up, cohesive strategy. We need to create connections between our website, our social media and our community.

In short, in order to attract new clients, we have to create the opportunities for people to SEE us. If ever there was a time to get out in the local community making connections and meeting people, then that time is now because I believe it’s these connections that will decide whether a business dies, survives or thrives in the future.

Box 1: Your blueprint to a connected marketing strategy

When you look at the big picture, marketing breaks down into three core objectives:

1. The first goal is to help people find you.

2. The second goal is that when people do come across you, to make it very easy for them to book an appointment.

3. And lastly, if they’re not ready to book an appointment, the next goal is to collect their email address so you can gently nurture those relationships by adding value and building trust, so that when they are ready to become a client, you have no competition.

Remember, the role of marketing is to build awareness and attract leads (ie. prospective customers) to your business. The role of sales is to convert those prospects into paying customers. To grow your business, you need to use a holistic, collaborative approach that involves both those components working together.

If we take those three marketing objectives a level of detail deeper:


Helping people come across you boils down to:

a. Making sure you appear in relevant internet search results which comes down to search engine


optimisation (SEO) – absolutely fundamental for local businesses.

b. Getting out into your local community, forging connections, setting up partnerships and being seen, heard or read about (eg. interviews or articles).

c. Proactively engaging in strategies to increase your social media reach (ie. getting in front of new prospective customers through the social networks).

When people do come across you, making it very easy to take the next step to booking an appointment:

a. This means optimising your website to allow them to book either online or over the phone.

b. Building trust by giving plenty of useful, addedvalue information to help them take the next step (ie. condition and treatment pages and fresh blog content).

c. Making sure you have plenty of social proof on your website (ie. testimonials, business logos) as this is one of the most effective ways to build trust and encourage prospects to become new customers.

30 Co-Kinetic Journal 2023;96(April):29-35

Beware of leaky funnels

Every single one of the three customer journey stages I’ve outlined are critical. If one is weak or missing altogether, you have what’s often called a leaky funnel.

For example, there’s no point investing in SEO, writing fresh blog content, and spending time on community or social outreach to get people onto your website, if it’s not optimised to a) get them to convert to a paying customer, b) share their email address with you or c) at the very least, take a helpful value-added piece of information with your branding and contact details on it, because you may never get them back to your website again, and your investment risks being either partially or totally lost.

Equally, there’s no point investing in writing high value pieces of content (lead magnets) and setting up email lead collection forms designed to get people to share their email address with you, if you don’t have a regular email nurture programme in place, because the minute that new email lead (prospect) joins your email list, they start to go cold. And worse still, if you annoy them with spammy salesy emails, the chances are they’ll just unsubscribe anyway and again your investment and hard work is lost.

Putting it into practice

The goals in Box 1 break down into specific marketing objectives:

1 Be visible = optimise your website for SEO to ensure you’ll be found on Google searches and get yourself out and about locally and online to ensure both you and your content is seen.

2 Build trust = optimise your website to convert prospects into paying clients by providing helpful, authority-building content and demonstrating social proof (ie. reviews, testimonials etc)

3 Nurture relationships = take your website visitors on a value-adding, trust-building email nurture journey and give them opportunities to become a paying customer.

There are three key channels (listed in order of impact) that you can use to achieve the marketing objectives above:

1 Your local community

2 Your website

3 The social media platforms

Before we dig into specifics, keep in mind at all times that the most successful and sustainable connections are built on mutual benefit, so with everything you do, try and make sure there’s a win-win for everyone involved. Even if you can’t see what that win-win is immediately, it doesn’t mean it’s not there. The important thing is to start the conversations.

And if you’re going to take the time to build these connections in the first place, you want to make sure that time investment is worth it. Set time aside to implement what you’ve agreed and make sure to do what you promise you will.

3 If people don’t choose to become a customer at that point, the next goal is to bring them into a trust-building nurture process by:

a. Giving web visitors a genuinely compelling reason to share their email address with you using high value pieces of content that solve targeted problems or answer questions your website visitors may have.

b. Committing to a consistent email nurture programme where you send regular valueadding, trust-building emails – generating a sense of reciprocity and staying top of mind with not only your prospects but also existing and past customers. (This also helps to increase word of mouth referrals.)

c. Offering educational and value-adding opportunities to this audience, that continue to build trust and helps move them closer to becoming a paying client.

The combined effect of these activities results in the building of a trusting and warm audience who are ready to take action, the minute you need them to.

Lastly, remember to try and connect everything together. If you meet people locally, invite them to interact with you on social media, and do the same for them. Small increases in social engagement can start to turn into big gains when it comes to how many people your posts reach (more later). And people you’ve met face to face are much more likely to engage with your social media posts than people who have only met you online.

1. Connecting with your local community

Let’s start here because it’s the most powerful of all three connections. Face to face interactions are easily the quickest way to build trust and particularly powerful when trust is a big component of the service you offer (which as we know, it is). Let’s delve into these opportunities in a bit more detail. ENTREPRENEUR THERAPIST 31

Sport and exercise-related opportunities

When was the last time you reached out and made contact with a person or business, in your local area, who provides one or more services that complement yours? Anyone working in any kind of sports or fitness role is likely to come into regular contact with people who are primed for injury, which makes this a great place to start. Here are some starting points:

l Sports shops – stores like cycle, running, snow sports or general sports shops

l Sports clubs and meets – golf clubs, racket sports, cricket, running, Park Runs, netball, hockey, football/ soccer, basketball, cycling clubs (many cycle stores have a cycling club), cold water swimming groups, ultimate frisbee, beach volleyball, walking clubs.

l Charity/sports events – local 5k/10k runs or walks, half marathon, triathlons, bike rides, swim-a-thons, fitness challenges.

l Coaches/fitness trainers – coaches eg. tennis, football, hockey, boxing, dance instructors, personal trainers, Pilates and yoga instructors, parkour.

l Exercise venues – gyms, gymnastic halls, boxing clubs, skate parks, running tracks, athletics fields, swimming pools, dance halls, parkour venues.

If you haven’t got a local running or cycling club nearby and you love running or cycling, why not organise your own? Even better if you have a clinic that you could make the meeting point, it’s a great opportunity to subtly reinforce your expertise.

But don’t stop with sports-related business, think outside the box. Do you have friends who run local businesses? What have you got to lose by organising to have a beer and brainstorm some ideas about how you could help promote each other’s businesses? Do they have any connections they can facilitate for you and vice versa, like contacts with local organisations, GP/primary care surgeries, health clinics, Women’s Institute groups for example?

Other connection opportunities

l Small businesses – it’s really powerful when local businesses team up, maybe your patients own businesses that could use some help, there’s a win-win.

l Local business or networking groups – this is a great place to meet up with other entrepreneurs in your local area who are actively looking to boost their businesses. Entrepreneurs Circle runs local meetings all over the UK.

l Community organisations – ChatGPT came up with these ideas for me – Wimbledon Village Business Association, Friends of Wimbledon Common, Wimbledon Choral

Society, Wimbledon Community Association, Merton Voluntary Service Council, Wimbledon Bookfest – that would give me some great places to start if I was still a practicing physio of course!

l Local charities – you could offer discounts to volunteer workers, or help raise money for the charity. Those with local shop venues would be a great place to distribute educational resources (eg. posters and leaflets).

Ways to collaborate

The following collaboration ideas apply whatever context you’re in whether it’s face to face or online and they’re just here as possible starting points, see where it leads you.

Direct referrals/discount opportunities

Usually this involves paying an introductory fee for the referrer and/or offering a discount for the person being referred.

Added value/bonuses

Say you collaborate with a local café, they could give you coupons you could give to the first 20 patients who visit that week that earns them a free coffee or cake, or a restaurant could offer a discount or a voucher for a free drink/starter/ desert. You get to give a nice added bonus to your customer and the partner business gets someone new to try their offering. Or you could reserve these bonuses for your best clients or for your new clients that you are particularly keen to impress.

In return, you could give vouchers for a discounted massage, a gait analysis, a bike fit or a ticket to an education event that you’re running. The idea is to cross-pollinate customers between businesses.

Education sessions or events

Education events are a fantastic way to make connections in your community. They are a great way to demonstrate authority, build trust and provide lots of reasons for local businesses or media outlets to link to you (which as we’ll see later is extremely powerful for SEO).

You can also choose the subject of your presentation, to appeal to a specific target audience. For example if you love treating runners, deliver a presentation on preventing or treating the most common running injuries. Or you could deliver a presentation on strategies for coping with the menopause to a local women in business group, or lifestyle strategies for managing arthritis to the local choral society.

The great thing is that you’re strategically tapping into audiences that other people have already built, preferably who match your ideal target customer, while at the same time offering great value and benefit to that group. You can widen your potential audience further by collaborating with other professionals who have complementary skill sets.

Then link everything together on your website. Add a blog post giving some helpful information in its own right, and explaining that you’ll be discussing this in greater detail at your event, with a link to the event sign up page. The blog is good for SEO in itself, and if you ask your growing network of local contacts to also link to it from their social media and

32 Co-Kinetic Journal 2023;96(April):29-35

their websites if possible, this will give you an even bigger SEO boost (more shortly).

Information provision

If you don’t want to go as far as running an education event, why not distribute helpful information resources like leaflets, or print out helpful posters for walls of clinics, shops and other venues?

Ideas include giving leaflets on preventing tennis injuries, to the local tennis club or promoting the importance of exercise for arthritis sufferers in say bingo halls, or nursing homes. All the time, your focus is on adding value and contributing to your community.

We’ve produced literally 100s of these peer-reviewed leaflets, all of which are included under our Co-Kinetic subscriptions, covering just about every population group. Why not ask your general practice if they would benefit from particular leaflets on specific topics? If we don’t already have them, we’ll produce them for you!

The key part here is that your logo and contact details are on every leaflet and poster you distribute.

In our latest issue of the Co-Kinetic journal we’ve produced two awesome posters covering the benefits of exercise for arthritis sufferers and an arthritis myth buster (or topic this quarter is arthritis!) which you can add your logo, website, and email address to and order them to be printed through Canva. What a great piece of value-adding content which also happens to feature your business details.

2. Your website and SEO

As I’ve mentioned above, it’s really important to connect your offline efforts with your online ones as it amplifies the impact of each thing you do. Good marketing should stimulate a cascade effect.

Your website has two key responsibilities

l Converting website visitors into customers

l Attracting potential customers by increasing the likelihood of someone searching for the services you provide, visiting your website.

Optimising your website for converting website visitors into customers

a) Make it easy for them to book an appointment

The first priority is when someone hits your website, making it really easy for them to find the information they need and to book (and attend) an appointment.That means, easy “Book Now” options and a clickable telephone number on every page along with all the info they need to actually attend their appointment (eg. map links, public transport options) and one or more ways to get in touch.

b) Build trust through your website

The second big role of your website is demonstrate your authority and build trust. Trust is the single most important factor in someone deciding to take the leap from checking out your website, to booking an appointment. They have to trust that you’re suitably qualified and experienced to help them with their specific need. That means being able to see your ‘knowledge’ on display and see that you’ve

helped similar people, who have been in similar situations to themselves. This is another reason why defining a clear target audience is beneficial.

Knowledge can be demonstrated with good educational content on your website (ie. treatment and condition pages and blog posts), and experience can be demonstrated with social proofing (testimonials, reviews and logos of businesses, sports clubs, organisations you’ve worked with).

Personally I’m not a fan of testimonials that aren’t shown on genuine review platforms such as Google, Facebook Review or TrustPilot. The minute you turn a quote into a graphic, how can anyone tell it’s authentic? They might look prettier but is it even worth the pixels it’s formed from? People are sceptical enough these days, don’t give them a reason to doubt your authenticity.

Trust can also be built by conveying a genuine sense of ‘giving’ through your site. I review a LOT of websites belonging to a huge range of therapists literally all over the world, and I’m becoming increasingly aware of the sub-conscious ‘vibe’ a site gives off. Some are really basic, which unfortunately just doesn’t reflect well on your clinical skill set, however good it may be. Others are


all business. The best ones convey a strong sense that the business genuinely cares for their visitor, whether they’re a patient or not, by sharing lots of value-adding, nurturing, trust-building content as well as giving all the information necessary to book an appointment.

c) Encourage visitors to give you their email address This is a majorly neglected part of most people’s websites but is a fundamental component to building a healthy business. A healthy email list is single-handedly your most profitable marketing asset. Before you think of skipping this section, because it’s boring and

you hate the idea of collecting people’s emails, check out GMB Fitness case study in Box 1 as an example of how it can be done supremely well, and in a way that offers 100% value at every level. And I love receiving their emails, I very rarely delete them as they’re always useful. A benchmark survey by MarketingSherpa found that the average value of a new email lead is $12 (US), so about £10 (GBP) at today’s exchange rate. One study by DMA (Data & Marketing Association) found that the average return on investment (ROI) for email marketing is $42 for every $1 spent. I bang on about it at just about every opportunity I get but email marketing done well, will always be your most profitable marketing activity. So if you’re lucky enough to get someone onto your website, don’t waste that opportunity, make sure to give them plenty of value-adding ways to share their email address with you. And then enter them into a nice, gentle, value-adding ongoing nurture email programme to keep building trust, generating reciprocity (the desire to give back to you) and keeping your business top of their minds.

Attracting potential customers onto your website in the first place

The reason I’ve listed this second is because your first priority is to ensure that when someone does visit your website, it’s optimised to give the best chance to convert that person into a customer. If it’s not, it doesn’t matter how many new people arrive on your site, because they’re likely to leave if you haven’t made it easy for them to take the next step. Once you’ve done the above, the next priority is to get as many people onto your website as possible. The two best routes for achieving that are:

a) Direct search engine searches

If someone searches for ‘osteopath near me’, they are searching with what’s often referred to as ‘buyer’s intent’. They have a problem, and they’re looking for a solution and in our industry, by the time they’re searching, that need is usually an immediate one. These are primed prospective

Box 2: GMB fitness email lead collection and nurture best practice example

A gold standard example of how to do this well, is the exercise platform GMB Fitness. Firstly their blog posts are 100% focused on offering value to their readers. You can check out their blog here Go on, I promise you’ll enjoy it.

Within every blog post, is a targeted ‘lead magnet’. By that I mean a helpful resource that is super-specific to the blog post. It’s embedded in a neat little box in the article – there’s nothing screaming at you and the leaflet is 100% focused on helping you answer a question, solve a problem, or do something you clearly desire to be able to do, otherwise you wouldn’t be reading the blog post.

For example, check out this article on Stretching (

Right near the top of the article they have a

little box with a download option for a stretching routine – highly specific to the article, helpful and value-adding – and I suspect they generate a lot of email leads from their website, plus the reader gets access to a high-value resource with GMB branding – a great little piece of marketing. The focus is always about adding value.

But the best bit is that their subsequent emails again are all about building on that value. It’s not a naff “Sign up to my email newsletter” (which we all know will result in a bucket load of spam emails), they offer targeted resources that deliver real solutions directly related to the article the person is reading.

This is brilliant example of great content marketing in action. Occasionally they run a sale but honestly, I’ve been subscribed to their emails for probably 6 or 7 years I think I remember 2 sales pitches in that time! Aspire to this because it’s all very doable if you focus on the doing the right things.

34 Co-Kinetic Journal 2023;96(April):29-35
Figure 1: 2023 Google algorithm ranking factors

customers ready to buy and you want to be as close to the top of the search results when that happens, and that boils very crucially down to search engine optimisation (SEO), one of the most important areas of digital marketing to get right if you’re a local business.

b) Links onto your website

The second way to get people onto your website is through links from third party websites, directories, or through social media channels.

Now this is where you’ll appreciate how things become truly connected because everything feeds into each other.

As you’ll see in Figure 1, 54% of where you’ll rank in an organic Google search (ie. without using Google Ads) comes down to three things, consistent publishing of engaging content is nearly 50% of that 54%. There’s your top priority.

The other two elements at level one are basically dependent on that engaging content existing in the first place. Backlinks are links to your website from other places, primarily websites, social media profiles and social media posts (both yours and other people’s).

The arrows hopefully help to indicate the connections. If you’re not publishing good engaging content, nobody is going to have a reason to link to you and you’ll have no meta titles to SEO-optimise, so you can’t even get out of the block.

And if you’re not fulfilling the top layer, the items on layer two ie. proving trustworthiness and authority, are virtually impossible to demonstrate, the end result is that it will be your competitors who are doing these things who will win those all-important clicks from rich supply of ‘buyer intent’ searches.

In short, you’ve got to a) give people the opportunities to link to you by doing things that are worth telling people about ie. running events or publishing fresh content and then b) you’ve got to proactively go out there and create those connections by asking people to link to you (both online and offline).

3. Social Media

Lastly let’s look briefly at where social media fits in. As you’ve read above, linking back to your website from your social media profiles and your posts, will help increase your backlinks and boost your SEO.

Equally, if you can build an engaged audience on your social networks, who will share your content, this builds a source of additional backlinks. The good thing about social is that it’s much easier to share links than it is to get people to add links onto websites (which requires website editing). Who’s prepared to do what, comes down to how good, strong and mutually beneficial your connection or relationship is with those people. Remember, this is not a one-way street. If you expect people to do things for you, you have to reciprocate the effort.

Social media algorithms prioritise content from accounts that have strong engagement and connections. When your content receives likes, comments, and shares from your connections, it signals to the algorithm that your content is valuable and relevant. This can help your content appear

higher in people’s social media feeds, increasing your visibility or reach.

By fostering relationships with your social media connections and creating valuable content which links back to your website, you can not only boost your social media presence but also your search engine optimisation.

In summary

Hopefully it’s clear from this article, just how much connections matter both face-toface and online. Successful marketing means getting out there and forging those relationships. Just think, if you swopped the time you spent producing ineffectual social media with time networking in your community, the impact on your business would be incomparable! You can’t hide behind a website that never changes, or a social media feed that is essentially a billboard of ads for your business, you need to get out there, be seen, add value and build trust. Why not start that journey today by committing to reaching out to just one person or business and see where it leads you? And as always, I’d love to hear your success stories.

Key Points

l Creating face to face connections in your local community is one of the most effective ways to generate new clients and grow your reach on social media

l Ranking highly on the search engines is another powerful way to gain new customers and the single most important factor in achieving that goal is to publish consistent, engaging content on your website

l Your email list will give you the best ROI of all your marketing activities so investing in email lead generation and building relationships with your list should also be high on your marketing to do list.


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. Tor’s leadership grew sportEX into the Co-Kinetic journal and more recently she has developed a technophobe-friendly marketing website containing pre-written, automated social media and a huge library of peerreviewed, tried and tested marketing resources. 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 and in mastermind groups and as a visiting lecturer to several UK universities.

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