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Efficacy of neuromuscular training, with minimal or no equipment, on performance of youth athletes

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Efficacy of neuromuscular training, with minimal or no equipment, on performance of youth athletes

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Abstract

Objectives

To investigate the effects of neuromuscular training, with minimal or no equipment, on physical performance of youth athletes.

Design

Systematic review with meta-analysis.

Methods

MEDLINE, , and SportDiscuss from inception to March/2022. Selection Criteria: youth athletes (15-24years), from Olympic team sports; used neuromuscular training 2-3 times/week for, at least, 6 weeks; had a control group/usual training group; physical performance as outcomes; EMBASE, CENTRAL, CINAHL PEDro randomized controlled trial. Data Synthesis: Pooled estimate of standardized mean difference (SMD), and 95% confidence interval (95%CI).

Results

Thirty-four studies (1111 participants) were included. Results showed that neuromuscular training improved power (SMD: 0.84 [95%CI: 0.58, 1.10]; n = 805; I 2 = 64%), speed (SMD: −1.12 [95%CI: −1.68, −0.57]; n = 688; I 2 = 90%) and agility (SMD: −1.21 [95%CI: −1.60, −0.83]; n = 571; I 2 = 76%) compared to control group, but showed no difference between groups for muscle strength (Quadriceps SMD: 0.34 [95%CI: −0.02, 0.69]; n = 132; I 2 = 0%, Hamstrings: SMD: 0.64 [95%CI: −0.04, 1.33]; n = 132; I 2 = 71%), balance and flexibility.

Conclusion

Clinically, neuromuscular training with minimal equipment may be useful for teams with limited resources to improve mainly athletes' power and agility, including those interventions that were designed to injury prevention. Future high-quality studies are likely to change these estimates.

Introduction

The ultimate goal of teams sports and their athletes is to improve performance through systematic training (Van Mierlo and Van Hooft, 2020). The most popular team sports are those included in the Olympic games (e.g., football, basketball). Although these sports require different abilities, they share important similarities and benefit from improvement in physical performance (Khlifa et al., 2010; Sedano, Matheu, Redondo, & Cuadrado, 2011).

Neuromuscular training is a combination of exercises known to enhance sensorimotor function and to contribute to the foundation of physical performance for most sports (Sañudo et al., 2019). Additionally, previous studies showed that neuromuscular training, including interventions primarily designed for injury prevention, are effective to improve balance, agility, sprint, jump, and strength among athletes from different sports (Pardos-Mainer et al., 2021). However, adherence to these interventions is challenging (ter Stege et al., 2014).

In general, these interventions require expensive equipment or extra time availability from athletes, adding barriers to its implementation (Chaabene et al., 2020; Hammami et al., 2018). For instance, amateurs' team sports may not have enough resources, particularly those in low and middle-income countries (Miragaia, Ferreira, & Ratten, 2017). Thus, identifying interventions with minimal or no equipment required, (e.g., body-weight exercises, elastic bands, hurdles) is crucial to improvement in performance of athletes from low-resourced teams (Benis, Bonato, & Torre, 2016; Brito, Vasconcellos, Oliveira, Krustrup, & Rebelo, 2014).

The aim of this systematic review was to investigate the effects of neuromuscular training, with minimal or no equipment, on performance of youth athletes from Olympic team sports.

Section snippets

Methods

The protocol of this review was registered in the Open Science Framework Database ( https://osf.io/twxv5/ ), and the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines were followed for reporting of this review.

Included studies

The search strategy identified 11,634 reports. After removing duplicates, 4671 reports were screened. Of those, 246 full texts were evaluated, and 37 reports from 34 original studies were included (Fig. 1).

Study characteristics

A total of 1111 participants (581 intervention; 530 control) were included. Team sports included were soccer ( n = 16, 47%) (Akbari, Sahebozamani, Daneshjoo, & Amiri-Khorasani, 2018; Arsenis et al., 2020; Brito et al., 2014; Daneshjoo, Mokhtar, Rahnama, & Yusof, 2012; Daneshjoo, Mokhtar,

Discussion

Our results show that neuromuscular training, with minimal or no equipment, may improve power, speed, and agility in youth athletes, compared to control intervention, but the evidence is very uncertain. Nevertheless, despite the limited evidence, we would argue that the magnitude of the effect found for power and agility may be clinically relevant to the athlete's performance on the field. In addition, the evidence is very uncertain about the effect of neuromuscular training, with minimal or no

Practical application

Based on the available evidence, our results suggest that neuromuscular training, with minimal or no equipment may improve performance, such as power and agility, in young athletes. Despite the very-low certainty of evidence, these results may be of relevance for the sport health community (e.g., strength and conditioning professionals) especially those with low financial and structural resources. In addition, neuromuscular exercises (e.g., squats, planks, Nordic hamstring curls, bridges,

Conclusion

There is very-low certainty of evidence that neuromuscular training, with minimal or no equipment, may improve power, speed and agility performance, compared to usual training, but the evidence is very uncertain about the effects of this intervention on muscular strength, dynamic balance, and flexibility. At present, neuromuscular training with no or minimal equipment may be used for teams with limited resources to improve mainly athletes' power, and agility. Based on the available very-low

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgements

The authors acknowledge the corresponding authors of included studies for their help in data acquisition.

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# data[].attributes.attachment_link.title
The efficacy of neuromuscular training, with minimal or no equipment, on performance of youth athletes: A systematic review with meta-analysis

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To investigate the effects of neuromuscular training, with minimal or no equipment, on physical performance of youth athletes.Systematic review with m...

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Effectiveness of Exercise Treatments with or without Adjuncts for Common Lower Limb Tendinopathies: A Living Systematic Review and Network Meta-analysis - Sports Medicine - Open

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Exercise is the place to start, and for most conditions, all they will need.

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Exercise is the place to start, and for most conditions, all they will need.

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Key Points

Several treatment modalities are used early on in managing lower limb tendinopathies without sufficient evidence to support their use.

Extracorporeal shockwave therapy does not appear to add any pain-relieving or functional benefits when added to eccentric exercise in patellar tendinopathy.

Exercise interventions other than eccentric exercise and adjuncts to eccentric exercise appear promising but need further high-quality evidence.

Introduction

Tendinopathy is a pathological state classically characterised by persistent pain and functional impairment due to damaged tendons. The tendon damage is secondary to abnormalities in its microstructure, composition and cellularity, usually as a result of repetitive mechanical overload [ 1, 2]. The primary aetiology of tendinopathy is linked to an impaired healing response secondary to repetitive tendon stress and overload [ 1, 2, 3]. Equally, it has been demonstrated that physical activity alone does not account for the extent of histopathological changes, suggesting that other factors are at the root cause of its aetiology [ 4]. Psychosocial factors are increasingly recognised to contribute to tendinopathy, and a biopsychosocial approach has been recommended for its treatment, which addresses the biological, psychological and social contributions to chronic pain and disability [ 5]. The tendons most commonly affected in the lower limb are the Achilles, patellar and gluteal (greater trochanteric pain syndrome; GTPS).

Whilst exercise has been implicated in inducing this condition, over the past 3 decades, strong evidence has demonstrated that rehabilitation with progressive loading improves pain and functional outcomes in tendinopathy [ 6]. The adaptive potential of tendons secondary to exercise has been demonstrated in several studies and there are multiple variables that may play a role and need to be considered for exercise interventions, such as intensity, load, frequency, muscle contraction type and repetitions [ 7, 8, 9]. Recent evidence suggests that loading magnitude and muscle contraction intensity may be more important than muscle contraction type [ 9].

The management of lower limb tendinopathies is complex. The need for long and often successive treatment modalities poses significant health and economic burden, which in conjunction with the often-debilitating effects of these conditions, make identification of the most effective treatments imperative [ 10, 11]. A significant proportion of patients do not regain full function after treatment, and chronic symptoms persist in approximately one-quarter of patients [ 12]. Over recent years, numerous therapeutic modalities have been assessed for treating lower limb tendinopathies, usually in conjunction with exercise therapy. These include, but are not limited to, extracorporeal shockwave therapy (ESWT), orthotics, ultrasound therapy (UST), laser therapy (LT), topical glyceryl trinitrate (GTN) therapy, corticosteroid (CS), platelet-rich plasma (PRP) and high-volume (HVI) injections. Surgery is reserved for treatment-resistant tendinopathy; however, the efficacy of surgical treatment is far from certain [ 12]. With the plethora of available interventions applied alone or in combination regimes, there is an increasing need for high-quality comparative studies and an overall assessment of the combined evidence that will inform management decisions and protocols.

The aim of the present study was to expand on our previous systematic review of patellar tendinopathy [ 13] and provide a more comprehensive living systematic review and network meta-analysis comparing the effectiveness of exercise interventions with or without adjunct treatments to other treatments or no treatment in patients with the commonest lower limb tendinopathies (Achilles, patellar tendinopathy and GTPS) with regard to patient-reported pain and function.

Methods

This living systematic review and network meta-analysis (NMA) was prospectively registered on PROSPERO (CRD42021289534), conducted and authored as per PRISMA-NMA" and "PERSiST" guidance [ 14, 15]. This review was administered at the Institute of Infection, Immunity and Inflammation, University of Glasgow, Scotland, and we plan to update the NMA annually for a minimum of 5 years. We intend to screen the literature annually to identify new eligible data and re-perform analyses where necessary. When new data become available, we will update the analysis and present the updated findings on the website of Glasgow University ( https://www.gla.ac.uk/researchinstitutes/iii/staff/nealmillar/). A plain-language summary for patients and clinicians dealing with lower limb tendinopathies will also be provided.

Eligibility Criteria

Types of Studies

Randomised controlled trials (RCTs) of any type that investigated patellar and Achilles tendinopathies and GTPS were eligible for inclusion. Only studies published in English were screened for inclusion.

Types of Participants

Studies of patients with mid-portion Achilles tendinopathy, patellar tendinopathy or GTPS were eligible for inclusion. A clinical diagnosis of Achilles tendinopathy, patellar tendinopathy or GTPS made by a medical professional was required for inclusion with or without radiographic confirmation. Diagnostic criteria for each type of tendinopathy were not controlled for. Duration of symptoms or level of physical activity were not exclusion criteria for the trials. The present study excluded trials with (1) patients with insertional Achilles tendinopathy, (2) trials with participants < 18 years old, (3) partial/complete tendon rupture, (4) previous tendon surgery, and (5) animal or in vitro studies.

Types of Interventions

Studies assessing the effectiveness of any form and duration of exercise therapy with or without adjunct treatments were included. Both supervised and non-supervised exercise programmes were eligible. Any type of intervention that was administered alongside exercise therapy was considered an adjunct treatment.

Types of Comparators

Any type of treatment (exercise or non-exercise-based), placebo/sham treatment or no treatment that was compared to an exercise therapy with or without adjunct treatments was considered as a comparator.

Types of Outcome Measures

The primary outcomes were patient-reported pain and function, measured by the visual analogue scale (VAS) or equivalent (0-10 or 0-100), and the Victorian Institute of Sport Assessment (VISA) scale (0-100), respectively. The VISA questionnaire has been developed into distinct questionnaires to assess pain and functional outcomes in Achilles (VISA-A) and patellar (VISA-P) tendinopathies and GTPS (VISA-G) [ 16, 17, 18]. For the purpose of analysis and pooling of results, outcome measures were divided into three distinct intervals, short-term (≤ 12 weeks), mid-term (> 12 weeks to  < 12 months) and long-term (≥ 12 months). No secondary outcomes were assessed. Where studies reported results at more than one time point within our pre-specified intervals, those closest to the longer end of the interval were used.

When trials used different types of patient-reported pain, the following hierarchy was used: (a) pain at rest, (b) pain with (any) activity, (c) pain during sports, (d) pain during the day, (e) pain at night, (f) current pain.

Literature Search

Search strategies were developed for each lower limb tendinopathy in "all fields" with the following Boolean operators: (a) '(patellar tendin* OR jumper's knee), (b) '(Achilles tendin*), (c) '(gluteal tendin* OR greater trochanteric pain syndrome OR GTPS) AND (treatment OR management OR therapy OR intervention OR shockwave OR exercise OR physiotherapy OR loading OR eccentric OR concentric OR platelet-rich plasma OR PRP OR glyceryl trinitrate OR GTN OR *steroid OR glucocorticoid OR injection OR laser OR acupuncture OR orthotics)'.

The following databases were screened for published and unpublished trials from inception to 15/03/22 by a single author: Medline, Embase, PubMed, Cochrane Central, Scopus, CINAHL SPORTDiscus, OpenGrey.eu and WorldCat.org. For unpublished or ongoing studies, we searched the WHO International Clinical Trials Registry Platform ( http://apps.who.int/trialsearch/) Clinical Trials.gov, The European Union Clinical Trials Register and the ISRCTN registry. All eligible studies' reference and citation lists were screened for further eligible trials. The PRISMA flow-chart is illustrated in Fig. 1.

PRISMA flow diagram summarising the article selection process

Data Extraction

Patient characteristics, duration of symptoms, nature of the therapeutic interventions, exercise programme description, outcome measures, and follow-up time points were extracted from individual trials and recorded in Microsoft Word version 16.43 (Microsoft Corporation) by two authors (GC and DC) in a previously constructed data extraction table. Additional file 1 was utilised where available for descriptive statistics. For missing data, attempts were made to contact the corresponding authors of studies published in the last 5 years, and if these were unsuccessful, the papers were excluded.

Data Handling: Synthesis of Results

Comparisons of interventions reported by two or more studies at similar follow-up time points were pooled quantitatively by pairwise meta-analyses in the absence of significant clinical heterogeneity (similar populations, follow-up time points and interventions). Only studies of patients with the same type of tendinopathy were pooled. Raw mean differences (MD) with their accompanying 95% confidence interval (CI) were calculated and used in the tests as the tools used across studies were the same. Finally, a network meta-analysis was conducted for both outcome measures (pain VAS and VISA) at each follow-up period where adequate data existed.

For the present article, "Achilles tendinopathy" refers to non-insertional Achilles tendinopathy only.

Risk of Bias and Strength of Evidence Assessment

The Cochrane Internal Validity Tool was used to assess the risk of bias for each RCT [ 19]. Studies were assessed by two authors separately (GC and DC), and disagreements were resolved with the involvement of the senior author (NLM). The overall risk of bias for each RCT was labelled as low or high based on how likely the assessor thought that the presence of high risk of bias in the individual domains was to affect the true outcomes of the assessed interventions. We avoided using pre-specified criteria (e.g. overall "high risk" if specific domains of the tool or a certain number of them were of high risk of bias for each study) as we believe that the assessor's judgement was more fair and accurate for determining the overall risk of bias.

The Grading of Recommendations Assessment, Development and Evaluation for network meta-analysis (GRADE-NMA) was used to appraise the strength (certainty) of evidence [ 20]. For pairwise meta-analyses, the strength of evidence was assessed based on four domains: overall risk of bias, imprecision, inconsistency and other confounding factors (including publication bias). The result of each comparison of interventions arising from the pooling of similar studies was assigned one of high, moderate, low or very low strength of evidence. This process was completed independently by two authors (GC and DC) for each outcome measure, and disagreements were resolved by the involvement of the senior author (NLM). For network meta-analyses, the strength of both the direct and the indirect evidence was taken into account as per GRADE-NMA, along with intransitivity (clinical heterogeneity of studies participating in direct versus those participating in indirect evidence) and similarly to pairwise meta-analyses, the results were assigned one of the aforementioned four strengths of evidence. Recommendations for clinical practice were given only based on results of high or moderate strength of evidence. An intervention was thought to be more effective than another intervention when its superiority was based on both statistical and clinical significance.

For network meta-analyses, the strength of evidence of the direct estimate was rated first using the overall risk of bias, inconsistency (statistical heterogeneity), indirectness (clinical heterogeneity) and publication bias (GRADE-NMA tool). Subsequently, the indirect estimate was rated using the lowest of the ratings of the two direct comparisons forming the most dominant first-order loops and intransitivity (differences in study characteristics of studies used in indirect comparisons). Finally, the network estimate was rated using the highest certainty of evidence between direct and indirect estimates, the incoherence (difference between direct and indirect comparisons-assessed using the "node splitting" approach) and imprecision.

Statistical Analysis

The Review Manager V.5 (RevMan) software was used to calculate the pooled mean difference and generate forest plots for pairwise meta-analyses and their accompanying heterogeneity tests (Chi 2 and I 2). STATA 16.1 with Ian White's extension (multivariate random-effects meta-regression) was used for network meta-analyses (frequentist approach) [ 21]. When exact numerical mean, mean difference or standard deviation (SD) values were not recorded in the individual papers, an estimated value was extrapolated from available graphs. When the results were recorded as mean difference and interquartile range (IQRs), the SD value was derived as IQR divided by 1.35. Where median values were reported, the mean was assumed to be the same. The RevMan software was used to generate SD values when only confidence intervals were recorded in trials. In studies in which only mean values were presented without SDs, the prognostic method described by Ma et al. [ 22] was used to generate an SD by calculating the mean of all the other SDs in that comparison.

Pooled SDs were calculated with the following formula:

$${\text{SD}}_{{{\text{pooled}}}} = \surd \left[ {{\text{SD}}_{1}^{2} \left( {n_{1} - 1} \right)} \right] + \, \left[ {{\text{SD}}_{2}^{2} \left( {n_{2} - 1} \right)} \right] \, + \cdots + \, \left[ {{\text{SD}}_{k}^{2} \left( {n_{k} - 1} \right)} \right]/\left( {n_{1} + \, n_{2} + \cdots + \, n_{k} {-} \, k} \right),$$

where SD = standard deviation, n = sample size, k  = number of samples.

The following formula was used for the sample size calculation as part of GRADE's assessment for imprecision:

$$N = \frac{{2\left( {a + b} \right)^{2} {\text{SD}}^{2} }}{{x^{2} }}$$

where N = the sample size required in each of the groups (optimal information size), x = minimal clinically relevant difference (MCRD); defined as 1.5 points for pain VAS and 13 points for VISA, SD 2 = population variance (calculated using pooled SD from included treatment groups), a = 1.96 (for 5% type I error), b  = 0.842 (for 80% power).

The optimal information size (minimum number of overall patients combined in each meta-analysis for sufficient "precision" in the GRADE assessment) with the use of the above formula was calculated as N = 34 patients for pain and N  = 20 for VISA.

Potential publication bias was not assessed as no pairwise meta-analyses included more than 10 studies. Expecting wide-range variability in studies' settings, a random-effects model was employed in all meta-analyses. Where heterogeneity was found to be high ( I 2 = 50-75%), the strength of evidence was downgraded by one level; where it was found to be substantial ( I 2  > 75%), it was downgraded by two levels.

Subgroup and sensitivity analyses were not performed as all pairwise meta-analyses had a maximum of only three RCTs.

Protocol Deviations

There were no deviations from the pre-defined protocol.

Definition of Loading Types

Isotonic-eccentric exercise types involving muscle contractions which result in movement of a limb and lengthening of the muscle unit.

Isotonic-concentric exercise types involving muscle contractions which result in movement of a limb and shortening of the muscle unit.

Isometric exercise types involving muscle contractions which result in no movement of a limb. The muscle unit may shorten marginally as the tendon elongates whilst under a contraction.

Slow resistance slow, isotonic exercises utilising both eccentric and concentric phases. Depending on the load used relative to repetition maximum (maximum load an individual can use for a defined number of repetitions), this can be "heavy" or "moderate" slow resistance.

Results

A total of 2834 studies were initially identified from the searches. An additional four studies were identified from other sources. After removing duplicate results and non-eligible study types, the titles ( n = 2102), abstracts ( n = 1487) and full texts ( n = 77) of the remaining studies were screened for inclusion by two authors independently. A total of 68 studies [ 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90] were found to be eligible and were included in the systematic review, 31 assessing interventions in Achilles tendinopathy ( n = 1792 patients, mean age 46 years), 31 in patellar tendinopathy ( n = 1109 patients, mean age 28 years) and 6 in GTPS ( n = 907 patients, mean age 55 years). The majority of outcome measures were assessed at short- and mid-term follow-up. Five (5) studies assessed immediate post-intervention outcomes only [ 31, 44, 63, 64, 82]. Patient and trial characteristics (Additional file 1: Tables S1-S3), risk of bias assessment results (Additional file 1: Tables S4-S6), strength of evidence assessment (Additional file 1: Table S7) and the tabulated results of the compared interventions (Additional file 1: Tables S8-S10) can be found in the supplementary material. The most common type of pain reported was "with single decline squat" in patellar tendinopathy (7 studies), "at rest" in Achilles tendinopathy (11 studies), and "over the last week" (5 studies) for GTPS.

Pairwise Meta-analyses

The pairwise comparisons of interventions are presented below for each tendinopathy type. The forest plots of results based on moderate or high strength of evidence are shown in Fig. 2, whilst those of low or very low strength of evidence can be found in the Additional file 1: Figures S1-S4. For each result, the accompanying parentheses show the MD of the pairwise comparison with its confidence interval and heterogeneity test and the number of pooled studies.

Meta-analysis results and forest plots of eccentric exercise plus placebo (control) versus eccentric exercise plus ESWT (intervention) for a short-term pain VAS in patellar tendinopathy and b short-term VISA-P in patellar tendinopathy

Achilles Tendinopathy

Eccentric Exercise Plus PRP Injection Versus Eccentric Exercise Plus Placebo

Short-term and Mid-term follow-up Based on evidence of low strength, there was no difference in VISA-A between the eccentric exercise plus PRP injection group and the eccentric exercise plus placebo injection groups at short-term follow-up [MD 1.52, 95%CI (− 2.49, 5.53), I 2 = 5%, P = 0.46, 3 studies] (Additional file 1: Figure S1a). At mid-term follow-up, there was a difference in VISA-A in favour of the eccentric plus PRP injection group when compared to the eccentric group plus placebo injection based on low strength of evidence, though not likely to be clinically significant [MD 5.05, 95% CI (1.45, 8.64), I 2 = 0%, P = 0.006, 3 studies] (Additional file 1: Figure S1b).

Eccentric Exercise Plus Low-Level Laser Therapy Versus Eccentric Exercise Plus Placebo

Short-term follow-up For VISA-A, we found very low strength evidence for a difference in favour of the eccentric exercise plus low-level LT when compared to eccentric exercise plus placebo at short-term follow-up, which is likely not clinically significant [MD 6.29, 95% CI (1.72, 10.85), I 2 = 85%, P = 0.007, very low strength, 2 studies] (Additional file 1: Figure S2).

Greater Trochanteric Pain Syndrome

Corticosteroid Injection Versus Exercise Therapy

Short-term and long-term follow-up We found low strength evidence for a difference in pain VAS scores favouring CS injection when compared to exercise therapy (mixed types) in patients with GTPS at short-term follow-up; this is likely to be clinically significant [MD 1.57, 95% CI (1.1. 2.1), I 2 = 94%, P = 0.01, 2 studies] (Additional file 1: Figure S3a). There was no difference in reported pain VAS scores between the groups at long-term follow-up based on evidence of low strength [MD − 0.7, 95% CI (− 0.6, 0.45), I 2 = 97%, P = 0.78, 2 studies] (Additional file 1: Figure S3b).

Patellar Tendinopathy

Eccentric Exercise Plus ESWT Versus Eccentric Exercise Plus Placebo

Short-term Based on moderate strength evidence, there was no difference in short-term pain VAS or VISA-P between eccentric exercise plus ESWT and eccentric exercise plus placebo ESWT [MD − 0.09, 95% CI (− 1, 0.84), I 2 = 0%, P = 0.84, moderate strength, 2 studies; MD − 1.8, 95% CI (− 8, 4.4), I 2 = 0%, P = 0.57, 2 studies, respectively] (Fig. 2).

Isotonic Exercise Versus Isometric Exercise

Short-term follow-up We found low strength evidence for no differences in pain VAS immediately post-intervention with isometric versus isotonic exercise in patients with patellar tendinopathy [MD 1.03, 95% CI (− 2.57, 0.5), I 2 = 70%, P = 0.19, 3 studies] (Additional file 1: Figure S4).

Network Meta-analysis

The network maps, network forest plots and comparative treatment class effects deriving from all performed network meta-analyses can be found in the Additional file 1: Figures S5-S10. Figure 3 illustrates the median treatment ranks for each tendinopathy for pain VAS and VISA at each follow-up time intervals where data were available. A total of 17 and 19 interventions participated in the network meta-analyses for Achilles and patellar tendinopathy, respectively. Data were insufficient for network meta-analyses in GTPS.

Median ranks of the effectiveness of interventions included in the network meta-analysis for a short-term VISA-A in Achilles tendinopathy. b mid-term VISA-A in Achilles tendinopathy, c for long-term VISA-A in Achilles tendinopathy and d short-term pain VAS in Achilles tendinopathy. PRP platelet-rich plasma, HVI high volume injection, MVCS mucopolysaccharides, type I collagen injection plus vitamin supplementation, ABI autologous blood injection, CS corticosteroid

Achilles Tendinopathy

Short-term follow-up Eccentric exercise plus HVI (with CS) had the highest probability of being the most effective treatment for improving VISA-A and pain VAS scores (probability 56% and 45%, respectively). Passive stretching plus a dietary supplement containing mucopolysaccharides, type I collagen and vitamin C (MCVC) and eccentric exercise plus HVI (without CS) had the highest probability of being the least effective treatment for VISA-A (probability 22% and 46%, respectively) (Fig. 3 a, b).

Mid-term follow-up Eccentric exercise plus HVI (with CS) had the highest probability (83%) of being the most effective treatment for improving VISA-A, whilst eccentric exercise plus MCVC dietary supplement had the highest probability (42%) of being the least effective treatment for improving VISA-A (Fig. 3 c).

Long-term follow-up Eccentric exercise plus prolotherapy had the highest probability (55%) of being the most effective treatment for improving VISA-A scores, closely followed by eccentric exercise plus HVI (with CS) and heavy slow resistance exercise. Combination treatment with low-level LT plus eccentric exercise had the highest probability of being the least effective treatment (44%) (Fig. 3 d).

Patellar Tendinopathy

Short-term follow-up For VISA-P, combination therapy with eccentric exercise plus hyaluronic acid injections had the highest probability (75%) of being the most effective intervention, whilst concentric exercise had the highest probability (42%) of being the least effective intervention (Fig. 4a). For pain VAS, slow resistance exercise of moderate load had the highest probability (22%) of being the most effective treatment, closely followed by eccentric exercise plus topical GTN, whilst concentric exercise had the highest probability (48%) of being the least effective treatment (Fig. 4 b).

Median ranks of the effectiveness of interventions included in the network meta-analysis for a short-term VISA-P in patellar tendinopathy and b short-term pain VAS in patellar tendinopathy. PRP platelet-rich plasma, GTN glyceryl trinitrate, rESWT radial extracorporeal shock wave therapy, fESWT focal extracorporeal shock wave therapy

Mid-term and long-term follow-up Data were insufficient for network meta-analyses in patellar tendinopathy at these follow-up time intervals.

Network Meta-analyses Strength of Evidence

For both Achilles and patellar tendinopathy, all results arising from network meta-analyses presented both in text and in figures are considered as of low/very low strength of evidence due to the high overall risk of bias of the included studies and intransitivity.

Discussion

The mainstay of treatment for lower limb tendinopathies is non-operative. Exercise therapy for at least 3 months results in an improvement in function and pain for the majority of patients [ 3, 6, 91]. Amongst different exercise programmes, eccentric exercise has been thought to be the gold standard management for patellar and Achilles tendinopathy and is usually prescribed as first-line treatment. The effectiveness of eccentric loading for these two tendinopathies is embraced by the research community; the vast majority of non-exercise interventions being assessed were administered alongside eccentric exercise. As a result, conclusions on the effectiveness of these interventions as monotherapies cannot be made. They should always be prescribed as an adjunct to a continuous exercise programme, which should constitute the main focus of the patient's management. The safety and good tolerability of eccentric exercise make it an even more attractive option. However, it relies heavily on patient compliance, especially where financial constraints at an individual or healthcare system level preclude long-term supervised programmes [ 81]. For GTPS, eccentric loading on its own is not recommended as the gluteal tendons have short excursion and eccentric exercises alone would be very challenging.

Our study includes all eligible evidence on the comparative effectiveness of exercise interventions for patellar tendinopathy, Achilles tendinopathy and GTPS with or without adjuncts. Our only result which can be used for strong practice recommendations is the lack of benefit on pain or VISA-P of ESWT added to eccentric exercise for patellar tendinopathy (moderate strength of evidence)-therefore, we do not recommend its use. The remaining results were of low or very low strength of evidence. In the following few paragraphs, we discuss promising interventions arising from our findings for each lower limb tendinopathy separately and also summarise the results of other similar systematic reviews and relevant evidence. Based on these, we provide our treatment recommendations for each tendinopathy.

Achilles Tendinopathy

For Achilles tendinopathy, there were no results of comparisons of interventions that were based on moderate or high strength of evidence. Based on evidence of low strength from our pairwise meta-analyses, PRP injections added to eccentric exercise were associated with no short-term benefit and a small, non-clinically significant mid-term benefit in VISA-A. Similarly, low-level laser therapy was associated with a small clinically insignificant short-term benefit in VISA-A when added to eccentric exercise.

From the network meta-analyses, HVI with CS combined with eccentric exercise ranked first in the network meta-analysis for short-term pain VAS and VISA-A, and it also ranked first for mid-term VISA-A improvement. Long-term VISA-A increases were likely to be the highest in patients receiving prolotherapy and eccentric exercise; however, only a single study contributed data for this treatment group. Heavy slow resistance exercise as monotherapy also ranked very highly (second) for mid-term and long-term VISA-A improvements and the single RCT that compared it to eccentric exercise found no differences at 12 weeks or 1 year for pain or VISA-A [ 28]. In the included RCTs, HVI with CS alongside eccentric exercise consistently demonstrated positive results, whilst those of HVI without CS combined with eccentric exercise were conflicting [ 30, 81]. It is not impossible that the clinical benefits of HVI with CS may be related to the CS alone, as demonstrated by a recent RCT that found that, added to heavy slow resistance exercise, US-guided CS injection was superior than a placebo injection for VISA-A in the short-, mid- and long-term [ 92]. HVI was administered under US guidance in all studies, and finally, HVI with or without CS was not associated with any complications; however, the very small (theoretical) risk of tendon rupture associated with locally-administered CS should always be taken into account and communicated to patients [ 81]. Finally, the limited published evidence on the effectiveness of isometric loading for immediate post-intervention pain relief in Achilles tendinopathy does not support its use [ 82, 93].

In their similar systematic review and network meta-analysis on Achilles tendinopathy, van der Vlist et al. [ 94] found no convincing evidence for the superiority of any interventions over others based on the lack of adequate strength of evidence, which is in agreement with our results. As a conclusion, they recommend a calf-muscle exercise programme to be prescribed as first-line treatment as it is easy, widely available, safe and cheap [ 94]. Another network meta-analysis by Rhim et al. [ 95] concluded that the addition of HVI with CS and ESWT to eccentric exercise could potentially improve long-term outcomes which is partly in agreement with our recommendations.

We recommend the use of a progressive eccentric or heavy slow resistance exercise for 12 weeks as first-line treatment for Achilles tendinopathy. For resistant cases (no or minimal improvement at the end of the programme), a US-guided HVI with CS could be added to the continuing exercise programme if available.

Patellar Tendinopathy

Pairwise meta-analyses found no interventions that were superior to others for patellar tendinopathy. For short-term pain relief, promising interventions from the network meta-analyses included slow resistance exercise of moderate load and eccentric exercise combined with topical GTN. For short-term VISA-P improvements, eccentric exercise combined with hyaluronic acid injections ranked the highest. Only single studies contributed data to the networks for each of these promising interventions; therefore, clinical practice recommendations for their use can only be weak at this point. No complications were reported with the use of hyaluronic acid injections in the included studies, whilst topical GTN may cause headaches [ 47, 96]. In the relevant included RCT, two hyaluronic acid injections were administered under US guidance 1 week apart, whilst three injections 1 week apart have also been used successfully for Achilles and patellar tendinopathy elsewhere [ 47, 97, 98]. Topical GTN was used as one patch (5 mg) daily for 12 weeks in the included RCT [ 71]. Heavy slow resistance exercise was as effective as eccentric exercise up to 6 months of follow-up in one of the included RCTs and in another RCT slow resistance exercise of moderate load (55% of one repetition maximum) was no less effective than that of heavy load (90% of one repetition maximum) [ 24, 50]. There was adequate evidence (moderate strength) for strong clinical practice recommendations to suggest that ESWT does not appear to add any benefits when used with eccentric exercise for either pain or VISA-P in patellar tendinopathy.

Isometric exercise has been suggested for immediate pain reduction in patellar tendinopathy as isotonic loading can be painful [ 63]. Three RCTs compared a bout of isometric versus isotonic muscle contractions for immediate post-intervention pain relief in young athletes and reported conflicting results [ 44, 63, 64]. Our pairwise meta-analysis found a difference of 1 VAS point favouring isometric loading, which however did not reach clinical or statistical significance (low strength of evidence). Mid- and long-term follow-up results for the effectiveness of isometric exercises on patellar tendinopathy do not exist from RCTs.

In a recent systematic review and network meta-analysis, Chen et al. [ 99] found no benefits of adding ESWT to eccentric exercise in their pairwise meta-analyses, which is in agreement with our findings. Their network meta-analysis found that dry needling and PRP injections were the highest-ranked interventions. However, their network methodology may have been flawed as some of the studies were not in the network loop (i.e. not all studies had common comparators). Finally, in a previous systematic review of RCTs, topical GTN was superior to placebo in the management of tendinopathy (all types combined); however, its side effects, especially headaches, should be considered and explained to patients [ 96].

We recommend the use of a progressive eccentric exercise or slow resistance exercise (of "moderate" or "heavy" load) for 12 weeks as first-line treatment for patellar tendinopathy. For resistant cases (no or minimal improvement by the end of the programme), a course of topical GTN or a course of 2-3 US-guided hyaluronic acid injections could be added to the exercise regime depending on availability, and the patient's and physician's preference. Where isotonic exercise is not tolerated due to pain, isometric exercise may be used in the initial stages of the treatment regime. ESWT is not recommended for patellar tendinopathy.

Greater Trochanteric Pain Syndrome

Gluteal tendinopathy, which has been renamed as the more generic term "GTPS", has not received as much attention in the literature as the other two lower limb tendinopathies. This is evident from our inability to perform a network meta-analysis due to insufficient data. Our pairwise meta-analysis results (based on very low strength of evidence) suggest that, for short-term pain relief, a CS injection may be superior to exercise therapy (mixed types). These benefits were likely to be clinically significant. The short-term benefits of CS did not last in the mid-term or long-term. In a RCT that included a CS injection, a ESWT and a home exercise treatment group found that the CS injection group had lower pain scores 1 month after treatment but the reverse was true 15 months after treatment [ 68]. Also, a significantly larger proportion of those treated with ESWT or exercise had their symptoms resolved or improved at 15 months compared to those treated with a CS injection. The most commonly reported complication with ESWT was skin irritation. In another RCT, combined with a home exercise programme, ESWT was significantly more effective than sham ESWT at 2 months for pain relief. Additionally, ESWT combined with exercise had significantly greater pain-relieving benefits at long-term follow-up compared with CS injection combined with exercise in another RCT [ 42]. No tendon ruptures or other major complications associated with ESWT or CS injections were observed in any of these studies. All included RCTs administered 3 weekly sessions of ESWT. Finally, isometric loading was found to be as effective as isotonic loading for pain and functional outcomes up to 12 weeks in a RCT [ 34].

In their systematic review, Barratt et al. [ 100] also reported the superiority of CS injections compared to exercise for short-term pain relief. Additionally, CS injections yielded more favourable short-term outcomes for pain compared to ESWT and usual care. Their general conclusion on the management of GTPS was that definitive recommendations could not be made due to the lack of high-quality evidence. In a recent network meta-analysis, Gazendam et al. [ 101] found no interventions superior to no treatment at 6 and 12 months. However, PRP injections and ESWT may provide short-term pain relief, and structured exercise could produce short-term improvement in functional outcomes [ 101]. Wang et al. [ 102] found that the existing evidence on the effectiveness of CS injections in GTPS is equivocal. A RCT that was not included in our systematic review as the participants did not perform exercise as part of their treatments found no benefits of CS injections compared to placebo injections [ 103]. Despite the possible short-term pain-relieving benefits of CS injections in GTPS, we do not recommend its use due to the lack of longer-term benefits and their possible side effects. Finally, education of patients with GTPS may be at least as important as the exercise programme itself and stretching of the gluteal tendons should be avoided as compressive loading may be exacerbating tendinopathic pain [ 34, 104].

We recommend the use of a progressive isotonic exercise programme (utilising both eccentric and concentric phases) for 12 weeks as first-line treatment for GTPS. Where isotonic loading is not tolerated due to pain, an isometric programme could be prescribed instead, at least in the initial stages of treatment. In patients with restricted hip movements due to concomitant hip osteoarthritis, an isometric programme could be used for the whole duration of the treatment regime. Combined isotonic/isometric programmes could also be used as first-line treatment. For resistant cases (no or minimal improvement by the end of the programme), a ESWT programme (3 weekly sessions) could be added to exercise if available.

Table 1 summarises our treatment recommendations for each one of the three tendinopathies. For all three tendinopathies, patient education should constitute an integral part of management, and it should include explanation of principles of management and gradual load increases, advice on avoiding positions and activities that exacerbate symptoms and as much supervision as possible to maximise compliance and ensure the exercises are performed correctly.

Table 1 A summary of our management recommendations for Achilles and patellar tendinopathies and greater trochanteric pain syndrome

Study Limitations

The most significant limitations of our study arise from the nature and inadequacy of the included evidence rather than methodological flaws at a meta-analysis level. We included all eligible RCTs and performed thorough assessment of the risk of bias and strength of evidence with pooling of results at pre-specified follow-up time points. However, the majority of results were based on low or very low strength of evidence. Placebo interventions were considered the same as no treatment when in reality, placebo could have its independent effects on tendinopathy. Many interventions were not connected to the network and therefore, could not be included in the network meta-analyses. For GTPS, the exercise treatment group was mixed including more than one type of loading. Finally, patient characteristics were not considered as subgroups would further decrease the strength of evidence; in reality, patients of different age groups, activity levels and duration of symptoms may respond differently to interventions.

Conclusion

There appears to be no convincing evidence currently to suggest that any adjuncts administered alone or alongside exercise are superior to exercise monotherapy for the treatment of Achilles tendinopathy, patellar tendinopathy or GTPS. Therefore, we recommend that exercise monotherapy continues to be used as a first-line treatment for these tendinopathies, and it will be effective for most patients. For resistant cases, we provide recommendations for addition of adjuncts/alternative loading programmes based on our results and the rest of the published evidence; the evidence for these is of low or very low strength; therefore, these recommendations may change in the future if evidence of higher strength suggests the superiority of other treatments, further research should focus on promising interventions with inadequate strength of evidence and especially on the comparison of different loading types used as monotherapies to inform clinical practice with more certainty.

Acknowledgements

None.

Funding

This work was funded by Medical Research Council Grant MR/R020515/1 (NLM).

Author information

Author notes

D. Challoumas and G. Crosbie are joint first authors.

Authors and Affiliations

School of Infection and Immunity, College of Medicine, Veterinary and Life Sciences, University of Glasgow, 120 University Avenue, Glasgow, G12 8TA, UK

Dimitris Challoumas, Gearoid Crosbie & Neal L. Millar

Department of Physiotherapy, School of Allied Health Professionals, University of Leicester, Leicester, UK

Seth O'Neill

Sports Medicine and Imaging Department, Clinica Diagonal,, C/San Mateu, Esplugues de Llobregat, Spain

Carles Pedret

Contributions

DC, NLM, and GC conceived and designed the study. DC and GC performed the analysis. CP, SO and NLM provided expert advice. All authors analysed the data. GC, DC, NLM, SO and CP wrote the paper. All authors read and approved the final version of the manuscript.

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Correspondence to Neal L. Millar.

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Challoumas, D., Crosbie, G., O'Neill, S. et al. Effectiveness of Exercise Treatments with or without Adjuncts for Common Lower Limb Tendinopathies: A Living Systematic Review and Network Meta-analysis. Sports Med - Open 9, 71 (2023). https://doi.org/10.1186/s40798-023-00616-1
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Keywords

Tendinopathy

Exercise

Achilles

Patellar

Greater trochanteric pain syndrome

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Effectiveness of Exercise Treatments with or without Adjuncts for Common Lower Limb Tendinopathies: A Living Systematic Review and Network Meta-analysis - Sports Medicine - Open

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Introduction Exercise therapy is usually prescribed as first-line treatment for lower limb tendinopathies. The multitude of exercise- and non-exercise-based management options can be overwhelming for the treating sports professional and patient alike. We chose to investigate the comparative effectiveness of exercise therapy with or without adjuncts for managing the commonest lower limb tendinopathies.

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Client-Centered Exercise Demonstration

First impressions about the prescription form in the demonstration stage and continue to be reinforced through subsequent workouts and all the stages of monitoring. There is a relative paucity of articles concerning the teaching and demonstration of new exercise skills, despite the fact that this often constitutes a vast majority of the time of a personal fitness trainer. Teaching behaviors such as exercise explanations, demonstrations, positive reinforcement, and performance feedback increase the level of exercise focus.

Clients need to understand how an exercise will help them. They need to see it demonstrated and then try it with some expert feedback. Finally, the exercise may need to be modified or integrated into a full prescription. These are the steps involved in form 5.8, Exercise Demonstration Model Checklist. Adapt this model to suit your client and situation.

The one-on-one exercise demonstration is a core element of your client-centered services. The exercise demonstration model (presented in the highlight box here, and as a checklist in form 5.8) identifies more than two dozen critical behaviors that make up a single demonstration. The items on the checklist guide you through this process. For many of the items, the checklist provides examples of behaviors or methods of showing that item. They are merely suggestions that may guide your actions or dialogue with your client.

There are four distinct steps.

The predemonstration sets the scene, in which you ensure that the client is comfortable, find out about the client's previous experience, and provide an idea of what is to come and why.

The actual demonstration stage teaches the client how to perform the exercise correctly and safely. Effective use of verbal and physical techniques adds clarity to the teaching.

The third stage is the client trial, in which you observe carefully and provide specific feedback.

The follow-up allows you to gather feedback from the client and provide client-centered prescription guidelines.

Demonstrating an exercise is both a science and an art. It requires a balance between your technical knowledge and your people skills. With practice, you will learn to alter the technical aspects to suit each client's personality and learning style.

You should always observe, analyze, and modify technique. You must have a sound knowledge of the biomechanics of the exercises and an ability to design multiple variations in technique to suit the abilities of your clients. In addition to designing appropriate exercises, you must reinforce good technique both by demonstrating new exercises and by observing your client as she attempts to duplicate your demonstrations.

These are key technical issues on which you must focus to provide effective exercise demonstration:

● Initial body position. Focus on overall body posture. Instruct your client to "set" herself into a good body position before any exercise. Focus on exactly where you want your client to begin. For example, when beginning a bench press, your client should press her low back into the bench, with feet on the bench (if possible) and hands slightly wider than shoulder-width apart. Establish what will be stabilized and how that will feel (e.g., shoulder girdle or pelvic stabilization).
● Movement pattern. From the starting position, describe the sequence of movements and the body or joint position at the end of the exercise.
● Cueing. Give alignment and "feeling" cues to assist in the execution phase of the exercise. For example, when your client is doing side-lying lateral leg raises, show how the hips are aligned one on top of the other, raising to approximately 45Â°, with knees facing forward.
● Safety and quality. Using your knowledge of the demands and biomechanics of the exercise, provide appropriate safety guidelines. Focus on quality versus quantity. This refers to the number of repetitions your client performs correctly and the speed at which they occur. When resistance equipment is being used, remember the issues we raised in "Direction of Force Application and Muscle Alignment" in chapter 3:

○ Is the path of motion defined by the machine the same as your client's path of motion?
○ Is the direction of force application safe and optimal?
○ Does the equipment allow proper alignment between the machine's fulcrum and the center of the moving joint?

● Spotting. Spotting is an important component of exercise demonstration. Spotting refers to the visual and physical aspects of monitoring clients as they execute exercises. Visual spotting is done for all exercises, whereas physical spotting is used primarily in weight training. Watch for correct body alignment, signs and symptoms of fatigue, signs of discomfort, control of movements, and the direction of the exercise energy. Assist the client to make technique corrections, attempt more repetitions, or complete the range of motion. For clients who are more advanced, verbal reinforcement cues are effective to correct their technique. Once the neural pattern (motor schema) has been cemented, the cues can prompt fluid modification during the repetition (Baker 2001). The simple use of one or two key words such as head up, pelvis stable, or pinch provides sufficient feedback based on the client's current knowledge of performance. Spotting the client provides an excellent opportunity to monitor good form. For more detail on spotting, see chapter 7.
● Positioning. While you are training or demonstrating to your client, your positioning can help you and affect your rapport with your client. Position yourself for the best view of the client's technique if you are not spotting. From the side or a 45Â° angle, you should also be able to view her face and most of her body. Match your client's upper body level, and avoid talking down to her. Like an athlete, be in a ready position to assist your client. Being casual by leaning or sitting can make you appear unprofessional.
● Touching or not touching. Many personal fitness trainers touch their clients to adjust their position. We must always respect individual boundaries. If you have not received permission to touch your client or are hesitant to ask, you can use a few strategies to help position your client without touching her. Demonstrate the exercise and then point out the adjustments on your own body while the client performs the exercise. Another technique is to provide a mental image such as "squeezing the abdomen like an accordion" (Cantwell 1998).

The skills involved in demonstration are significantly based in the psychosocial domain. Table 5.11 outlines some of these psychosocial aspects involved in the stages and activities, from the time we meet our clients for the program demonstration until later in the program follow-up.

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It is important within the exercise demonstration to adjust your approach to suit each client's learning and personality style. In the beginning stages, focus on giving only the important points. As your client becomes more experienced, offer more alternative exercises, allowing your client to make his own selection. Base the amount of information you share with your client on his current stage of learning as well as on his preferred learning style. These are different learning styles and personalities, each followed by an example of how you would use that learning style with a client:

● Learning by doing: Have the client perform a series of abdominal exercises at a very slow and controlled pace, rather than the faster pace to which she is accustomed.
● Learning by observation: Demonstrate for your client the difference between a slow and faster pace for the exercise, then have her try it. Ask your client to comment on specific items she observed or felt - for example, "Did I look in full control of my body during the fast pace?" or "How did the slow exercises feel? Was there more energy required to perform the series slow or fast?"
● Learning by knowing the theory: This is a combination of your client's experience and observations; ask, for example, "What does this mean about the next time you will do sit-ups?"
● Learning by applying the information to individual situations: Have your client consider how this information will apply to other exercises he executes. "What would be the best way to perform muscle endurance exercises? Where else can this information apply?"

Teaching strategies can also be based on clients' personality characteristics. During the initial part of your meeting, try to determine their predominant personality style. Here are three different personality styles, each followed by an example of how you would adapt the demonstration for that client:

● Technical personality: Explain the pros and cons of your exercise choice or design. Deliver information at a moderate pace and be specific about your feedback.
● Sociable personality: Maintain a relaxed pace, inviting feedback and regularly checking on comfort. Be a good listener.
● Assertive personality: Be businesslike, reasonably fast paced (once their execution is successful), and stimulating. You may need to limit the options you present, but be sure to incorporate clients' input.

Exercise Demonstration Model

1. Predemonstration

● Set climate by making client feel comfortable and being receptive and responsive.
● Provide overview by explaining the purpose of this session and what is to happen in this session.
● Determine client's background and experience by asking, "Have you done this exercise before?" "Have you used this type of equipment before?" "What was your experience?"
● Clarify purpose of exercises by explaining the specific muscles used (major prime movers) and relevance to stated needs and wants.
● Encourage the client to ask questions and provide input.

2. Demonstration

● Provide precise and appropriate verbal instructions.
● Position client appropriately to watch demo.
● Provide clear physical demonstration (4-6 reps before client trial).
● Ensure that overall technical execution was smooth and confident.
● Ensure beginning position alignment and proper grip.
● Isolate the movement (i.e., no compensation or inappropriate movements).
● Stabilize the pelvis and key joints.
● Ensure that terminal points of range of motion are appropriate.
● Demonstrate safety, including controlled breathing and no Valsalva maneuver.
● Demonstrate safety, including controlled speed and no momentum at the end of the range of motion.
● Ensure efficient use of time with descriptions and explanations.

3. Client Trials

● Set client up by positioning and alignment.
● Select appropriate weight (moderately difficult).
● Ensure trial safety by controlling breathing, momentum, and plane of movement and ensuring no joint locking.
● Ensure effective spotting by being in position to observe and assist with starting and finishing positions.
● Have client execute a full set.
● Provide feedback to the client, which may include providing specific information and monitoring, focusing on behavior and not the person, correcting one aspect at a time, and being positive and helpful (providing success).
● Demonstrate verbal skills such as cueing during execution, paraphrasing, summarizing, and questioning.
● Demonstrate nonverbal skills such as using correct body position, being engaged, providing eye contact, and ignoring distractions.

4. Follow-Up

● Obtain feedback from client by asking how it felt (i.e., awkward, comfortable, difficult) and encouraging the client to ask questions and provide input.
● Demonstrate active listening skills by responding to feedback.
● Provide prescription guidelines (including weight, reps, and sets, or frequency, intensity, time, and type) that integrate and interpret information from client trial.
● Suggest a method of progression or encourage self-monitoring and assessment.
● Provide a modification on request (problem solving).

Teaching Cues and Common Problems During Exercise Demonstrations

Spotting and positioning are technical elements but relate directly to client execution. Poor spotting or positioning could result in serious injury to the client or trainer; good spotting provides a trust-building experience that rivals any counseling technique. Cueing is a prompt or a signal that acts as a reminder to do something. As trainers we are teachers, reminding (cueing) our clients of the correct position, area of stabilization, or movement; but we also have a physical presence through our own positioning and spotting.

The following are three common resistance exercises, one lower body, one upper body, and one for the trunk. Common execution problems and appropriate cueing are presented.

Lower Body Example: Leg Press or Hack Squat

A common fault is bringing the weight too low. When the knee tracks beyond the toes, excessive forces are placed on the posterior cruciate ligament. A tactile range-limiting cue such as a palm of the hand on the knee may be effective. Some clients may turn their feet inward or outward to try to isolate parts of the quads. Assure your clients that there is no consensus that foot position can alter quad muscle recruitment. Encourage them to find the most comfortable foot position that poses the least stress. In many lower body resistance exercises, you should assist the client at the end of the movement or if the speed decreases because of fatigue.

Upper Body Example: Barbell Curl

A common fault is moving the torso or shoulder joint during the execution. Extending the torso in the up phase creates momentum. To deter this habit, you may have your client perform the exercise with the upper back against a wall. Flexing the shoulder joint draws assistance from the anterior deltoid and upper pectoralis major. Placing a finger on the posterior elbows of your client will be a sufficient tactile cue not to lift the arms forward. The faults described are actions that do not allow the elbows to move through a full range of motion and decrease the muscle fiber recruitment of the biceps. In many upper body resistance exercises, you should position yourself close to the client where you have the most effective position for assistance. For dumbbell exercises, position your hands at the joint that is immediately below the weight.

Trunk Example: Exercise Ball Crunch

A common fault is using a position on the ball that does not allow for a range of motion suited to the client strength. A position of support in the middle and upper back will decrease the range of motion and reduce the lever arm length, creating an easier modification. A lower starting position allowing the spine to slightly hyperextend prestretches the abdominal muscles, changes the fulcrum, and increases the lever arm, therefore increasing the contractile range of motion. Initially you may need to stabilize the ball against a wall with your feet or with available equipment. Monitor the position of your client, observing the fulcrum of the movement, the range of motion, and perceived difficulty of the client. With many trunk exercises, you must teach pelvic stabilization to minimize low back curvature and strain. Have clients touch their abdominal area to cue this pelvic stabilization and monitor their breathing.

Reinforcing the Client in the Demonstration

The client trial and follow-up stages are an excellent opportunity for motivation and reinforcement. Baker (2001) described three methods of reinforcing behavior.

Achievement reinforcement helps cultivate motivation to achieve preset goals. Recognize even a small improvement, but make sure it is praiseworthy because clients will know if you are sincere.

Sensation motivation comes from the feeling of execution excellence and, if reinforced immediately, will remain clear in the kinesthetic memory.

Verbal reinforcement should be positive and specific to the performance. To correct a client error, avoid negative phrases such as "No . . . that's not right," "That's too fast," or "Don't lock your elbows." Instead try more positive corrective cues such as "If you adjust that position, you should feel the difference," "Keep that cadence of 1 up and 3 down," or "Keep your elbows soft . . . good."

Reinforcing the client during the trial and follow-up stage is an effective means of motivating him to continue with positive behaviors or to modify incorrect techniques. Westcott and colleagues (2003) found that high levels of focused trainer - client interaction should address major aspects of proper exercise performance without being too technical during the first few weeks of training. They further suggested that comments should not disrupt exercise flow and should be exercise focused, reinforcing the client's training efforts.

h4>Connecting With Your Client

Try to get a broad picture of the human side of program demonstration. Imagine that you are demonstrating a modified squat to a novice middle-aged client. In the following, a description of your role in each stage precedes a brief sample statement appropriate for that stage of the exercise demonstration.

Predemonstration

This first step requires a sales technique. You need to sell the benefits and show your client how the exercise is relevant to him.
By doing the squats regularly, you will be better able to climb longer flights of stairs, lift heavier objects from the floor, and walk farther without fatigue.

Demonstration

You are the role model, yet you must be sensitive to your client's style of learning - tactile, auditory, or visual.
Stand with feet shoulder-width apart, knees slightly bent; your back is pushed flat against the wall with your arms on your thighs for support, like this.

Client Trials

Your focus is on your client's behavior. Leave him with a feeling of success and an idea of how to do better.
As you bent your knees to lower your body, your knees moved beyond the line of your toes initially, but then you pressed your hips farther back as you lowered your body and realigned . . . that's good.
Ask for your client's feelings. If you have rapport with him, you will gain valuable insights. Knowing that you are there for him gives him the confidence for greater autonomy.
Are there any aspects of the exercise you are unsure of or want to clarify? Which part of the program are you most looking forward to?
Learn more about Client-Centered Exercise Prescription, Third Edition With Web Resource.

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Learn how to explain, demonstrate, and correct exercises when working with clients

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First impressions about the prescription form in the demonstration stage and continue to be reinforced through subsequent workouts and all the stages of monitoring. There is a relative paucity of articles concerning the teaching and demonstration of new exercise skills, despite the fact that this often constitutes a vast majority of the time of a personal fitness trainer.

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London International Consensus and Delphi study on hamstring injuries part 1: classification

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Muscle injury classification systems

There are multiple, differing muscle injury classification systems. 2-7 Anatomy is key to most systems 3 5 7 8 and most use some form of imaging (particularly MRI and ultrasound (US)). 4-6 9 There is a high incidence of MRI negative HSI, from 17% to 31%, 9-12 and many systems incorporate a grade 0 for HSI with negative imaging. 2-4 6 13 Some classifications use components of subjective and objective examination or function, 11 14-16 which may associate with time to return to sport (TRTS) following HSI. 11 17 18 Several reviews on classification systems in muscle injury are available. 1 19-24 None of these systems are specific to individual hamstring muscles but the specific muscles have anatomical and functional differences that are relevant in management. 25 While early classification systems for muscle injuries traditionally followed a severity of injury approach (ie, grading system), 2 14 15 26 27 they have evolved to also consider the anatomical tissue involved (ie, fascia/muscle vs tendon and connective tissue), 3 13 and the mechanism of injury 2 13 ( table 1).

Limitations of current muscle classification systems

These classification evolutions have assisted clinicians in planning management and prognostication. Different anatomical tissues have different healing time frames and load capacity, resulting in differences in optimal rehabilitation prescription, progression, readiness to return to sport (RTS), 28 and risk of reinjury. 29 Current muscle injury classification systems are generic and do not differentiate between muscles, even though muscles have different anatomy and architecture. Intramuscular connective tissue and myotendinous junction (MTJ) architecture, for example, differ considerably between hamstring muscles and within individuals. 30 31 The individual hamstring muscles have different roles, 32 even within components of a single movement. 33 Clinicians should consider these factors when prescribing rehabilitation as the management of an injury with the same classification, within a different hamstring muscle, may require individualised management to optimise outcome. Anatomical architectural considerations, including loss of tension, anatomical displacement and sciatic nerve involvement may also be important in surgical decision making. HSI classification systems may benefit from considering muscle-specific differences in anatomy, function or injury pattern when assessing validity, outcomes and in the further evolution of classification systems. 19 22

Reliability and validity of classification systems

Many classification systems do not have validity or reliability evaluation, often because it is difficult to assess pathophysiology and healing outcomes at a tissue level. Surrogate measures of healing and recovery are typically used. Clinical assessment and/or imaging findings correlating with HSI severity, prognosis and outcomes are most pragmatically useful and are often used to validate systems. 17 34 Most use TRTS, 35 but time to return to full training (TRFT), 10 reinjury rates 29 and performance metrics 36 have also been studied. The complete resolution of HSI signs on imaging is unlikely to be necessary for successful RTS. 37 There is a high incidence of MRI negative injuries 9-12 but this may not impact reliability or validity of classification systems as many systems incorporate a grade 0 and these HSI generally have a better prognosis. 10 38 Online supplemental material 2 describes current HSI classification systems and available validity reliability data)

The British Athletics Muscle Injury Classification (BAMIC) group have investigated the prognostic validity of their system, 28 and they, and others, have also demonstrated good intra and inter-rater reliability of the BAMIC system. 12 39 In a study of 44 track and field athletes with 65 HSI, 29 they observed that increased TRFT and injury recurrence was associated with injuries that involved hamstring tendon tissue ('c' classification). TRFT was also significantly associated with grading severity (less in grade 0 (10±4.7 days) but higher in grade 3c (84±49.4 days)). In that study there was no significant difference in TRFT between myofascial (A) and myotendinous (B) injuries or between grade 1 and grade 2 injuries. The study did not include direct or contusion muscle injuries, described in the Munich system, as these are rare in track and field. The BAMIC group have also outlined a rehabilitation approach, informed by the athlete's BAMIC classification 28 and completed a further 4-year follow-up study after implementation of this rehabilitation approach. 10 This did note a significant difference in TRFT between grade 1 and grade 2 HSI classified by BAMIC and again a significant difference in TRTS for injuries that involved the tendon ('c' classification). The reinjury rates in this 4-year study were very low at 2.9% overall and 0% in the 'c' classification.

Wangensteen et al compared the level of agreement between BAMIC, Chan, and modified Peetrons classifications using a mixed sport cohort comprising 176 HSI with MRI images, 12 reporting 'substantial' to 'almost perfect' intrarater and inter-rater reliability when scored by experienced radiologists. For BAMIC, there was an association between TRTS for grades 0 and 2 and 1 and 3. For HSI location, there was no association in TRTS between types a and b and a and c, but there was between b and c. The Chan system demonstrated no associations between anatomical site related to proximity, but differences were found on anatomical site within the muscle (2a-e). The Chan authors reported difficulties with association due to the low frequency of injury in many of the categories (3a, 4b and 4c categorised just 1, 2, 2 injuries, respectively). Many categories had large individual TRTS, which means an individual with a HSI 3c injury would have a 95% chance of returning to sport anywhere between 3.9 and 57.5 days. In this study, for MRI positive injuries (87% of this cohort), the grading systems and the BAMIC anatomical site accounted for only 7.6%-11.9% of total variance in TRTS.

These studies suggest that anatomical site and severity grading are likely to be helpful, but not fully sufficient to explain TRTS. There is likely to be a role for clinical findings and reasoning and other individual athlete and sporting factors alongside classification systems to enhance prognostication. Considering all of these contributors is the role of the expert clinician in sport.

Some authors suggest difficulty in grouping all three hamstring muscles together when classifying these injuries and suggest that each muscle should be classified separately, to consider differences in connective tissue, fascia, and tendon architecture that produce different injury types, healing rates and prognoses. 19 20 22 The BAMIC classification paper comments that the specific injured hamstring muscle should be named with the associated classification, but outcome papers are challenging with this approach due to small numbers in the subsequent classification groups. Differences in rates of healing or prognosis between hamstring muscles, or locations such as the T junction injury, are not consistent and subclassification may not be required, 10 although these studies contain small numbers. Many systems make no differentiation between tendon injuries in the proximal, distal or intramuscular tendons, which may have different healing rates and reinjury risk, requiring modifications to rehabilitation and possible surgical consideration. 40-42 Most authors have found differences in rehabilitation outcomes or reinjury risk with intratendon injuries, 43 but not all. 35 Further discrimination of class c injuries to include the distance of retraction and categorisation between the intramuscular tendon and free tendon may be helpful with respect to surgical decision making. 44

Classifications that use a scoring system (examination, history and imaging findings carrying different weight) produce a combined score, such as that of Cohen et al, 6 who observed that a combined score of >10 corresponded to a worse prognosis (games missed) and demonstrated that the percentage of muscle tendon involvement, the number of muscles, and the amount of retraction were significant predictors of TRTS, but age and location were not. Conversely, Hamilton et al observed that this combined score did not provide a clinically useful prognosis for RTS, reflecting the challenges of attempting to accurately determine RTS duration. 45 This is due to rarity of severe injuries and therefore studies contain insufficient numbers of these injuries to validate classification.

Classification systems for surgical decision making

Surgery may be required for some HSI, although these tears only probably represent 0%-5% of HSI in certain athlete groups. While many bony injury classification systems assist with rehabilitation and orthopaedic surgical decision making, 46 classification systems for muscles, have historically not included surgical considerations as part of their system, due to the lack of evidence to inform surgical indications. 44 Two classification systems have attempted to describe different types of proximal hamstring tendon injuries and consideration of surgical repair. Wood et al described five types of injury, detailing amount of displacement, sciatic nerve involvement and location. 8 Lempainen et al have attempted to separate each tendon proximally to allow surgical consideration even in partial injuries such as semimembranosus. 47 Treating these proximal free tendon injuries non operatively can cause significant morbidity and failure to RTS. 48

Unfortunately, there are no reliability data for these surgical systems. Prognostic information using a cohort of 72 operations provides incidence and outcomes for the subtypes in the Wood System. 8 44 Several recently validated patient-reported outcome measures (PROMs) may help, 49 50 although these scores relate to proximal hamstring ruptures, and there may other types of HSI where surgery may be indicated. As knowledge advances on key indications for surgery, HSI classification systems should evolve to optimise decision making around the role of surgery.

Classification for high-grade intramuscular tendon or MTJ injuries

There are some intramuscular HSI for which surgical intervention has been considered. These include injuries at the 'T junction' of the biceps long head, proximal biceps MTJ, conjoint intramuscular tendon and semimembranosus separation injuries. 51-53 Injuries at these sites are classified within the constructs of existing classification systems rather than as defined entities. Further work is required to clarify clinical outcomes and surgical indications for injuries at these sites and to establish whether existing classification systems should be adapted to incorporate further understanding of these injuries and to assist with decision making.

Summary

There are a number of classification systems available for use by clinicians, but no single system allows optimal treatment planning or prognostication. Current classification systems are nonspecific for the individual hamstring muscle injured, despite each muscle having different anatomy, innervation, functional roles and injury patterns. 54 Apart from direct contusion injuries, the mechanism of injury has been largely overlooked in classification systems, but different mechanisms of injury may cause specific injuries such as slow stretch versus high intensity running HSI. 55-57 Pattern recognition, however, is complex as a single mechanism of injury (eg, high speed running) may cause multiple different types of HSI. 10

Management of HSI must consider the demands of the particular sport, such as the differences in injury patterns for sprint versus pivot type sports, or those with and without physical contact. Elite level sports require a higher performance demand and often aim to reduce TRTS. The management decisions in elite sport may be different depending on sporting demand, time of season, patient goals and many other contextual factors. 58 Different sporting levels are currently not considered in classification systems.

Clinicians managing high-grade injuries may benefit from classification systems that aid rehabilitation or surgical decision making. Furthermore, while some classifications consider proximal HSI avulsions, further evidence is required regarding the optimal management of intramuscular tendon injuries that may help inform rehabilitation guidelines and surgical indications. Finally, the testing of reliability and validity of HSI classification is a priority. No current classifications are able to predict TRTS or the risk of reinjury.

In view of these classification gaps and lack of robust evidence, we undertook a consensus process, including an international Delphi Study, seeking expert opinion to enhance decision making in the classification of HSI in order to inform clinical management for athletes presenting with HSI.

Due to the limitations of small athlete numbers in studies that evaluate muscle injury classifications, and the vital importance of clinical expertise, a consensus with international Delphi process was conducted to aid progress in this area of significant interest.

Aims

To determine the current global practice of classifying HSI.

To determine the key aspects of decision making in the classification of HSI.

To provide best practice for decision making in the classification of HSI.

Study design

A modified Delphi study design was used, including an international panel of experts, with the aim of reaching a consensus on best practice for classification after HSI. In the situation where clinicians must make assessment and treatment decisions based on incomplete, weak and poor-quality evidence, clinical expertise and experience become vital. A research approach to gain insight from practitioners' expertise is useful. Single experts can be useful but a scientific approach that aims for a consensus/agreement among a group of experts can provide more optimal recommendations. 59 The London 2020 international hamstring consensus group was established as a multidisciplinary collaboration to advance the assessment and management of HSI. The Delphi methodology was thought to present a systematic and scientific approach to capture the decision-making experience and expertise of global experts to identify and investigate areas in HSI where new decision making approaches could be developed. There have been previous Delphi consensus studies in muscle injuries, 2 60 injury prevention 61 and aspects of management of HSI, such as return to play 62 63 but other aspects of hamstring assessment and treatment may also benefit from this approach such as classification systems, decision making in rehabilitation and the justification for surgery, particularly given the disparate and conflicting approaches used currently. 22 64

The description of our modified Delphi methods is described below, following guidance on Delphi studies 65 66 and web survey design, 67 but can also be found in online supplemental file 1.

Participants: expert panel

Identifying appropriate experts is vital to the Delphi process 68 and an international, representative, multidisciplinary group of expert clinicians and researchers were invited to participate in this study, based on their expertise in the assessment and management of HSI. A purposive, heterogeneous representative sample of experts was chosen to ensure a mix of-professional discipline (sport and exercise medicine physicians, physiotherapists, surgeons, sport and exercise scientists/researchers, strength and conditioning specialists and athletic trainers), international experience, sex and sporting discipline in line with Delphi methodology. 69

The criteria for expert inclusion were- a high level of expertise assessing, managing and/or researching HSI, based on-the number of injuries seen; years worked managing HSI; peer-reviewed publication (authorship) in hamstring research; willingness to complete the digital survey and or attend the consensus meeting and sufficient level of written and spoken English.

Possible experts were excluded if they had (1) insufficient experience of assessment or management of HSI, (2) insufficient time to fully complete the online survey. Clinicians and non-clinicians were included but asked to answer only those survey questions related to their fields of expertise. (see methodology supplement). Domains of surgery, postsurgical recovery and rehabilitation were also identified and experts were chosen, with sufficient expertise in these combined areas as well as classification.

Coaches and trainers comprised 6% of the experts for the final survey. Athletes were not included; however, we would acknowledge their voices as vital. Many of our experts have also been athletes and 38% of the final survey expert respondents reported a personal history of HSI.

There is no guideline for number of experts to be involved in a consensus, 69 but the sample size was set at 30 for the initial survey to ensure a full international and multidisciplinary sport/ profession mix. A possible drop-out and non-response rate was predicted. The study aimed to follow research recommendations with opinion-based research questions. 65 70

Modified Delphi process

The study comprised two rounds of a purposive digital survey interspersed with a face-to-face meeting round. Each round was modified, based on feedback, to achieve a consensus among the international panel of experts. Each Delphi round comprised a digital questionnaire, an analysis, and a feedback report. The study was undertaken after a review of decision-making aspects of the assessment and management of HSI. The literature was searched, the evidence discussed and the author team led a review of the evidence presented as a narrative summary to inform the consensus rationale and knowledge gaps (see online supplemental file 2).

Round 1 involved a digital survey, with open-ended questions to a global group of clinicians and researchers with expertise in HSI. The round 1 survey (see online supplemental appendix 1) aimed to gather information, and understand, from the experts' viewpoint, where are the gaps in the literature evidence and clinical practice in HSI decision making. The initial round 1 survey comprised open-ended qualitative information gathering questions and some quantitative data questions using Likert scales to determine level of agreement. The survey used a digital institution-based software package-Opinio V.7.12 (copyright 1998-2020 ObjectPlanet, Oslo Norway). The surveys in this study followed the Checklist for Reporting Results of Internet E-Surveys 67 and the reporting standard for conducting and reporting Delphi studies 66 to avoid bias.

The responses from the initial survey were collated and analysed with a thematic and factor analysis 71 (see online supplemental table 1). The expert panel identified four key domains classification and diagnosis, surgery, rehabilitation and return to running (RTR) and sport) (and key questions for these domains (see tables in online supplemental appendix 3). This paper deals with results of classification and diagnosis, with subsequent papers covering surgery and rehabilitation. The questions on diagnosis and classification were outlined and presented for discussion. All the panel members who completed the survey were invited to the discussion meeting. The discussion took place via a group consensus 2-day meeting, alongside an international conference, to allow as many of the participants to join as possible. A nominal group consensus model was followed with a facilitated, structured approach to gather qualitative information, from this group. 72 This approach has been followed in other consensus projects. 73 74 In discussions, facilitators maintained impartiality and ensured balanced discussion to avoid 'eminence bias'. 65 They aimed to work towards agreement but not force consensus. Dissenting and outlier views were considered important, representing differences in practice. This approach aimed to avoid 'herding bias'. 75 76

After discussions, the key consensus statements were synthesised and refined. These sessions were chaired by each steering committee author related to their area of specialisation-classification (JM), Rehabilitation (BMP), RTR/RTS (MG) and surgery (FH). Statements were gradually refined through a process of facilitated debate until the entire panel were satisfied and on day 2 were put to the group for anonymous electronic voting. See online supplemental appendix 4 for the list of statements-rehabilitation, RTS/RTR, classification and surgery.

The consensus steering committee (established an a priori criterion threshold of 70%, with ≥70% agreed/yes responses constituting statement acceptance. 70% has been used successfully by other Delphi studies. 77-79 Eighteen statements on the diagnosis and classification of HSI reached sufficient group agreement.

The final Delphi round involved a further online survey was developed, to test these statements with this survey to a wider global international group of experts who met the previous inclusion/exclusion criteria. The participants voted on the statements with yes, no, uncertain ('forced choice') responses. This made the final survey shorter and less onerous for participants, but some further Likert or factor ranking questions determined level of agreement. (See examples within methodology supplement).

These experts voted on statements and ranked their key decision-making factors or justifications related to the domain areas found in the round 1 survey.

Expert panel for final round

The final survey with voting on the consensus statements, was split into domain sections-classification, surgery, rehabilitation, RTR/RTS. Participants were asked to complete only the domains (sections of the survey) that were within their field and scope of expertise. The survey responses were evaluated for completeness. Survey responses in each domain were evaluated by two steering group members and any incomplete responses from non-experts in that particular domain were removed from the analysis. Within their expertise areas, panel members were asked to complete sections as carefully as possible and provided with response options such as 'uncertain'. Open-ended boxes after each consensus statement also allowed them to comment, and comments and areas of disagreement were collated and analysed.

Steering committee

The surveys were designed by two experienced clinical academic physiotherapists, and a professor of orthopaedic surgery, who each have greater than 20 years clinical experience treating HSI and research expertise in HSI, as well as previous experience with Delphi research. A structured, iterative process was undertaken to develop the survey and it was piloted by a mixed group of five sports medicine physicians, five physiotherapists and five orthopaedic surgeons, and the survey was further refined based on their feedback. The expert panel were approached by email located from publicly available correspondence information on peer reviewed journal articles. Information was provided prior to participation but actively completing the survey was implied (and stated) as the consent to participate. Any participant who withdrew had data removed.

Respondents

The volume of responses made reporting in one single paper difficult. For this reason, three papers are presented with decision-making domain areas of-classification, surgery and rehabilitation and RTS.

The response rates and the inclusion and exclusions for each survey round are given in the flow chart in figure 1. The compositions and characteristics of the expert panel for each round survey and the face-to-face meeting are reported below in table 2.

Preferred HSI classification system

Table 3 presents the participants preferred HSI classification system. For both surveys 1 and 2, BAMIC, Munich and Barcelona ranks 1, 2 and 3, respectively.

In the initial survey, we asked participants what questions need answering in HSI classification. The initial survey results are presented in tables 4-6. Top three questions are: (1) are there different clinical presentations for fascial/muscular/Iintramuscular tendon and free tendon injuries, (2) which HSI classification system most effectively guides management and (3) does the classification of injury relate to recovery time (return to performance)?

When considering the key factors that influence clinician's decisions for requesting imaging, the top three answers were (1) loss of range of motion and/or strength and/or tension and/or integrity on examination, (2) symptoms and (3) injury mechanism. Tables 5 and 6 (initial survey) deal with the key factors in referral for imaging and key examination considerations for diagnosis.

Table 7 reports the consensus statements from our meeting days and reports the results of round 2 digital survey from the 99 respondents. The levels of agreement for each of these statements is reported and those that achieved more than 70% are highlighted.

Areas of agreement/disagreement

We observed that clinicians use multiple sources of information in their decision making to inform diagnosis, classification, management and prognosis of HSI. Both imaging and clinical examination findings were considered essential and informed each other when making decisions on treatment of HSI

Justification for imaging

Imaging was deemed vital for classification; however, the survey respondents did not agree that imaging was vital for diagnosis. Survey respondents and our consensus meeting panel noted that a proportion of HSI present without positive imaging findings, and the failure of MRI to accurately predict TRTS. 17 80 Clinicians expressed that they prioritised loss of range of motion (ROM)/loss of tension and symptom levels to decide on imaging, with some external factors considered important such as the type or level of sport and cost or patient expectations. 81

While these findings are similar to the literature on the justification of imaging in HSI, there are few specific MRI or US guidelines for HSI. 82-85 These are often incorporated into general guidelines for musculoskeletal imaging. 83 86 The low range of clinical justifications may leave out some significant imaging justifications-and knowing examination features that trigger early investigation may save time and enable an athlete to receive appropriate and targeted rehabilitation. 56 87 88 Although minor and low grade HSI may not require imaging, 11 intramuscular tendon injuries cannot be easily diagnosed solely with clinical examination features 89 and if this is an important potential diagnosis for that athlete, imaging should be obtained. In the second-round survey, ( table 7) respondents commented that imaging and anatomy were important, but their votes showed lower levels of agreement for imaging being essential for classification (70.3%) but not for diagnosis (56.6%) and stronger agreement on preference for clinical examination, functional markers and history findings to be considered.

Clinical features

Immediate physical examination signs including bruising, loss of muscle tension, palpable defects and/or significant weakness and excessive/no response on provoking activities warrant further investigation (LOA 92.6%).

In the area of clinical investigation to aid diagnosis or assessment of severity, our consensus panel and survey respondents put great weight on clinical assessment findings to help diagnose and classify HSI. Immediate physical examination signs like bruising, loss of muscle tension, palpable defects and/or significant weakness and excessive/no response on provoking activities showed strong agreement as justifications for ordering imaging. Many clinicians suggested these could be diagnostic and put most emphasis on loss of tension or muscle/strength function to aid diagnosis. Second to this were symptoms and the mechanism of injury. The failure of the athlete to improve also triggered further investigation (see table 5).

Types of imaging

MRI was the investigation of choice over US. This is consistent with literature which focuses on MRI based classification systems. Koulouris and Connell compared the use of US to MRI for the diagnosis of acute HSI, finding MRI detected proximal hamstring avulsion injuries in 100% of cases compared with only 58.3% of cases with US scan. 90

MRI side to side differences were felt to be less important (LOA 49.5%) due to negative MRI findings in a high proportion of HSI, 11 but also financial reasons and the degree of contralateral incidental pathology often found on MRI. The consensus group and survey respondents were also discriminating in their use and timing of US, with use in the early stage (pitch side)-within the first 48 hours (LOA 14.8%) or even for primary diagnosis-after the first 48 hours (LOA 21.8%) was not practiced. There was more agreement on its use in the rehabilitation phase, possibly to monitor healing stages (LOA 61.8%), however, this did not reach our threshold LOA. This finding agrees with literature 91 and guidelines on the use of US. 83 84 86 US has some advantages for imaging muscle including evaluation of fluid/haematoma and scar, as well as real time movement and opportunity to support intervention. It can be used in conjunction with MRI, 92 but the panel was in agreement that MRI was the most helpful imaging modality.

HSI classification systems

Most of the survey respondents use the BAMIC system (57%), although they concurrently use Munich and the Barcelona systems, but less commonly used US or earlier grades 1-3 systems. While they wanted a single classification system with agreed nomenclature and terminology, they indicated that none of the classification systems were perfect, and all had areas that required improvement. Clinicians wanted a classification to help with prognosis and outcome information and provide guidance for treatment decisions, as well as allowing them to grade severity. While they acknowledged that no one classification system may be able to meet all these requirements, there was strong agreement that terminology should be consistent and agreed.

Areas where classifications must evolve

We should differentiate between muscles in the classification (LOA 88.9%).

Classification needs clear parameters such as (but not limited to):

Free tendon versus central tendon (LOA 86.1%).

Anatomical, radiological classification (LOA 95.1%).

Should evolve to include surgical criteria (LOA 51.2%).

Mechanism of injury should be commented alongside the classification (where appropriate/known) (LOA 82.0%).

Beyond anatomical classification, there is a need to have:

While the survey respondents acknowledged that imaging and the involved anatomical tissue were important, many expressed the need to individualise muscles-in part, due to the differing architecture and functional roles between the hamstring muscles. This is reflected in the types of injuries, with the muscles differing in their injury patterns. Our panel agreed that it was likely to be important to consider individual muscle factors such as function and anatomy. 19 22 Muscle architecture was also a factor in the agreement on free tendon versus the intramuscular tendon.

Some comments suggested a gap in the current classification systems in classifying intramuscular tendon injuries, for example, the BF central tendon 40 or the connective tissue T junction between BF long and short head. 41 These pathologies have typical injury patterns within the BF. Some clinicians reported that the implications of these injury pattens may differ between sports. This may be one significant reason why some respondents suggested muscle specific classification was required while others suggested that sports specific classification should be considered. There are also anatomical differences within individuals, making specific classification more challenging. 54

The panel acknowledged the importance of clinical history and examination findings in classification. They suggested a place in the classification systems for mechanism of injury and functional criteria. Surgical criteria were rated as important, but this statement did not reach consensus, reflecting differences in opinion on the role of surgery. HSIs that need surgical consideration are uncommon but ideally would be highlighted early to prevent delays in treatment and risk of reinjury, longer recovery and complications. 93 However, further evidence on the indications for surgery is required to enable subsequent clear classification and identification of these injuries so rare injuries are not misdiagnosed by clinicians who may not deal with these types of injury regularly. 42 Finally, many suggested a multicomponent, multivariable classification system was important, and clinicians voted highly on the inclusion of functional criteria such as walking and running/sprinting in classification systems. They also wanted more effective PROMs that have received much attention, validation and reliability work in other injury types. 94

Are HSI registries relevant?

Clinicians came close to agreement on the need for HSI registries. Some clinicians operated in countries where registries are common for high volume injuries, such as anterior cruciate ligament injuries. These registries, however, have been set up under an orthopaedic framework. In HSI, the percentage of patients requiring surgery is small. In elite sports, such as football, registries may already exist in some form, and it may be more appropriate for the most impacted sports to use an international sporting framework (ie, PHAROS, UEFA, FIFA).

Limitations

The panels for our three Delphi rounds were international, The London international hamstring consensus meeting face-to-face group comprised 15 out of 35 respondents (43%) to the initial digital survey. This may set up a bias, however, the panel attending were heterogenous, with a multidisciplinary mix of profession, location, sport, age and domain expertise in treatment of HSI. They comprised clinicians from Australia, Netherlands, Ireland, the Middle East but the majority of the face-to-face meeting panel were UK based. We sought and invited experts from Asia, Africa and South America, however, there were less identifiable experts (clinical or published) from these locations, and they could not attend due to pandemic travel restrictions. This may mean their HSI management practices are not represented, possibly introducing bias. However, our meeting panel all worked in elite sport with work schedules that included the management of international patient/athlete cohorts . Most did not train professionally in the UK and their work experience and current work schedules comprised USA, Africa, Middle East, Australia and Asia. They reported that many of their athletes trained internationally, and with international coaches, reflecting the current international nature of elite and Olympic sport. To further reinforce the integrity of the consensus, and provide more international perspective, authors were included with significant Middle East hamstring work experience.

Our group of experts had multiple domains of expertise and scope of practice. This consensus project involved disparate domains of-surgery, postsurgical and non-surgical rehabilitation, classification, diagnosis, running and RTS. It was harder to evaluate expertise in classification and diagnosis and the criteria chosen for expertise were harder to establish, academic criteria were thought to be important, but very few experts had published on classification, although they used classification systems. Many trainers and coaches had less expertise in the diagnosis and classification domain and were not included as experts, although in some countries, trainers will have this expertise. Choosing criteria for expertise is difficult for any Delphi study and this represents one weakness of this methodology. 76 Our classification section received the most responses. While we trusted the survey respondents to complete only those fields that encompassed their expertise, it may be possible that some respondents completed sections outside their domain and level of expertise or scope of practice. This was the reason for lack of full response rate for every section. Open-ended questions in the first round meant that we only took information that our experts submitted, which was used and adapted for the basis of subsequent rounds. We did not include athletes/patients in these surveys, as domain-specific professional knowledge was required, but statements suggesting athletes should lead and guide decision making in their own treatment received high (unanimous) LOA. Also 38% of respondents to our survey reported had undergone HSI, possibly contributing to the patient/thlete voice. Further work would ideally include athletes, coaches and other sport stakeholders, whose perspective is vital.

While we attempted to be inclusive, the representation of women is low in our panels, (2/39, 1/15 and 18/99). We found less publicly available information directing to women experts, and it was found that female rates of publication are lower in HSI, with less publicly available information on expertise. Although we attempted to invite these clinicians/researchers, the response rates lower for the women we surveyed and invited to our meeting. This has been a weakness in other consensus research. We recognise this as a significant limitation of our consensus and recommend that future work specifically prioritises endeavours to enhance representation of women within consensus and Delphi group methodology as their voice is also vital.

Where possible we aimed to include equity-deserving groups while maintaining our expertise criteria for inclusion and further work should aim to include these groups. Balancing inclusion and expertise can be challenging but should be prioritised in any Delphi study.

Recommendations from Consensus on diagnosis, classification and grading of HSI ( box 1).

Key points

While classification systems exist for hamstring injuries (HSIs) and encompass anatomical and imaging criteria, current classification systems are not specific to individual (hamstring) muscles.

Classification systems have evolved to include the specific anatomical tissue (ie, muscle, myotendinous, tendon) as well as severity of injury gradings, and some include the mechanism of injury and athlete factors.

Clinicians most commonly use the British Athletics Muscle Injury Classification (BAMIC) system, with Munich and Barcelona systems also used for the classification of HSI.

This expert panel recommends MRI as the imaging of choice for diagnosis with few panellists prioritising diagnostic ultrasound. Neither modality is recommended as a means of monitoring rehab progression or deciding on readiness to return to sport.

Experts agree classification systems for HSI should evolve to include parameters around: individual hamstring muscles, intramuscular injuries, mechanism of injury, sporting demand, functional criteria and patient-reported outcome measures.

There is a need for more research into criteria that determine the need for surgical intervention.

There is a need for more research into the effectiveness of classification systems to prognosticate and guide treatment decision making.

Patient consent for publication

Consent obtained directly from patient(s).

Ethics approval

Ethical approval for the study was sought and obtained from the institutional ethical review board (Project ID 5938/002). Participants were informed prior to commencing the surveys, with completion implying consent.

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London International Consensus and Delphi study on hamstring injuries part 1: classification

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Muscle injury classification systems for hamstring injuries have evolved to use anatomy and imaging information to aid management and prognosis. However, classification systems lack reliability and validity data and are not specific to individual hamstring muscles, potentially missing parameters vital for sport-specific and activity-specific decision making.

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Physio for combat sports; Hands, Wrists & Elbows | Physiotutors Podcast Ep. 024 | Ian Gatt

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In this super sized episode of the podcast I sit down (twice so a small audio shift) with Ian Gatt - there was just so much for us to cover that we quite sim...

# data[].attributes.wish_content.attachment_props.entities.urls[].title
Ian Gatt - The Sporting Hand & Wrist: Inform Performance Episode 88

# data[].attributes.wish_content.attachment_props.entities.urls[].description
Episode 88: Andy McDonald chats to Ian Gatt the GB Boxing Head of Performance Services / Lead Physio. Ian is also the Physio and Cutman for boxer Anthony Jos...

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Get asked many times for resources around #Hands 🖐️ #Wrists 🤛

Free Access 👇👇👇
https://t.co/ff9bcNOFyo

https://t.co/zbqmX82KCk

https://t.co/K69JO3DBNM

https://t.co/wFHheQ8b2I

https://t.co/Iz6bfsK6bY

https://t.co/VMEK0dnStQ

Enjoy! 🧠📈👊😊
#allabouttheupperlimb 🖐️🤛💪 https://t.co/FB2CJK1WU2

# data[].attributes.attachment_link.metadata.attachment_props_source.data.text
Get asked many times for resources around #Hands 🖐️ #Wrists 🤛

Free Access 👇👇👇
https://t.co/ff9bcNOFyo

https://t.co/zbqmX82KCk

https://t.co/K69JO3DBNM

https://t.co/wFHheQ8b2I

https://t.co/Iz6bfsK6bY

https://t.co/VMEK0dnStQ

Enjoy! 🧠📈👊😊
#allabouttheupperlimb 🖐️🤛💪 https://t.co/FB2CJK1WU2

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Clinical Edge - Physio Edge 088 Combating hand & wrist injuries part 1 with Ian Gatt

# data[].attributes.attachment_link.metadata.attachment_props_source.data.entities.urls[].description
Hand and wrist assessment and treatment can be overwhelming. There are a lot of tendons, ligaments and bones crammed into a small area, you need to worry about ligament and cartilage tears, rehabing fine and gross motor control, strengthening, and then there are a bunch of fancy-looking splints. How would you like to get a better grip on hand and wrist injuries? In this podcast with Physiotherapist (English Institute of Sport Boxing Technical Lead Physio) Ian Gatt, we discuss hand and wrist injuries in

# data[].attributes.attachment_link.metadata.attachment_props_source.data.entities.urls[].title
Clinical Edge - Physio Edge 089 Combating hand & wrist injuries part 2 - Objective assessment with Ian Gatt

# data[].attributes.attachment_link.metadata.attachment_props_source.data.entities.urls[].description
Your knuckles getting crushed in an overenthusiastic handshake by hands the size of watermelons isn't a fun experience. Do these knuckle-crushers know they're squeezing that hard, or do they just regularly snap pencils while taking notes, and wonder why pens and pencils are so fragile nowadays? How much grip strength do you actually need, even if you're not planning on crushing any knuckles the next time you meet someone? How much grip strength do your patients need when recovering from a hand, wrist or

# data[].attributes.attachment_link.metadata.attachment_props_source.data.entities.urls[].title
Clinical Edge - Physio Edge 090 Combating hand & wrist injuries part 3 - Treatment with Ian Gatt

# data[].attributes.attachment_link.metadata.attachment_props_source.data.entities.urls[].description
Squeezing a stress ball and strengthening with 0.5kg dumbells will only get you so far with your treatment of hand and wrist injuries, and soon enough you'll hit a wall with treatment results. How are you going to smash through that wall, and help your patients keep working or playing, or get back to work and sport? If you've felt limited with your hand and wrist treatment and exercises, you'll love the treatment approach and strengthening exercises from the third and final podcast in this series with

# data[].attributes.attachment_link.metadata.attachment_props_source.data.entities.urls[].description
Head of Performance Services & Lead Physiotherapist - Great Britain Boxing - Cited by 225 - Sports Injuries - Hand-Wrist Injuries - Upper Limb Injuries - Boxing

# data[].attributes.attachment_link.metadata.attachment_props_source.data.entities.urls[].title
Physio for combat sports; Hands, Wrists & Elbows | Physiotutors Podcast Ep. 024 | Ian Gatt

# data[].attributes.attachment_link.metadata.attachment_props_source.data.entities.urls[].description
In this super sized episode of the podcast I sit down (twice so a small audio shift) with Ian Gatt - there was just so much for us to cover that we quite sim...

# data[].attributes.attachment_link.metadata.attachment_props_source.data.entities.urls[].title
Ian Gatt - The Sporting Hand & Wrist: Inform Performance Episode 88

# data[].attributes.attachment_link.metadata.attachment_props_source.data.entities.urls[].description
Episode 88: Andy McDonald chats to Ian Gatt the GB Boxing Head of Performance Services / Lead Physio. Ian is also the Physio and Cutman for boxer Anthony Jos...

# data[].attributes.attachment_link.metadata.attachment_props.original_text
Get asked many times for resources around #Hands 🖐️ #Wrists 🤛

Free Access 👇👇👇
https://t.co/ff9bcNOFyo

https://t.co/zbqmX82KCk

https://t.co/K69JO3DBNM

https://t.co/wFHheQ8b2I

https://t.co/Iz6bfsK6bY

https://t.co/VMEK0dnStQ

Enjoy! 🧠📈👊😊
#allabouttheupperlimb 🖐️🤛💪 https://t.co/FB2CJK1WU2

# data[].attributes.attachment_link.metadata.attachment_props.text
Get asked many times for resources around #Hands 🖐️ #Wrists 🤛

Free Access 👇👇👇
https://t.co/ff9bcNOFyo

https://t.co/zbqmX82KCk

https://t.co/K69JO3DBNM

https://t.co/wFHheQ8b2I

https://t.co/Iz6bfsK6bY

https://t.co/VMEK0dnStQ

Enjoy! 🧠📈👊😊
#allabouttheupperlimb 🖐️🤛💪

# data[].attributes.attachment_link.metadata.attachment_props.entities.urls[].title
Clinical Edge - Physio Edge 088 Combating hand & wrist injuries part 1 with Ian Gatt

# data[].attributes.attachment_link.metadata.attachment_props.entities.urls[].description
Hand and wrist assessment and treatment can be overwhelming. There are a lot of tendons, ligaments and bones crammed into a small area, you need to worry about ligament and cartilage tears, rehabing fine and gross motor control, strengthening, and then there are a bunch of fancy-looking splints. How would you like to get a better grip on hand and wrist injuries? In this podcast with Physiotherapist (English Institute of Sport Boxing Technical Lead Physio) Ian Gatt, we discuss hand and wrist injuries in

# data[].attributes.attachment_link.metadata.attachment_props.entities.urls[].title
Clinical Edge - Physio Edge 089 Combating hand & wrist injuries part 2 - Objective assessment with Ian Gatt

# data[].attributes.attachment_link.metadata.attachment_props.entities.urls[].description
Your knuckles getting crushed in an overenthusiastic handshake by hands the size of watermelons isn't a fun experience. Do these knuckle-crushers know they're squeezing that hard, or do they just regularly snap pencils while taking notes, and wonder why pens and pencils are so fragile nowadays? How much grip strength do you actually need, even if you're not planning on crushing any knuckles the next time you meet someone? How much grip strength do your patients need when recovering from a hand, wrist or

# data[].attributes.attachment_link.metadata.attachment_props.entities.urls[].title
Clinical Edge - Physio Edge 090 Combating hand & wrist injuries part 3 - Treatment with Ian Gatt

# data[].attributes.attachment_link.metadata.attachment_props.entities.urls[].description
Squeezing a stress ball and strengthening with 0.5kg dumbells will only get you so far with your treatment of hand and wrist injuries, and soon enough you'll hit a wall with treatment results. How are you going to smash through that wall, and help your patients keep working or playing, or get back to work and sport? If you've felt limited with your hand and wrist treatment and exercises, you'll love the treatment approach and strengthening exercises from the third and final podcast in this series with

# data[].attributes.attachment_link.metadata.attachment_props.entities.urls[].description
Head of Performance Services & Lead Physiotherapist - Great Britain Boxing - Cited by 225 - Sports Injuries - Hand-Wrist Injuries - Upper Limb Injuries - Boxing

# data[].attributes.attachment_link.metadata.attachment_props.entities.urls[].title
Physio for combat sports; Hands, Wrists & Elbows | Physiotutors Podcast Ep. 024 | Ian Gatt

# data[].attributes.attachment_link.metadata.attachment_props.entities.urls[].description
In this super sized episode of the podcast I sit down (twice so a small audio shift) with Ian Gatt - there was just so much for us to cover that we quite sim...

# data[].attributes.attachment_link.metadata.attachment_props.entities.urls[].title
Ian Gatt - The Sporting Hand & Wrist: Inform Performance Episode 88

# data[].attributes.attachment_link.metadata.attachment_props.entities.urls[].description
Episode 88: Andy McDonald chats to Ian Gatt the GB Boxing Head of Performance Services / Lead Physio. Ian is also the Physio and Cutman for boxer Anthony Jos...

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RFD And Exercise Progressions - Get Back To Sport

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Welcome to post 28 of Strength & Conditioning for Therapists. I'm getting a little bit excited in anticipation of announcing the launch of my new 6-week Online S&C Course - for therapists, of course! Keep

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RFD And Exercise Progressions - Get Back To Sport

# data[].attributes.attachment_link.description
Welcome to post 28 of Strength & Conditioning for Therapists. I'm getting a little bit excited in anticipation of announcing the launch of my new 6-week Online S&C Course - for therapists, of course! Keep

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What happens at a football medical? | INSIDE FC Bayern

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Team Work: How the team doctors of FC Bayern work | Mini documentary

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336 days - Giulia Gwinn's tough way back

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Unseen Journey - Hector Bellerin's ACL recovery

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Unseen Journey - Hector Bellerin's ACL recovery

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EP1: Home To Repair. Unseen Journey: Hector Bellerin

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Authors: Michael Cole (BSc, PGC(H)E, PgDip, PFHEA, NTF), Briony Hurd, Karl Anthony and Abdulayneyn Nassir
Introduction
In part one we discussed how Sports and Exercise Rehabilitation is taught in higher education in the United Kingdom and suggested an alternative approach to the traditional 'expert-student' paradigm. This article demonstrates the "fruits of our labours" by presenting a report produced by three BSc Sports Therapy students in partnership with their senior lecturer. The following report demonstrates this collaborative approach to co-producing Sports Medicine knowledge in higher education.
Part 2: What is Sports and Exercise Rehabilitation?
Sports and Exercise Rehabilitation (SER) is an evidence-informed, structured and progressive athletic reconditioning programme with the aims of (i) returning the athlete to optimum performance (or the non-athlete to required function) following an injury, or other trauma, including management of pain or dysfunction (Moksnes and Glasgow, 2017)); (ii) addressing associated risk factors; and (iii) reducing the risk of re-injury. To achieve these aims, SER practitioners are advised to employ a multidisciplinary approach combining aspects of clinical reasoning, physical therapy, strength and conditioning, sports psychology, and current concepts in sports science (Kraemer, Denegar and Flanagan, 2009; Crockett, 2011; Dhillon, Dhillon and Dhillon, 2017) to devise, and implement, a rehabilitation programme tailored to the athlete's unique circumstances. In keeping with the fundamental principles underpinning athletic training programmes, an SER programme is split into several phases, each with its own primary focus, to guide and support the athlete's optimal progression from point of trauma or pain to return to competitive performance, and beyond.

Conceptual models provide a common framework for a multidisciplinary rehabilitation team to optimise the physical and psychological outcomes of the patient. Safe and effective sports and exercise rehabilitation can be informed by a number of models. Knowles' (2016) approach illustrates a "reconditioning" model - a criteria and performance-based process with the end goal in mind, progressing backwards to the injury date. Lorenz, Reiman and Walker (2010) suggest a periodised approach to rehabilitation and Reiman and Lorenz (2011) suggest that a rehabilitation programme should emphasise the integration of strength and conditioning principles. Furthermore, Blanchard and Glasgow's (2014) model explicitly foregrounds the relationship between exercise prescription and clinical reasoning. As shown in figure 1 the model progresses through cycles, actively encouraging a systematic approach to optimal loading, adding new stimuli at each progression.

In comparison, Taberner, Allen and Cohen (2019) emphasise the use of the control-chaos continuum as a framework for returning to sport. Illustrated in Figure 2 this individualised model transitions from high control exercises in early injury to unpredictable and minimally controlled exercises in the later stages of rehabilitation. Progression is only accepted when risk of re injury is minimal.

Effective rehabilitation can be accomplished by combining multiple models and modalities (Beam, 2002). However, the exercise rehabilitation programme is structured it should always be informed by a thorough understanding of the athlete's injury status, performance needs and goals (Reiman and Lorenz, 2011) combined with sound clinical reasoning and knowledge of the biological healing process (Moksnes and Glasgow, 2017). This will ensure the athlete is able to return to optimal function and safely return to sport and competition with minimal risk of reinjury.

It is widely accepted that return to competition comes after the athlete has reached, or superseded pre-injury performance levels (Ardern et al., 2017; Buckthorpe, Frizziero and Roi, 2019; ACPSEM Physiosinsport, 2020). Specific functional tests can act as reference throughout the phases of rehabilitation and return to play (RTP) decision-making (Hoog et al., 2016; Gomez-Piqueras et al., 2018). Spikes in acute workload occur across a variety of sporting seasons, according to individual/team performance and playing positions, this means baseline measures should be taken during low-loading periods (Black et al., 2016; ACPSEM Physiosinsport, 2020).

Load can be monitored through various means; variability has been highlighted amongst different methods and brands, thus validating methods is warranted (Beato, Devereux and Stiff, 2018; Crawford et al., 2018; Fox et al., 2018; Ferioli et al., 2021). Selected tests and load management techniques should reflect the kinematic patterns involved in sport (Bridge et al., 2014; Black et al., 2016; Da Silva Santos and Franchini, 2016; Güler and Ramazanoglu, 2018; Tayech et al., 2020).

A predetermined successive criterion based on optimal loading and progression of sport-specific qualities can strategically and safely progress an athlete from injury to preinjury performance and beyond whilst reducing re-injury risk (Moksnes and Glasgow, 2017; Dhillon, Dhillon and Dhillon, 2017; Serner et al., 2017; Buckthorpe, Frizziero and Roi, 2019; Taberner, Allen and Cohen, 2019). Rehabilitation programmes shift from general recovery and inflammation optimization in the phase immediately following the injury (summarised in the 'PEACE' and 'LOVE' acronyms (Dubois and Esculier, 2020)), to more sports-specific criteria in subsequent phases that address the increased demands of the sport on the tissues, systems and holistic personhood (Arden et al., 2017; Dhillon, Dhillon and Dhillon, 2017; Moksnes and Glasgow, 2017; Serner et al., 2017; Taberner, Allen and Cohen, 2019; Buckthorpe, Frizziero and Roi, 2019).

Incorporating psychological measures of assessment can support favourable psychosocial parameters being met, increasing rates and minimising time for RTP (Ivarsson et al., 2017; Buckthorpe, Frizziero and Roi, 2019; Nwachukwu et al., 2019; Green et al., 2020 McCrea et al., 2020). Premature RTP decisions and previous injury are risk factors for recurrent injury (Green and Pizzari, 2017; Dingenen and Gokeler, 2017; Green et al., 2020). The Strategic Assessment of Risk and Risk Tolerance (StARRT) framework was developed to consider the specific history and wider athletic context in addition to biomedical factors, the specific stresses placed on the tissue during participation, and the psychosocial variables that augment the decision process and facilitate a more robust RTP decision (Shrier, 2015; Arden et al., 2017; Blanch and Gabbett, 2017; Dingenen and Gokeler, 2017; Buckthorpe, Frizziero and Roi, 2019).
References (Part 2)
ACPSEM Physiosinsport (2020) 'Control the Chaos in Rehab with Matt Taberner LockdownLearning 0906'. 14 June. Available at: https://www.youtube.com/watch?v=UUbOS34GsyU (Accessed 06 August 2021).

Ardern, C.L., Glasgow, P., Schneiders, A., Witvrouw, E., Clarsen, B., Cools, A., Gojanovic, B., Griffin, S., Khan, K.M., Moksnes, H. and Mutch, S.A. (2016) '2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy', British journal of sports medicine, 50(14), pp. 853-864. doi: 10.1136/bjsports-2016-096278.

Beam, J. W. (2002) 'Rehabilitation Including Sport-Specific Functional Progression for the Competitive Athlete', Journal of Bodywork and Movements Therapies, 6(4), pp. 205-219.

Beato, M., Devereux, G. and Stiff, A. (2018) 'Validity and Reliability of Global Positioning System Units (STATSports Viper) for Measuring Distance and Peak Speed in Sports', The Journal of Strength and Conditioning Research, 32(10), pp. 2831-2837. doi: 10.1519/JSC.0000000000002778.

Black, G. M., Gabbett, T. J., Cole, M. H. and Naughton, G. (2016) 'Monitoring Workload in Throwing-Dominant Sports: A Systematic Review', Sports Medicine, 46(10), pp. 1503-1516. doi: 10.1007/s40279-016-0529-6.

Blanch, P. and Gabbett, T.J. (2016) 'Has the Athlete Trained Enough to Return to Play Safely? The Acute: Chronic Workload Ratio Permits Clinicians to Quantify a Player's Risk of Subsequent Injury', British Journal of Sports Medicine, 50(8), pp. 471-475. doi: 10.1136/bjsports-2015-095445.

Blanchard, S. and Glasgow, P. (2014) 'A Theoretical Model to Describe Progressions and Regressions for Exercise Rehabilitation', Physical Therapy in Sport, 15(3), pp. 131-135.

Bridge, C. A., da Silva Santos, J. F., Chaabene, H., Pieter, W. and Franchini, E. (2014) 'Physical and Physiological Profiles of Taekwondo Athletes', Sports Medicine, 44(6), pp. 713-733. doi: 10.1007/s40279-014-0159-9.

Buckthorpe, M., Frizziero, A. and Roi, G. S. (2019). 'Update on Functional Recovery Process for the Injured Athlete: Return to Sport Continuum Redefined', British Journal of Sports Medicine, 53(5), pp. 265-267. doi: 10.1136/bjsports-2018-099341. http://dx.doi.org/10.1136/bjsports-2018-099341.

Crawford, D. A., Drake, N. B., Carper, M. J., DeBlauw, J. and Heinrich, K. M., (2018) 'Validity, Reliability, and Application of the Session-RPE Method for Quantifying Training Loads During High Intensity Functional Training', Sports, 6(3), p. 84. doi: 10.3390/sports6030084.

Crockett, B. (2011) 'Rehabilitation of the Athlete', Missouri Medicine, 108(3), pp. 173-175.

Da Silva Santos, J. F. and Franchini, E. (2016) 'Is Frequency Speed of Kick Test Responsive to Training? A Study with Taekwondo Athletes', Sport Sciences for Health, 12(3), pp. 377-382. doi: 10.1007/s11332-016-0300-2.

Dhillon, H., Dhillon, S. and Dhillon, M. S. (2017) 'Current Concepts in Sports Injury Rehabilitation', Journal of Indian Orthopaedics, 51(5), pp. 529-536. doi: 10.4103/ortho.IJOrtho_226_17.

Dingenen, B. and Gokeler, A. (2017) 'Optimization of the Return-To-Sport Paradigm After Anterior Cruciate Ligament Reconstruction: A Critical Step Back to Move Forward', Sports Medicine, 47(8), pp. 1487-1500. doi: 10.1007/s40279-017-0674-6.

Dubois, B. and Esculier, J.-F. (2020) 'Soft-tissue injuries simply need PEACE and LOVE', British Journal of Sports Medicine, 54(2), pp. 72-73. doi: 10.1136/bjsports-2019-101253.

Ferioli, D., Scanlan, A.T., Conte, D., Tibiletti, E. and Rampinini, E. (2021) 'The Business End of the Season: A Comparison Between Playoff and Regular-Season Workloads in Professional Basketball Players', International Journal of Sports Physiology and Performance, 16(5), pp. 655-662. doi: 10.1123/ijspp.2020-0405.

Fox, J. L., O'Grady, C. J., Scanlan, A. T., Sargent, C. and Stanton, R. (2019) 'Validity of the Polar Team Pro Sensor for Measuring Speed and Distance Indoors', Journal of Science and Medicine in Sport, 22(11), pp. 1260-1265. doi: 10.1016/j.jsams.2019.06.012.

Gomez-Piqueras, P., Gonzalez-Rubio, J., Sainz de Baranda, P. and Najera, A. (2018) 'Use of Functional Performance Tests in Sports: Evaluation Proposal for Football Players in the Rehabilitation Phase', Turkish Journal of Physical Medicine and Rehabilitation, 64(2), pp. 148-154. doi: 10.5606/tftrd.2018.1462.

Green, B. and Pizzari, T. (2017) 'Calf Muscle Strain Injuries in Sport: A Systematic Review of Risk Factors for Injury', British Journal of Sports Medicine, 51(16), pp. 1189-1194. doi: 10.1136/bjsports-2016-097177.

Green, B., Bourne, M. N., van Dyk, N. and Pizzari, T. (2020) 'Recalibrating the Risk of Hamstring Strain Injury (HSI): A 2020 Systematic Review and Meta-Analysis of Risk Factors for Index and Recurrent Hamstring Strain Injury in Sport', British Journal of Sports Medicine, 54(18), pp. 1081-1088. doi: 10.1136/bjsports-2019-100983.

Güler, M. and Ramazanoglu, N. (2018) 'Evaluation of Physiological Performance Parameters of Elite Karate-Kumite Athletes by the Simulated Karate Performance Test', Universal Journal of Educational Research, 6(10), pp. 2238-2243. doi: 10.13189/ujer.2018.061022.

Hoog, P., Warren, M., Smith, C. A. and Chimera, N. J. (2016) 'Functional Hop Tests and Tuck Jump Assessment Scores Between Female Division I Collegiate Athletes Participating in High Versus Low ACL Injury Prone Sports: A Cross Sectional Analysis', International Journal of Sports Physical Therapy, 11(6), pp. 945-953. PMCID: PMC5095946.

Ivarsson, A., Tranaeus, U., Johnson, U., and Stenling, A. (2017) 'Negative Psychological Responses of Injury and Rehabilitation Adherence Effects on Return to Play in Competitive Athletes: A Systematic Review and Meta-Analysis', Open Access Journal of Sports Medicine, 8, pp. 27-32. doi: 10.2147/OAJSM.S112688.

Knowles, B. (2016) 'Reconditioning: A Performance-based Response to Injury', in Joyce, D. and Lewindon, D. (eds.) Sports Injury Prevention and Rehabilitation: Integrating Medicine and Science for Performance Solutions. Abingdon: Routledge, pp. 4-10.

Kraemer, W., Denegar, C. and Flanagan, S. (2009) 'Recovery from Injury in Sport', Sports Health, 1(5), pp. 392-395. doi: 10.1177/1941738109343156.

Lorenz, D. S., Reiman, M. P. and Walker, J. C. (2010) 'Periodization: Current Review and Suggested Implementation for Athletic Rehabilitation', Sports Health, 2(6), pp. 509-518.

McCrea, M., Broglio, S., McAllister, T., Zhou, W., Zhao, S., Katz, B., Kudela, M., Harezlak, J., Nelson, L., Meier, T. and Marshall, S.W. (2020) 'Return to Play and Risk of Repeat Concussion in Collegiate Football Players: Comparative Analysis from the NCAA Concussion Study (1999-2001) and CARE Consortium (2014-2017)', British Journal of Sports Medicine, 54(2), pp. 102-109. doi: 10.1136/bjsports-2019-100579.

Moksnes, H., and Glasgow, P (2017) 'Principles of Sports Injury Rehabilitation', in Brukner, P., Clarsen, B., Cook, J., Cools, A., Crossley, K., Hutchinson, M., McCrory, P., Bahr, R. and Khan, K. (eds.) Brukner and Khan's Clinical Sports Medicine. Volume 1 Injuries. 5th edn. Sydney: McGraw-Hill Education, pp. 277-284.

Moksnes, H., and Glasgow, P (2017) 'Principles of Sports Injury Rehabilitation', in Brukner, P., Clarsen, B., Cook, J., Cools, A., Crossley, K., Hutchinson, M., McCrory, P., Bahr, R. and Khan, K. (eds.) Brukner and Khan's Clinical Sports Medicine. Volume 1 Injuries. 5th edn. Sydney: McGraw-Hill Education, pp. 277-284.

Nwachukwu, B. U., Adjei, J., Rauck, R. C., Chahla, J., Okoroha, K. R., Verma, N. N., Allen, A. A. and Williams, R. J., (2019) 'How Much do Psychological Factors Affect Lack of Return to Play After Anterior Cruciate Ligament Reconstruction? A Systematic Review', Orthopaedic Journal of Sports Medicine, 7(5), p.2325967119845313. doi: 10.1177/2325967119845313.

Reiman, M.P. and Lorenz, D.S. (2011) 'Integration of Strength and Conditioning Principles into a Rehabilitation Program', The International Journal of Sports Physical Therapy, 6(3), pp. 241-253.

Serner, A., Hölmich, P., Tol, J. L., Thorborg, K., Lanzinger, S., Otten, R., Whiteley, R. and Weir, A. (2021) 'Progression of Strength, Flexibility, and Palpation Pain During Rehabilitation of Athletes with Acute Adductor Injuries: A Prospective Cohort Study', Journal of Orthopaedic and Sports Physical Therapy, 51(3), pp.126-134. doi: 10.2519/jospt.2021.9951.

Shrier, I. (2015) 'Strategic Assessment of Risk and Risk Tolerance (Starrt) Framework for Return-To-Play Decision-Making', British Journal of Sports Medicine, 49(20), pp. 1311-1315. doi: 10.1136/bjsports-2014-094569.

Taberner, M., Allen, T. and Cohen, D. D. (2019) 'Progressing Rehabilitation After Injury: Consider the 'Control-Chaos Continuum', British Journal of Sports Medicine, 53(18), pp. 1-6. doi: 10.1136/bjsports-2018-100157.

Tayech, A., Mejri, M. A., Chaouachi, M., Chaabene, H., Hambli, M., Brughelli, M., Behm, D. G. and Chaouachi, A. (2020) 'Taekwondo Anaerobic Intermittent Kick Test: Discriminant Validity and an Update with the Gold-Standard Wingate Test', Journal of Human Kinetics, 71(1), pp. 229-242, doi: 10.2478/hukin-2019-0081.

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A COLLABORATIVE APPROACH TO TEACHING AND LEARNING SPORTS AND EXERCISE REHABILITATION IN HIGHER EDUCATION (PART 2) - UEL Teaching

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Authors: Michael Cole (BSc, PGC(H)E, PgDip, PFHEA, NTF), Briony Hurd, Karl Anthony and Abdulayneyn Nassir Introduction In part one we discussed how Sports and Exercise Rehabilitation is taught in higher education in the United Kingdom and suggested an alternative approach to the traditional 'expert-student' paradigm.

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The role of Sport and Exercise Medicine in 21st century healthcare

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The role of Sport and Exercise Medicine in 21st century healthcare

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Is medical training adequate to promote health and give patients what they need? The role of Sport and Exercise Medicine in 21st century healthcare

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A 21st century workforce

The increasing demand for physical activity for health has stimulated a growth of sport and exercise medicine (SEM), which is not reflected in undergraduate medical training.1 Currently programmes fail to provide health professionals with the skills to promote sleep, nutrition and active living, which will restrict clinicians' ability to address key causes of non-communicable diseases and limit the transition to preventative healthcare.2

This global training issue is reported in North America, Europe, Oceania and the Middle East.3 4 Medical students in the USA are only required to take 8 hours of physical activity education, and in the UK, the total SEM teaching averages 4.5 hours over 5 years. Two-thirds of SEM fellows in the USA had not received instruction on exercise prescription, and a study of graduating doctors in the UK found only half felt comfortable giving physical activity advice.4 5 There has been little change since these findings were published, and there remains an urgent need for improvement.5

Undervaluing musculoskeletal medicine?

One-third of people experience musculoskeletal (MSk) complaints, which are a major cause of ill health and disability. They account for 30% of primary ...

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Is medical training adequate to promote health and give patients what they need? The role of Sport and Exercise Medicine in 21st century healthcare

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The increasing demand for physical activity for health has stimulated a growth of sport and exercise medicine (SEM), which is not reflected in undergraduate medical training.1 Currently programmes fail to provide health professionals with the skills to promote sleep, nutrition and active living, which will restrict clinicians' ability to address

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How to optimise load, range and speed in tendon rehab - RunningPhysio

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How to optimise load, range and speed in tendon rehab

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How to optimise load, range and speed in tendon rehab

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Our articles are not designed to replace medical advice. If you have an injury we recommend seeing a qualified health professional. To book an appointment with Tom Goom (AKA 'The Running Physio') visit our clinic page. We offer both in-person assessments and online consultations.
We're talking tendons again! In our previous video I discussed 4 great loading programmes for tendinopathy. In our new one, we go a step further to explore how you can manipulate load, range and speed to meet your patient's needs. There's also a walkthrough of how to apply these principles in proximal hamstring tendinopathy.
If you'd like to learn more about rehab for patient's with tendinopathy then check out our webinar series on lateral hip pain which you can access for free on our Running Resource Page. We fit a lot into this series including common mistakes and how to fix them, pain and pathology and rehab progression:

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How to optimise load, range and speed in tendon rehab - RunningPhysio

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Our articles are not designed to replace medical advice. If you have an injury we recommend seeing a qualified health professional. To book an appointment with Tom Goom (AKA 'The Running Physio') visit our clinic page. We offer both in-person assessments and online consultations. We're talking tendons again!

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What is the Surgery Toolkit

Staying active is important if you're waiting for or recovering from surgery. If you're fit and strong, your surgery has the best chance of success, and you'll likely recover quicker.

Over time, exercise can also increase your mobility, help your balance and boost your mood.

We know it can be difficult to take the first step. You might be nervous or not know what exercises to try when you're waiting for surgery.

So, that's why we created Let's Move for Surgery.

In the Surgery Toolkit you'll find tailor-made, follow-along exercise routines for hip, shoulder and knee replacement, as well as full body workouts to help you maintain overall fitness.

You can also explore personal stories and advice from those living with arthritis who have been through joint replacement surgery, and tips on keeping active from a physiotherapist.

Getting started

Before you get started:

Remember to stay hydrated while you're exercising.

Make sure you have plenty of space around you to avoid injury.

It is also important to get advice and support from your healthcare professional about what exercises are suitable for you.

Hip replacement exercises for before and after surgery

In this 15-minute follow-along exercise video, physiotherapist Milly Abdullah is joined by Lin who lives with arthritis and has undergone a hip replacement. Together they demonstrate the recommended stretching and strengthening exercises for before and after hip replacement surgery.

Knee replacement exercises for before and after surgery

Daljit, who is awaiting knee surgery, joins Milly to demonstrate a range of exercises designed for before and after knee replacement surgery.

Shoulder replacement exercises for before and after surgery

In this 15-minute follow-along video, physiotherapist Milly is joined by Chris who lives with arthritis and is awaiting shoulder replacement surgery. Together they demonstrate stretching and strengthening exercises for before and after shoulder replacement surgery.

Full body strengthening around the home for before and after surgery

In this 10-minute follow-along routine, Keith joins Milly to demonstrate strengthening exercises you can add to your daily routine around the home. These exercises focus on strengthening the whole body, including the quads, glutes and shoulders.

Milly and Keith highlight different versions of the exercises so you can make them work for you. They also recommend making physical activity a habit by attaching it to other habits in your daily routine.

Cardio workout for before and after surgery

This movement video is for those with arthritis who are undergoing different types of surgery, such as joint replacement.

The follow-along routine is designed for daily use and can also be completed in short bursts throughout the day. Once you are familiar with the exercises, why not add each one into your daily routine?

Personal stories and advice

Why movement is so important before surgery

In this video you will learn more about the mental and physical benefits of keeping active while you wait for surgery. Keir, Sue, Lin and Leony, who all live with arthritis, describe their experiences and the impact that keeping moving had on their lives and their joint replacement surgeries.

Why movement is so important after surgery

Keir, Sue, Lin and Leony share their experiences of recovering from joint replacement surgery and how keeping active was key to their recovery.

They describe what physical activities worked for them and offer tips and advice on how to get started, stay motivated as well as the long-term benefits.

How to keep active whilst waiting for surgery

Physiotherapist Milly provides advice on some of the best ways to keep active ahead of surgery, including: how to get started, how to make exercise work for you, how to form an exercise habit, and the importance of listening to your body and your healthcare professionals.

Sue, Leony and Keir also share what worked for them as they prepared for surgery.

Why it's important to keep joints mobile before and after surgery

This animation illustrates the benefits of exercising and what happens to our joints when we exercise.

How to use Let's Move with Leon while waiting for surgery

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Staying active is important if you're waiting for or recovering from surgery. If you're fit and strong, your surgery has the best chance of success, and you'll likely recover quicker. Over time, exercise can also increase your mobility, help your balance and boost your mood.

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Research shows that regular physical activity offers numerous health benefits including, but not limited to, the regulation of blood pressure, management of anxiety and depression and the prevention of weight gain. ACSM provides recommendations and guidelines for physical activity and exercise based on the latest science and insights from health professionals.

ACSM is known throughout the industry as the "gold standard" when it comes to exercise recommendations. Thanks in large part to the publication of ACSM's Guidelines for Exercise Testing and Prescription, now in its 11th edition. GETP has been a staple resource for professionals since 1975.

The Physical Activity Guidelines for Americans, 2nd edition, published by the U.S. Department of Health and Human Services, gives the most current physical activity recommendations for all age groups and special populations.

ACSM and CDC recommendations state that:

All healthy adults aged 18-65 years should participate in moderate intensity aerobic physical activity for a minimum of 30 minutes on five days per week, or vigorous intensity aerobic activity for a minimum of 20 minutes on three days per week.

Every adult should perform activities that maintain or increase muscular strength and endurance for a minimum of two days per week.

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Research shows that regular physical activity offers numerous health benefits including, but not limited to, the regulation of blood pressure, management of anxiety and depression and the prevention of weight gain. ACSM provides recommendations and guidelines for physical activity and exercise based on the latest science and insights from health professionals.

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Karate After Arthroscopic Hip Surgery - BJSM blog - social media's leading SEM voice

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BJSM blog - social media's leading SEM voice

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Keywords: Karate, Arthroscopic surgery, rehab

Managing injuries in high-risk contact or multi-movement sport requires a diverse set of skills and an excellent understanding of the sport by the treating clinician. Literature including Karate athletes is widespread, however, these focus on epidemiology, rather than the rehabilitation of injuries.
The Gap
At the time of my hip surgery no-one was able to comment on my ability to return to Karate or kicking. Literature exploring the physiotherapy rehabilitation of Karate athletes after arthroscopic hip surgery was also scarce. The lack of literature and the collaboration needed during the rehab and return to sport (RTS) phase of my recovery highlighted the gap in RTS knowledge for Karate athletes among clinicians. Given the significance practicing Karate holds to those that engage in it, I have created the following guide to assist clinicians on returning their athletes both to kicking and to Karate after their injury. My hope is that this blog can help to close the gap.
Kicking
Karate encompasses many kicking techniques. The strength and mechanics required to execute these is variable between Karate athletes and type of kick. Given the variability, the below exercises should serve as a base for returning to kicking. Each exercise can be adapted to individual kicks your Karate athlete will be returning to. Normal joint mechanics should be restored prior to commencing this programme and global strengthening of gluteal and other support muscles as per normal rehab guidelines would continue alongside.

"Following hip arthroscopy 82% (95% CI=74-88%) of athletes return to their pre-injury level of sport" (Memon et al., 2018)

Karate encompasses a wide array of techniques from beginner to advanced, static to dynamic, individual to partner work. Given the variety available to Karate athletes, a RTS can be facilitated following restoration of baseline strength and joint mechanics.

Phase 1: Basic Techniques

Basic techniques: punches, strikes, blocks, kicks and stances as tolerated by the athlete. These can be progressed to completing techniques while moving through stances.

Phase 2: Kata

Kata is made up of a series of techniques and stances completed in multiple directions at varying speeds and intensities. These can be slowly returned to as tolerated at reduced intensity.

Phase 3: Individual dynamic techniques

The ability to complete combinations of techniques is important in Karate practice. Initially this can be completed at a slow speed, increasing speed as tolerated.

Phase 4: Partner dynamic techniques

This is inclusive of all partner work excluding sparring. Typically, this is choreographed sequences of techniques with both an attacker and a defender. The Karate athlete should slowly reintroduce any takedowns as tolerated.

Phase 5: Kumite (sparring/hand to hand combat)

Kumite has varying rules depending on the style of Karate. Rules may vary from full body contact to points sparring where an opponent will move in to score a "point" and then move back. When your athlete can comfortably complete all other training, they can progress to kumite.

Phase 6: Advanced techniques
Conclusion:
As tolerated - may be inclusive of weapon work
Authors name and affiliations
Returning to Karate after any injury is challenging. There is no perfect time frametimeframe , however, there is a great variability in intensity and physical requirements of different aspects of Karate. Given the immense importance Karate has to its practitioners, the earlier your Karate athlete enters the dojo the better. The lack of literature and the collaboration needed during the rehab and RTS phase of my recovery highlighted the gap in RTS knowledge for Karate athletes among clinicians. Let this blog start to close that gap.
References
Kirsten Evans is a musculoskeletal physiotherapist undertaking her Sports Physiotherapy post graduate studies at the School of Physiotherapy, University of Otago, New Zealand. She is a practicing Senior physiotherapist for Habit Health Christchurch and trains at Seido Karate Christchurch.

Gavagan, C. J., & Sayers, M. G. L. (2017). A biomechanical analysis of the roundhouse kicking technique of expert practitioners: A comparison between the martial arts disciplines of Muay Thai, Karate, and Taekwondo. , (8), Article e0182645. https://doi.org/10.1371/journal.pone.0182645

Memon, M., Kay, J., Hache, P., Simunovic, N., Harris, J. D., O'Donnell, J., & Ayeni, O. R. (2018). Athletes experience a high rate of return to sport following hip arthroscopy. Knee Surgery, Sports Traumatology, Arthroscopy , (10), 3066-3104. https://doi.org/10.1007/s00167-018-4929-z

(Visited 35 times, 4 visits today)

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Karate After Arthroscopic Hip Surgery - BJSM blog - social media's leading SEM voice

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Keywords: Karate, Arthroscopic surgery, rehab Managing injuries in high-risk contact or multi-movement sport requires a diverse set of skills and an excellent understanding of the sport by the treating clinician. Literature including Karate athletes is widespread, however, these focus on epidemiology, rather than the rehabilitation of injuries.

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The KNEE Program for elite players - Netball Australia

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The program is a complete warm up for an elite netballers (state and national representatives). There are four main components of the program with a large variety of exercises included in each section. Players don't need to perform every exercise each time. Multiple choices are given to provide variety, prevent boredom and enhance skill acquisition.

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Envelope of Function | Overload Injuries Explained

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Envelope of function / Overload injuries

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Envelope of function / Overload injuries

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Envelope of Function | Overload Injuries Explained

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Musculoskeletal pain and exercise—challenging existing paradigms and introducing new

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Musculoskeletal pain and exercise—challenging existing paradigms and introducing new

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Mechanisms of central and peripheral sensitisation

Central sensitisation typically describes an increased responsiveness of nociceptive neurons in the central nervous system (CNS) to normal input. With central sensitisation, there are changes in the properties and function of neurons in the CNS, with an increase in pain response relative to the presence and intensity of noxious peripheral stimuli. 9 10

In humans and clinical studies, we can measure surrogates which are thought to be reflective of central sensitisation and cover many different underpinning mechanisms. 9 Central sensitisation can be seen as an umbrella term, 9 the main characteristics of which are:

Hyperalgesia is an increased pain response to normally painful stimuli and may be as a result of increased peripheral or central pain sensitivity. 13 If someone were to experience a pin prick to their knee, they may score the pain one out of 10, for example. However, if they were suffering with chronic knee pain, with hyperalgesia, the same pin prick stimuli would result in a more painful response and a higher pain score being reported.

Allodynia, by contrast, is a pain response to a stimulus that is not normally painful. 10 14 An example of allodynia is the person who is suffering from chronic low back pain who complains of pain when they are hugged.

TSP is a progressive increase in pain perception in the response to repeated stimuli of the same intensity and thought to represent central pain facilitation occurring at the dorsal horn neurons when integrating the incoming nociception. 11 A variety of stimuli can be used to assess temporal summation in humans, including heat, cold, pressure and electrical. For example, a patient with chronic knee pain performing knee exercises may complain of increasing levels of pain the more repetitions of the same exercise they perform, which could be attributed to TSP.

Another commonly assessed pain mechanism in musculoskeletal pain research is the DNIC paradigm. 12 It describes a descending endogenous pain modulation system encompassing an array of overlapping mechanisms from the CNS that may modulate and inhibit pain. 15 The two main mechanisms are the activation of descending nociceptive inhibitory mechanisms 16 and the release of endogenous opioids. 17 DNIC can be assessed in humans through the conditioned pain modulation (CPM) response (also known as 'pain inhibits pain'). During CPM, the descending pain inhibitory responses are challenged during a painful conditioning stimulus. This is used as a proxy of the overall effectiveness of the endogenous analgesic system, likely occurring through both the opioid and non-opioid pathways. An example of CPM in action is when one might report lower pain scores for a primary complaint, say low back pain, in the presence of a secondary painful stimulus, for instance placing the hand in ice cold water.

The role of the immune system

It is thought the immune system plays an important role in chronic pain states, including the development of long-term hyperalgesia and allodynia. 18-20

Affective aspects of pain

Identification of pain-related fear and negative emotional states, such as kinesiophobia, catastrophising, low self-efficacy, anxiety and depression, are becoming increasingly recognised in some musculoskeletal disorders. 22 23 Research has shown that these psychological factors might affect the function and quality of life in patients with pain and can modulate the individuals' pain experience and therefore may play a role in the development and/or maintenance of chronic pain states. 24-30 A systematic review of self-management interventions for chronic musculoskeletal pain (16 studies; n=4047) found self-efficacy and depression were the strongest prognostic factors (irrespective of the intervention). 31 Reducing pain catastrophising and increasing physical activity were the strongest mediating factors, that is, factors which may explain how different treatments may work. 31

Pain can negatively affect physical activity and mental thought processes and requires cognitive resources. 32 33 It has been proposed that pain-related fear amplifies the experience of pain; indeed there is strong evidence that pain is experienced more strongly when there is a greater focus of attention on it. 34-38 A person with pain-related fear may have a greater amount of attention bias, by which it means they pay the pain greater attention, with greater emotional meaning attached to it. 25 The mechanisms by which pain-related fear is thought to influence central sensitisation are: (1) increasing nociceptive transmission via spinal gate mechanism 39; (2) via modulation of the descending pathways 39 and (3) temporal summation, where increasing magnitude of spinal dorsal horn neurons activation increases glutamine sensitivity, thus producing a pain response disproportionate to the stimulus experienced. 9 25 Indeed, evidence from neuroimaging has demonstrated the role of the amygdala and pain-related fear, and its potential over activity, as a facilitator of chronic pain and central sensitisation. 40-42

Affective aspects of pain-reconceptualisation of pain-related fear

Some patients report fear of doing further tissue damage if an activity or exercise is painful. 43-45 A major consideration of the beneficial effects of painful exercise is the potential associated learning involved. Painful exercises have the potential to help reconceptualise pain-related fear, that is, patients may be challenged to think differently about pain and tissue damage, and allowing painful exercises offers an opportunity for patients to reintroduce movement that were previously perceived as a threat. The amygdala is often referred to as the fear centre of the brain 5 and plays a key role in shaping our response to fear, particularly our response to pain-related memories and fear. 5 The cingulate cortex also plays a role in our response, 42 with both areas of the brain communicating directly via the descending nociceptive inhibitory system. 24 46 47 In chronic pain states, the brain acquires long-term maladaptive pain memories that associate tissue stress and load with danger and threat, 48 for example, bending forwards in individuals with low back pain, raising the arm or lifting objects with shoulder pain or squatting type movements with individuals with knee pain.

By allowing painful exercises, with appropriate 'safety-cues', new inhibitory associations may be made; these new inhibitory associations theoretically may compete with the original conditioned response, so that it becomes suppressed. 52 Safety-cues may include statements such as: 'your shoulder is painful because it has become deconditioned and not used to movement. We need to exercise your shoulder, so it will become strong and conditioned to enable you to do what you need to do'. Research supporting this concept has come from animal studies 53 54 that have reported involvement of the medial prefrontal cortex (mPFC) in the learning of new inhibitory associations, which has direct projections onto the amygdala. 52 For instance, the mPFC might have a role in the storing of long-term extinction memories that block and suppress the amygdala. Human studies on military personnel with and without a clinical diagnosis of posttraumatic stress disorder (PTSD) have confirmed this inverse relation between activity in the mPFC and amygdala. 55 Patients with PTSD had decreased activation of the mPFC, with correlated increased activation of the amygdala. 55 Clinically, this is an important point, since it highlights that despite a positive response to therapy, pain-related fear may never truly been eliminated. It may, given certain conditions, for example during an acute flare up, resurface.

It is thought that allowing painful therapeutic exercises could reduce the threat perception, and thus the activity of the amygdala and somatosensory cortex, 56 with positive modulation of the nociceptive inhibitory systems. An example of this in practice would be providing safety-cues to a patient who is fearful of lifting a painful shoulder they have been resting for long periods.

Central pain processes

It has been recognised that an acute bout of exercise can result in analgesia and this phenomenon is termed exercise-induced hypoalgesia (EIH) and is one form of endogenous pain modulatory processes. 59 It is thought that EIH is dependent on multiple analgesic mechanisms that contribute to changes in pain sensitivity. 60 Evidence for the analgesic effect of exercise comes from experimental studies that attenuate pain sensitivity, as measured by pressure pain thresholds and temporal summation. 11 60 61 A number of different exercise interventions have been investigated, including cardiovascular exercise (running and cycling) and resistance exercise, including isometric and dynamic resistance. 59 It is thought the endogenous opioid system is triggered by exercise-induced activation of arterial baroreceptors following increases in heart rate and blood pressure, with an associated dose response. 3 62 63 Exercise can trigger the release of β-endorphins from the pituitary and hypothalamus, in turn activating µ-opioid receptors peripherally and centrally, triggering the endogenous opioid system. 64 The hypothalamus projects onto the periaqueductal grey (PAG) resulting in further endogenous analgesic effects via the descending nociceptive inhibitory mechanisms. 3 A recent systematic review concluded that painful exercises typically have higher loads and dose of exercise 4 and a theoretical reason painful exercises may have a greater affect than pain free exercises could be a greater EIH.

The immune function and pain-related fear

As discussed previously, the immune system may play a role in chronic pain states, and the development of long-term hyperalgesia and allodynia. 18-20 This section now returns to this topic, in relation to exercise and, specifically, questioning the belief that exercises must be pain-free.

It is well understood that regular general exercise reduces the risk of developing age-related illnesses, such as heart disease and type 2 diabetes. 67 However, regular general exercise also reduces susceptibility to viral and bacterial infections, suggesting that there are mechanisms at play that improves the overall immune function. 68 69

What are the new findings?

Central and peripheral pain mechanisms, the immune system and affective aspects of pain appear to respond differently when pain is allowed during exercise.

Pain during therapeutic exercise for chronic musculoskeletal pain need not be a barrier to successful outcomes.

There is a potential rationale and mechanisms behind the additional benefit of allowing painful exercises, over pain-free exercises, in the management of chronic musculoskeletal pain.

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Musculoskeletal pain and exercise-challenging existing paradigms and introducing new

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Chronic musculoskeletal pain remains a huge challenge for clinicians and researchers. Exercise interventions are the cornerstone of management for musculoskeletal pain conditions,1 with the benefits being well-established.1 2 Exact mechanisms underpinning this effect on musculoskeletal pain are currently unclear.3 Little is known on the optimal dose and type of exercise, with therapists' and patients' behaviour and beliefs around pain during exercise often overlooked in exercise prescription.

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Rehabilitation of scapular dyskinesis: from the office worker to the elite overhead athlete

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Rehabilitation of scapular dyskinesis: from the office worker to the elite overhead athlete

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Abstract

The scapula functions as a bridge between the shoulder complex and the cervical spine and plays a very important role in providing both mobility and stability of the neck/shoulder region. The association between abnormal scapular positions and motions and glenohumeral joint pathology has been well established in the literature, whereas studies investigating the relationship between neck pain and scapular dysfunction have only recently begun to emerge. Although several authors have emphasised the relevance of restoring normal scapular kinematics through exercise and manual therapy techniques, overall scapular rehabilitation guidelines decent for both patients with shoulder pain as well as patients with neck problems are lacking. The purpose of this paper is to provide a science-based clinical reasoning algorithm with practical guidelines for the rehabilitation of scapular dyskinesis in patients with chronic complaints in the upper quadrant.

Introduction

Chronic neck and shoulder pain are among the three most prevalent musculoskeletal disorders in the general population, with more than 60% of individuals suffering neck/shoulder pain at some stage throughout life. 1 , 2 Although great variability in prevalence figures on neck/shoulder pain is reported, it can be seen as an important medical and socioeconomic problem in western society. 3 In addition, its prevalence is known to increase with computer workload, or with participation in an overhead sport. 4 , 5

There is a strong relationship between chronic neck and shoulder pain and dysfunction of the scapula. The scapula functions as a 'bridge' between the shoulder complex and the cervical spine and plays a very important role in providing both mobility and stability to the neck/shoulder region. Since the first clinical papers in the literature regarding the role of the scapula in athletic shoulder function and the possible relation to shoulder pain in the overhead athlete, there has been a growing interest in the scapular kinematics, scapular evaluation and intervention principles and programmes. 6-8 Although the association between abnormal scapular positions and motions and glenohumeral joint pathology has been well established in the literature and summarised in recent review articles, studies investigating the relationship between neck pain and scapular dysfunction have only recently begun to emerge. 9 , 10 It is clinically recognised that patients with mechanical neck pain may exhibit similar alterations in scapular orientation and motion to that observed in patients with painful shoulder disorders. This is feasible in view of the close relationship of the scapula through the axioscapular muscles with the cervical and midthoracic portion of the spine. 11 , 12

Numerous scientific and review papers have been published regarding the biomechanical background of scapular dyskinesis, the association with shoulder pathologies and the clinical assessment of scapular dysfunction. 6 , 9 , 10 , 13 , 14 Although several authors have emphasised the relevance of restoring normal scapular kinematics through exercise and manual therapy techniques, to date, no paper has thoroughly approached overall scapular rehabilitation guidelines decent for both patients with shoulder pain as well as patients with neck problems. 9 , 13 , 15-17 However, rehabilitation guidelines should be specified since, within these groups of patients, the physical conditioning requirements are not homogeneous: the demands on cervical and axioscapular muscle function in an elite overhead athlete will be different from those of a storeman lifting heavy boxes repetitively above chest level or from those required by an office worker working daily on a computer.

Therefore, the purpose of this paper is to provide a science-based clinical reasoning algorithm with practical guidelines for the rehabilitation of scapular dyskinesis in patients with chronic complaints in the upper quadrant, in particular shoulder and cervical spine disorders. 15 These guidelines may help the clinician to put the rehabilitation of scapular dyskinesis into a precise perspective of the thorough treatment of shoulder and/or neck dysfunction. 15 , 18 , 19

Scapular dyskinesis in relation to neck and shoulder pain

There is a body of evidence suggesting that patients with impingement symptoms and glenohumeral instability consistently show altered scapular kinematics. 20-28 With respect to scapular orientation in the resting position, it has also been demonstrated that individuals with neck pain may display altered postural behaviour, especially when performing prolonged sitting tasks, such as during computer use. 29 Increased cervical and thoracic curves and a slouched posture are known to affect scapular orientation, shoulder muscle strength and shoulder range of motion. 30-32 Scapular dynamic stability has primarily been investigated in association with shoulder pathologies where a reduced clavicle retraction, scapular upward rotation, scapular posterior tilt and increased clavicle elevation have been reported. 9 Recently, Helgadottir et al 33 , 34 demonstrated a significantly reduced clavicle retraction on the dominant side in patients with insidious onset neck pain and whiplash-associated disorders (WAD) both at rest and during arm elevation.

These changes in scapular kinematics can be attributed not only to altered scapular recruitment patterns (eg, altered serratus anterior muscle activity) or muscle performance (eg, force imbalance in the upper and lower trapezius muscle), but also flexibility deficits in the soft tissue surrounding the scapula may restrict normal scapular movement during daily activity and sport-specific movements. 6 , 20 , 35-39

Cause-consequence relationship between scapular dyskinesis and neck or shoulder pain

There is no consensus about the cause-consequence relationship between scapular dyskinesis and shoulder or neck pain. Several mechanisms can potentially contribute to alterations in scapular kinematics. 9 These include pain, soft tissue stiffness, muscle activation or strength imbalances, muscle fatigue and thoracic posture. It is unclear whether the alterations found in scapular kinematics are compensatory or contributory to neck/shoulder pathology. Recently, a first prospective study was published showing that scapular dyskinesis, based on visual observation, is a risk factor for shoulder pain during the season in professional rugby players. 67 Possibly, scapular dyskinesis predisposes the subject to develop neck/shoulder pain, but once the abnormality presents, scapular dyskinesis may be exacerbated by pain-inhibition mechanisms. The latter is often found in clinical practice. Bilateral scapular abnormal positioning and movement patterns (suggesting the primary cause for shoulder pain) are frequently observed during clinical examination, but to a worse degree on the painful side (suggesting scapular dyskinesis being exacerbated by pain). To support this observation, experimental pain studies have demonstrated that pain may directly contribute to the initiation of altered behaviour and function of the axioscapular muscles. 57 According to a new theory of pain adaptation, it is suggested that during episodes of pain, there is a redistribution of activity within and between muscles, which may have some benefit in the short term (protection from further pain or injury), but there is the potential for adverse long-term mechanical consequences to pain-sensitive tissues. 68

Irrespective of the direction of cause and effect, it is generally believed that the clinician should focus on scapular evaluation and rehabilitation prior to, or in concordance with, the treatment of the neck or shoulder. Indeed, scapular dyskinesis tends to jeopardise optimal shoulder and neck function through various mechanisms, from decreasing the width of the subacromial space, threatening the fulcrum of the humeral head into the glenoid fossa, to inducing abnormal compressive and shear forces in the cervical spine, thus compromising cervical motion and stability. Moreover, scapular dyskinesis may lead to a breakage in the kinetic chain, during overhead athletic activities as well as during prolonged daily activities of the upper quadrant. 5 , 6 The scapula plays a very important role as a link between the trunk and the arm, transferring and increasing the energy, power and equilibrium from the lower extremities and the trunk into the arm. 5 , 69 In order to fulfil this task, the scapula has to be in the correct position and all scapular muscles should be activated at the right time in sufficient amount to allow the ground reaction forces to be transferred into the shoulder, and finally into the most distal link of the chain, the hand. Abnormal scapular position and kinematics might lead to a breakage of the functional kinetic chain, putting other links at risk for injury. Therefore, the therapist should always observe, examine and treat scapular dyskinesis in patients with shoulder and neck pain.

Rehabilitation of scapular dyskinesis

The intervention strategy for scapular rehabilitation should be based on the clinical evaluation of the patient to permit appropriate goal setting. First of all, a comprehensive initial patient interview is necessary to ascertain the individual's functional requirements and problematic activities. During the physical examination, the therapist should address all possible deficiencies found on different levels of the kinetic chain. Based on the results of clinical assessment, appropriate treatment goals should be set leading to proper rehabilitation strategies.

Although the therapist should address all possible deficiencies found on the different levels of the kinetic chain, this review will not describe all aspects of treatment, but will focus solely on scapular rehabilitation. 70 Therefore, although considered to be key points in functional shoulder and neck rehabilitation, more proximal links in the kinetic chain, such as thoracic spine mobility and strength, core stability and lower limb function, will not be addressed in these clinical guidelines.

Until now, therapeutic guidelines for treating scapular dysfunction have been developed within the scope of shoulder pain, whereas therapeutic guidelines intended to restore normal scapular function in neck pain patients are mainly based on the results of shoulder studies, owing to the lack of research in this field. However, as it is suggested that similar disturbances in scapular function may be found in both shoulder and neck patients, we believe that the basic treatment approach for both patient groups is mutual, with specific focus pending on the functional demands of the patient. For example, in office workers, rehabilitation will be focused on the correction of the function of the axioscapular muscles, scapular orientation with arms by the side, and during prolonged upper limb activities. However, in overhead athletes, the ultimate treatment goal is to exercise advanced scapular muscle control and strength during sport-specific movements.

Figure 1 summarises a recently published clinical reasoning algorithm that the clinician may use in the treatment of scapular dyskinesis. 15 In the upper part of the algorithm, a summary is presented of the possible causes for scapular dyskinesis, as described in the first part of this review, whereas in the lower part therapeutic strategies are suggested. The algorithm is further divided into two columns, as a patient presenting with scapular dyskinesis may have flexibility problems or muscle performance problems, or both. Each side of the algorithm needs a specific approach regarding rehabilitation. Flexibility deficits need to be addressed by stretching and mobilisation techniques, whereas muscle recruitment normalisation is the main goal for the patient who has muscle performance problems. If both flexibility deficits and muscle dysfunction are responsible for the scapular dyskinesis, both problems should be addressed. It is imperative to determine whether the flexibility deficits are primary or secondary, based on the relative weakness of the antagonist. In the first case, reducing flexibility problems should precede motor control learning; in the second case, gaining stability may relax the tight muscle.

Scientific rationale for a scapular rehabilitation programme

Recently, several studies have examined the effectiveness of a scapula-based rehabilitation programme. 75 , 114-120 Vande Velde et al 116 showed that a 12-week scapular training programme resulted in a significant increase in isokinetic scapular muscle strength in healthy adolescent swimmers, and from a study of Merolla et al, 117 strength increase in the glenohumeral external rotators was apparent after a 6-month training programme in volleyball players with scapular dyskinesis. The latter study is of particular importance since it showed that scapular training improved glenohumeral muscle function, specifically the external rotators which are highly stressed during overhead activities. However, both the studies mentioned were performed on healthy non-injured overhead athletes. Recently, De Mey et al 119 showed that after 6 weeks of training according to the method described by Cools et al, 102 overhead athletes with impingement symptoms showed improved scapular muscle recruitment. In this study, surface EMG activity was recorded from the four major scapular muscles before and after the training programme. The main result was that the relative muscle activity for UT during arm elevation significantly decreased compared to the pretraining test and compared to the other scapular muscles. In view of the assumption that UT is often overactive in patients with impingement, a decrease in activity implicates a more efficient scapular recruitment pattern. 37 In addition, SPADI scores showed significant functional improvement and less pain after completing the scapula-based exercise programme. A few randomised controlled trials confirmed the value of scapular exercises in the treatment of shoulder impingement. 75 , 120 In general, these studies show better results regarding functional outcome, strength and patient satisfaction if a scapular approach is implemented in the treatment protocol. However, further research is required to show that restoring scapular control directly influences shoulder and neck pain.

Conclusion

In summary, there is evidence of scapular kinematic alterations associated with shoulder and neck pain. There is also evidence of altered scapular muscle recruitment patterns in these patients, with respect to changes in strength, flexibility, motor control and timing of the surrounding muscles. In particular, lack of flexibility, in combination with muscle dysfunction of SA and LT, might be the clinical base for a treatment programme given to these patients. The available evidence in clinical trials supports the use of therapeutic exercise in the rehabilitation of these patients; however, future studies should be performed to confirm the effectiveness of these exercise protocols.

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Rehabilitation of scapular dyskinesis: from the office worker to the elite overhead athlete

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The scapula functions as a bridge between the shoulder complex and the cervical spine and plays a very important role in providing both mobility and stability of the neck/shoulder region. The association between abnormal scapular positions and motions and glenohumeral joint pathology has been well established in the literature, whereas studies investigating the relationship between neck pain and scapular dysfunction have only recently begun to emerge.

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Progressing rehabilitation after injury: consider the ‘control-chaos continuum’

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Progressing rehabilitation after injury: consider the ‘control-chaos continuum’

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High control

Aims: Return to running with high control over running speeds/loads ( figures 1 and 3), low musculoskeletal impact forces, building player confidence.

First, determine key considerations specific to the injury (eg, speed progression for hamstring injury or passing volume for a groin injury) and the individual (eg, position or style of play) alongside potential risk factors for reinjury ( table 1). The goal during an early return to running is a gradual increase in the volume of running at lower speeds, thereby limiting high-speed running (HSR) exposure (<60% maximal speed (MS)) and musculoskeletal demands (online supplementary video 1). Linear running at lower speeds also minimises high acceleration/deceleration magnitudes ( figure 1). Sport-specific tasks, that is, incorporating a ball, are minimised to reduce movement variability, and manipulation of work to rest ratios enables appropriate energy system development ( figure 1).

Moderate control

Aims: Introduce change of direction (COD) with the ball, reduce control (somewhat controlled chaos) and HSR load progression ( figure 2).

We progressively integrate COD to gradually reduce control, with acceleration/deceleration demands determined by the intensity and volume of directional changes. The goal is to both reduce the degree of task constraint 8 and to progressively increase explosive distance (distance covered accelerating/decelerating, i.e, from 2 to 4 ms −1 <1 s) relative to the player's preinjury training demands. We increase linear HSR (60%-70% MS) and COD activities with and without the ball to increase movement variability (online supplementary video 2), the relative proportion of these activities depends on both the player and the specific injury ( table 1).

Control to chaos

Aims: Introduce football specific weekly structure ( figure 4) to overload game-specific demands reflecting a transition from control to chaos (inclusion of limited volume of movements with unanticipated actions).

In our framework, fitness development has a football-specific focus that incorporates technical aspects, moving from control to increasing levels of chaos. The week is structured to overload game components using 'intensive' and 'extensive' football to increase training specificity. 9 Intensive football overloads the musculoskeletal system and specific energy systems through acceleration, deceleration and COD components in restricted areas (online supplementary video 3). 9 Drills include more reactive passing and movement (online supplementary video 4), as well as progressive, positional-specific acceleration/deceleration to replicate explosive movements (online supplementary video 5). 9

Extensive football reflects typical match demands, using larger areas to produce higher speed and distance. 9 Drill presciption progressively incorporates running at higher speeds (>65%-80% MS) using aerobic power interval runs to target the required energy systems (online supplementary video 6).

Moderate chaos

Aims: Increase HSR under moderate chaos (unpredicted movements, minimal limitations), with the addition of pass and move and specific pattern of play drills.

In this phase, HSR loads increase further under both control and chaotic conditions. Extensive sessions target HSR (>75% MS) including subtle directional changes (online supplementary video 7), and progressive increments in sprint distance based on the player's relative match demands, minimising 'spikes'-large/acute increments in load. Additionally, we include pass and move drills of increasing specificity alongside pattern of play drills to address technical skill progression (online supplementary video 8). Accumulated weekly total distance should now have reached typical training levels ( figure 2). 3

High chaos

Aims: Return the player to relative weekly training demands ( figure 2) and include drills designed to test worst-case scenarios (high speed/high chaos).

Technical considerations: passing/crossing and shooting; graded in intensity from short/mid/long range while jumping/heading and tackling; graded in intensity as static/movement/in-context. The volume of technical actions should be progressively increased and be player and injury specific.

In the final phase, we emphasise position-specific conditioning and reflect game intensity with volumes relative to weekly preinjury training outputs. Positional specific speed/speed-endurance drills (online supplementary videos 9 and 10) prepare players for game activity-where the speed/direction of the pass dictates how fast the player moves. Technical considerations specific to the injury in question (eg, ball striking activity for a groin injury) form part of our final criteria for return to training, alongside strength and power diagnostics ( table 1).

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Progressing rehabilitation after injury: consider the 'control-chaos continuum'

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Early reintegration to training and match play following injury increases the risk of reinjury.

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Drill design using the ’control-chaos continuum’: Blending science and art during return to sport following knee injury in elite football

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Drill design using the ’control-chaos continuum’: Blending science and art during return to sport following knee injury in elite football

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Integration of strength and conditioning principles into a rehabilitation programme

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Integration of strength and conditioning principles into a rehabilitation programme

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Michael P. Reiman, PT, DPT, OCS, SCS, ATC, FAAOMPT, CSCS 1 and Daniel S. Lorenz, DPT, PT, ATC/L, CSCS 2

Abstract

Background and Purpose:

Rehabilitation and strength and conditioning are often seen as two separate entities in athletic injury recovery. Traditionally an athlete progresses from the rehabilitation environment under the care of a physical therapist and/or athletic trainer to the strength and conditioning coach for specific return to sport training. These two facets of return to sport are often considered to have separate goals. Initial goals of each are often different due to the timing of their implementation encompassing different stages of post-injury recovery. The initial focus of post injury rehabilitation includes alleviation of dysfunction, enhancement of tissue healing, and provision of a systematic progression of range-of-motion and strength. During the return to function phases, specific return to play goals are paramount. Understanding of specific principles and program parameters is necessary when designing and implementing an athlete's rehabilitation program. Communication and collaboration amongst all individuals caring for the athlete is a must. The purpose of this review is to outline the current evidence supporting utilization of training principles in athletic rehabilitation, as well as provide suggested implementation of such principles throughout different phases of a proposed rehabilitation program.

Evidence Acquisition:

The following electronic databases were used to identify research relevant to this clinical commentary: MEDLINE (from 1950-June 2011) and CINAHL (1982-June 2011), for all relevant journal articles written in English. Additional references were accrued by independent searching of references from relevant articles.

Results:

Currently evidence is lacking in the integration of strength and conditioning principles into the rehabilitation program for the injured athlete. Numerous methods are suggested for possible utilization by the clinician in practice to improve strength, power, speed, endurance, and metabolic capacity.

Conclusion:

Despite abundance of information on the implementation of training principles in the strength and conditioning field, investigation regarding the use of these principles in a properly designed rehabilitation program is lacking.

Keywords: periodization, program design, rehabilitation, strength, training

Background and Purpose

Strength and conditioning is traditionally thought to exist only in the training of the healthy athlete, while rehabilitation is for the athlete who has been injured. Once the athlete completes their post-injury rehabilitation with the athletic trainer and/or sports physical therapist, they often then move onto the strength and conditioning coaches to resume their "weight room workouts" and re-integration with the team. The strength and conditioning coach, in consultation with the athletic trainer and/or sports physical therapist, uses an understanding of the proper technique and application of several types of exercise to develop a program to ready the rehabilitating athlete for competition.

Evidence supporting the implementation of strength and conditioning principles into such a program is currently sparse.1-6 Several authors have investigated both conservative1-4,6 as well as post-surgical interventions.5 While each of these studies have integrated specific strength and conditioning concepts, none have employed the entire spectrum of strength and conditioning as it applies to the rehabilitating athlete. The purpose of this clinical commentary, therefore, is to describe these strength and conditioning principles, and provide a suggested implementation of their use throughout the entire rehabilitation process, not just during the return to sport phase.

Assessment of the Athlete and the Post-Injury Training Program

Proper implementation of a post-injury training program requires assessment of the rehabilitating athlete, their sport, and the defined training program principles themselves ( Figure 1 ). Periodic re-assessment of the athlete, as well as the program and its outcomes can provide the sports physical therapist the necessary information required to manipulate the various training program variables to achieve the desired goals. Specific training principles ( Table 1 ) should be addressed when designing the athlete's program. The sports physical therapist should consider the phase of rehabilitation that the rehabilitating athlete is in when implementing such a program. The specific program parameters of strength, power, endurance, and hypertrophy must also be carefully considered and targeted when planning the program.

Table 1.

Principle

Definition

Individuality

Treating the athlete as an individual and designing their training program specifically for them. Several factors should be considered when designing a resistance training program, including age, sex, medical history, previous training background, injury history, overall health, training goals, motivation, and any healing restraints related to the injury or surgery.

Progressive overload

States that in order to continue making gains in an exercise program, stress to the system must be progressively overloaded as it becomes capable of producing greater force, power, or endurance. The principle of specificity states that the body makes gains from exercise and training according to the manner in which the body trains. The way the athlete trains is how he or she will function.

Specificity

When developing a training program using this principle, one should consider the following:

* Energy-source specificity: training the correct energy system

* Muscle action specificity: gains in strength are in part specific to the type of muscle action used in training (e.g., isometric, concentric/eccentric, isokinetic).

* Muscle group specificity: training the muscle group(s) and joint(s) that are involved in the sport.

* Velocity specificity: training gains are specific to the velocities at which exercises are performed. Exercise selection and order of performance specificity

Volume and Intensity

Volume relates to the total amount of weight lifted in a training session. Intensity (or load) is the amount of weight assigned to an exercise set. Volume and intensity are inversely proportional.

Frequency

The number of training sessions per specific time-frame (typically enumerated on a weekly basis).

Rest period

The length of time for recovery between sets and exercises. Rest period is dependent on the sport the athlete is participating in, the training goal(s) (strength, power, endurance, hypertrophy), load lifted, and the training status of the athlete.

Type of resistance

The primary types of resistance available to the athlete are: free weight and elastic resistance (which affords multi-planar, whole body patterns of movement resistance training), machine resistance (provides increased stabilization for isolated muscle strengthening), aquatic resistance (provides multi-planar resistance with fluid resistance/assistance dependent on positioning), and isokinetic resistance (provides accommodating resistance with large amounts of reliable and valid data).

Variation/Periodization

The planned manipulation of training variables (load, sets, and repetitions) in order to maximize training adaptations and to prevent the onset of overtraining syndrome.18

▪ Linear/classical

Linear: This model is characterized by high initial training volume and low intensity. As training progresses, volume decreases and intensity gradually increases based on changing exercise volume and load across several predictable mesocycles. The program over a 12-month period is referred to as a macrocycle, and two subdivisions are the mesocycle (3-4 months) and the microcycle (1-4 weeks).

▪ Non-linear/undulating

Non-linear periodization (NP) is based on the concept that volume and load are altered more frequently (daily, weekly, biweekly) in order to allow the neuromuscular system more frequent periods of recovery. Phases are much shorter providing more frequent changes in stimuli, which may be highly conducive to strength gains.18

▪ Reverse

Reverse: this model is the inverse of the linear model in which intensity is initially at its highest and volume at its lowest.

The requirements or demands of any given sport must be ascertained in order to determine how to properly manipulate the training variables throughout the program. For example, training for a football lineman in the latter phases of rehabilitation should emphasize explosive power in activities performed that last 7-10 seconds with 20-60 seconds of recovery time to best replicate the demands of the sport.7,8 In the earlier phases of rehabilitation it may be necessary to correct specific impairments, such as muscle imbalances, that may contribute to injury.9-12 The inability of a rehabilitating athlete to perform a specific task can be identified using various measures (self-report, impairment based, bio-psycho-social, and/or performance based measures). An individual's ability to properly function occurs along a continuum, and therefore should include these multiple measures.13,14 The assessment continuum should include a subjective report of functional ability, observation and examination of impairments, and functional performance testing as appropriate. Functional performance testing has previously been defined as using a variety of physical skills and tests to determine (1) one's ability to participate at the desired level in sport, occupation, recreation, or to return to participation in a safe and timely manner without functional limitations and (2) one's ability to move through as many as three planes of movement. Functional performance is assessed using nontraditional (e.g. beyond manual muscle and range-of-motion) testing that provides qualitative and quantitative information related to specialized motions involved in sport, exercise, and occupations.13 The comprehensive assessment approach can be utilized to not only assess the rehabilitating athlete and their sport demands, but the success of the implemented program as well. If specific program parameter(s) (e.g. functional movement, strength, power, endurance, and/or hypertrophy) are determined to be deficient in the rehabilitating athlete during testing, the program can be modified to correct these deficiencies. Limitations demonstrated in fundamental movement patterns15,16 would require amelioration prior to placing emphasis on power training. Since it has recently been suggested that assessment of an individual's overall functional ability is multifactorial14 complete description of functional assessment is beyond the scope of this clinical commentary. For additional suggestions on the implementation of the assessment of the athlete, the reader is referred elsewhere.13-17

Traditional Training Program Parameters

Specifically training a muscle or group of muscles to achieve the desired goals of increased strength, power, endurance, and hypertrophy is paramount. The reader is advised to consult other sources18-20 for detailed information on training of these parameters, as it is also beyond the scope of this commentary to do so. General parameters will be discussed here.

Training for muscle performance including strength, power, and endurance, requires different program design and does necessitates variability in exercise prescription ( Table 2 ). Strength training typically involves a load/ intensity of 80-100% of the maximum amount of weight that the individual can lift one repetition (1 RM), utilizing approximately 1 to 6 repetitions.18-23 Power training, on the other hand, requires a primary component of velocity of movement. Therefore, since velocity is inversely proportional to the amount of load lifted, the load will have to be relatively lighter than loads utilized in strength training in order to accomplish the necessary velocity. Power training though does require a foundation of strength.

Table 2.

Primary Parameter Trained

Repetition Range

Strength and Power

0-6

High Intensity Endurance much greater than Strength and Power

6-12

Low Intensity Endurance greater than High Intensity Endurance

12-20

Low Intensity Endurance

20-30

While strength and power training can require similar components of training, endurance training is fairly unique. Endurance training can involve many methods (circuit training, etc.) but the common theme is high repetitions with lighter loads.18-23 The relative work to rest ratio is the lowest amongst the primary three parameters of muscle performance. Endurance training can be a method to achieve hypertrophy training since moderate loads and repetition range of 8-12 is suggested for hypertrophy training.18,22,23

Phases of Injury Rehabilitation

Regardless of the type or region of injury, basic phases of rehabilitation have been described in the literature.3-5,24-34 Dependent on the injury status, whether surgery was involved, and the restrictions associated with the recovery, the duration of these phases will differ. There are some common characteristics, goals, precautions and criteria for progression to the subsequent phase. Described below and in Table 4 is a general outline of the various phases of rehabilitation based on multiple previous protocols, literature sources,3-5,24-34 as well as opinions of the authors. Criteria for progression, goals of each phase, and characteristics of each phase therefore are the authors' opinions based upon available protocols and past literature.

Table 4.

Training Emphasis

Non-Linear Periodization Phase

Parameter Trained

Training with Team

Phase I, Immediate rehabilitation: Characterized by tissue and/or joint inflammation and pain, disuse, detraining, loss of muscle performance, potential immobilization (dependent on injury), and initiation of tissue repair and/or regeneration. The primary goals to be addressed during this phase are protection of the integrity of the involved tissue, restoration of range-of-motion (ROM) within restrictions; diminishment of pain and inflammation, and prevention of muscular inhibition. Major criteria for progression to Phase II include: minimal pain with all phase I exercises, ROM≥75% of non-involved (NI) side, and proper muscle firing patterns for initial exercises.

Phase II, Intermediate rehabilitation: Characterized by continuation of tissue repair and/or regeneration, increased use of involved body part or region, decreased inflammation, and improved muscle performance. The primary goals to be addressed during phase II include: continued protection of involved tissue(s) or structures and restoration of function of the involved body part or region. Criteria for progression to Phase III include: close to full ROM/muscle length/joint play, and 60% strength of primary involved musculature when compared to the uninjured side.

Phase III, Advanced rehabilitation: Characterized by restoring normal joint kinematics, ROM, and continued improvement of muscle performance. The primary goals to be addressed during this phase are restoration of muscular endurance and strength, cardiovascular endurance, and neuromuscular control/ balance/proprioception. Criteria for progression to phase IV include: strength > 70-80% of non-involved (NI) side and demonstration of initial agility drills with proper form (e.g. avoidance of medial collapse35 of bilateral lower extremities, coordinated and symmetrical movement of all extremities, controlled movement of entire body).

Phase IV: Return to function: Characterized by activities that focus on returning the athlete to full function. The primary goals to be addressed during this phase are successful return to previous functional level in the athlete's preferred activity, and prevention of re-injury.

Designing a Training Program with Consideration for the Injured Athlete Needs Analysis of Training Program

In order to properly design a patient and sports specific rehabilitation program, a needs analysis should be performed.36 Performing a comprehensive analysis (Recall Figure 1 ), investigating such factors as the physiological and biomechanical requirements of a sport is required when designing the program. Components of a needs analysis include a general biomechanical analysis of the sport which rehabilitating athlete participates in, an analysis of the energy sources utilized in the sport, and an analysis of the common injury sites and patterns for the sport.36 Furthermore, an appropriate physiological analysis allows the clinician to devise a program that addresses specific strength, range of motion, flexibility, power, endurance, and speed requirements for any given sport. For example, an American football player needs more muscle size and strength than a cross-country athlete or a soccer player. Only by addressing these requirements specifically will an athlete be successful in returning to their sport or activity. Next, a biomechanical analysis is required to choose training activities that develop the athlete in a manner most specific to the sport. Specificity of training is a foundation of both functional and resistance training programs.18 It is the authors opinion that the sports physical therapist should be well-versed on injury patterns that are present in the sport in which the rehabilitating athlete is participating to ensure that prevention strategies are included. For example, female soccer and basketball players have demonstrated a higher risk for anterior cruciate ligament ruptures than athletes who participate in other sports.37-41 Likewise, American football lineman and gymnasts are at an increased risk for spondylolysis and spondylolisthesis compared to athletes in other sports.42-45 Each of these examples shows how training programs for the rehabilitating athlete should be specifically designed to accommodate each individual athlete's needs to maximize performance and avoid subsequent injury. The reader is directed to Table 5 for an illustration of these concepts.

Assessment of Rehabilitating Athlete's Strengths and Weaknesses

Assessment of each rehabilitating athlete's strengths and weaknesses can be a complex undertaking. As previously mentioned, proper assessment of an athlete's functional capacity is multi-factorial, involving multiple variables.14 Along with the assessment of the rehabilitating athlete's strengths and weaknesses, knowledge of their training history/status, injury history/status, and basic physical characteristics is warranted. Training status may depend on numerous factors, including length of time playing the sport, length of time specializing in the sport (or position within a sport), and the level of competition at which the athlete is accustomed to participating.

Training Program Design Principles

Once the clinician has determined the rehabilitating athlete's needs, the next step in designing the rehabilitation program is manipulation of the program principles. As previously mentioned, it is beyond the scope of this article to discuss all the necessities of program design; however some discussion of these principles is warranted especially in light of the paucity of literature regarding their implementation in the rehabilitating athlete The program principles of interest to the sports physical therapist for manipulation include: exercise selection, training equipment availability, training frequency, exercise order, rest interval and resistance/training load.

Exercise Selection

Exercise selection is a critical program principle for which the clinician should account. Multi-joint exercises are exercises that involve many muscle groups in one exercise.18 Examples of multi-joint exercises include squats, deadlifts, cleans, bench presses, and push jerks. Typically, these exercises are done first in the training session because they are the most fatiguing, but also because they are recommended most for increasing muscle and bone strength.18 The other type of exercise is known as supplementary, or isolation exercises. Examples of isolation exercises include front raises, lateral raises, and knee extensions. Since these isolation exercises are primarily single joint-single plane exercises, they are a good choice for the untrained or inexperienced athlete.18 Ultimately, though, the experienced athlete will require several multi-joint exercises in their program in order to be successful.

Progression to multi-joint exercises involves more instruction and greater time to practice in order for the athlete to establish the necessary coordination to properly execute the exercise safely and effectively. Performing large muscle mass, multi-joint exercises early in the workout has been shown to produce significant elevations in anabolic hormones.46-48 This type of an anabolic response may potentially expose smaller muscles (such as those in the affected area) to a greater anabolic response than that resulting from only performing small muscle exercises.47,48

Availability of Training Equipment

A lack of certain equipment necessitates changes or does not allow the performance of some exercises.36 In the context of free weights, lack of floor or ceiling space may hamper lifts that could involve dropped weights or pushing weights overhead. For example, many Olympic lifts performed overhead (i.e. snatch, jerks) are performed with bumper plates that bounce on the ground to promote athlete safety if a lift is missed, or if maximal lifts are attempted. In any of these cases, the bar is often dropped to the floor where it bounces and could potentially injure others. Some machines may not be multi-dimensional enough to be sport-specific for the rehabilitating athlete,36 so the clinician will need to supplement training programs with appropriate exercises. For example, when the rehabilitating athlete needs to perform a chest press motion, it may be more appropriate to use the dumbbell or barbell bench press than a weight machine. These lifts, although utilizing the same musculature, require the athlete to make adjustments to complete the lift given that the axis of movement is not fixed and may follow an unpredictable course compared to a seated chest press using a weight machine which only has one axis of movement.

Training Frequency

Training frequency ultimately depends on the volume and load of exercises, the type of movement (multi vs. single joint) that prevails throughout the workout, the training level of the athlete, the goals of training, and the health status of the athlete.36 Traditionally, resistance training on alternating days is encouraged in the early stages of training to ensure recovery,36 but frequency may increase with increased training experience. Previous authors have demonstrated insignificant differences in strength gains observed between training 1, 2, 3, or 5 days per week if the volume was kept constant.18 When near maximal resistances are used, more recovery time is advocated.18,19,22,23

The sports physical therapist must also consider other concurrent training in which the athlete is involved. A young pitcher may not only be in season, but may also be working with a pitching coach once or twice a week in addition to resistance training. The frequency of training may need to be reduced to accommodate the athlete's schedule of training in order to ensure that proper rest and recovery is achieved. Similarly, an increase in training frequency may be warranted if the athlete appears to be reaching a plateau or making minimal gains in one or more of the training parameters (e.g. strength, power, endurance).

Exercise Order

The ability to perform the desired load and volume of each exercise is dependent on proper order of exercise.36 Proper coordination of the integration of multi-joint and isolated strengthening exercises requires careful planning on part of the sports physical therapist. Each individual athletes physical condition, as well as the their particular strengths and weaknesses will require consideration when designing the training program.36 Various methods of utilization of exercise order will be described.

Because multi-joint exercises require the most coordination, skill, and proper levels of energy, it is encouraged that they are performed first in the training session. For example, the bench press should be performed prior to tricep extensions. Since multi-joint lifts are the most fatiguing, the athlete is unlikely to obtain the maximum benefit of these exercises if the smaller muscle groups are fatigued from previous exercises. Pre-exhaustion is a training technique is a training technique in which a muscle is fatigued in a single-joint, isolated movement prior to performing a multi-joint exercise involving the same muscle.36 An example of pre-exhaustion training is performing leg curls or leg extensions prior to a back squat or deadlift. The sports physical therapist may utilize this technique if they feel that the multi-joint movements are not completely developing the muscles in question or to help alleviate the effects of training boredom. To the author's knowledge, no studies exist utilizing pre-exhaustion as a training technique.

There are various methods of pairing exercises to challenge the athlete, alleviate boredom, and emphasize muscle endurance and hypertrophy. Super setting involves alternating agonists and antagonists with minimal rests between exercises. For example, a bench press followed by a seated row or a bicep curl followed by a triceps pushdown would be examples of super sets. Compound setting is performing two different exercises of the same muscle group in alternating fashion with little to no rest between exercises. Anterior lunges followed by squats or barbell bicep curls followed by alternating dumbbell curls are both examples of compound setting. Athletes in poor physical condition may find super setting, compound setting, or pre-exhaustion techniques too strenuous in the early stages of training.36

Other methods to manipulate exercise order are to have an athlete perform upper and lower body exercises in an alternating fashion. The clinician can also have the athlete perform upper body push and lower body pull exercises alternatively, or vice versa. Lastly, the athlete can perform a "push-pull" routine. Here, the athlete can perform a front squat followed by a deadlift. Push-pull may involve agonists and antagonists, but may also include an upper body "push" exercise coupled with a lower body "pull", or vice versa. Collectively, these methods allow more exercises to be completed within a session and allow greater intensity of each exercise due to extended recovery of the each muscle group being worked. Plus, these methods help promote balance and symmetry of agonist-antagonist training.

Rest Period & Resistance/Training Load

Manipulation of all of the above training variables are applicable to the rehabilitating athlete, but it will require the sports physical therapist to design athlete specific programs, keeping the above principles in mind. Regardless of injury, it is advised that the athlete have at least 24 hours of recovery between sessions, and 48 hours in between sessions working the same muscle group.18,21,22 For a rehabilitating athlete who is seen only 1-2 times per week, a total body routine is advocated to maximize training balance. If training is done 4-5 days per week, a split routine is advocated by the authors of this review to allow proper recovery between muscle groups used. Regarding the athlete who is rehabilitating 3-5 days per week, the authors suggest activities on "off days" might include flexibility training, yoga, balance and proprioceptive exercises, or core/abdominal training.

Determining the training load and rest ratios requires careful consideration of the rehabilitating athlete's sport and the body part or region to be trained. For example, muscles of the trunk are primarily slow twitch, type I muscle fibers49-51 that necessitate high repetition, low load endurance based training. Other, more explosive muscles that are prime movers, utilized in jumping (e.g. quadriceps and gastrocnemius) require strength based training programs, progressing to lower loads at explosive speeds, and plyometric type training for development of power.

Training load is usually determined with 1 RM testing in strength and conditioning. The use of 1 RM testing is often disadvantageous for the rehabilitating athlete as it requires a systematic progressive increase in maximum load lifting capability. Although this method is the most advantageous and accurate method of determining 1 RM, the use of estimating 1 RM and training load charts is advisable for these athletes. Other methods for determining training load include the DeLorme technique, the Daily Adjusted Progressive Resistance Exercise (DAPRE) technique, the OMNI-RES, or the Oddvar Holten method.52-55 These tables are intended to be used as a guide until the athlete has developed the neuromuscular capabilities that will allow them to safely and effectively test with heavier loads to more accurately determine their 1 RM.18 The use of such tables is but one method of determining load, as other methods have proven effective.55 Training volume is typically prescribed in terms of the number of repetitions per set, number of sets per session, and the number of sessions per week.56 The importance of training volume for maximal strength and hypertrophy gains during early phases of resistance training has previously been demonstrated.57-59 Untrained, normal individuals were shown to experience maximal strength gains with a mean training intensity of ≈12 RM, while trained individuals demonstrated these gains with a mean training intensity of ≈8 RM.59

The length of the rest period is dependent on the training goal, the relative load lifted, the sport in which the athlete participates, and the training status of the athlete. The rest period is a primary determinant of the overall intensity of a workout, as rest period length is strongly related to the load lifted.18,21,60 The rest period length not only determines how much of the adenosine triphosphate-phosphocreatine (ATP-PCr) energy source is recovered,60 but also how high post exercise lactate concentrations become in the blood.47,61-63

Other training principles were outlined and defined in Table 1 . Additionally, Tables 2 and ​and3 3 provided descriptions of training load and rest period suggestions. Utilization of concepts and suggestions given in these tables, as well as the outline provided in Figure 1 will provide the sports physical therapist the necessary framework to design a proper training program for the rehabilitating athlete. Integration of these principles into a specific program is the next step.

Table 3.

Primary Parameter Trained

Rest Period

Muscular Power

5-8 minutes

Maximal Muscular Strength

3-5 minutes

Muscular Hypertrophy

1-2 minutes

Muscular Endurance

30-60 seconds

Integration of Training Principles and Parameters into a Rehabilitation Program for the Injured Athlete

The previous sections offered suggestions regarding multiple parameters and the opportunities for their manipulation of these training principles for the rehabilitating athlete, based on current evidence and principles used with normal (uninjured) athletes. Additionally, Table 1 defines periodization, as well as the difference between linear and non-linear periodization. The rehabilitating athlete may need to be considered similar to the untrained category initially with respect to the injured body part. Therefore, as outlined in Table 4 the initial non-linear periodization phase for the injured body part or region should be an emphasis on higher repetitions and muscle endurance/hypertrophy with a later initiation of strength-based training. As the patient progresses further in their rehabilitation, additional progression into more aggressive strength training and power training should be incorporated. Unlike linear periodization, where the emphasis is on only one parameter (endurance, hypertrophy, strength, endurance), non-linear periodization allows the clinician the ability to train more than one of these parameters at a time, while still emphasizing one of them in a particular phase. Although the literature is lacking regarding the utilization of types of periodization with the rehabilitating athlete, the opinion of the authors of this review is that the non-linear form of periodization would most likely fit the rehab process in most instances. Additionally, it is the authors' suggestion that the rehabilitating athlete continue with some form of training with their team. Table 4 also offers ideas on how to integrate the rehabilitating athlete into team training components. This is a general framework upon which the reader can build and individualize a program specific to the needs of each rehabilitating athlete.

As an alternative to non-linear periodization previously described, a rehabilitation program could be constructed using short duration linear periodization. Utilizing a short duration linear program would require initial emphasis on high volume and low intensity (endurance and/or hypertrophy phase). Progression into the strength/power phase and eventually to the power phase at end stage rehabilitation would then occur. Once again, the authors of this commentary assert that non-linear periodization may prove to be a more advantageous method of program design for the rehabilitating athlete as it affords implementation of multiple variables into the different phases throughout the rehab program.

CONCLUSION

Strength and conditioning principles and training parameters are a necessary component of the decision making and tailoring of any rehabilitation program. This is especially important in the rehabilitation and full return to function of an injured athlete. The sports physical therapist implementing such programs should be cognizant of each the components and variables for the rehabilitation program of an athlete. Currently the literature has little to offer regarding of the integration of strength and conditioning concepts into the rehabilitation of the injured athlete. The benefit of integration of these training principles during the rehabilitation of an injured athlete, although intuitive for best practice, remains elusive. Future studies should investigate the extent of the relationship between strength and conditioning principles and their integration into a rehabilitation program for the rehabilitating athlete. Determining how integral a role these training principles play for athletic rehabilitation is long overdue.

REFERENCES

13. Reiman MPManske RC. Functional Testing in Human Performance. Champaign, IL.: Human Kinetics; 2009 [ Google Scholar]

19. Reiman MP. Training for Strength, Power and Endurance. In: Manske RC, ed. Post-Operative Rehabilitation for the Patient with Post Surgical Sports and Orthopedic Knee and Shoulder Surgery. Philadelphia, PA: Mosby; 2006 [ Google Scholar]

20. Fleck SJKraemer WJ. Designing Resistance Training Programs. 3rd ed. Champaign, IL: Human Kinetics; 2004 [ Google Scholar]

21. Baechle TREarle RWWathen D. Resistance Training. In: Baechle TREarle RW, eds. 3rd ed. Champaign, IL: Human Kinetics; 2000 [ Google Scholar]

36. Wathen D. Exercise Selection. In: Baechle TREarle RW, eds. Essentials of Strength Training and Conditioning. 3rd ed. Champaign, IL.: Human Kinetics; 2000 [ Google Scholar]

Articles from International Journal of Sports Physical Therapy are provided here courtesy of North American Sports Medicine Institute

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INTEGRATION OF STRENGTH AND CONDITIONING PRINCIPLES INTO A REHABILITATION PROGRAM

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Michael P. Reiman, PT, DPT, OCS, SCS, ATC, FAAOMPT, CSCS 1 and Daniel S. Lorenz, DPT, PT, ATC/L, CSCS 2 Rehabilitation and strength and conditioning are often seen as two separate entities in athletic injury recovery.

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A theoretical model for exercise progressions as part of a complex rehabilitation programme design

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A theoretical model for exercise progressions as part of a complex rehabilitation programme design

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Beginning With the End in Mind: Implementing Backward Design to Improve Sports Injury Rehabilitation Practices

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Beginning With the End in Mind: Implementing Backward Design to Improve Sports Injury Rehabilitation Practices

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‘Where is the load?’ Revisiting StARRT by including an athlete’s sport-specific training capacity?

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‘Where is the load?’ Revisiting StARRT by including an athlete’s sport-specific training capacity?

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'Where is the load?' Revisiting the Strategic Assessment of Risk and Risk Tolerance (StARRT) framework for return to sport by including an athlete's sport-specific training capacity?

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Revisiting the StARRT framework

The Strategic Assessment of Risk and Risk Tolerance (StARRT) framework has been instrumental in the way practitioners view return-to-sport (RTS) decision-making.1 2 According to the framework, RTS decisions should be based on the practitioner's risk assessment of outcome, involving an athlete's estimated risk compared with their risk tolerance within the particular context. Activity risk assessment is the second step in the StARRT framework, synthesising information relevant to the expected cumulative stresses placed on the injured tissue/structure(s). Several important factors are included in this assessment, but what is not listed is the athlete's sports-specific training capacity. This represents an athlete's overall ability to cope with diverse demands of training and competition imposed by their ecosystem and perform at the required level. It is perhaps the most ecologically important consideration since it encapsulates the 'actual' demands and requirements of the athlete's sport and their level of participation.3-5 While the importance of monitoring training load in rehabilitation has been established,6 7 we emphasise that sufficient consideration has not been given to the role of the athlete's sports-specific training capacity in decision-making ...

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'Where is the load?' Revisiting the Strategic Assessment of Risk and Risk Tolerance (StARRT) framework for return to sport by including an athlete's sport-specific training capacity?

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The Strategic Assessment of Risk and Risk Tolerance (StARRT) framework has been instrumental in the way practitioners view return-to-sport (RTS) decision-making.1 2 According to the framework, RTS decisions should be based on the practitioner's risk assessment of outcome, involving an athlete's estimated risk compared with their risk tolerance within the particular context.

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High-value care in musculoskeletal health care: a way forward?

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High-value care in musculoskeletal health care: a way forward?

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Shoulder: Consensus statement on rehab and return to sport

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Shoulder: Consensus statement on rehab and return to sport

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Exercise prescription for aging adults - Physio Network

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Access all classes Start free trial With Dr Mariana Wingood 2 hours 5 modules Among older adults, exercise and physical activity are an essential component of maintaining functional mobility, preventing hospitalisation and falls, improving quality of life, and improving general health and wellbeing.

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Introduction

Having been a part of many youth related special interest groups in physiotherapy and strength and conditioning, I have seen some common trends and been involved in many interesting discussions around the management of adolescent injury/pain. The main mistake I see clinicians and coaches make is attempting to treat youth injury and pain the same way they would an adult with a similar condition. Therefore, the purpose of this blog is to provide a guideline for clinicians to follow when managing adolescent injuries/pain.

This blog will be split into 3 parts for ease of reading and to signpost clinicians to the most relevant information. These are:

Part 1 - Anatomy and physiology of growth and development along with unique paediatric red flags.

- Considerations for creating an effective intervention with children / adolescence, and the implication for practice of the long term athletic development model (LTAD) implications.

- Finally, we will tie it together with some common conditions we'll see in the clinic. We'll also give an example how management would change along the LTAD framework depending on the age of presenting conditions and goals.

Alright, let's rip into part 1!

Growth/Maturation Phases

Childhood growth and development is characterised by both longitudinal bone growth as well as subsequent remodelling of that bone to deal with the forces that are applied to it. From approximately four years old until puberty, mass and length accumulates uniformly. From this time until mid adolescence, appendicular long bone growth outstrips skeletal density deposition, and axial bone growth. This can lead to some of the unique things like greenstick fractures seen in immature skeletons.

The most important event to highlight here is the phase of peak height velocity (PHV), a point during early puberty where long bone growth hits the accelerator. This is where the epiphyseal plate begins closing via ossification of the cartilage at the epiphyseal line and further calcification occurs at the epiphysis to form a longer bone. This time, traditionally known as ''the growth spurt'', can be a potential area of vulnerability in an immature skeleton. Peak bone deposition rate usually occurs around 6-12 months after PHV. The individual's hormonal, nutritional and physical activity status will all greatly impact bone development (1-4).

Clinical Tip:

A quick question to determine the likelihood of PHV being associated with the clinical presentation is to ask about recent rapid change in shoe size (due to distal long bone growth). A failure to reach PHV (approximately 11.5 years for girls and 13.5 for boys) in physique sensitive sports like ballet and gymnastics must be noted as a possible sign of Relative Energy Deficiency in Sports (RED-S) and relevant referral discussions should be made.

Tendon/Ligaments:

Tendons and ligaments in childhood/adolescence are highly active tissue, laying down most of the framework from which we gradually modify in our adult years. Early in childhood the make-up of these tissues is biased towards a highly cellular environment with the extracellular matrix's (ECM) functional force transmitting collagen proteins relatively sparse. In response to loading during growth, these cells signal greater composition of ECM proteins, especially in areas of high force (Musculotendinous Junction and Entheses/Apophysis). During growth the apophysis is another site of importance for pain and injury risk as the tendon tissue grows longitudinally much slower than the underlying bone placing a traction stress at this point (5).

Muscle/Neuromuscular Coordination:

The hypertrophic response to mechanical loading in the child/adolescent will be limited until puberty is reached and sex hormones are adequate. Strength and neuromuscular control of a joint segment can still be optimised via neurological mechanisms within the context of the repeated bout effect in training. This differs to the post pubertal period where greater emphasis can be put on hypertrophy in a periodised plan for joint stability. Furthermore, the period of PHV is often associated with negative changes in coordination as the athlete must adapt to their rapidly growing bodies. Management of training loads is required due to the increased risk of injury during this period (1,6).

Things Not To Miss

The 5 "S' of Paediatric Red Flags

Symptoms: Though common to have stress points during growth and development due to the different tissue development rates, symptoms presenting at any of these sites should at least be flagged.

Systemic: Anything not presenting as an isolated single joint, or showing signs of affecting more than just the musculoskeletal system. Septic arthritis is a common orthopaedic emergency in children. Therefore, think of signs of infection.

Symmetry: Though slight asymmetries in growth are completely normal, anything overly obvious should not be missed here. Think of large leg length and spinal alignment differences.

Skeletal Dysplasia: Abnormal bony growth patterns in young children need to be considered and referred appropriately.

Stiffness: Conditions like juvenile arthritis or other systemic conditions present as joint stiffness (7).

Salter-Harris fractures

It is beyond the scope of this blog to outline all the types but for further learning I would direct you to here (8). The basic premise is that these fractures are either along or through the epiphyseal line and can impact bone growth and development. These are important not to miss as they can present as joint pain, but the consequences can be a lot higher for abnormal development of a child. Normal fracture related flags should prompt this investigation.

Slipped Capital Femoral Epiphysis

This is a paediatric orthopaedic emergency with either hip or knee pain or both, a limp and a lack of/and painful hip internal rotation (9).

Spondylosis / Spondylolisthesis

Any paediatric back pain presentation coinciding with a change to training load, in a physique/weight based sport with dietary restrictions should be flagged. It's also worth having a high index of suspicion of sports with repetitive lumbar extension and rotation (10).

Conclusion

Alright, that's part 1 all wrapped up. I hope it's been useful for you. You should now have a better understanding of the anatomy and physiology of adolescents and how to spot some paediatric red flags.

Don't forget to share this blog!

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How to Manage Adolescent Pain, Injury and Training - Part 1/3 - Physio Network

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Introduction Having been a part of many youth related special interest groups in physiotherapy and strength and conditioning, I have seen some common trends and been involved in many interesting discussions around the management of adolescent injury/pain.

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Strength and Conditioning in physical therapy – How Much is Enough

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Strength and Conditioning in physical therapy – How Much is Enough

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Note: This is an updated version of an article I did for my own blog in 2018.

As a physio, strength coach and semi-retired powerlifter who has worked with and learned from people who have squatted over a thousand pounds to people who can barely get out of their own chair, it got me thinking: "for the regular person who's not a competitive athlete and just wants to look good, feel good, and be healthy, how much strength is enough? How much cardiovascular fitness is enough? At what point does trying to improve those areas become detrimental to health and cross-over into high performance athletics?" That is the topic of today's article.

If you're interested in learning more about effective exercise for clinical and athletic populations, checking out the Physio Network Masterclasses:

Perspective #1: We should just let people do the activities they want and live their life that way

There's a lot to be said for this especially given the rates of obesity and inactivity in the world. To quote Stan Efferding "the best form of activity is the one you'll do and stick to."

From a compliance perspective - yes it's important that people enjoy the activities that they are doing. Not everyone enjoys running or slugging weights. It is what it is. As much as people like to knock CrossFit - it's helped to excite a lot of people to get physically active and has a great sense of community.

My only concerns with this perspective are two fold:

Concern 1 - In some regions, especially in my home and current country of Canada where it seems to be either cold and snowy or stinking hot all year, many activities that people enjoy (i.e. certain sports, walking, gardening) just don't get done. What good is an activity if you're not doing it for five months (or more) out of the year?

Concern 2 - Are these activities enough to build both strength, cardiovascular fitness, lean body mass, and bone density?

Furthermore, look at the person who just walks and does things around the house and then has a heart attack during the first major snowfall of the winter while shovelling snow. Those activities that the person took part in did not prepare them enough for a more physically demanding (yet essential) task.

Some research has questioned whether low intensity activities such as walking can provide enough of a stimulus to maintain health, especially through the aging process (1).

As such, while it's important that people pick activities they enjoy, they need to be done consistently and there needs to be enough of a stimulus to promote health and to enable more strenuous essential activities to be done while still maintaining a reserve of physical function afterwards.

Perspective #2: We should turn all our physical therapy or personal training clients into powerlifters, endurance athletes or functional fitness freaks

As my friend Nick Tumminello said we tend to train our clients based on our specific biases - whether it's cardio, bodybuilding, powerlifting, kettlebells, Crossfit or the like.

While all of these activities can have great benefits on physical function - my concerns are two fold.

First of all, these activities carry a higher health risk than just training for general health.

Stan Efferding has said (2) "if you want to be healthy don't compete." While strength sports such as bodybuilding, powerlifting, strongman, and Crossfit do have an injury rate comparable to (or slightly less than) those of non-contact sports (3), an injury rate ranging from 1 every 10 years to over 1 per year is a lot for someone who's not pursuing highly competitive athletics. In addition, there are other health risks involved from carrying too much body weight which include osteoarthritis (OA), insulin sensitivity, high blood pressure, and sleep apnea.

Endurance sports, while widely considered to be healthier than strength sports, actually have a much higher rate of injury (4). In a very popular and semi-recent paper recreational runners are less likely to develop knee OA than the sedentary population, however, competitive runners are more likely to develop knee OA (5). In addition, the relationship between cardiovascular fitness and health is not 100% linear. High performance endurance athletes can have higher mortality and adaptations of the heart that can predispose them to other health issues (6).

Secondly ... training like a high-level athlete can become very burdensome from a time, effort and money perspective. Many high-level athletes train, eat, sleep and recover like it's their job. Eating 6 meals a day, being in bed by 8 to 10 every night, not being able to go out much, and training 8-10+ hours a week doesn't seem like the lifestyle most people want to live when their goal is just to be healthy.

As such - training like a competitive athlete isn't the answer either.

Well, what is the answer?

It's tough to give specifics without understanding a person's goals, general health, and demands of his or her life.

A good general guideline for what I consider to be "sufficient" strength and cardiovascular fitness is for people to:

Be able to do physically demanding activities such as factory and farm work, help move furniture, and be able to play some sports with coworkers/kids without these tasks being a "max effort" or causing such fatigue or muscle soreness that they can't be performed consistently.

Have appropriate levels of bone density and lean body mass

...all throughout the lifespan. Some may disagree but that's my standard.

Some good specific indicators of fitness are the following:

Being able to do at least 40 pushups straight (7)

Being able to stand on one leg (eyes open) for at least 20 seconds (8)

Being able to run a mile in at least 8 minutes (9)

A Timed Up and Go (or TUG) time > 12 seconds (10)

For most people who are healthy, 2-4 days a week of some well designed strength training and a bit of cardiovascular exercise (or playing some kind of recreational sport) along with some NEPA (non exercise physical activity such as moving at work), should have the desired effect without being burdensome or counterproductive to health.

Wrapping up

I hope this article provided some useful food for thought on making the distinction between optimal health and optimal athletic performance. As always - thanks for reading.

If you're interested in learning more about effective exercise for clinical and athletic populations, checking out the Physio Network Masterclasses:

Don't forget to share this blog!

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Strength and Conditioning in Physiotherapy - How Much is Enough - Physio Network

# data[].attributes.attachment_link.description
Note: This is an updated version of an article I did for my own blog in 2018. As a physio, strength coach and semi-retired powerlifter who has worked with and learned from people who have squatted over a thousand pounds to people who can barely get out of their own chair, it got me thinking: "for the regular person who's not a competitive athlete and just wants to look good, feel good, and be healthy, how much strength is enough?

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Rehabilitation of athletic injuries with the goal of returning to sport requires progressive exercise prescription. This Masterclass explores the principles and commonalities across sports rehab while providing a structured approach to prescribing and progressing exercise.

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Exercise Prescription in Sports Rehab - Physio Network

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Access all classes Start free trial With Dr Teddy Willsey 2 hours 5 modules Rehabilitation of athletic injuries with the goal of returning to sport requires progressive exercise prescription. This Masterclass explores the principles and commonalities across sports rehab while providing a structured approach to prescribing and progressing exercise.

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​Eating and sleeping routines change during the holy month of Ramadan unlike any other month. The thirty-day period is the perfect opportunity for anyone who is trying to lose weight through healthy diet and exercise. Some people may create an exercise planner in advance while fasting, as some prefer to work out before Iftar, and others after.

Research has shown that fasting for 30 consecutive days without performing any physical exercise or activity reduces strength and physical fitness. Muslims have to remain active in the month of Ramadan to stay healthy.

This year, Ramadan occurs during summer. High temperatures should be taken into account when performing physical activity.
A few questions come to mind when fasting and are as follows:

When is the best time for a fasting person to work out - before or after Iftar?

1. Before Iftar
Precautions should be taken and proper guidelines followed when working out before Iftar. Exercising just before Iftar should be limited and for no longer than 60 minutes, preferably in an air-conditioned location. After you break the fast, drink sufficient amounts of fluids and water to replenish salts and minerals lost by the body, and have a good rest.

2. After Iftar
It is advisable to perform physical activity three hours after you break the fast as by then the body has completed the digestion process, and preferably in an air-conditioned location.

Tips and guidelines for exercising during Ramadan

Perform physical activity for 30 minutes at least every day in an air-conditioned location.

Avoid aggressive and high-intensity exercise during daytime and especially in hot weather. Hot days increase body fluid loss which could lead to dehydration.

Choose a convenient time to work out during Ramadan, either just before Iftar or two to three hours after Iftar. Avoid physical activity immediately after you break your fast as all of the body's energy will be directed towards digestion of food.

Individuals should consult with their physician before starting any physical activity if they are unsure of their health.

Reduce physical inactivity, such as sitting in front of the television for extended periods of time, and organize instead family activities such as going for a walk or performing household chores.

Stop any physical activity immediately if you experience dizziness, nausea, difficulty breathing or chest pain.

Drink sufficient quantities of water between Iftar and Suhour to avoid dehydration during fasting.

Hind Rustom Baqer, Health Counselling Expert
Health Education Programs
Ministry of Public Health

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​Eating and sleeping routines change during the holy month of Ramadan unlike any other month. The thirty-day period is the perfect opportunity for anyone who is trying to lose weight through healthy diet and exercise. Some people may create an exercise planner in advance while fasting, as some prefer to work out before Iftar, and others after.

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twitter threads for rehab? They can really help!

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twitter threads for rehab? They can really help!

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If you’ve been following along with the rehab of the athlete post-LET procedure, here are some of the exercises from her past couple weeks of programming. I’m progressing the program this week, so here’s a look back: 1/

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If you’ve been following along with the rehab of the athlete post-LET procedure, here are some of the exercises from her past couple weeks of programming. I’m progressing the program this week, so here’s a look back: 1/

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If you’ve been following along with the rehab of the athlete post-LET procedure, here are some of the exercises from her past couple weeks of programming. I’m progressing the program this week, so here’s a look back: 1/

# data[].attributes.attachment_link.metadata.attachment_props.original_text
If you’ve been following along with the rehab of the athlete post-LET procedure, here are some of the exercises from her past couple weeks of programming. I’m progressing the program this week, so here’s a look back: 1/

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If you’ve been following along with the rehab of the athlete post-LET procedure, here are some of the exercises from her past couple weeks of programming. I’m progressing the program this week, so here’s a look back: 1/

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How Should I Warm Up? RAMP Protocol Explained | CSCS Chapter 14

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Sample movement screening protocol (Volleyball)

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Sample movement screening protocol (Volleyball)

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Do you have shoulder pain and are progressively losing your range of motion or ability to reach, lift, or generally use your arm? You may be experiencing adhesive capsulitis, better known as frozen shoulder!

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Calf Injury Exercises (Complete Protocol)

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Risk reduction program with videos in the Remain in the Game series

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Risk reduction program with videos in the Remain in the Game series

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Lumbar strength and stretching exercises

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Lumbar strength and stretching exercises

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Football Australia Perform+ (updated version of FIFA 11+ program ^hip/groin)

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Football Australia Perform+ (updated version of FIFA 11+ program ^hip/groin)

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[1] Bizzini M, Dvorak J. FIFA 11+: an effective program to prevent football injuries in various player groups worldwide-a narrative review. Br J Sports Med 2015;49(9):577-579.

[2] Whalan M, Lovell R, Thorborg K, Sampson JA. The 11+ of the future: a primary injury prevention framework for sub-elite football. Br J Sports Med Online First: 15 October 2020. Doi: 10.1136/bjsports-2020-102788.

[3] Thorborg K, Krommes KK, Esteve E et al. Effect of specific exercise-based football injury prevention programs on the overall injury rate in football: a systematic review and meta-analysis of the FIFA 11 and 11+ programs. Br J Sports Med 2017;51(7):562-571.

[4] Whalan M, Lovell R, Steele JR, Sampson JA. Rescheduling Part 2 of the 11+ reduces injury burden and increases compliance in semi-professional football Scand J Sci Med Sport 2019;29(12):1941-1951.

[5] Bizzini M, Impellizzeri FM, Dvorak J et al. Physiological and performance responses to the "FIFA 11+" (part 1): is it an appropriate warm-up? J Sports Sci 2013;31(13):1481-1490.

[6] Impellizzeri FM, Bizzini M, Dvorak J et al, Physiological and performance responses to the FIFA 11+ (part 2): a randomised controlled trial on the training effects. J Sports Sci 2013;31(13):1491-1502.

[7] Veith S, Whalan M, Williams S et al. Part 2 of the 11+ as an effective home-based exercise programme in elite academy football (soccer) players: a randomised control trial Science and Medicine in Football 2020 under review

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1] Bizzini M, Dvorak J. FIFA 11+: an effective program to prevent football injuries in various player groups worldwide-a narrative review. Br J Sports Med 2015;49(9):577-579. [2] Whalan M, Lovell R, Thorborg K, Sampson JA. The 11+ of the future: a primary injury prevention framework for sub-elite football.