SPNZ BULLETIN PAGE
Issue 3 June 2017
SPNZ Sports Physiotherapy Symposium
Feature Never Too Old for Change
FEATURE TOPIC: Change
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SPNZ Members’ Page Welcome to Sports Physiotherapy New Zealand SPNZ EXECUTIVE COMMITTEE President
Hamish Ashton
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Contents FEATURE TOPIC: Change
SPNZ MEMBERS PAGE See our page for committee members, links & member information
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ASICS Endless Engineering with the GEL-KAYANOTM 24
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EDITORIAL By SPNZ President Hamish Ashton
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SYMPOSIUM SPNZ Sports Physiotherapy Symposium
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In this issue:
SYMPOSIUM SPEAKER PROFILES Speaker Profiles for the SPNZ Sports Physiotherapy Symposium
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FEATURE Never Too Old for Change by Louise Johnson, Physiotherapist
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ASICS EDUCATION AWARD—WINNING RECIPIENT Winner of the ASICS Education Award for March 2017
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HPSNZ CORNER Para-sport
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SPRINZ Early Specialisation in Youth Sport – Time to Reset the Dial for Parents and Coaches?
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CLINICAL SECTION- ARTICLE REVIEW Tendinopathy: Clinical Diagnosis, Load Management, and Advice for Challenging Case Presentations
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RESEARCH PUBLICATIONS BJSM Volume 51, Number 11, June 2017
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COURSE REVIEW Course Review: SPNZ Level 2 - the Lower Limb in Sport by Aveny Moore
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CLASSIFIEDS Situations Vacant and Courses
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ASICS
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Editorial Hamish Ashton, SPNZ President Greetings to you all. As this edition of our bulletin has a bit of a mixed bag of content, we were wondering what we could call it. The topic of ‘change’ was suggested, which fits well. Not only a few of our bulletin articles reflect some sort of change, there are also big changes happening, or about to happen, with our profession. The first change I would like to mention, is a change of region and timing for our sports symposium. As hopefully you are aware from information already sent out, and on social media, this year’s symposium will be on October 14th and 15th in Auckland. What won’t change is the quality of speakers and topics presented. Like our previous symposiums, all talks will have some sort of take home messages on how you can use the information in your practice. By the time you receive this, early bird registrations should be open. With most of our speakers already confirmed, a provisional programme will be on the website and updated regularly. We are also looking to bring back our popular pre-and post-symposium workshops – more details will be out on the website shortly. Secondly is the possible name change for our SIG. Thanks to all of you who have made comment on the possible change. There are some very valuable comments for us as an exec to ponder through with regard to any possible change. We, as always, will take your opinions on board when we make a decision on where to go next. Any change, if it does take place, will have to go to a vote at our AGM. We will keep you informed on this process.
many of you as possible on how we are doing and what more you want out of us. Up to now this survey has had a good response rate so we have had a good spread of information to consider in our planning. As we do appreciate your input and time doing this we have usually offered a prize draw. Unfortunately, we can’t offer prizes to everyone but for this year’s ASICS (our main sponsor) have come on board to offer something amazing. Finally, there are the changes that are happening with PNZ – our professional body. We are PNZ and it represents and promotes us as a group of professional and dedicated health professionals. At the end of last year there were roadshows round the country explaining about the proposed changes. In hindsight these weren’t done as well as they could have been and with feedback received PNZ listened and changed their process and pathway for change. Over the first half of this year a group of dedicated and experienced physiotherapists from all walks of life have been meeting to construct a new organisation to represent us now and in the future. This has been a huge opportunity for our profession, in that we are redesigning our professional body in a way that we as physiotherapists best see how it should work. Shortly a briefing on what we have done will be released for comment, opinion and voting on. When this comes out please read and comment on it as YOUR OPINION WILL COUNT. Hamish
Every couple of years we like to get feedback from as
4th SPNZ SPORTS PHYSIOTHERAPY SYMPOSIUM Pullman Hotel Auckland — October 14-15th 2017 *****Early Bird Registration Now Open***** Registration @ https://pnz.org.nz/Event?Action=View&Event_id=2115 Prices Early Bird
After August 1st 2017
SPNZ
$330
$380
PNZ
$400
$450
Non-member
$590
$590
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Symposium
WE WOULD LIKE TO WELCOME YOU TO ATTEND:
OUR 4TH BIENNAL SPNZ SPORTS PHYSIOTHERAPY SYMPOSIUM
Pullman Hotel Auckland October 14-15th 2017 Dr Phil Glasgow Phil was the Chief Physiotherapy Officer for Team GB at the Rio 2016 Olympic Games.
Phil is particularly interested in understanding the factors that influence the development of mastery and effective performance in both sporting and professional environments.
Featuring:
Chris Bishop
Dr Bruce Hamilton
Chris is the founder of The Biomechanics Lab in Adelaide.
Rob Moran
Chris’ research has focussed on the relationship between the foot and shoe, in both how the foot moves inside the shoe and how the shoe design can be optimised to influence the biomechanical function of the foot .
Dr Steve Kara Justin Ralph And many more quality speakers
For further information and to register please see our website: http://sportsphysiotherapy.org.nz/
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Symposium Speaker Profiles Key Note Speaker - Dr Phil Glasgow Phil Glasgow was head of sports medicine at the Sports Institute Northern Ireland for 14 years before becoming a director of performance consultancy company Refine Performance Ltd. In early 2017. Phil is particularly interested in understanding the factors that influence the development of mastery and effective performance in both sporting and professional environments. Phil is also a visiting professor of the School of Sport at Ulster University and teaches on a number of postgraduate programmes at various UK and European universities. Invited Speakers Include: Chris Bishop Chris’ research has focussed on the relationship between the foot and shoe, in both how the foot moves inside the shoe and how the shoe design can be optimised to influence the biomechanical function of the foot. Dr Bruce Hamilton In 2013 Dr Hamilton was appointed medical lead for both High Performance Sport NZ and the NZ Olympic Committee. He is responsible for ensuring NZ has a world class medical service to support NZ’s elite Olympic athletes. Dr Steve Kara FRNZCGP, Dip Sports Med, M Phil (Hons)) Stephen is in his 10th season as team doctor for the Blues Super Rugby Team, having been involved with rugby medicine since 2004. He has held previous roles with Auckland Rugby and has travelled as team doctor for NZ U19 Teams and Maori All Blacks. He works full-time within the realm of rugby medicine, is an educator for World Rugby in Pitchside Immediate Care and is chairman of Sports Medicine NZ. Stephen has an interest in sports related concussion and has commenced work at Axis Sports Medicine Clinic, focussing on the assessment and management of community based sports concussion. Rob Moran Rob Moran is a senior lecturer in the Department of Osteopathy at Unitec where he teaches on the undergraduate and postgraduate degrees in subjects such as critical thinking, clinical reasoning, physical examination and research methods and also works with postgrad students as a thesis supervisor. His clinical interests are centred on the integration of manual therapy in an ancestral health framework including diet, sleep, exercise, and pyschosocial factors. Rob's current doctoral research is investigating musculoskeletal injury in people participating in CrossFit. Jordan Salesa Jordan has extensive professional experience having been a physiotherapist with: Manu Samoa (7’s & 15’s) 2000 -2007, Samoan Olympic & Commonwealth Games Team – Sydney 2000, Manchester 2002, NZ Olympic & Commonwealth Games Team – Athens 2004, Melbourne 2006, Beijing 2008, New Delhi 2010, London 2012, Glasgow 2014, Rio 2016 and has been appointed to the Gold Coast CWG for 2018. Justin Ralph Justin completed a Post-Graduate Diploma in Musculoskeletal Physio in 2012 and is an advanced certified bike fitter through the Serotta International Cycling Institute. He is a High Performance Sport NZ Provider and has worked with New Zealand Cycling – World Cups/World Championships (2005-2010) including the European Training Centre - France (2008), Paralympics New Zealand, and was a provider at the London Paralympic Games 2012
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Feature Never Too Old for Change
LOUISE JOHNSON DIP PHYS, ADP (OMT) My favourite line at work is that I am older than the building itself – is it wrong of me to gently remind the millennials of where it all began?? I trained in Auckland way back in the early 80’s with a very small class of 42 students. We were the last intake at the Grafton campus before it shifted to the Shore. In my class were such people as Lynley Bradnam, Sharon Kearney, Mark Plummer and Karen Sutton to name just a few (sorry to the rest). Between us all we have looked after a massive number of High Performance athletes and teams. How we did this I have no idea as we certainly had some crazy times. I did the hospital thing for a couple of years then slotted into Post Grad courses at AUT University. I was in and out of the NZ hockey team at this stage but dogged with a right knee injury. So like a lot of clapped out physios, switched to sports physiotherapy with a vengeance. I worked in England and Spain with their national hockey teams and then returned in the early 90’s and picked up the NZ women’s hockey job for the 1992 Barcelona Olympics. I worked with NZ Hockey for 10 years and had stints with various other sports in and around Olympics and Commonwealth games. Concurrently, I worked with Steve White and Rick Knight out at Pakuranga, certainly picking up many skills from these blokes. Deciding to grow up, get married and have kids meant I thought my travelling days were over, until Dame Valerie Adams walked into my clinic. Wow, what a journey and I will be eternally grateful to Dame Valerie for giving me the opportunity to be a part of her whanau and life over the past 15 years – and it ain’t over yet.
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Feature Never Too Old for Change continued...
Please describe your current role and how you ended up there. My current role is as a full time physiotherapist in the performance health team at High Performance Sport New Zealand at the National Training Centre housed at the AUT Millennium Campus in Auckland. I am the point of contact physiotherapist for Yachting New Zealand and the Dame Valerie Adams Campaign. I transitioned to full time at HPSNZ a couple of years ago as I was struggling to fulfil my part time roles in private practice and with Dame Valerie who was based in Switzerland at the time. I thought it would be a simple case of continuing my work that I had been performing as a preferred provider – but I can say hand on heart that I have never been so wrong! In a snap shot – in Private Practice we work on a fee for service model or possibly in a contracted injury management role. Very rarely are you in a situation where you can immerse yourself in a multidiscipline performance based model and be able to take your time to develop a performance impact. I was certainly
immersed with Dame Valerie’s programme but not a whole sport. There was a clear shift in the competencies that had to be developed quickly. I could no longer treat, call, email and run. Below are three points of difference that I noticed the most. 1.
You are not alone.
I do have to have a laugh at myself as for the first time in my life I had a boss. This did take some adjustment – believe you me. For a while there I was a little intimidated as to if I could make a decision, which is no different from working in any big organisation. However, as time has gone on and you get a handle on what all the three letter anagrams mean – you realise you are working in a highly motivated, performance driven multilayered team of experts. Your feeling of autonomy returns and it becomes good fun. Really good fun. The below diagram is an attempt to show where you sit with the various groups you work with.
HPSNZ: is a government organisation and with that comes a responsibility to systems and accountability for the public dollar Region: understanding that there are six training hubs that will have regional variations Sport: Having the ability to immerse yourself within a sport Discipline: The need to keep to your scope of practice and ethics of our profession
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Feature Never Too Old for Change continued...
2.
Get used to the 5+ Service Model
This 5+ model is basis of the Performance Health Team Service Plan. Fiona Mather presented this at the Jill Cook and Karim Kahn SPNZ Roadshow in Auckland last year. It is a brilliant model and one you learn to learn, then learn to love, then live. Injury management is still the corner stone of our work but in a lot of ways, it is the easy bit. The key message is that if we were only delivering Injury and Illness management then New Zealand could not compete on the world stage. We need to compete with other performance health systems in the world where the focus is on optimising the time athletes spend training which includes helping them cope with the demands of their sport both in New Zealand and worldwide whilst minimising the risk of injury. (I have been lucky enough to see this in action mainly in Switzerland, England and the USA with Dame Valerie when on the Diamond League circuit.) This model is the start of a holistic approach to provide a wrap-around management for our athletes and sports that is meaningful and sustainable with the overall aim of enabling NZ athletes to train more of the time.
Research
A very quick explanation of the 5+ headings are in the below table. Of course they are just words and where the work lies is in the development of the systems.
Injury Management
Acute injury management, ongoing rehabilitation, return to play
Injury Prevention
Planned interventions to reduce injury incidence based on known injury trends, profiling, programme planning, design, modifications
Athlete Monitoring
Injury surveillance, profiling, benchmarks, outcome measures, wellness surveys, injury monitoring
Performance Optimisation Planning and Co-ordination
Physical prep, coach interaction, technic specific of sport, Inter disciplinary team (IDT) working, maintenance work, event support Admin, planning, meetings, reports, case management
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Feature Never Too Old for Change continued...
3. Old dog – new tricks Unashamedly, in the past I have been able to fake a fair bit by jumping on other peoples’ admin skills. Rather proud of my spreadsheets now – although the real work is what needs to go into them. The key message is about influencing athletes and coaches with meaningful performance based data. For instance, we know that the elite senior sailors completed more trainings. This is in line with Raysmith and Drew (2016)) whereby in Australian Track and Field athletes the “Likelihood of achieving performance goal increased by 7-times in those that completed over 80% of planned training weeks.” Obviously it is all about the performance and being able to see where you can get a percentage change and
impact. A simple act like being able to detect aliments early before they become true injuries and to keep the athletes training meaningfully can be the performance impact. What are the types of injuries you commonly see? Sailing athletes need to be very strong and nimble in order to sail the boat fast, in the right direction and consistently. Our 2016 Injury Surveillance indicates the biggest time loss injuries were new traumatic contact injuries to hands, wrists and fingers. The sailors also sustained a fair amount of what is termed “ailments” whereby they may have a complaint that warrants treatment but is not a time loss injury. These were in the more traditional low backs, necks and knees.
This photo is the new foiling Nacra 17. It is a great shot of what looks like a ghost ship – where are the two sailors?? They are there, on the other side in perfect aerodynamic position. These boats are super-fast, hard to control and sailors fall off – getting tagged by the foils and rudders.
What do you think are the key elements in successfully preventing injury? We have modified using the term “screening” as we know that there is doubt on the injury predictive value of
the process as discussed (Bahr, 2016). However, we are beginning to think and hopefully show that the real value is in tracking changes within the athlete. The very asymmetry you pick up in your profiling may in fact be their super power for their discipline. Please do not try to undo any asymmetries until you can understand why it
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Feature Never Too Old for Change continued... is there. Is it an unwanted asymmetry and worth addressing or is it years of adaptive change and beneficial to the skill required for the sport. Needless to say, many a conversation needs to happen with the athlete, coach and inter-disciplinary team (IDT) to determine this. Our main method of athletic monitoring is profiling the athlete, benchmarking for that sport and then regularly (both with us and by self) retesting to track changes. The really good athletes do this anyway so it is a case of setting up the system for the newbies and ensuring it actually means something. The other methods of going through the injury prevention process is a critical evaluation of the injury surveillance data. This process of reflective thinking is way more complicated than the four step Van Mechelen (1992) process form but it is a great place to start and is an easier process to discuss with the performance team. Injury prevention is a whole topic in itself. The Meeuwisse (2007) paper describing “the susceptible athlete” is a brilliant concept and you see it all the time. We also know that load management monitoring (Blanch & Gabbett, 2016) is critical in injury prevention. We have access to the training stress balance (TSB) and/or the acute/chronic workload ratio information. This data is generally collected and monitored by the physiology and S & C teams. However, it forms a vital part of our return to play guidelines in order to keep compromised athletes training and loaded appropriately. The Performance team is also interested in wellness and optimal training. We currently run an integrated Wellness survey and it will be interesting to see if there is a relationship with injury upon further analysis. What do you see as the major challenges for sports physiotherapy? The focus on performance creates a holistic approach to the management of athletes which encourages integration across disciplines and most importantly with coaches. The responsibility for athlete health is a collective one and relies on the integrated team approach and it is this approach which has moved us from sports physiotherapist to integral members of the performance team. With the ultimate aim of optimising training whilst mitigating the risks of injury. This does create the side effect of creating a bit of a gap between good sports physiotherapy clinical skills and
how to run a high performance sports programme. Clearly the immediate challenge is to upskill and provide a pathway for motivated sports physiotherapists into the pro sport and high performance sport setting. It is not the clinical skill set of physiotherapists that is the issue, but one of gaining the system skills and understanding of how to work effectively as an integral member of the performance team. Clinical management of injuries is very important however the value of the practitioner is in their ability to translate the impact on injury upon performance. None of the concepts or systems are hard to learn and should not be seen as any form of elitism. You can compare it to any change of setting e.g. hospital, occupational health contracts and corporates. The advantage we have had is to take the time to really think of where we can make a difference and how to implement, communicate and immerse. Jeepers: What now? HP and Pro Sport is a brilliant industry to work in. If interested, three quick suggestions to start developing some 5+ systems are: Upskill your soft skills. Take the time to learn how people like to work, including yourself. In order to work in the High Performance world, you will certainly need all your communicative skills to be able to adapt and work effectively
Engage and immerse yourself within sports and the sports medicine world I suspect if you have managed to read all this then you are indeed engaged in sports and the sports medicine world, so sorry for sounding a bit clichéd. However, do take the time to have a working (not expert) knowledge of the other disciplines involved in HP sport – e.g. physiology, nutrition, S &C. This will help you establish your scope of practise and role clarity. Develop really detailed condition and sport specific return to play documents with the coaching staff. This will result in really meaningful and critical conversations about the demands of your sport.
Gather information to help understand the impact of Injury on performance.
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Feature continued... Injury surveillance data is the easy place to start. If you are involved in a team then start with the likes of unavailability for selection due to injury noting: position, site, severity, (training days lost) traumatic or overuse, new or follow up injury. A simple spreadsheet will suffice. After a couple of months, you will have some data to play with and a basis to get curious. Then your readings can be targeted and start to have context. Think not of a one off “screening” but how to effectively track changes within your athletic population Final Say. The last word I would say – is that it is not often that you can develop as a person while on a career pathway. I have been astounded by the opportunities I have been given to develop my skillset both within and outside of the physiotherapy world since transitioning from the private practice scene. High performance sport is not for everyone as you certainly need to give a fair bit of yourself to the job – but it is just so rewarding. As the late John Clarke would say, “Give it a crack, Trevor.”
References Blanch P, Gabbett TJ. 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. Br J Sports Med:50:471 – 475 A Dynamic Model of Etiology in Sport Injury: The Recursive Nature of Risk and Causation. Willem H. Meeuwisse et al. Clin J Sport Med Volume 17, Number 3, May 2007 Roald Bahr (2016): Why screening tests to predict injury do not work—and probably never will…: a critical review. BJSM 2016 Raysmith B, Drew MK. (2016). Performance success or failure is influenced by weeks lost to injury and illness in elite Australian Track and Field athletes: a 5yearprospective study. J Sci Med Sport. Oct;19(10):778-83. doi: 10.1016/ j.jsams.2015.12.515. Van Mechelen W, Hlobil H, Kemper HCG. (1992). Incidence, severity, aetiology and prevention of sports injuries. A review of concepts. Sports Med;14(2):82—99.
ASICS Education Award—Winning Recipient The winning recipient of the above award for March 2017 is Lee -Anne Taylor, Assistant Head of School, School of Health and Sports Science, Eastern Institute of Technology. This recipient has satisfied the Education Committee of the criteria for application as per the SPNZ Education Awards Terms and References. Lee-Anne’s research investigates the effects of a 6 week pre-season netball conditioning programme which runs over several netball seasons. Measures include strength testing, balance, agility, functional movement screening and netball specific skills and therefore looking at the prevalence and prevention of knee and other lower limb injuries. The first pilot study was conducted in 2016. An abstract relating to current findings has been accepted for the International Sports Science and Sports Medicine Conference to be held at Newcastle University, UK. This conference now includes sports physiotherapy. We will look forward to Lee-Anne’s report on this conference which will be published in the SPNZ bulletin.
The next round of applications closes on 31 August 2017. All members are encouraged to view the Terms and Conditions of this award available on our website at sportsphysiotherapy.org.nz.
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HPSNZ Corner This edition of HPSNZ Corner delves into all things Para-sport. We chat to Megan Munroe, the lead physiotherapist for Paralympics and Paralympics New Zealand.
Please tell us a little bit about yourself and your current role.
What do you consider the strengths needed to work in Para-sport?
I graduated as a physio in 2007 from the Robert Gordon University in Aberdeen, Scotland. I then came to New Zealand in search of adventure and worked as a physio in the hospital and private practice system before returning to the UK in 2009 where I worked for the NHS and military. My interest in Para-sport sparked working at DMRC Headley Court, the main military rehabilitation centre outside of London. I worked in the lower limbs team mainly working in hip and groin and lower limb exertional pain rehab. We started to get increasing numbers of late stage amputees where sport was used a vehicle for rehabilitation. There were no limits, these guys wanted to be Ironmen, rock climbers and boxers. I completed my Masters in Sports and Exercise Medicine through The University of Glasgow in 2012 and I volunteered as a physio at the London 2012 Olympics and Paralympics working at boxing and rowing. Best summer of my life! The rest is history, it opened huge doors for me and I've never looked back.
I think the ability to communicate, work as a team, appreciate and compliment other disciplines within your team, understand performance and what it takes to make an impact on performance. You need to have the ability to see the bigger picture and understand your place within that picture. You need to see the athlete as a person and not be clouded by their impairment. I focus on what they can do rather than what they can’t.
I returned to New Zealand in 2013 and I now work full time at High Performance Sport NZ at the National Training Centre based at AUT-Millennium in Auckland and part of my role is being the lead physio for Paralympics New Zealand Swimming. I have worked for 4 years with Para-Swimming mainly in a co-ordination and touring role until I became full time at HPSNZ in Jan 2016. The highlight of this was going to the 2016 Rio Paralympic Games where New Zealand won 21 medals and retained their number one in the world per capita ranking. I absolutely love my job and am very passionate about working in Para-sport and the impact Para-sport has at community and grass-roots level.
What are some good resources for me if I am interested in Para sport? In 2014 and 2015 we published articles on the physiotherapy and medical issues that commonly present working in Para-sport. Below are links to these articles in the New Zealand Journal of Sports Medicine. Athletes with limb deficiency. Dr Jake Pearson. https://sportsmedicine.co.nz/wp-content/ uploads/2016/02/NZJSM-Vol-40-Issue-2.pdf Athletes with limb deficiency: Physiotherapy-specific issues. Megan Munro and Justin Ralph. https://sportsmedicine.co.nz/wp-content/ uploads/2016/01/NZJSM-Vol-41-Issue-1.pdf Athletes with spinal cord injuries. Dr Jake Pearson. https://sportsmedicine.co.nz/wp-content/ uploads/2016/01/NZJSM-Vol-41-Issue-2.pdf Athletes with spinal cord injury: Musculoskeletal issues and remedies. Megan Munro, Justin Ralph and Dr Jake Pearson. https://sportsmedicine.co.nz/wp-content/ uploads/2016/01/NZJSM-Volume-42-Issue-2-2015.pdf
What are the main differences that you see to working in a Para-sport role?
If you are interested in working in Para-sport, who do you get in touch with?
I think it's important to be able to think outside the box and have a good imagination. I think working in Parasport really improves your clinical reasoning as very little is 'normal' and you are constantly challenging yourself to come up with unique, unconventional ways of achieving a performance outcome or injury prevention strategy. Working in Para-sport is a lot of fun. I work closely with the Limb Centres and enjoy the challenge of making weird and wonderful adaptations for the gym and pool to get the desired outcome.
Paralympics New Zealand http://www.paralympics.org.nz/ Megan Munro – megan.munro@hpsnz.org.nz Halberg Disability Foundation http://www.halberg.co.nz/ Local Para Feds For example - http://www.parafedauckland.co.nz/ http:// www.parafedcanterbury.co.nz/
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SPRINZ
Early Specialisation in Youth Sport – Time to Reset the Dial for Parents and Coaches?
By Chris Whatman The debate around specialisation in youth sport has soaked up a lot of press of late. In the 21st Century, youth sport has seen a dramatic increase in its competitive and professional nature. The manner in which youth in New Zealand engage in sport has certainly changed, with increasing opportunities to specialize early and undertake structured training opportunities via school sports academies and expanding representative pathways. Recent evidence from our research group, based on a small pilot study, suggests the prevalence of early specialization in kiwi kids is similar to those reported overseas (Whatman, Walters, Schluter, McGowan, & Knight, 2017). Specialization is defined as ‘‘year-round intensive training in a single sport at the exclusion of other sports’’ (Jayanthi, LaBella, Fischer, Pasulka, & Dugas, 2015). The two main issues that arise are whether or not early specialization increases the chances of future success and whether or not it increases the risk of injury. Physiotherapists who are managing injuries in youth athletes are in a great position to educate parents, coaches and kids about the key issues. It appears that much of the push for increasing early specialization comes from the often quoted 10,000-hour rule which states that outstanding performers in a range of fields have a background of at least this much deliberate practice. The rule comes from a 1993 study by Ericsson (1993) which reported data showing the best violinists had accumulated about 10,000 hours of practice by the age of 20. The authors maintained that the common thread to elite performance in the various fields (including sport) was an extended history of intense, deliberate practice. However not all authors endorse this view arguing that experts may have undertaken more deliberate practice because they were good at something (Macnamara, Hambrick, & Oswald, 2014). Support for this alternate view comes from a recent metaanalysis that concluded deliberate practice does not correlate positively with expert performance
(Macnamara et al., 2014) and in fact it explains only a fraction of the variance in ability (only 18% in sports). A recent consensus statement from the American Orthopaedic Society for Sports Medicine stated, “Although there may be specific sports where early specialization is required due to early ages of peak performance (e.g. gymnastics, figure skating, diving), the overall evidence supporting early specialization, as a general requirement for elite performance in sport where peak performance is achieved in adulthood, is not convincing.” Several authors have in fact suggested that early sampling of many sports, with gradual specialization in later adolescence is more likely to lead to later success. Moesch (2011) found that a group of Danish elite senior athletes reported less hours of training prior to the age of 15 compared to near elite athletes and levels of specialisation were similar. Furthermore, elite senior athletes spent less time on junior national teams and more time on senior national teams. Similarly in a large cohort of German Olympic athletes, success as juniors and training hours had little association with future senior success (Gullich & Emrich, 2006). This is further echoed by a large-scale National Athlete Development Survey of Australian athletes (Gulbin, Oldenziel, Weissensteiner, & Gagné, 2010) with respondents (including Olympians) reporting a variety of participation experiences across multiple sports before specialization. The International Olympic Committee (IOC) produced a recent Consensus Statement on youth athletic development, suggesting that exposure to a number of sports skills enhances the likelihood of achieving and sustaining an enjoyable, high level of performance (Bergeron et al., 2015). Furthermore a recent review by Meyer (2016) concluded that based on the current evidence, the development of diverse motor skills in the growing years is fostered when parents and educators facilitate opportunities for free unstructured play and youth should be encouraged to participate in a variety of sports. CONTINUED ON NEXT PAGE
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SPRINZ Early Specialisation in Youth Sport – Time to Reset the Dial for Parents and Coaches?
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This emphasises the need to have space in a child’s weekly schedule to allow unstructured free play. Again recent evidence from our own group suggests kiwi kids who are more specialized undertake less free play which has been linked to injury risk (Whatman et al., 2017). Furthermore based on current evidence the Developmental Model of Sport Participation (DMSP), which has a focus on early diversification and play, is the best supported model of athlete development to explain long-term participation and performance in sport (LaPrade et al., 2016). editorials Of concern for physiotherapists is the potential for increased risk of injury due to early specialization. There have been several position statements and written recently on this very topic, most warning of the potentially damaging effect of early specialization on long term physical and mental health. However, while it seems we should rightly be concerned, it needs to be acknowledged that there is a lack of current evidence establishing a cause and effect relationship between early specialization and increased injury risk. A systematic review published this year highlighted that this is a relatively new area of research, reporting only three studies meet the inclusion criteria (Fabricant et al., 2016). All the studies were retrospective in nature which clouds injury history with recall bias and also makes it difficult to determine if any observed increase in injury risk is in fact due to specialization or actual training volume. The authors concluded there was currently only moderate evidence that specialization is linked to overuse injury and that further prospective studies are required. This is consistent with the earlier 2014 statement from the American Medical Society for Sports Medicine, ‘‘The relationship between injury and sports specialization has not been clearly demonstrated”. In addition to the risk of musculoskeletal injury is the potential for psychological harm as a result of early intensive specialization in sport. Young athletes can suffer stress and anxiety when exposed to inappropriate and unrealistic demands and expectations and related psychological overload (Bergeron et al., 2015). The
psychological stress of an unhealthy sports environment has been linked to increased risk of depression and anxiety. For those wondering what advice to give several simple “rules of thumb” have been proposed. Firstly, don’t specialize in one sport pre-puberty, second, limit participation to less than 8 months per year and third, limit participation to fewer hours per week than your age in years. These guidelines require further investigating but all three recommendations were found to be associated with decreased injury risk in a retrospective study published this year involving 2011 male and female athletes aged 12-18 years. To gauge levels of specialisation physiotherapists can ask three simple questions; ‘‘Have you quit other sports to focus on one sport?’’, ‘‘Do you train more than 8 months out of the year in one sport?’’ and ‘‘Do you consider your primary sport more important than other sports?’’. A categorical classification system is used to assess the sport specialization questions (yes = 1, no = 0), with a score of 3 considered high specialization, a score of 2 considered moderate specialization, and a score of 0 or 1 considered low specialization (Jayanthi et al., 2015). So it seems this is one of those rare occasions where kids can have their cake and eat it! Kids can sample many sports and likely reduce their risk of injury, without reducing chances of success as an adult and probably improving it (while also increasing their likelihood of lifelong enjoyable sports participation). While we wait for more evidence, most kids are best advised to sample a variety of sports, have fun and try and leave room in their weekly schedule to hang out with their mates and play in the park. Many parents, coaches and sports administrators probably need to reset their expectations around when specialization should occur, when competitive events occur and the level of skill/difficulty expected at each age. In keeping with their role in educating clients on how to live a physically healthy lifestyle, physiotherapists are in an ideal position to educate parents and coaches in this space. CONTINUED ON NEXT PAGE
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SPRINZ Early Specialisation in Youth Sport – Time to Reset the Dial for Parents and Coaches?
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References Bergeron, M. F., Mountjoy, M., Armstrong, N., Chia, M., Côté, J., & Emery, C. A. (2015). International Olympic Committee consensus statement on youth athletic development. British Journal of Sports Medicine, 49(13), 843-851. Ericsson, K., Krompe, R., & Tesch-Romer, C. (1993). The role of deliberate practice in the acquisition of expert performance. . Psychological Reviews, 100(3), 363-406. Fabricant, P. D., Lakomkin, N., Sugimoto, D., Tepolt, F. A., Stracciolini, A., & Kocher, M. S. (2016). Youth sports specialization and musculoskeletal injury: a systematic review of the literature [Review]. Physician and Sportsmedicine, 44(3), 257-262. doi:10.1080/00913847.2016.1177476
A. (2016). Sports Specialization, Part II: Alternative Solutions to Early Sport Specialization in Youth Athletes. Sports Health, 8(1). Moesch, K., Elbe, A., & Hauge, M. (2011). Late specialization: the key to success in centimeters, grams, or seconds (cgs) sports. Scandinavian Journal of Medicine and Science in Sports, 21, e282-e290. Whatman, C., Walters, S., Schluter, P., McGowan, J., & Knight, R. (2017). Injury attitude and specialization in kiwi youth sport; what's the story? Symposium conducted at the meeting of the Injury Prevention and Team Care Conference, Auckland, New Zealand.
Gulbin, J., Oldenziel, K., Weissensteiner, J., & Gagné, F. (2010). A look through the rear view mirror: Developmental experiences and insights of high performance athletes. Talent Development and Excellence, 2(2), 149-164. Gullich, A., & Emrich, E. (2006). Evaluation of the support of young athletes in the elite sports system. European Journal of Sport Society, 3(2), 85-108. Jayanthi, N. A., LaBella, C. R., Fischer, D., Pasulka, J., & Dugas, L. R. (2015). SportsSpecialized Intensive Training and the Risk of Injury in Young Athletes A Clinical Case-Control Study [Article]. American Journal of Sports Medicine, 43(4), 794-801. doi:10.1177/0363546514567298 LaPrade, R., Agel, J., Baker, J., Brenner, J., Cordasco, F., & Engebretsen, L. (2016). AOSSM Early Sport Specialization Consensus Statement. The Orthopaedic Journal of Sports Medicine, 4(4). Macnamara, B., Hambrick, D., & Oswald, F. (2014). Deliberate practice and performance in music, games, sports, education, and professions: a meta-analysis. Pyschiological Science, 25(8), 1608-1618. Meyer, G., Jayanthi, N., DiFiori, J., & Faigenbaum,
Chris Whatman, Senior Lecturer, Discipline Leader Sport and Exercise Science, Leader Sports Kinesiology & Injury Prevention Research Group (SPRINZ) https://sprinz.aut.ac.nz/areas-of-expertise/sportskinesiology-and-injury-prevention/staff-profiles/chriswhatman
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Clinical Section - Article Review Tendinopathy: Clinical Diagnosis, Load Management, and Advice for Challenging Case Presentations Peter Malliaras, BPhysio (Hons),PhD1.2 Jill Cook, PhD1.3 Craig Purdam, MSportsPhysio3.5 Ebonie Rio, BPhysio (Hons), MSportsPhysio, PhD1.3 Journal of Orthopaedic & Sports Physical Therapy, Volume 45, Number 11, November 2015, Pages 887-898
ABSTRACT The features of patella tendinopathy are: 1. Pain localised to the inferior pole of the patella 2. Load related pain that increases with the demand on the knee extensors, particularly in activities that store and release energy in the tendon A thorough examination is required to diagnose patella tendinopathy and the contributing factors. Management of patella tendinopathy should focus on progressively developing load tolerance on the tendon, the musculoskeletal unit and the kinetic chain as well as addressing key biomechanical and risk factors.
Patella tendinopathy is most commonly characterised by pain located to the inferior pole of the patella and load related pain that increases with the demand on the knee extensors, notably in activities that store and release energy in the patella tendon.33
ceases almost immediately when load is removed. 75 Pain is rarely experienced in the resting state. 75 Pain may improve with repeated loading,55,75 but there is often an increase in pain the day after energy storage activities.75
Patella tendinopathy is primarily a condition of relatively young male athletes playing sports which require repetitive loading of the patella tendon57 that repetitively store and release energy. Repetition of the activity over a single session of exercise57 or insufficient rest between sessions81 can induce pathology and a change in the tendons mechanical properties which is a risk factor for developing symptoms.17,61 The relationship between pain and pathology is unclear, the presence of pathology appears to be a risk factor for an athlete to become symptomatic.17,61 Tendon pathology includes increase in tenocyte numbers and rounding, and in ground substance expression, causing swelling, matrix degradation and neovascular ingrowth.53,58
‘Dose-dependant pain’ is a key feature; the pain increases as the magnitude or rate of application of load on the tendon increases.55 Assessing pain irritability is a fundamental part of managing patella tendinopathy and consists of determining the duration of symptom aggravation following energy-storage activities like a training session.
Examination of Patella Tendinopathy Patella tendinopathy has specific and defining hallmark clinical features32,55 1. pain localised to the inferior pole of the patella 2. load-related pain that increases with demand on the knee extensors notably in activities that store and release energy in the patella tendon 57,77 Other signs and symptoms may be present but are also common to other pathologies. Tendon pain occurs instantly with loading and usually
‘Irritable’ tendon pain is pain provocation of greater than 24 hours, and ‘stable’ tendon pain is defined as settling within 24 hours after energy-related activities. Aggravation of symptoms manifests as pain during loading, eg. walking downstairs. A thorough examination of the entire lower extremity is necessary to identify deficits at the hip, knee and ankle/ foot region. Deficits in energy-storage activities can be assessed clinically by observing hopping and jumping. Clinically these athletes with patella tendon pain tend to reduce knee flexion and appear stiff in their landing. Patella tendinopathy imaging does not confirm patella tendon pain as observed pathology may be asymptomatic. Differential Diagnosis Tendinopathy can also occur at the quadriceps tendon or distal insertion of the patella tendon at the tibial tuberosity. CONTINUED ON NEXT PAGE
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Clinical Section - Article Review Tendinopathy: Clinical Diagnosis, Load Management, and Advice for Challenging Case Presentations continued... Quadriceps tendinopathy is characterised by pain localised to the quadriceps tendon32 often associated with movements requiring deep knee flexion.72
Kongsgaard et al54 compared eccentric loading with heavy slow resistance (HSR) training and found moderate evidence supporting the HSR program.60
Distal patella tendon pain is localised near the tibial tuberosity.32,78
A 4 stage rehabilitation progression (outlined in the table) for patella tendinopathy is suggested based on current evidence, focusing on developing load tolerance of the tendon, the musculoskeletal unit, and the kinetic chain. Progression criteria are individualised based on pain, strength and function.
The infrapatellar bursa is an intimate part of the distal patella tendon attachment8 and irritation of the bursa often coexists with distal patella tendinopathy. Mild or whole patella tendinopathy is generally from a direct blow.42 Although these have management subtleties, principles equally apply.
different features and the progressive-loading
Hoffa’s fat pad has vascular connections to the patella tendon67 and fascial connections to the patellofemoral and tibiofemoral ligaments and patella tendon.15 Fat pad injury of insidious onset associated with repetitive endrange extension is common but it may also occur acutely with a tibiofemoral hyperextension incident. The main differentiation from patella tendinopathy is the site felt during end range extension or direct digital pressure.26,64 Patello-femoral related pain is generally diffuse around the patella. Aggravation of symptoms of patellofemoral pain is often created with low load and may be reduced by taping. This rarely exists with patella tendinopathy. Plica injuries and chondral injuries may also produce anterior knee pain. Plica injuries are clinically painful with activities requiring shallow knee flexion, has a history of snapping sensation and can be confirmed on MRI. Chondral lesions clinically have significant joint effusion. Age is also a consideration in differential diagnosis. Patella tendinopathy and isolated Hoffa’s fat pad are common in adolescents.13 Adding to this challenge of differential diagnosis are growth related injuries of Osgood-Schlatter syndrome and Sinding-LarsenJohansson syndrome. Management of Patella tendinopathy Eccentric exercise is the most investigated intervention,60 however, eccentric exercise for the treatment of patella tendinopathy may be too aggressive for athletes with high irritability.34,93 Used in isolation it fails to address impairments that may exist through the kinetic chain and there is limited high quality data to demonstrate positive clinical outcomes.
Initially there must be loading modification. Reducing high load energy-storage activities that may aggravate pain. Some pain is acceptable during and after exercise but symptoms should resolve quickly after exercise as monitored by the 24 hour response.54 A painprovocation test such as single-leg decline squat70 is administered daily at the same time each day and if the pain has returned to baseline within 24 hours of the activity or rehabilitation, the load has been tolerated. Stage 1: Isometric Loading is indicated when pain limits the ability to do isotonic exercise.18 Resistance should be increased as quickly as tolerated and performed on a single leg if possible. The key is to progress the load based on tolerance and regular reassessment of pain response with load tests. A good prognostic sign for isometrics is as immediate reduction in pain with loading tests after isometric exercise. In stage 1, isometric exercises should be used in isolation. Other exercises can be initiated during this phase to address other strength and flexibility deficits throughout the lower extremity. Stage 2: Isotonic loading is initiated when it can be performed with minimal pain. Isotonic load is important to restore muscle bulk and strength through functional ranges of movement. Exercise should initially be limited to between 10and 60 degrees knee flexion and progressed to 90 degrees as pain permits, then to single leg loading. Stage 1 exercises should be continued on the ‘off’ days to manage pain within the limits of muscle fatigue and soreness associated with isotonic loading. Stage 2 exercises should be continued throughout rehabilitation and return to sport. Stage 3: Re-introduction to energy-storage loads on the myotendinous unit is critical to increase load tolerance of the tendon and improve power as a progression to return to sport. Initiating this stage is based on, 1. Good strength, 2. Good load tolerance with initial energystorage exercises, defined as minimal pain while performing exercise, and 3. Return to baseline pain during load tests. Progression should be developed CONTINUED ON NEXT PAGE
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Clinical Section - Article Review Tendinopathy: Clinical Diagnosis, Load Management, and Advice for Challenging Case Presentations continued... within the context of the loads the athlete is required to attenuate for their sport and performance level. Choice of exercise will depend on the demands of the individual sport. The introduction of energy-storage exercises is often the most provocative stage and can take several weeks to months for some athletes. Loading is performed every third day, based on 72 hour collagen response to high tendon loading. 56 Progressions are guided by pain and return to isometrics may be necessary at times to settle pain. Stage 4: Return to sport. Progression back to sport specific training can be commenced when the athlete has completed energy-storage progressions that replicate the demands of his or her sport. Return to sport is recommended when full training is tolerated without symptom provocation and after existing deficits have been resolved. Ideally sports loads should be performed every 3 days and no more than 3 highintensity training or competition sessions within a week for the first year of return. Maintenance Stage 2 strengthening twice weekly using loaded, single -leg exercises with stage 1 isometric exercises intermittently. Continue addressing other flexibility and strength deficits. Common Management Pitfalls Rehabilitation of patella tendinopathy is slow and frustrating. Failure to gain control of pain, normalise muscle capacity, effectively progress energy-storage exercises, and effectively progress return-to-sport training and intensity is common. Unrealistic time frames: educate patients and other stakeholders about realistic time frames and set short and long term goals based on strength and functional targets. Inaccurate Beliefs and Expectations about Pain: Athletes need to be aware that some pain during rehabilitation is acceptable and not necessarily harmful. Failure to Identify Central Sensitisation: careful pain mapping may identify diffuse sensitivity often associated with a long history of pain. Overreliance on Passive Treatments: exercise is the most evidence-based intervention.39 Passive intervention may be a useful adjunct but have not been shown to normalise tendon matrix or muscle tissue or to address other muscle deficits throughout the lower extremity.
Not Addressing Isolated Muscle Deficits: Altered neuromuscular output is likely to be a response to pain and thus inhibit quadriceps Failure to Address Kinetic chain Deficits: Addressing other potentially contributing factors present throughout the lower extremity is essential for resolution of patella tendinopathy. Not Adequately Addressing Biomechanics: Landing kinematics should be retrained to reduce ground reaction and peak loading forces. Difficult Presentations Highly irritable tendon: pain is significantly increased for several days after progressive loading. Set short term goals only and consider anti-inflammatory drugs as an adjunct. CONCLUSION Patella tendinopathy can be difficult to manage. The cornerstone of patellar tendon management and rehabilitation remains highly specific and a thorough approach to progressive loading of the lower extremity, muscle-tendon unit and tendon through a 4 stage rehabilitation program based on clinical evidence appears effective in guiding athletes back to sport. A very useful article
A full set of references is available on request
Pip Sail Physiotherapist
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Research Publications British Journal of Sports Medicine www.bjsm.bjm.com Volume 51, Number 11, June 2017 CONCENSUS STATEMENT
Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016 Paul McCrory, et al http://bjsm.bmj.com/content/ ORIGINAL ARTICLES
The Sport Concussion Assessment Tool 5th Edition (SCAT5): Background and rationale Ruben J Echemendia, et al http://bjsm.bmj.com/content/
The Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5): Background and rationale Gavin A Davis, et al http://bjsm.bmj.com/content/
The Concussion Recognition Tool 5th Edition (CRT5): Background and rationale Ruben J Echemendia, et al http://bjsm.bmj.com/content/ REVIEWS
What is the definition of sports-related concussion: a systematic review Paul McCrory, et al http://bjsm.bmj.com/content/
What are the critical elements of sideline screening that can be used to establish the diagnosis of concussion? A systematic review Jon Patricios, et al http://bjsm.bmj.com/content/
What tests and measures should be added to the SCAT3 and related tests to improve their reliability, sensitivity and/or specificity in sideline concussion diagnosis? A systematic review Ruben J Echemendia, et al http://bjsm.bmj.com/content/
What domains of clinical function should be assessed after sport-related concussion? A systematic review Nina Feddermann-Demont, et al http://bjsm.bmj.com/content/
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Course Review Course Review: SPNZ Level 2 - the Lower Limb in Sport
AVENY MOORE On 20th and 21st of May SPNZ held its second Level 2 course, this time covering the Lower Limb in Sport. It was presented at AUT by Justin Lopes (physiotherapist), Dr Peter McNair (Professor of Physiotherapy) and Geoff Potts (physiotherapist, clinical educator and DHSc Student). The venue allowed for practical sessions and use of the AUT physiotherapy gym equipment which was a great way to get some hands on practice as well as mentoring and feedback around examination techniques and exercise prescription. Peter McNair opened with biomechanical principles related to rehabilitation which provided us with the science behind sport-specific demands and their potential effects on healing and pain processes. Refreshing and updating knowledge around the pathophysiology of muscle healing in relation to rest, mobilisation, ice and non-steroidal anti-inflammatory drugs was a valuable boost to clinical decision making whether on the side line or in the clinic. Discussion around the conflict between short term versus long term outcomes, early return to sport vs long term outcomes and the reduction of co-morbidities long term was excellent and stimulated us to keep translating our knowledge base into clinical practice. Geoff Potts as well as being a skilled experienced physiotherapist is a numbers and systems junkie and over the weekend shared his knowledge around knee examination and a systematic approach to rehabilitation. He discussed periodisation of rehabilitation, programming rehabilitation through the application of exercise principles, increasing tissue capacity and using knowledge from specific measures
to build specific, generalised, and functional exercise programmes. He was able to share clinical tips and encouraged a more scientific understanding behind the way we prescribe exercise to our sporting population in particular. Geoff also covered the assessment and treatment of calf and hamstring injury and we all enjoyed the gym sessions discovering that walking backwards on the treadmill even at 5km/hour is challenging on many levels and an excellent “reveal” of a client’s readiness for return to running and sport. Justin Lopes, with his wealth of experience in football and roller derby, covered the sporting foot and ankle. Again, a thorough practical session on assessment was valuable as was Justin’s clinical experience around considering how we communicate both with our clients and other members of the sports medicine team. We rounded out the weekend with several case studies and we all felt more able to create a thorough treatment plan. In my area of practice I see active baby boomers, weekend warriors and sporty kids, rather than elite sports people, however the application of principles learned on the SPNZ courses is relevant to all levels of activity. As sports physiotherapists, we encourage exercise across the age span and understanding how to develop and progress an exercise programme to rehabilitate our clients is crucial to their recovery. We need to be able to communicate this to them and discuss management with others involved in their recovery. I encourage anyone interested in improving their sports physiotherapy skills to take part in the education pathway SPNZ has developed.
Dear Physiotherapist You are invited to take part in an international osteoarthritis (OA) research study being conducted by the University of Otago, AUT, and international collaborators. This study is investigating confidence in disease knowledge and clinical skills and attitudes related to OA care. The survey will be completed by physiotherapists, GPs, and nurses in NZ, Australia and Canada. The data will be used to inform the development of online elearning resources for primary care health professionals that can be accessed free of charge. By completing the survey you can also enter the draw for a $500 Prezzy Card and download a certificate of participation for CPD purposes. Click here to access the survey and more information (or copy and paste the full URL into your browser: https://tinyurl.com/survey-OA). If you have any questions, ben.darlow@otago.ac.nz or peter.larmer@aut.ac.nz. Ben Darlow, Senior Lecturer University of Otago, Wellington
Peter Larmer, Associate Professor and Head, School of Clinical Sciences, AUT University, Auckland
Phone 04 918 6051
Phone 09 9219999 ext 7322
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Classifieds
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Classifieds DUNEDIN Integrated Health Otago Physiotherapist Integrated Health Otago (IHO) is a multi-disciplinary clinic based in Dunedin, New Zealand. We are looking for a highly motivated, dynamic, physiotherapist interested in manual therapy and functional rehabilitation to join our experienced team on a full time basis. At IHO our vision is to provide our clients with quality evidence based health care through a multi-disciplinary approach. The successful applicant will be working in an enthusiastic and friendly team alongside osteopaths, physiotherapists, a digestive health practitioner, an acupuncturist and traditional Chinese medicine practitioner. Our clients cover a wide spectrum from acute sports injuries to those complex patients with multiple pathologies. You will be provided with ample opportunity to learn and develop manual therapy skills and diagnostics with weekly in-services training, with external courses actively encouraged. IHO has contracts with local and national level football teams, ranging from junior to senior male and female teams. The successful applicant will be mentored in on field triage, assessment treatment and functional rehabilitation. If you are interested in this professionally challenging position and gaining experience in a national level sporting environment, please send your expression of interest and a copy of your CV to Deb Webb at enquiries@integratedhealthotago.co.nz
PALMERSTON NORTH Churchyard Physiotherapy Musculoskeletal Physiotherapist We are busy and need someone great to fill a new fulltime permanent position starting June/July 2017. We have two clinics – one in central Palmerston North that was completely rebuilt and expanded in 2014 and has hand therapists on site. The other is the Massey University Student Health Physiotherapy clinic, situated on campus. Both clinics are fully computerised using Gensolve. We have the contracts with Manawatu Rugby. If working with sports teams is your thing then there are plenty of opportunities in this area. But it isn’t just about sports injuries – we treat a diverse range of clients so you will get lots of experience treating all musculoskeletal conditions including ACC Pain Service Clients. You will work in a supportive environment, with six other therapists and a great admin team. We have a regular inservice education programme and you will receive assistance with CPD. Our appointments are structured such that you have 40 minutes for new patient assessments and 20-40 minutes for follow-ups. Admin time is scheduled into the day. New graduates and new overseas arrivals are offered additional support and mentoring with senior staff on a one-on-one basis. Start date ASAP! Sign on bonus so contact us to today! If you are interested or just want to know more about the role: Check us out at www.churchyardphysio.co.nz. Call Fiona on 06 3548008 or 027 2203179 Email Fiona fiona@churchyardphysio.co.nz
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Classifieds