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ISSUE 3 l June 2013

BULLETIN FEATURE TOPIC: The Female Athlete www.spnz.org.nz SPNZ EXECUTIVE COMMITTEE President

Dr Angela Cadogan

Secretary

Michael Borich

Treasurer

Dr Gisela Sole

Website & IT

Hamish Ashton

Committee

Dr Tony Schneiders Bharat Sukha Jim Webb David Rice

EDUCATION SUB-COMMITTEE Chelsea Lane David Rice Jim Webb

Dr Grant Mawston Dr Gisela Sole

EDITORIAL ASSISTANT Aveny Moore

SPECIAL PROJECTS Monique Baigent

Karen Carmichael

Deborah Nelson

Kate Polson

Amanda O’Reilly

Charlotte Raynor

Welcome to the June 2013 Edition In this Edition: EDITORIAL: Fair Play In Sport – An Ethical Minefield for Sports Physiotherapists By Dr Angela Cadogan

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LATEST NEWS

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THE ACC GUIDELINES ON THE SIDELINE TREATMENT OF ACUTE INJURY - WHAT YOU SHOULD KNOW

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FEATURE: Sarah Cowley: Physiotherapist and Elite Athlete - A View From the Other Side of the Treatment Table

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CLINICAL SECTION Article Review: The Female Athlete Triad: Patients Do Best with a Team Approach

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RESEARCH SECTION

Advertising terms & conditions click here.

SPNZ Research Reviews: Stress Fractures, Optimising Adherence, Possible Predictors of Injury in the Female Athlete

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LINKS

JOSPT: Volume 43, No. 6, 2013

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ADVERTISING

Sports Physiotherapy NZ List of Open Access Journals

IJSPT: Volume 8, No. 3 2013 Health Research Reviews

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Sports Health - A Multidisciplinary Approach: Volume 5, No. 3 May/June 2013

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IFSPT

ASICS

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JOSPT

Shoe Report: Kayano 19

Asics Apparel and order form McGraw-Hill Books and order form Asics Education Fund information

CONTACT US Michael Borich (Secretary) 26 Vine St, St Marys Bay Auckland mborich@ihug.co.nz

CONTINUING EDUCATION CALENDAR

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CLASSIFIEDS

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EDITORIAL Fair Fair Play In Sport – An Ethical Minefield for Sports Physiotherapists By Dr Angela Cadogan

The issue of “Fair Play” in sport has recently been highlighted in several high-profile sports and sporting competitions in which world anti-doping standards and corruption by players, umpires and officials has been highlighted in the media. As individuals, teams and sporting organisations strive to obtain the competitive edge necessary for sporting success, methods of enhancing player’s physical abilities, influencing on-field performance for the purposes of financial gain or altering the outcome of a match and breaking the rules of the game for competitive advantage are becoming increasingly common in sport. As physiotherapists, it is easy to believe you are ‘removed’ or not affiliated with breaches of ‘fair play’ in sport, particularly at the more social and recreational levels. But ‘cheating’ takes many forms, and remaining detached from the issue is not as easy as it may first seem. Sport NZ (previously SPARC) defines fair play as abiding by the principles of ‘integrity, fairness and respect.’ It is by these principles that the spirit of competition thrives. This spirit requires: 1. Honesty in the contest 2. Politeness between all participants 3. An acceptance in good spirit of the result. The difference between ‘fair-play’ and ‘cheating’ is a matter of philosophical debate. However, generally ‘fair-play’ is considered the standard to which sports people of all ages and levels of sport, are held. Breaches of the ‘fair-play’ spirit may take many forms, including lack of respect for the opposition and not accepting the result in ‘good spirit’ (‘bad losers’), but it is the lack of honesty-in-contest (or cheating) with which sports physiotherapists may bear witness to, or may be pressured to become directly involved with in the pursuit of sporting success. Let us first take a look at some forms of ‘cheating’ in sport, then discuss the ramifications for sports physiotherapists. Performance Enhancement. There are many recent examples at elite levels of sport where ‘performance enhancement’ has hit the headlines in the form of utilisation of banned substances, or doping methods. None would be more high profile than Lance Armstrong’s admission in January this year that he had been “cheating” (doping and taking banned substances) for the last decade, and owed all seven of his Tour de France titles and the millions of dollars in endorsements that followed to his use of illicit performance-enhancing drugs. In October 2012, the U.S. Anti-Doping Agency (USADA) issued a report in which 11 former Armstrong teammates exposed the system with which they and Armstrong received drugs with the knowledge of their coaches and help of team physicians. The USADA reported that the U.S. Postal Service Cycling Team ran the most sophisticated, professionalized and successful doping program that sport has ever seen. Closer to home, the Australian sporting landscape was rocked in February this year after the Australian Crime Commission released the findings of a year-long investigation that alleged widespread drug use by elite athletes and links with organised crime. A prominent sports scientist was accused (and later admitted) administering peptides to NRL players while working with the Cronulla Sharks team in 2011. There is also an allegation that Sharks players were given the widely used blood-thinning agent warfarin to promote anaerobic capacity. The move is reported to have backfired when several warfarin users suffered mysterious bruising that sounded alarm bells through the club's medical staff. Upon release of the Australian Crime Commissions’ report, the Cronulla board sacked football general manager, head trainer Mark Noakes, physiotherapist Konrad Schulz and long-serving medico, team doctor Dave Givney although the extent of their involvement in the controversy was unclear. Subsequently multiple athletes from a number of clubs in the professional football leagues, including Australian Rules Football were suspected of using or having used performance enhancing substances including peptides, hormones and illicit drugs. The sacking of team medical staff highlights the complex issue of what constitutes complicity in an act. The issue was reignited a short time later by reports of the tragic death of Jon Mannah, a former Cronulla Sharks player, who died from Hodgkins lymphoma in January this year, aged 23 years. Mannah had previously recovered from lymphoma in 2009, and some questioned whether the relapse of lymphoma was related to peptide use as part of a supplements programme while at the Cronulla Sharks in 2011.

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EDITORIAL

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Fair Play In Sport – An Ethical Minefield for Sports Physiotherapists cont’d... CONTINUED FROM PREVIOUS PAGE. And who can forget the 2012 Summer Olympic Games, where Nadzeya Ostapchuk (a former world champion) was awarded the gold medal for women’s shot put, despite testing positive for steroids both before and after winning the event. The gold medal was subsequently awarded to New Zealand’s Valerie Adams.

Nadzeya Ostapchuk. Corruption In Sport In the murky world of Indian cricket administration, what appears to be widespread corruption threatens the future of one of the world’s largest annual sporting events, the Indian Premier League (IPL). Match-fixing, spot-fixing, match betting by officials and taking of illegal payments all threaten the credibility of the event and some prominent individuals involved with it. The corruption has already seen sponsors starting to shy away from the IPL competition, taking their millions of (American) dollars of sponsorship money elsewhere. Three weeks ago, in the midst of the 2013 IPL competition, Delhi police arrested three Rajasthan Royals players for spot-fixing. Eleven bookies were also arrested at that time, including a former Royals player. A Pakistani umpire, Asad Rauf (one of the International Cricket Council’s (ICC) elite panel of umpires), has also been stood down by the ICC amid accusations of spot-fixing and has been withdrawn from the Champions Trophy being held in England next month. The Indian media alleged Rauf was in contact with Bollywood actor Vindu Dara Singh, arrested on charges of acting as middleman between bookies, players and officials. Rauf is the second Pakistani umpire to be investigated for fixing after another ex-international panel umpire was banned for four years in April following a sting operation by an Indian news channel which showed him agreeing to fix matches. Pakistan has a history of match-fixing controversies. Three of their players—Salman Butt, Mohammad Asif and Mohammad Aamer—were banned and jailed in a spot-fixing scandal in 2010. Former captain Salim Malik and paceman Ataur Rehman were banned for life and six top players including Wasim Akram, Waqar Younis, Inzamam-ul Haq, Mushtaq Ahmed and Saeed Anwar were fined in a match-fixing inquiry in 2000. Whether sports medicine personnel working in these environments have been offered money to influence selections based upon player availability due to injury is unknown, but the potential is certainly there.

Intentional Rule-Breaking Those of you who attended the 2012 SPNZ Symposium in Tauranga may recall Dr Lynley Anderson (Bioethics Department, University of Otago) talking about the “Bloodgate” incident. In 2009, The Harlequins rugby union team were facing off in a Heineken Cup quarter-final game against Irish team Leinster, who were expected to make it to the finals. Steph Brennan, Australian-trained Harlequins physiotherapist, subsequently admitted bringing on a fake blood capsule for Tom Williams (one of the players) to use during the game to enable a tactical substitution allowing CONTINUED ON NEXT PAGE.


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EDITORIAL

Fair Play In Sport – An Ethical Minefield for Sports Physiotherapists cont’d... CONTINUED FROM PREVIOUS PAGE. Nick Evans, a New Zealand player and more accurate goal-kicker who had been previously injured in the game, to re -enter the game. Brennan later said it was the fifth time he had used blood capsules, starting in the 2005-06 season. Three of the occasions were to get players with suspected concussion off the pitch. Former Harlequins' doctor, Wendy Chapman, also admitted to a General Medical Council disciplinary panel that she had acceded to request from Williams to cut his mouth after the match to fool suspicious match officials. Afterwards, Brennan also took an active role in drafting false witness statements regarding the event.

Harlequins physiotherapist, Steph Brennan, assisting Tom Williams from the field after using a blood capsule. Brennan had been due to start work with the England Rugby Football Union in September 2009 as an England physiotherapist until his role in Bloodgate was exposed. He was banned from rugby for two years and the Health Professionals Council (HPC) disbarred him from practising. He subsequently won a High Court battle to overturn the decision to strike him off for his part in the ‘Bloodgate’ controversy, however he continues to work under a 5-year caution period. In addition, the Harlequins club was fined £260,000, the Director of football (Dean Richards) was banned for 3 years, the Club Chairman resigned and the Club Doctor (Chapman) was initially suspended, but has subsequently been re-instated by the General Medical Council with a similar 5 year statement on her Registration. While this took cheating in sport to a new level and directly involved sports medicine personnel in the deceit, there are many forms of ‘cheating’ that involve intentional breaking of the rules to gain an unfair advantage in a competitive situation. Those of us who are old enough will remember one of the most famous instances of cheating occurred during the 1986 FIFA World Cup quarter-final, when Diego Maradona used his hand to punch the ball into the goal of England goalkeeper Peter Shilton. Another example of this, more recently was Luis Suarez's handball during the quarter finals of the 2010 FIFA World Cup when in the dying seconds he punched the ball off the line, preventing a clear Ghana goal. And in cricket, who could forget the infamous “underarm bowling” incident of 1981, which may technically have been within the rules of the game, but does that make it “fair play”? While these forms of cheating are, in many cases, overt and generally penalised by referees or umpires in accordance with the rules of the game, many are not so clear and represent a clear intention to deceive. This is not only a problem in elite sport. The temptation to cheat in sport is driven by the desire to win, and starts at an early age. Its moral acceptance in children may subsequently be reinforced by the behaviours of ‘role model’ athletes. A recent British survey revealed that two of every three children aged 8 to 16 years had ‘cheated’ in school sports because they feel under pressure to win. In addition, 75% believed their team-mates would cheat if they felt they could get away with it. A separate survey of parents showed that nearly two-thirds (65 per cent) believed cheating by high-profile sportsmen and women had led their offspring to believe it was acceptable for them to follow suit. CONTINUED ON NEXT PAGE.


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EDITORIAL

Fair Play In Sport – An Ethical Minefield for Sports Physiotherapists cont’d... CONTINUED FROM PREVIOUS PAGE. Most cheating at this level involved professional fouls, time wasting and ‘diving’, however other forms of cheating include faking birth certificates in age-group sports, genealogy for national team representation, faking injury or exaggerating injury severity to enable a tactical substitution and equipment modifications (ball tampering in cricket, yachting hulls, baseball cork-bats etc). Fair Play and the Sports Physiotherapist. At all levels of sport, there is pressure in varying degrees and there is always a strong desire to win. Athletes, individuals, teams and sporting organisations will push the rules of the game to the limit in pursuit of sporting (and often financial) success, whether it is in a high school rugby ‘grudge match’, or an international test match. As physiotherapists we may be knowingly or unknowingly be party to ‘cheating’ (the intentional breaking of rules to gain a competitive advantage) in the pursuit of others towards this goal. We are intimately entwined in team management and organisational structures, and are often privy to individual players and athletes private conversations meaning we may become aware of ‘cheating’ despite our lack of direct involvement in it, or our own benefit from it. Where does this leave us? Where a physiotherapist knowingly participates in ‘cheating’, the answer is clear, and the experience of Steph Brennan highlights the uncompromising penalties those involved in ‘cheating’ rightly face. Since the HPC initially struck Steph off, there has been hot debate among physiotherapists as to whether striking off was the correct action for the HPC to take or whether it was excessive. Some have taken the view that Steph failed to maintain the "high standards of personal conduct" which form a part of the HPC's regulations and that he therefore deserves all he gets. Others feel that Steph clearly made a stupid mistake to put Harlequins before his profession and his morals, but that the public (whom the HPC exists to protect) was not better served by banning this man from practising. He has also shown very public remorse and has clearly been reflecting on his actions, having undertaken a series of lectures to physiotherapy students on the importance of medical ethics. What about the other situations I have discussed in this article? The Australian Rugby League drug scandal, the Tour de France, individual Olympic athletes, spot- and match-fixing and betting in the IPL. Physiotherapists are immersed in these environments and it is highly likely that, even if not directly involved, physiotherapists will at some point become aware of behaviours or practices that breach the spirit of ‘fair-play’. What moral, ethical or professional obligation do they have to disclose such breaches and where do they go with this information? Steph Brennan says that, at the end of the 2007‑08 season, when the club held a review of the Heineken Cup campaign, he had given a presentation and said that he and the other physiotherapists had strong reservations about the fake blood substitutions, protesting that they were being compromised as health professionals. He said he did not get a satisfactory response and told the subsequent hearing that he wished he had stood up to the club's former director of rugby, Dean Richards, who is serving a three-year suspension for his part in the fake blood plot, but feared losing his job. "I regret it every day," he said. "I followed orders and went on the pitch to deceive the referee and wish I hadn't. I felt sick and wanted us to lose. It was stupid and dodgy. I was so ashamed I couldn't face the fans." Professional Standards in Sports Physiotherapy in New Zealand In an effort to answer some of these questions and provide clarity regarding the standards of professional behaviour expected of sports physiotherapists in New Zealand, SPNZ have been working with Dr Lynley Anderson to develop a Sports Physiotherapy Code of Conduct to address this, and many other ethical issues facing sports physiotherapists. We will shortly be sending a draft of the Sports Physiotherapy Code of Conduct to members for consultation. In the draft document, it is clearly stated that Sports Physiotherapists: 1. Will be aware of current anti-doping policies and banned substances, and will not engage in any activity that encourages or enables the use or administration of any prohibited substance. 2. Will not knowingly be involved in instigating or being party to cheating for sporting gain.

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EDITORIAL

Fair Play In Sport – An Ethical Minefield for Sports Physiotherapists cont’d... CONTINUED FROM PREVIOUS PAGE. When finalised, this document will be used by the public, athletes and sporting organisations as the standard that physiotherapists in New Zealand are expected to uphold. In upholding the standards of ‘fair play’, refusal to participate in or exposing ‘cheating’ behaviours or practices is not without personal risk that may include loss of their job, reducing the chances of working in similar positions in the future, and is likely to have wider ramifications for potentially high-profile athletes, other support staff, officials and sporting organisations. If nothing else, I hope this article may prompt many physiotherapists to consider ways in which they may be asked, or pressured into tasks or practices that breach standards of fair play in sport. In my days on the club rugby sideline I recall several instances where I was asked to be party to ‘cheating’ behaviour, and in the heat of the competition it is not an easy situation to deal with, particularly as a young and inexperienced physiotherapist. However we are now closer to formalised standards in the form of the Sports Physiotherapy Code of Conduct, that we hope will give physiotherapists in these situations more confidence to refuse to participate in such actions knowing they have the backing of documented professional standards. I will end with a final word from Steph Brennan, who feels that his case has highlighted not just the pressure that is faced by physiotherapists working in elite/professional sport but also the importance of withstanding that pressure and keeping a cool head under fire: "I want the profession, and most importantly sports physiotherapists, to learn from my mistakes. Sports physiotherapy is a very different role for the physiotherapist than any other job in public or private health, but that should not mean we forget our standards of ethics and practice."

Sports physiotherapy is a very different role for the physiotherapist than any other job in public or private health, but that should not mean we forget our standards of ethics and practice."


LATEST NEWS

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Tribute to Robin McKenzie Robin McKenzie passed away on May 13th 2013. The physiotherapy profession worldwide has lost one of its most respected and influential members. Few physiotherapists in the history of the profession have influenced clinical practice more than Robin McKenzie. Robin developed the Mechanical Diagnosis and Therapy approach to spinal pain and became an international expert in the management of spinal conditions, and has left the legacy of the McKenzie Institute International, a not-for-profit organisation that continues to teach the MDT approach throughout the world, helping thousands of patients recover from spinal and peripheral pain. His expertise and enthusiasm was far-reaching, and Robin was awarded honorary life membership of many physiotherapy and orthopaedic manual therapy organisations around the world. In the 1990 Queen's Birthday Honours he was made an Officer of the Most Excellent Order of the British Empire, and in the 2000 New Year’s Honour, he was awarded a Companion of New Zealand Order of Merit. We mourn the loss of one of physiotherapy’s true legends, and the thoughts of SPNZ members are with his family at this time.

SPNZ Educational Courses SPNZ Level 1 Courses continue. The Promotion and Prescription of Physical Activity and Exercise Course is being held on June 22nd and 23rd at AUT University in Auckland. Only 20 places available – register early. SPNZ members receive early notification and a discount on course fees for all SPNZ Courses. Go to the SPNZ Courses/CPD section of our website for the Course Programme and Registration form. Instructions on how to register can be found at the end of the Registration form. The Sideline Management course will be run in the South Island and will be advertised shortly to SPNZ members.

Sports Physiotherapy Code of Conduct The Sports Physiotherapy Code of Conduct is in its final stages. SPNZ members will shortly receive a draft copy of this document as the consultation process begins. Dr Lynley Anderson is finalising the Sports Physiotherapy Code of Conduct prior to consultation with interested parties. SPNZ will be consulting with our members first, followed by wider consultation with other national and international physiotherapy and medical organisations, as well as with sporting organisations and other end-users of sports physiotherapy services. We hope to have completed consultation and to disseminate the final document by the end of this year.

ACC Regulations Regarding Claims for Sideline Sports Injuries Dr Tony Schneiders (SPNZ) and ACC have been working together to clarify the rules and regulations around claiming for physiotherapy services provided for sideline sports injuries. SPNZ were prompted to look into this following an ACC investigation of a physiotherapist’s claims for services provided at a sports event in 2012. The article highlights the need for ALL physiotherapists to be aware of their practice’s EPN contract terms, especially if you are working as an employee or independent contractor for the practice principal/contract holder. We urge ALL physiotherapists who work with sports teams, at sports venues or at sports events to read the article later in this Bulletin.

SPNZ Website Upgrade and Public Resources The 'find a sports physiotherapist' is now live on our website. It is split into regions for easy searching and lists can be altered to be searched by first name, last name, town and key sport. This feature has been designed to allow you as Members of SPNZ to promote yourself to your colleagues and the public. For those who have not viewed it click here to access it. As we develop more public information we will start promoting the website to the public, funders and other interested parties. If you haven't sent me your details they can be added by filling out the form here As mentioned this is for you to promote your interests and expertise and not that of your clinic so please fill the form out as clearly as possible.

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LATEST NEWS

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SPNZ Member Benefits Remember to take advantage of the full range of SPNZ member benefits: 

FREE online access to JOSPT (value approx USD$275)

FREE Editions of the Quarterly APA “Sports Physio” Magazine

25% Discount on all McGraw-Hill book publications

Discount on ASICS shoes and clothing

Funding Support for continuing education and research (Asics Education Fund).

Substantial discount, Advanced Notice and preferential placing on SPNZ Educational Courses

Access to website with clinical and relevant articles

Sports Physiotherapy Forum to discuss ideas and ask questions

Bi-monthly SPNZ Bulletin featuring Activity, Course and information updates

FREE classified advertising in the SPNZ Bulletin

International Journal of Sports Physical Therapy - Individual Subscriptions Available The IJSPT journal is available to purchase for individual members. SPNZ members interested in subscribing to this journal can purchase an individual subscription through the journal directly. To purchase a subscription go to the IJSPT website, and click on “subscriptions”. Subscription rate for 2013: 

Individual

$60 (USD)

Student

$35 (USD)

SPNZ is now on Facebook

Check us out at:

www.facebook.com/SportsPhysiotherapyNZ Website Gems Links to Video Clips Online interviews of interest


LATEST NEWS

First Announcement 3rd SPNZ Symposium Rotorua 15-16 March 2014 Exercise and Activity Through the Ages

Key Note Speaker: Professor Craig Purdam (Australia) Head of Physiotherapy, Australian Institute of Sport Craig Purdam is the Head of Physical Therapies at the Australian Institute of Sport. He has worked as a clinician in elite sport for over 30 years and has been a physiotherapist at five Olympic Games (1984-2000) and a longstanding physiotherapist to the Australian National Men’s Basketball team over that period. He has also had other associations with the Australian national swimming, track and field and rowing teams. He was awarded the Australian Sports medal in 2000 and in 2009 was appointed an adjunct Professor to the University of Canberra. His undergraduate qualification was gained in 1975, a postgraduate diploma in Sports in 1992, a Masters in Sports in 2000. He was awarded specialist status in Sports Physiotherapy through Fellowship of the Australian College of Physiotherapists in 2009. Craig Purdam’s major clinical and research interests are in the fields of tendinopathy, chronic hamstring injury and tissue loading, adaptation and healing mechanisms. He has co-authored around 21 scientific papers on tendinopathy research during the period of 2000-2012.

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The ACC Guidelines on the Sideline Treatment of Acute Injury - What You Should Know As winter sports hits full swing, we provide a timely reminder about the ACC regulations regarding claims for the sideline treatment of acute sporting injury. Dr Tony Schneiders has been working with ACC to try to clarify the rules and regulations around what you can claim for and what you can’t claim for under both regulation fees and ACC (EPN) contracts. DID YOU KNOW?  If you work for an EPN contracted clinic:  You cannot claim for services provided at sports venues or sports events if they are not specified in the contract as the ‘service location’.  Prior approval is required from ACC to provide “off-site” treatments at sports tournaments.  If you breach these conditions, you will be held individually responsible, not the practice principal/ contract holder.  You cannot claim for sports field attendances involving basic “First Aid” icing or strapping.  Full clinical records including assessment and treatment details and ACC outcome measures are required for all sports injuries for which physiotherapy treatment fees are claimed.

All physiotherapists who work with sports individuals, teams or at sporting events or tournaments should read this article and ensure you are familiar with the fee structure under which you operate (regulation or EPN contract fees) and what your responsibilities are with regard to ACC claims.

Sports Physiotherapy New Zealand (SPNZ) received an enquiry last year from a physiotherapist who was working at a major community sports event assessing and treating athletes as part of the medical team for a regional sports injury clinic. The physiotherapist, employed and working under an EPN contracted practice, was providing acute sports injury cover in one specific sporting arena of the main event and on one day saw over 25 injured athletes. The physiotherapist subsequently lodged an ACC 45 form for all patients they had attended to. A short time elapsed before the principle of the practice the physiotherapist was employed at was contacted by ACC. ACC stated that upon audit, it was noted that the physiotherapist had lodged over 25 PT01’s on one given day. The auditor was reported to have commented that it was extraordinary that the physiotherapist could have performed a complete assessment of all patients and that it could not have been physically possible to see that many patients over that time period given the contract they were employed under. The auditor’s argument was that a PT01 under the existing contract would usually take approximately 40min, and that by seeing a minimum of 25 patients, it would require at least 1000 minutes equating to 16 hours solid work. According to the physiotherapist, it was relayed to their employer that this could possibly be considered fraudulent under current guidelines.

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CONTINUED FROM PREVIOUS PAGE. While ACC usually do not directly contact the physiotherapist involved, unless they have a current contract, it is considered best practice by ACC to deal directly with the signatories to the contracts which are usually the practice principals. The physiotherapist concerned contacted members of the SPNZ executive asking for advocacy. The physiotherapist denied knowingly committing fraud, felt that they had spent sufficient time with each athlete to assess, treat and/or refer on for further investigations. The SPNZ executive discussed this case at length and, following some preliminary investigations that revealed the physiotherapist concerned was not a member of SPNZ, it was decided that SPNZ could not advocate for them directly but would investigate the circumstances in a general sense to best inform members of the issues that surrounded this case. EPN Contract When the physiotherapist was questioned further regarding their practice, it was noted that they were billing ACC for the work performed at this sports event through the clinic where they primarily worked. This clinic was operating under an EPN contract which the physiotherapist was aware of. However, what the physiotherapist was not aware of was that the contract for physiotherapy services stated the service location which was the principal’s practice address with clear distinctions on where these could be and also the requirement for seeking permission from the ACC Physiotherapy Programme Manager if these were to change. The standard EPN contract also has exclusions which include service location at “sports venues” without prior approval from ACC. These EPN contractual items are outlined below under their relevant sections: 5. SERVICE LOCATION 5.1 The Vendor will ensure that Physiotherapy Services are provided at the location(s) specified in Part A, clause 2 (“Service Location”). 5.2 The Vendor may provide Physiotherapy Services at the following locations in addition to the Service Location(s) in the following circumstances: (a) Home or domiciliary visits to a Client where the Client is unable to attend a Service Location; (b) The Client’s workplace where a Client is unable to attend a Service Location and there are appropriate facilities at the workplace to provide a consultation. (c) Additional Off-Site services where prior approval has been obtained from the ACC Physiotherapy Programme Manager.

10. EXCLUSIONS 10.1 The following services, without limitation, are not included in the Physiotherapy Services to be provided under this Agreement: (a)

Services included in other contracts for services with ACC including (without limitation), Independence Allowance Assessments, one-off Case Manager requested assessments, Stay at Work Contracts, Independent Medical Assessment Contracts, and Progressive Goal Attainment Programme Contracts, Work Hardening Programme, Hand Therapy Contract, Activity-Focus Programmes, Functional Reactivation Programme, Functional Capacity Evaluation Contract and Employment Maintenance;.

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(b) Provision of services at any location not specified in Part A Clause 2 “Service Location” including sports venues, schools or events (e.g. sporting tournaments) unless prior approval has been given by ACC (refer Part B, clause 5.2 (c) “Service Location”). In this case it is clear that the physiotherapist was in breach of their contractual obligations, albeit unwittingly. The physiotherapist stated that they had joined the clinic after the contract had been awarded and had not been made aware of the document by the principal and while a defence could be mounted based on ignorance; it is likely it was not justifiable or defendable in this case. While this case seems clear cut having reviewed the standard EPN contract, it stands as a lesson to all physiotherapists and especially those working at sports events/teams etc. to be aware of the regulations and contracts they are working under.

Regulation Fees We did however proactively contact ACC on a general point based around the standard Cost of Treatment Regulations to see if there were stipulations in place which limited the ability of physiotherapist’s to treat athletes at sporting events. We contacted the supplier manager at ACC in our region who subsequently conferred with the ACC Corporate Office and responded to our query, which asked “what the situation was for treating athletes outside registered businesses when claiming on regulation fees; e.g. on the sports field/court sideline.” The Supplier Managers response was: “Firstly there is nothing in the Cost of Treatment Regulations that gives guidance to off-site consultations, this being a difference as you've noted between the Regulations and the (EPN) Physiotherapy Contract. While the contract pays a higher rate overall, it does set service parameters. ….. treating athletes on the sideline of a sports field or otherwise away from the practice premises under the Regulations. ACC is unlikely to have an issue providing the physiotherapist: 1.

is appropriately registered

2.

complies with sector standards of their own governing bodies and the HPCA

3.

meets ACC standards (eg: see page 81 of the Treatment Provider Handbook: (http://www.acc.co.nz/forproviders/publications-and-forms/index.htm) with regard to any treatment being for a covered injury;

4.

a. being necessary and appropriate b. given at an appropriate time and place c. of a necessary number d. is within the provider's scope of practice e. that it's not given simply as "first aid". that the provider is required to document the consultation as per normal practice, lodge an ACC45 claim form, evaluate treatment outcomes using outcome measures; and use the ACC32 where applicable.

First Aid “Regarding the "first aid" comment, we've had instances where ACC has been invoiced for basic icing and/or strapping - which we don't pay for. The provider would still need to document the consult as per normal practice, lodge ACC45 claim forms, evaluate treatment outcomes using outcome measures, use the ACC32 where applicable, etc.” Members of the SPNZ executive discussed this response and concluded that this of course does raise some very important questions that do need further discussion and debate by the profession and particularly SPNZ members in conjunction with ACC to further determine future clarity. These include, but are not limited to: 1.

What constitutes “basic first aid” and could physiotherapists be reimbursed for applying it, if it resulted in decreased morbidity and positive rehabilitation outcomes for patients? CONTINUED ON NEXT PAGE.


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2.

Ice (as an example) is commonly used in a clinical setting as a treatment modality with efficacious outcomes in decreasing pain, muscle spasm, secondary hypoxic injury, etc. Is the type of application the issue here (e.g. ice bag vs ice massage vs cryokinetics?), the environment, or the modality itself.

3.

Strapping is an acceptable component of acute injury management, prevention, and rehabilitation. Should this be further considered for funding under ACC legislation?

4.

If the decision to exclude the reimbursement of these ‘basic first aid� treatment modalities is only based on the environment (sideline) in which they are applied does that contravene the ACC Act which promotes the optimum recovery and rehabilitation of injured New Zealanders?

While we believe we understand where this approach from ACC might have historically come from; anecdotally due to the occasional opportunistic physiotherapist triaging and servicing entire teams of athletes inappropriately and seeking reimbursement through ACC; should all subsequent physiotherapy encounters with athletes in a sporting environment be treated in the same light? The SPNZ Executive were of the opinion that for a treatment to be compensable with ACC that it demonstrates; a clear association with clinical assessment and reasoning, adequate diagnostic procedures as appropriate, and that clear measurable outcomes are established prior to the application of specific modalities that result in efficient and effective outcomes for injured patients. We would like to hear from members who would like to explore this issue further with the possible intent of setting up an informal working party with the focus to further discuss these issues with the wider profession and ACC to move towards a common set of requirements that need to be outlined in order for the athlete (patient) to receive the best possible care and expedite their recovery from injury. We look forward to your consideration and interest in being involved in this process and working with ACC in productive mode in the future. Ka kite ano Tony Schneiders PT PhD

This information in this article regarding the ACC Regulations was read and approved by Vaughn Cross, ACC Supplier Manager.


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FEATURE SARAH COWLEY: PHYSIOTHERAPIST AND ELITE ATHLETE A VIEW FROM THE OTHER SIDE OF THE TREATMENT TABLE Sarah Cowley graduated from AUT in 2006 with a BHSc (Physiotherapy).

Physiotherapy background: Following physio school she worked at a Musculoskeletal Clinic in Auckland which had a sports focus. She lived for a year in Christchurch and was based at QE2 Stadium in a busy multidisciplinary clinic which again saw a number of athletes and weekend warriors. Athletic background: At the moment Sarah is a full time athlete (high jump), mixed in with a bit of part-time study ď Š She has won a number of New Zealand titles over the years as a multi eventer and in individual events. Her biggest achievement was competing at the 2012 London Olympics. In the event she qualified for the Olympics in, she set the New Zealand second best all time heptathlon score (6135points), and high jump (1.91m). She competed at the 2006 Commonwealth Games, 2011+2009+2005 World University Games, 2000 World Junior Championships and 2001 World Youth Championships. Other interests: Track and field, healthy living and spending quality time with family and friends.

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FEATURE

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Sarah Cowley: Physiotherapist and Elite Athlete continued... CONTINUED FROM PREVIOUS PAGE. What are you focusing on at the moment Sarah? Since the Olympics I have switched to concentrate solely on high jump. It took me a while to figure out what I wanted to do following London but I am excited about the change in focus and the” flying” ahead of me. Can you tell us about your experience as an athlete at the 2012 London Olympics? How did it feel being on the other side of the treatment couch? I had high expectations going into the Olympics and they were totally exceeded by the shear size and scale of the event. I had done a lot of work with my sports psych in order to prepare for this feeling of being overwhelmed. My highlight was competing, as that is what I had worked so hard to have the opportunity to do. The heptathlon field was of an extremely high standard and it was rewarding for me as an athlete to be able to compete against the best in the world. Being the Olympics, many of my family and friends realised that all the effort I had put into my sport and realising my dream was justified and worth it. They gained an increased level of understanding about my sport and event which, for me, was really nice. Being on the other side of the treatment couch is something I’ve been very used to as an athlete. I was fortunate to have my physiotherapy team with me on the NZ team in London. They are a crucial part of my team and keeping me in one piece. I knew I was in the best of hands and I certainly made them work hard leading into the heptathlon and throughout my two days competing.

From an athlete’s perspective but with your physiotherapist’s hat on too, what do you think are the key elements in a successful athlete/physiotherapist relationship at the elite level? As an individual athlete you are part of a team and your physiotherapist has a big part to play in this make-up. Understanding athlete’s loads in training and specific technique in field events is really important. If you don’t know what your athlete is doing then how can you best serve them? I trust my medical team to take care of the details and they trust me to tick the boxes too in looking after my body. Communication is essential, as well as knowing when to talk and when not to… In a high pressure environment like the Olympics, words matter – so think first before saying. Just being able to have a laugh with your physio and having the physio table as a safe environment is a blessing. 

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FEATURE

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Sarah Cowley: Physiotherapist and Elite Athlete continued... CONTINUED FROM PREVIOUS PAGE. What have been the most important strategies for you in terms of: Preventing injury….recovery is essential and should be counted like another session. You wouldn’t skip a session so do it properly and avoid shortcuts. Be smart about when to continue – something easier for me to say then do! Keeping a detailed training diary with training loads and how my body is/has been feeling is really important in my monitoring. Optimising performance…nutrition, body composition, mental fitness along with precise planning and an uncompromised commitment to getting the best out of my body and mind. Recovering from competition and injury…recovery procedures –simple RICE has been a mainstay for me, massage, lots of stretching, rest (actually doing nothing!), and a big dose of patience is necessary. Who else should be involved in an athlete’s support team? Coach, sports doc, massage therapist, nutritionist, physiologist, bio-mechanist and sports psych. What are the types of injuries you commonly see in elite female athletes? In my sport the common injuries in elite female athletes are tendon injuries and stress fractures. Both involve loading issues and close monitoring, as we know if not managed successfully can develop into something much bigger. Soft tissue injuries are common in particular as an athlete is nearing a peak as high intensity/low load training sessions are more frequent. As a female athlete you walk a fine line in pushing your limits and your health. I would say over-training is an injury as well. It’s a dark hole to get out of so again daily monitoring of energy levels and training performance is essential. Do you think there are any issues specific to the “female athlete” that physiotherapists should pay particular attention to?  Hormonal patterns and how the athlete is within their cycle.  Nutrition - is the female athlete fuelling themselves sufficiently to meet their training load and with the right fuels?  General fatigue levels and tracking injury patterns. What are the major challenges in working with this sport? Track and field athletes are precious and have a unique level of awareness of their bodies. A track and field athlete will most likely not compete if their body is less than 90% fully fit. So maintaining a high level of body health is essential. Working with coaches and the wider team presents another challenge. A coach needs to know their athlete can still be working very hard if they are injured doing other types of training besides running.


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CLINICAL SECTION ARTICLE REVIEW The Female Athlete Triad: Patients do best with a team approach

Low energy availability, menstrual dysfunction and diminished bone mineral density make up the female athlete triad – a complex disorder that has wide-ranging severity. Major Warr, B. Woolf, K. JAAPA April 2011 24(4) Article Review: This review article outlines the most recent diagnostic criteria, prevalence and presentation components of the female athlete triad. This is followed by a screening tool that is applicable to New Zealand physiotherapy practice and the current evidenced based treatment options for managing this complex disorder. Diagnostic Criteria The female athlete triad was defined in 1997 by the American College of Sports Medicine (ACSM) as the presence of an eating disorder (anorexia or bulimia), amenorrhea and osteoporosis. In 2007 this was expanded to redefining amenorrhea as menstrual dysfunction (amenorrhea or oligomenorrhea) and osteoporosis to a low bone mineral density (BMD). Additionally the diagnosis of anorexia or bulimia was replaced with ‘low energy availability’. Thus the current diagnostic criteria for the female athlete triad is: low energy availability (does not meet her current energy [calorie]) requirements; no longer needing to present with anorexia or bulimia in the presence of diminished bone health and menstrual dysfunction. The ACSM recommend that this is viewed as a continuum rather than consisting of three separate components so as to allow for early diagnosis and intervention before osteoporosis and amenorrhea are presented. Prevalence Because the female athlete triad presents as a continuum, identifying true prevalence can be difficult. However some studies have identified figures as high as 78% of female high school athletes exhibit one or more of the components based on the current diagnostic criteria, especially among sports where weight restrictions or aesthetic presentations are required such as gymnastics and ballet. What is more disturbing and of more importance is that in a recent survey (2006) only 43% of physiotherapists were able to identify all three components of the female athlete triad. Presentation Low energy availability: Optimal energy availability occurs when energy intakes meets energy expenditure. There are three main factors that can influence this: Firstly there are behavioural disorders towards food which are the hallmark of eating disorders. Secondly there is the more discreet energy restriction associated with avoidance of food groups such as meat, dairy or fats. This may be perceived as a healthy practice by the athlete but in fact may decrease the energy intake and availability compared to the training intensity. Thirdly, either consciously or unintentionally the levels of training may be at a high level where the athlete is unable to keep their energy intake equal to the training demands. Any of these scenarios can affect the energy available for musculoskeletal health, growth, thermoregulation and reproduction. Current research is very limited as to the optimal dietary requirements but it may be as high as 45 kilocalories per kilogram of fat free mass per day (kcal/kg/FFM/d) for female athletes. Menstrual dysfunction: Amenorrhea is defined as absence of the menstrual cycle and can be either primary (failure to menstruate in females older than 15 yrs) or secondary presentation (absence of menses for more than 90 days). Oligomenorrhea is the prolonged (>35 days) menstrual cycle which can indicate hormonal irregularities. Absence of menstruation can be due to decreased concentrations of Oestrogen due to low energy availability in the athlete .Energy deficits lead to hypothalamic suppression of gonadotropin-releasing hormone (GnRH). The presence of GnRH is required to stimulate the process of hormonal flow on effect resulting in ovaries producing and releasing Oestrogen. Oestrogen induces ovulation and therefore menses if the egg is not fertilized. Without Oestrogen a state of anovulation occurs and the menstrual cycle ceases. Use of the oral contraceptive pill may result in a regular menstrual cycle but mask the hormonal effects of inadequate energy availability in a female athlete.

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CLINICAL SECTION

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ARTICLE REVIEW CONTINUED... CONTINUED FROM PREVIOUS PAGE. Low bone mineral density: The focus in BMD is not so much assessing for osteoporosis but in emphasizing optimal BMD. Dual-energy absorptiometry (DEXA) is the gold standard in measuring BMD and is reported in T-scores and Z-scores. T-scores are measured against the general population but Z-scores are measured against a population of similar age. It is the ACSM recommendation that DEXA scans in athletes are evaluated using Z-scores with the parameters for athletes being between -1.0 and -2.0 with osteoporosis being diagnosed (in this population) with a Z-score less than -2.0 with risk of fracture. Bone mass is affected by dietary intake, specifically calcium and vitamin D levels which may be inadequate in an athlete with a low energy uptake. Reduced concentrations of Oestrogen also results in increased rate of bone resorption. Oestrogen in bone slows osteoclastic activity but does not inhibit osteoblasts building of bone and increases calcium absorption. Young females are at the age where more bone is being accumulated but with the female athlete triad, bone is being resorbed at detrimental rates with bone resorption increasing in as few as five days following low energy availability. In summary, athletes with dysfunctional menstrual cycle resulting in inadequate Oestrogen stores and low energy availability adversely influencing calcium absorption will lead to suboptimal BMD. Screening ACSM guidelines expect health providers of athletes to be able to screen female athletes to identify those at risk. See Table 1 for screening questions that may assist with the identification of athletes at risk of developing the triad .When one component of the disorder is present the remaining two components should be considered which should include diagnostic studies such as hormone blood levels and DEXA scans. Treatment The ACSM recommends a multidisciplinary approach to managing this complex disorder. Cessation of training is indicated especially where there is an eating disorder associated with weight loss and the presence of stress fractures or bone stress reaction. Eating disorders need to be assessed and managed by dietician and behavioural health specialists. The goal is to establish optimal energy intake with optimal macro and micro nutrient balance without dramatic changes in weight. Historically, use of Oestrogen based oral contraceptive was used to manage irregular periods; however, the current trend is now via improved dietary management to improve energy availability. Even small improvements in energy availability will lead to increased production of GnRH increasing Oestrogen concentrations and improved menses. Dietary supplements of calcium and vitamin D will also assist with bone building. Physiotherapy can address the rehabilitation of injuries such as stress fractures with emphasis being on maintaining range of motion, flexibility of affected joints. Physiotherapists can also provide education and programmes to beneficially assist bone health. This should include resistance training with the article recommending being performed at least 2-3 times a week with the focus being on multi-joint activities before single joint activities performing 1-3 sets of 8-12 repetitions. When an athlete returns to training or is being monitored during intense training as an at risk athlete, the physiotherapist is an integral part of the multi-disciplinary team. Managing athletes under these conditions dictates very close monitoring and a strong team approach to ensure the wellness of the athlete is secure.

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CLINICAL SECTION

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ARTICLE REVIEW CONTINUED... CONTINUED FROM PREVIOUS PAGE. CONCLUSION The female athlete triad is a complex disorder where prevention is the best approach. Physiotherapists need to be vigilant to presentation of key indicators and using a screening tool can assist with diagnosis. Management requires a multi-disciplined team approach who are equipped with adequate knowledge and strong communication skills. Table 1: Screening questions for female athletes What is your usual weight? Do you want to weigh more or less than you do now? What is your ideal body weight? Do you lose weight regularly to meet weight requirements for your sport? Have you ever taken supplements or vitamins to help you gain or lose weight? What is your highest and lowest weight since age 18? How many times has your weight fluctuated by at least 5 lb (2.25kg) in the past year? If you did not consciously control your weight, what do you think it would be? At what age did you have your first period? Do you have regular periods now (intervals of 21-35 days)? Do your periods fluctuate with training? Are you on birth control pills? If so, which ones? How long have you been taking birth control pills for? Are you taking birth control pills for contraception, irregular cycles or cramps? Have you ever been diagnosed with a stress fracture?

Reviewed by Kate Polson MHSc(Hons); Dip Phty, Dip MT, MNZCP; MNZSP


SPNZ RESEARCH REVIEWS

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Stress Fractures, Optimising Adherence, Possible Predictors of Injury in the Female Athlete www.sportsphysiotherapy.org.nz/resources

An Exploration of Athletes’ Views on Their Adherence to Physiotherapy Rehabilitation After Sport Injury Marshall A, Donovan-Hall M, and Ryall S (2012). Journal of Sport Rehabilitation 21:18-25. Article Summary: This is a small retrospective, qualitative study involving 8 participants who were interviewed in a structured process to explore factors that may have an influence on their adherence to a physiotherapy intervention, which was mostly exercise therapy. All the participants were athletic club members who had suffered either a lower limb or low back injury in the last 5 years. They were no longer receiving physiotherapy. Interviews were transcribed and themes were identified. Two sets of themes were identified; factors reflecting the athlete’s own adherence behaviour and perceptions of the physiotherapist’s impact on athlete adherence. The impact of the injury had both psychological and physical components. Stress associated with not being able to compete or train was a big psychological issue. Some other factors associated with decreased adherence were: feeling better, lack of support or direction from the physiotherapist, not remembering or too many exercises, lack of time, exercises that were too complex or not sport specific, boredom with exercises, no noticeable improvement, and a lack of understanding re why doing exercises. Rationale of the treatment was important in compliance and also liaison between the physiotherapist and coach. Physiotherapy factors involved in adherence were supportive, sympathetic, attentive and approachable physiotherapists. Experienced physiotherapists helped, they were perceived as knowing what they were doing and a physiotherapist with an interest in or who played sport, as well as physiotherapist having the approval of the coach. The physiotherapist had to give a clear explanation in a variety of ways, regular treatment was also important for adherence.

Clinical Applications: Clinically quite a lot can be drawn from this study. As physiotherapists we are not able to change adherence factors intrinsic to the athlete, however there are a number of factors that we can address to improve compliance with an exercise regime. Provide a clear explanation, using drawings, diagrams and demonstrations to show the athlete what is going on and why they need to do the exercise programme. Make the programme sport specific, or at least explain how it relates to the sport in question. See the athlete regularly especially in the latter stages of rehabilitation when the pain has decreased and compliance reduces, and as we all know this can be a crucial stage especially in the prevention of recurrence. Write the exercise programme down and give strategies for working the programme into busy schedules. Continually get and give feedback to/from the athlete about how they are perceiving their progress and how they are going, monitor the exercises. Although this was a small study a lot of this information has come out previously in other studies and this study reinforces those points. Reviewed by Karen Carmichael BSc, BPhty, M(SportsPhysio)


SPNZ RESEARCH REVIEWS

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Stress Fractures, Optimising Adherence, Possible Predictors of Injury in the Female Athlete continued www.sportsphysiotherapy.org.nz/resources

The Female Athlete Carol A. Boles, Cristin Ferguson (2010). Radiol Clin N Am 48: 1249-1266 Article Summary: Within sporting communities different injury patterns are seen between female and male competitors, this article reviews the evidence for anatomical and physiological differences contributing to anterior cruciate ligament (ACL) tears, patellofemoral pain, hip pain, stress fractures, back pain and lateral epicondylitis being more common in the female athlete. ACL tears: Females have a higher incidence of non contact ACL ruptures, numerous theories have been proposed and these are discussed though no clear reason has been proven. Some of the theories pertaining to female anatomy, physiology and biomechanics discussed are      

An increased risk of tear relative to ACL size has been demonstrated Narrowed femoral condylar notch have increased likelihood of ACL tear Increased Q angle Hormonal Factors, high levels of Oestrogen Quadriceps dominant landing and cutting techniques, with reduced hip and gluteal activation and decreased flexion at knee and hip Greater maximal ankle eversion

Patellofemoral Pain Syndrome: In the running population it is seen in up to 62% of females and 38% of males. This discrepancy is contributed to anatomical alignment and biomechanical differences in the female form. A larger Q angle, hyperpronation of the foot increases the lateral forces on the patella. Weak isometric hip abduction and external rotation increases the internal rotation of the femur during weight bearing activities leading to patella malalignment. Female Athlete Triad (FAT): The definition was modified in 2007 to describe the disorder as more of a spectrum with the extreme being disordered eating, amenorrhea and osteoporosis. It is still strongly believed that those athletes competing in sports with an aesthetic component are more at risk. Athletes with full blown FAT are fairly uncommon; but even one component increases the risk of morbidity in the young female population. The 3 entities of FAT are interrelated; female athletes with disordered eating including inadequate energy supplies are more than twice as likely to have menstrual irregularities. Menstrual irregularities can affect bone mineral density (BMD). The return to normal menstrual function does not equate to return to normal BMD and with peak bone density being related to that obtained during the adolescence years the young female athlete with reduced bone density is unlikely to regain the loss. A positive correlation has been shown with menstrual dysfunction and stress fractures. This highlights the importance of some form weight bearing activity in the adolescence female, optimising the development of peak bone mass. As a woman ages the role of muscle strength becomes more important in bone health. Muscle strength training has been shown to have a positive effect on bone mass in the post menopausal woman. Awareness of the injury patterns in the female athletic population and the anatomical and physiological theories behind these allows us as physiotherapists to encompass the individual as a whole and provide a holistic approach to treatment.

Reviewed by Deborah Nelson BPhty, PGD Musculoskeletal


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SPNZ RESEARCH REVIEWS Stress Fractures, Optimising Adherence, Possible Predictors of Injury in the Female Athlete continued www.sportsphysiotherapy.org.nz/resources

Stress fractures About the Tibia, Foot, and Ankle Shindle M, Endo Y, Warren R, Lane J, Helfet D, Schwartz E, Ellis S (2012). Stress Fractures About the Tibia, Foot, and Ankle. The Journal of the American Academy of Orthopaedic Surgerons 20:167-176. Article Summary Stress fractures of the tibia, foot and ankle are common in competitive athletes and can lead to considerable delay in return to play. Risk Factors: Intrinsic and extrinsic factors can increase the risk of stress fractures. Intrinsic: Metabolic state, menstrual patterns, level of fitness, muscle endurance, anatomic alignment, microscopic bone structure and bone vascularity. Extrinsic: Training regimen, dietary habits, equipment (footwear, playing surfaces) Stress fractures are more common in poorly vascularised areas of bone, watershed areas lack the ability to respond to stress and heal e.g., fractures of the navicular, fifth metatarsal and anterior tibia. Diagnosis: Usual key subjective and objective features include, an insidious onset of 2-3 week period, often a correlation with change in training habits/equipment. Medical History: Endocrinopathies (diabetes), autoimmune, eating disorders, depression, malabsorption syndromes, bariatric surgery, gastroesophageal reflux disease. Objective Examination: Tenderness over affected bone, percussion of the bone away from the fracture site may produce pain, functional tests such as hopping on 1 foot can illicit pain. Imaging: Plain Radiographs: most useful. Appearance of stress fracture will differ in x-rays depending on whether cortical or cancellous bone is involved and the acuity of the injury. Cortical bone (e.g. metatarsal shaft); Subtle radiolucency or poor definition of the cortex. Later findings show a thickening and sclerosis of the endosteum and periosteal new bone formation. Cancellous bone (e.g. calcaneus); Appears as a band of sclerosis, characteristically orientated perpendicular to the trabeculae. Bone Scan: Good for identifying potential areas of pathology in patients with non-contiguous simultaneous fractures (e.g. 2nd MT and mid shaft of tibia). Sensitive but not specific as a bone scan can also pick up tumors, infections and stress reactions without a fracture. MRI: Highly sensitive for endosteal marrow oedema and periosteal oedema, typically the earliest features of a stress fracture. Ultrasonography: Sensitive in identifying fractures in superficial bones (metatarsals) CT: Rarely indicated but it allows differentiation of complete versus incomplete fractures Non-Surgical Management: In general, rest and immobilisation. Importance of classifying the fracture as low-risk or high-risk. There is a developing interest in effective pharmacologic interventions to either prevent stress fractures or accelerate recovery. Electrotherapy (pulsed ultrasound and extracorporeal shock wave therapy) have also been proposed but with limited clinical studies. High-risk stress fracture sites: Anterior Tibial Diaphysis: Less common but more concerning than posteromedial tibial stress fracture. Management is challenging especially in high performing athletes due to it being under constant tension from posterior muscles, poor vascularity may predispose it to delayed union, non-union or a complete fracture. Surgery involving intramedullary nail or tension band plating have also been explored. CONTINUED ON NEXT PAGE.


SPNZ RESEARCH REVIEWS

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Stress Fractures, Optimising Adherence, Possible Predictors of Injury in the Female Athlete continued www.sportsphysiotherapy.org.nz/resources

Article Summary continued Navicular: Susceptible based on specific vascular and biomechanic properties. Central third of the navicular body identified as a zone of maximum sheer stress. The centre is also devoid of a direct blood supply and has difficulty healing. Both surgical and non-surgical options available. Proximal 5th Metatarsal: Usually occurs just distal to the metaphyseal/diaphyseal junction. Fractures are common in basketball, football and soccer players. Problems can occur due to the poor blood supply. There are both surgical and non-surgical options Great Toe Sesamoids: Can also get stress fractures and common in footballers, runners, golfers and gymnasts. Surgery can be indicated if there is a delayed union, non-union or a re-fracture.

Clinical Applications: Stress fractures occur mostly around the tibia, foot and ankle. Many factors affect these; metabolic state, blood supply, training regimen and foot anatomy (varus/valgus hindfoot; plantarflexed first ray). The location of the injury can help predict the rate of healing and dictate the treatment and management of the fracture. Sports physiotherapists need to be aware of the subjective and objective symptoms of stress fractures and refer the athlete for imaging if it is likely. A multidisciplinary approach will be needed to assist the athlete in returning to sport in the most appropriate time frame. Reviewed by Charlotte Raynor MPhty, BSc(Hons), NZRP, MNZSP


RESEARCH PUBLICATIONS

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JOSPT Volume 43, Number 6, 2013 www.jospt.org

RESEARCH REPORT Risk Factors for Meniscal Tears: A Systematic Review Including Meta-analysis RESEARCH REPORT Relationships Between Biomechanics, Tendon Pathology, and Function in Individuals With Lateral Epicondylosis RESEARCH REPORT Baseline Characteristics of Patients With Nerve-Related Neck and Arm Pain Predict the Likely Response to Neural Tissue Management RESEARCH REPORT Description of a Weight-Bearing Method to Assess Hip Abductor and External Rotator Muscle Performance RESEARCH REPORT Impact of Movement Sequencing on Sciatic and Tibial Nerve Strain and Excursion During the Straight Leg Raise Test in Embalmed Cadavers RESEARCH REPORT Clinimetric Testing Supports the Use of 5 Questionnaires Adapted Into Brazilian Portuguese for Patients With Shoulder Disorders RESEARCH REPORT Lower Mechanical Pressure Pain Thresholds in Female Adolescents With Patellofemoral Pain Syndrome RESEARCH REPORT Enhanced Proprioceptive Acuity at the Knee in the Competitive Athlete MUSCULOSKELETAL IMAGING With Slides Rupture of the Anterior Cruciate Ligament and Bucket Handle Tear of the Medial Meniscus MUSCULOSKELETAL IMAGING With Slides Symptomatic Discoid Medial Meniscus


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RESEARCH PUBLICATIONS

International Journal of Sports Physical Therapy Volume 8, Number 3, 2013 IJSPT June 2013 ORIGINAL RESEARCH Lower extremity functional tests and risk of injury in Division III collegiate athletes. Roller-massager application to the hamstrings increases sit-and reach range of motion within five to ten seconds without performance impairments. The comparison of the empty can and full can techniques and a new diagonal horizontal adduction test for supraspinatus muscle testing using cross-sectional analysis through ultrasonography. Reliability of the Myotonometer® for assessment of posterior shoulder tightness. Early regeneration determines long-term graft site morphology and function after reconstruction of the anterior cruciate ligament with semitendinosus-gracilis autograft: a case series. A survey of exercise-related leg pain in community runners. Effectiveness of the emergency response course in improving student physical therapists and licensed physical therapist decision-making related to acute sports injuries and medical conditions. CASE REPORT Rehabilitation of a partially torn distal triceps tendon after platlet rich plasma injection: a case report All-epiphyseal ACL reconstruction: a three-year follow-up Rehabilitation and functional outcomes after extensive surgical debridement of a knee infected by fusobacterium necrophorum: a case report Treatment of hamstring strain in a collegiate pole-vaulter integrating dry needling with an eccentric training program: a resident’s care report CLINICAL COMMENTARY – DIAGNOSTIC CORNER Cysts of the lateral meniscus CLINICAL SUGGESTION Clinical application of the right side-lying respiratory left adductor pull back exercise.

Health Research Reviews Register (FREE) and download the latest “NZ Research Reviews”

http://researchreview.co.nz SPORTS MEDICINE AND PHYSICAL ACTIVITY

ORTHOPAEDICS AND HEALTH

Diabetes and Obesity

Bone Health

Foot and Ankle

Hip and Knee Surgery

Pharmacy

Mental Health– Behavioural Disorders

Rehabilitation

Pain Management

Sports Medicine Travel Medicine Wound Care


RESEARCH PUBLICATIONS

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SPORTS HEALTH

A Multidisciplinary Approach Volume 5, Number 3 (May/June 2013) Sports Health EDITORIAL Sports Specialization vs Diversification SPORTS PHYSICAL THERAPY Immediate Effects of Lumbopelvic Manipulation and Lateral Gluteal Kinesio Taping on Unilateral Patellofemoral Pain Syndrome: A Pilot Study Patellar Tendinopathy: Preliminary Surgical Results Nonoperative Treatment in Lumbar Spondylolysis and Spondylolisthesis: A Systematic Review ATHLETIC TRAINING Improvements in Shoulder Endurance Following a Baseball-Specific Strengthening Program in High School Baseball Players A Survey Examining the Correlations Between Japanese Little League Baseball Coaches’ Knowledge of and Compliance With Pitch Count Recommendations and Player Elbow Pain Functional Performance Testing for Power and Return to Sports PRIMARY CARE Sports Specialization in Young Athletes: Evidence-Based Recommendations Concussion Management, Education, and Return-to-Play Policies in High Schools: A Survey of Athletic Directors, Athletic Trainers, and Coaches Susceptibility for Depression in Current and Retired Student Athletes ORTHOPAEDIC SURGERY Traumatic Subscapularis Tendon Tear in an Adolescent American Football Player Incidence and Injury Characteristics of Medial Collateral Ligament Injuries in Male Collegiate Ice Hockey Players Traumatic Laryngeal Fracture in a Collegiate Basketball Player Open Patellar Tendon Debridement for Treatment of Recalcitrant Patellar Tendinopathy: Indications, Technique, and Clinical Outcomes After a 2-Year Minimum Follow-up IMAGING Lisfranc Injury in a West Point Cadet Society News


ASICS

Page 27

ASICS REPORT

Kayano continues to be the flagship model in the ASICS struc-

The biggest changes has been a deeper Guidance Line and

tured cushioning range. It's a shoe that is always striving for

the replacement of Space Trussic with a NEW lighter Guidance

the best in comfort, performance and support, with many run-

Trussic. Guidance line is a groove running from heel to toe

ners upgrading to newer models or 2000 series wearers look-

providing less surface tension, making it easier to plantarflex the

ing for a change. The 19th edition has a sleek, eye pleasing

foot and reach propulsion quicker. This assists in moving the foot

upper with noticeable improvements in weight and a smoother

from midstance to propulsion, unloading muscles and improving

transition at propulsion. Additionally, its the lightest Kayano

gait efficiency. The new Guidance Trussic links into the Guidance

ever created.

Line and with improved flex grooves in the forefoot, runner expe-

A lighter shoe requires less effort to move from heel to toe, allowing runners to be more efficient with less fatigue. As runners fatigue impact increases placing load on muscles, ten-

rience at propulsion has never been better. This is a great new addition to an already popular shoe that gets the runner off the ground quicker!

dons and bones. Making a shoe lighter will therefore assist in

It is a known fact that women and men run differently and as a

injury prevention, faster times, and better comfort. Some

result differ in levels of impact and injury. Kayano 19 continues

brands have lowered the heights of the midsoles (soft foam) to

with Solyte Dynamic Duomax (ASICS's best cushioning material

reduce weight. Kayano V19 has shaved 20-30 grams from the

morphed into a flexible shape to adapt to each runner's loading

shoe by maintaining the midsole height s and using intelligent

patterns) with a soft layer on top using different cushioning for

changes to improve wearer comfort and ride without sacrific-

men and woman. This improves comfort and customizes the

ing injury. Keeping the same midsole heights also allows past

shoe for men and women. An additional 3mm of foam (Plus 3) is

Kayano wearers easier adaption with less chance of injury

also placed in the heel of women's shoes to help relieve strain on

when moving to Kayano 19.

the Achilles tendon and improve comfort.

The key changes have been in the upper, a deeper mid-

Kayano 19 is a shoe designed to support the foot and leg as the

sole guidance line, a new Trussic system and a lighter twist

runner fatigues especially during endurance events when the

gel in the forefoot.

strain on muscles, tendons and bone is the greatest. Runners

A lighter clutch heel counter has removed the traditional heavier hard thermoplastic from the heel and replaced it with the flexible clutch counter on the outside of the shoe. This innovative system allows the shoe to adapt to individual differences in the anatomy of the heel and ankle. Being flexible, it also allows the shoe to move with the heel preventing heel irritation at propulsion when the calves are pulling upwards. Combined with PHF (personal heel fit — ASICS's moulded foam in

who spend greater time in midstance are likely to develop shin, knee and Achilles injury. Changes to Kayano 19 have not only reduced weight but made it easier to unload muscles by moving from midstance to propulsion with less muscle expenditure. The net effect is a lighter, more comfortable shoe that helps prevent injury. This is certainly noticeable on the first run. Kayano 19 will not disappoint and will continue to be a "go to" shoe for podiatrists and shoe stores when managing the injured athlete.

the heel) there is significant improvement in all round comfort and weight.

NOVEMBER 2012


CONTINUING EDUCATION CALENDAR

Page 28

Upcoming courses and conferences in New Zealand and overseas in 2013.

For a full list of local courses visit the PNZ Events Calendar

LOCAL COURSES & CONFERENCES When?

What?

Where?

3rd SPNZ Symposium

Rotorua

More information

2014 15-16 March 2014

See Physiotherapy NZ Website

Click Here

INTERNATIONAL COURSES & CONFERENCES When?

What?

Where?

More information

30 August 2013

IFSPT Symposium

Johannesburg, South Africa

http://ifspt.org/education/ conferences/2013-ifspt-general-meetingand-congresses/

30 Aug- 1st Sept 2013

The Leuko Tape Sport Physiotherapy Congress

Gauteng, South Africa

http://www.sport-physio.co.za/

2 Sept 2013

IFSPT Symposium

Cape Town, South Africa

http://ifspt.org/education/ conferences/2013-ifspt-generalmeeting-and-congresses/

25-26 Oct, 2013

Glasgow Sports Conference

Glasgow

8-9 Nov 2013

Salzburg Sports Physiotherapy Symposium

Salzburg

http://spowww.sbg.ac.at/ssps2013/ index.php?id=95

17-20 Oct, 2013

APA Conference. New Moves

Melbourne

http://www.physiotherapy.asn.au/ Conference2013

Nov 15, 2013

SportFisio 11th Annual Conference

Bern, Switzerland

http://r20.rs6.net/tn.jsp? e=0014PUpTeosLp3nXXroB4ozWJPfo1 LkxFMNv3yvQ3ZJB0Mwz91nQFceMRLKAyUn0m7WgpdAohUiZdrLKteP2jXs8 MJYrbtBKEu1YG4olSxupZCw0AmCaw W85Lv0XEuD65j

Dec 5-7th, 2013

Team Concept Conference

Las Vegas

http://www.spts.org/education/teamconcept-conference

2013


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