SPNZ BULLETIN PAGE
Issue 5 October 2016
Feature Dance Physiotherapy Members’ Benefits Online Journals FEATURE TOPIC: Dance Physiotherapy
PAGE 2
SPNZ Members’ Page Welcome to Sports Physiotherapy New Zealand SPNZ EXECUTIVE COMMITTEE President
Hamish Ashton
Secretary
Michael Borich
Treasurer
Timofei Dovbysh
Website
Blair Jarratt
Sponsorship
Bharat Sukha
Social Media
Timofei Dovbysh
Committee
Monique Baigent Rebecca Longhurst Justin Lopes
Visit our website www.spnz.org.nz CHECK OUT THESE LINKS
Join us on Facebook
List of Open Access Journals Asics Apparel and order form
Follow us on Twitter
Emma Mark EDUCATION SUB-COMMITTEE Hamish Ashton - chair
Sports Physiotherapy NZ
McGraw-Hill Books and order form Asics Education Fund information
Join us on Linkedin Groups
IFSPT and JOSPT
Monique Baigent Dr Angela Cadogan Justin Lopes Emma Mark Dr Grant Mawston Dr Chris Whatman BULLETIN EDITOR Aveny Moore SPECIAL PROJECTS Karen Carmichael Rose Lampen-Smith Amanda O’Reilly Pip Sail
ADVERTISING Deadlines for 2015: February Bulletin: April Bulletin: June Bulletin: August Bulletin: October Bulletin: December Bulletin:
31st January 31st March 31st May 31st July 30th September 30th November
Advertising terms & conditions click here.
ASICS EDUCATION FUND A reminder to graduate members that this $1000 fund is available twice a year with application deadlines being 31 March 2017 and 31 August 2017
Through this fund, SPNZ remains committed to assisting physiotherapists in their endeavours to fulfil ongoing education in the fields of sports and orthopaedic physiotherapy. An application form can be downloaded on the SPNZ website
CONTACT US Michael Borich (Secretary) 26 Vine St, St Marys Bay Auckland mborich@ihug.co.nz
sportsphysiotherapy.org.nz.
PAGE 3
Contents FEATURE TOPIC: Dance Physiotherapy SPNZ MEMBERS PAGE See our page for committee members, links & member information
3
EDITORIAL By SPNZ President Hamish Ashton
4
MEMBERS’ BENEFITS On-line Journals
5
FEATURE Inge Bahle - Dance Physiotherapist
6
PLANET OF THE APPS
3D4 Medical iMuscle 2
9
In this issue:
CASE STUDY OCD Case Study
11
SPRINZ How much is too much… Do you have any idea of the load your athletes are exposed to?
13
ASICS Running smarter to perform better: key considerations to improve your distance running performance
14
CLINICAL SECTION - ARTICLE REVIEW Dance Physiotherapy Article Reviews
16
Turnout for Dancers: Hip Anatomy and Factors Affecting Turnout
17
RESEARCH PUBLICATIONS JOSPT Volume 46, Number 10, October 2016
18
BJSM Volume 50, Number 19, October 2016
19
CONTINUING EDUCATION Local courses and conferences
20
CLASSIFIEDS Job Vacancies
22
PAGE 4
Editorial Hamish Ashton, SPNZ President or weird they might initially sound. Though from courses and the AGM suggest we are on track we are here to represent you, so if comments, ideas, suggestions or even please let Michael or me know.
feedback generally you have criticism
On a more personal note the winter season has just come to a close for me. It wasn’t a good year all round with our team coming last, so being relegated for next season. Over the year, we also had issues with some players and the club as a whole. For the first time, in I think 22 years on the sideline, I got to the end of the season and thought - did I enjoy the year? I, however, don’t feel ready to retire as yet.
Welcome to the October SPNZ bulletin with the topic of dance. Though dance technically falls under the category of Arts, I think it is common sense to recognise dancers as athletes. With the training they undertake and the physical capabilities they require, they match or surpass many an athlete. Thanks Inge for providing the feature article for this issue. Last weekend we had our first level two course – the Sporting Upper Limb. After many years of planning it has been good to see these under way. A big thanks goes out to Angela Cadogan and her team for getting this up and running. By all accounts it was an excellent course. On that note we have to apologise for the delay in the registration for the Level one exercises course coming out. We had good interest for it to be held in Wellington then found it really difficult to find an appropriate venue to hold it in. this has been sorted now and the registration process is underway. Please therefore try to support it so it goes ahead. This is the course that lets you do the level two courses The level two Special Populations course which was initially advertised for the end of November has unfortunately had to be postponed until early next year. One of the main tutors of the course was called in to a Silver ferns camp the weekend it was due to be held on so is now unavailable. New dates will be out as soon as we can organise them. In a couple of weeks’ time your SPNZ exec sit down for the weekend for a planning session. This is a big event on the exec calendar as we able to spend some time discussing where we want to go as a SIG without skype having breakdowns and dropping one of us out of the conversation on a regular basis. Though we haven’t done a questionnaire for a while asking for your opinions, ideas or future events, we are always open to ideas, however good
I have always seen my work on the sideline as a hobby. This my wife just can’t understand, as I am still being a physio, and working, albeit not for a decent wage. Living in Tauranga we often have to travel for games, and over the last 3 years we have travelled to play in Auckland every other weekend. These are usually a good 12 hour days. But me aside, it got me thinking about what we give to sport in New Zealand as sideline physiotherapists. Over the last 6 or more years I have been a judge on the Bay of Plenty Sports Awards. Doing this has always been challenging but also rewarding. I don’t know about other regions, but we rewarded the athletes, the coaches, and referees. There was also the occasional award for administrators. Nowhere were physiotherapists acknowledged for their role. Perhaps this was because we are considered “working” or perhaps there is no way in the system to acknowledge us. I suppose another question may be – should we even need to be acknowledged at this level? I, however, wish to recognise you for the time and dedication you have put in to the team you have worked with this year, be it the U12 beginners, or if you were away with our international athletes at the Olympics and Paralympics in Rio. Each team has its challenges and specialist skills, and requires a degree of commitment from us. This usually goes way beyond what we are paid. The work we do out there working with teams and athletes makes us as a physiotherapy group unique. So those who have finished for the season, pat yourself on the back for getting through the year and enjoy the weekends now that they are 100% longer. Those that are working over the summer, enjoy the upcoming season. At least the weather should be nicer to you. Hamish
PAGE 5
Members’ Benefits
There are many benefits to be obtained from being an SPNZ member. For a full list of members’ benefits visit http://sportsphysiotherapy.org.nz/benefits/ In each Bulletin we will be highlighting individual member benefits in order to help members best utilise all benefits available.
Free full text online access to JOSPT JOSPT is one of the top physiotherapy journals in the world. Scholarly and peer-reviewed, JOSPT features the latest evidence-based research and clinical cases in musculoskeletal and sports-related health, injury, and rehabilitation, including physical therapy, orthopaedics, sports medicine, and biomechanics. With 12 issues over the year it strives to offer high-quality research, immediately applicable clinical material, and useful supplemental information in a variety of formats.
British Journal of Sports Medicine British Journal of Sports Medicine (BJSM) is a multimedia portal for authoritative original research, critical reviews and timely debate in sport and exercise medicine (SEM) as well as clinical education and implementation success stories. BJSM’s web, print, video and audio material serves the international sport and exercise medicine community with the journal recognised as a leader in sports medicine social media.
Aspetar Bi-monthly hard copies of Aspetar delivered to your front door.
PAGE 6
Feature Inge Bahle
DANCE PHYSIOTHERAPIST Introduction This feature is not about sports medicine, but its little sister – dance medicine. It is less well known, but just like for sports, there is an international organisation – IADMS (International Association for dance Medicine & Science) that supports the dance medicine professionals, dance teachers and athletes, holds annual international conferences, has its own peer journal, supportive resources, a website and a growing membership world-wide. About myself: I grew up and did my undergraduate qualification in Germany, graduating in 1988. I went through the Kaltenborn/Evijent manipulative therapy courses, and got a postgraduate diploma in Brugger therapy before embarking on an OA that brought me to New Zealand. Meeting my (now) husband tramping on the Keppler Track, I decided to give New Zealand a go. On the way here I participated in a 6 month PNF course in California. I achieved full NZ registration in 1994 and continued my learning through attending NZMT and McKenzie concept courses, gained a Postgraduate Diploma in Rehabilitation through Otago University (2002), an International Diploma in MDT (2009) and a Masters in Physiotherapy looking at acute knee injuries (2012). During that time I mostly worked in private practice in Wellington, being director of Te Aro Physiotherapy in Wellington from 2003 – 2015. I presented on dancers and their injuries at the local sports medicine branch and presented on tibia stress fracture rehabilitation for a dancer at the Occupational Health Conference last year – together with Dr Jake Pearson. I sold my clinic in Wellington and resigned from my role as RNZB physio in order to move to Wanaka earlier this year and am now enjoying the new life style. I now see a lot of snow sports injuries..... How I become a dance physiotherapist I came to the world of dance medicine more by accident than through planning. My clinic was next door to the Royal New Zealand Ballet Company and when the Company looked for an in-house physiotherapist in 2005, I was approached. I looked after the RNZB dancers for the following 10 years, as well as the Footnote Dance Company, and dance students from Whitireia Performing Arts. I became a member of IADMS, attended the conferences when I could, subscribed to the Journal of Dance Medicine & Science and learned as much as possible about dance specific injuries and treatment. Over time, I became a dance physiotherapist, and loved it. A day in a life of a professional dancer and how I fit in RNZB dancers work from 9am to 5.30pm on 5-6 days per week. The day starts with a 90 minute “class”, that prepares them mentally and physically for rehearsals. The class has three distinct parts – warm-up on the barre, balance and turning exercises (pirouettes), then 30 minutes of jumps. Class is planned and executed by the ballet master/mistress, (dance coaches of which the RNZB has two), and is followed by at least three sessions of rehearsals – each about 90 minutes long. There is no off-season – the dancers perform 4 seasons per year, each split in roughly 6 weeks rehearsal time
and 6 weeks performing and touring. They usually have a week in between seasons to recover, and over Christmas 2 weeks. My role was to look after the dancers’ health (about 32 of them) and the job description evolved over time. Initially it was treating injuries as they presented themselves, but over time the role changed as I got to know the company and the demands on the dancers better and my focus changed – from being the ‘ambulance at the bottom of the cliff’ to injury prevention. Every new dancer to the company now is screened for injury risk, including screening for BMI, eating habits (if appropriate, with the nutritionist), hyper mobility (using the Beighton scale amongst other tools) and especially active turn-out and lower limb alignment in turn-out. (see pictures and articles). Based on that assessment, tailored injury prevention programmes are put in place and monitored regularly. Seasonal injury risk was also assessed and programmes were put in place accordingly – for example a calf rise programme, executed during daily class, to prevent posterior impingements and TA problems from increased pointe work. It was introduced for the “Swan Lake” season many years ago, but was so successful that it was kept going for classical seasons. What are your specific areas of interest/research? In one word: injury prevention. The ratio overuse to CONTINUED ON NEXT PAGE
PAGE 7
Feature Inge Bahle - Dance Physiotherapist continued... What do you think are the key elements in successfully preventing injury in dance? 1. Screening for risk factors, such as previous injuries, hyper mobility, potential bone density issues (female triad, but some male dancers also have issues), alignment, strength and correct turn-out. However, screening alone is useless. It needs to be accompanied by personalised and tailored programmes (multidisciplinary in some cases) to address deficits. Those programmes need to be monitored and changed over time to ensure progress.
acute injuries is 2:1 in dance. And overuse injuries, at least in theory, are preventable. Early intervention and load management are the two key ingredients. To get the dancers on board a lot of education had to happen – especially around the fact that reporting a niggle does NOT mean to stop dancing. Physiotherapy hours were changed to lunch and after work – so dancers did not need to come out of rehearsals. Treatment happens in the “green room”, the dancers “hang-out” place, making it easy to pop in and casually mention a niggle. Dancers realised that small changes to their work load – like reduced jumps, or pointe work in class, for a short period of time, can prevent serious problems. A massage therapist was introduced, an ice machine was bought, gym-programmes were developed and it became “normal” to use the gym across the road for extra work outs on “easy days”. Dancers and artistic staff were educated every step of the way and, once results could be seen, were supportive. Tibia stress injuries and posterior ankle impingements reduced and to compare injury statistics over the years, it is very rewarding to see serious injuries reduce. What are the types of injuries you commonly see? As mentioned earlier, overuse injuries rate highly. So I see a lot of bone stress, typically in the 2 nd metatarsals, which take the brunt of the load when on pointe, or midshin in the tibia, most likely due to the torsional component of loading – landing in over-turn-out and poor alignment. Common are also lower limb tendinopathies – in the Achilles, patella and – more specific to dance – FHL (flexor hallucis longus)and tibialis posterior tendons. Knee and lumbar spine injuries feature under acute injuries and I have seen three ACL ruptures over those 10 years.
2. Getting the balance between intense training and recovery right, and that is different for every dancer, depending on individual risk factors, current work load and performance roles, and level of experience. The physiotherapist is there to walk alongside the dancer throughout and ‘tweak’ the load according to symptoms, as well as trying to create a supportive environment by educating artistic staff and choreographers. However, the main responsibility lies with the dancer/athlete to ensure symptoms are kept under control. Extremely difficult in a culture of ‘more is better’ and ‘the show must go on’ – dancers face extreme pressure to keep going, irrespective of injury status. Who else is involved in the “support” team that you communicate with and how do you integrate with them to optimise injury prevention and rehabilitation? Just before I left the Company, the support team consisted of the following: an in-house massage therapist, an in-house (dance specific) Pilates instructor, a conditioning team, two nutritionists (one specialised in sports, one in eating disorders), an associated sports physician, psychologist as needed, the Company ACC case manager, the artistic director and ballet master/ mistress, and me. Weekly meetings between the main team members, discussing work capacity of individual dancers and cross-refer for specific rehab, followed by
CONTINUED ON NEXT PAGE
PAGE 8
Feature Inge Bahle - Dance Physiotherapist continued... emails to keep everyone in the loop are the main ‘structured’ means of communication. Much is relied through casual communication, though. As most is happening in-house, it is easy to just walk over to the rehearsal studio or Pilates room to clarify an issue or ask a question Are you involved in performance aspects for your clients? Yes, often. Most of the injury prevention programmes also lead to performance enhancement. For example: 1. A deep squatting and plyometrics programme for the season “Petruska” led to less male dancers off with patella tendon injuries. One part of the performances required cassock-style dancing with deep squat and split jumps. The dancers also performed faster and higher jumps as a result. 2. A tailored plyometrics programme for the whole company was added on after class three times per week for 4 weeks to improve jumping height for a classical season. Once the programme finished, some of the male dancers continued in their own time as they found it enhanced their performance on stage. 3. Traditional dance training does not prepare the cardiovascular system for performance on stage. A high intensity cardio programme introduced two to three times per week for 20 minutes straight after class prepared the dancers for longer performances. Initially frowned upon by artistic staff, they soon noticed that dancers also could be rehearsed to a higher intensity. What are the key attributes you feel are required to work with elite level athletes? 1. Communication skills are the key to any good therapist-patient relationship. However, they are even more vital in an environment where so many stakeholders are involved and decisions need to be made quickly. Good communication is key to the athletes trusting the therapist and buying into the often unpopular treatment regime. Effective communication is needed when dealing with coaches and managers, who need to know when the athlete is ready for what amount of loading. 2. A willingness to learn and listen and be part of a team. That also means having an in-depth knowledge of the particular environment the athlete is in – the specific sport/dance, training schedule, touring schedule and what happens when on tour and away from their normal and usually controlled environment, eating habits at
home and on tour, personal issues that can impact on performance. Again – listen and learn and adapt accordingly. What do you see as the major challenges for sports and dance physiotherapy? PNZ is currently in an environment of change and it is the challenge and opportunity for Sports Physiotherapy NZ to create a strong voice within the new frameworks, as well as building stepping stones to a career path towards specialisation. Sports medicine is a field of its own, with dance medicine being a smaller sub-part, both including performance enhancement and screening for musculoskeletal, neurological, nutritional and mental well -being of the athlete. One of the challenges for therapists working in the field of dance is the constant clash between traditional and modern, sports medicine inspired training methods. Dancers are seen as artists, not high performing athletes. Introducing new training concepts from the world of sport is seen as betrayal of the art form and met with strong resistance. It is the challenge for any aspiring dance physiotherapist to introduce smarter ways of training for dancers, while still respecting the tradition.
PAGE 9
Planet of the Apps Your monthly App review by Justin Lopes - Back To Your Feet Physiotherapy, SPNZ executive member.
Hi team, This edition of the app review is slightly different as along with the usual app review I would like to let you all know about a new online learning module that has been developed for FIFA that I have found to be really useful and engaging over the last couple of months – check out the information at the end of my section for a link on where to go to find more information.
App: 3D4 Medical iMuscle 2 What it is used for:
Exercise prescription based on anatomy used
Category:
Health & Fitness
Updated:
3.9.6
Version:
3.8
Size:
297 MB
Language:
English
Seller:
3D4Medical.com © 3D4Medical, LLC 2014
Rated:
4+
Requires:
Requires iOS 6.0 or later. Compatible with iPad.
Cost:
$6.99 inc GST on iPad, $3.99 on iPhone
Pros: Great for demonstrating how muscles work and what their actions are. You can review your anatomy and the little GIF’s of people doing the exercises are useful to remind yourself about technique. You can keep your progress and history of the workouts you do within the programme. You can search by exercise, muscle, equipment for different exercises.
Cons: You can’t currently send the programs from Apple supported products to Android and both the sender and receiver need to have downloaded the App for the receiver to be able to see the workout you have sent them. No proprioception exercises (although you could add your own). Does take up some storage space (363MB) before you add any extra data to it.
It has over 600 different exercises stored in the app. You can add your own exercises by uploading photos This is great if you want to share workouts with someone who needs visual cues about how to perform the exercises. You can create your own workouts, add your own exercises, and edit the numbers of sets, types of weights (eg kettlebell, bodyweight, dumbells etc). You can click on specific muscles and see what the action of the muscle does (although don’t expect the little GIF to be too specific with the movements particularly with muscles that work over 2 joints. It also shows what secondary muscles are used in a movement. I reckon this is great value for money. But 3D4 also sell this in a bundle with some of their Essential Anatomy apps – all of which are useful and are very well presented. Overall Rating: 4.85/5
CONTINUED ON NEXT PAGE
PAGE 10
Planet of the Apps App: 3D4 Medical iMuscle 2
Along with the BJSM Learning Modules that Tech Savvy Tim reviewed in an earlier edition of the App reviews, another option for doing online learning modules is the FIFA Diploma in Football Medicine. The FIFA Diploma in Football Medicine is a free online Diploma that has been edited by Dr Mark Fulcher and its primary objective is to help disseminate evidence-based information used by health practitioners when managing football players, and to improve the care of football players and other athletes around the globe. The diploma is free of charge, 100% online and allows the possibility for users to complete it at their own pace. You complete modules by clicking through the pages, listening to Soundcloud or podcasts and watching digital training modules on you tube. There is a multiple choice question and answer section at the end of each module that you need to get 100% to pass the module… but you are allowed to have unlimited goes at it! I have found this resource to be engaging, well presented, up to date and very interesting and there is a wealth of information to anybody who is looking after athletes on the diploma. It is easiest to do on a tablet or PC but I have completed modules on my Iphone – best to do when you are connected to WIFI as some of the videos can use up some data. Head to http://f-marc.com/footballdiploma/ to register and start completing your modules now! I’ll race ya. Happy apping… Cheers, Justin For further discussion on this App check the SPNZ LinkedIn forum page Click here
PAGE 11
Case Study OCD Case Study Introduction Increasingly children are self-referring themselves to sports physiotherapy practices. As children are a special population of their own, and injuries and management of children and adults differs, it is important that they are treated as an entity of their own rather than as small adults. This case study outlines an interesting presentation of an acute haemarthrosis of the juvenile knee Patient Presentation Eight year old girl presented to physiotherapy with her mother, with a swollen and painful knee. The patient reported slipping, twisting and falling whilst running during physical education at school. This was accompanied by a collapse of her knee and a popping sensation. The injury was followed by immediate swelling pain and inability to weight bear. Patient described a progressive tightening and stiffening of the knee as the day progressed. Patient at this time reported no previous knee injuries. During objective examination the patient was questioned about a scar on her knee, which it transpires was from the ‘last time my knee gave out’. Patient reported similar mechanism of injury and signs and symptoms, but the knee settled within a day. No significant medical history. Patent otherwise fit and healthy. No medications. No family history of bleeding disorders. Objectively patient presented with tense haemarthrosis of the knee, antalgic gait, and restricted knee range of motion (flexion and extension). Testing revealed; a negative Lachman’s test, no patella apprehension and some pain provocation with some meniscal tests. Initial treatment of the patient consisted of; immediate xray referral with low threshold for referral to orthopaedic specialist, relative rest, gentle range of motion exercises and ice, compression and elevation to control and relieve inflammation and pain. Review of the patient happened after the weekend, at which time x-ray had not yet been undertaken, as they were hoping it was not required. At this time, it was re-iterated to the patient’s guardian that x-ray was essential for the correct diagnosis to be ascertained and therefore the instigation of the correct treatment and management for this condition. X-ray was indicative of Juvenile osteochondritis dissecans (JOCD),the separation of an articular cartilage subchondral bone segment from the articular surface in skeletally immature children, with a potential bony tumour sitting behind the JOCD. MRI confirmed a Stage III lesion implying that the articular cartilage breached, high signal changes behind fragment
indicating synovial fluid between fragment and underlying subchondral bone 1 (Robertson et al). The patient went forward for surgical repair of the JOCD. Goals and Key Treatment Elements The first goal for this patient was to establish a diagnosis to ensure correct treatment and management was initiated as soon as possible. As x-ray for indicative of a significant JOCD with potential bony tumour, primary management for this patient fell outside of the scope of practice for a sports physiotherapist. Therefore onward referral to an orthopaedic surgeon was undertaken. Sports physiotherapists are often the first practitioners to see these patients who self-refer to private practice clinics. It is therefore imperative that, as a profession, we have an understanding of this special population and treat them accordingly. Key Case Point Seeing an acute haemarthrosis in a child is unusual and did not sit well with us. Immediate referral for imaging was the key in this case. This case was also a lesson in trusting your gut when something just does not feel right about a patient. Discussion An acute haemarthrosis in a child or adolescent signifies a significant knee injury. There are several underlying conditions that may cause an acute haemarthrosis in the knee, such as: patella dislocation, ligament rupture, osteochondral defect, intra-articular fractures or meniscal tear 2,3, however no consensus exists in the literature as to which one is most commonly the culprit. This is likely due to the differences in study designs, populations and study inclusion criteria. Matelic et al2, found that 14 of their 21 subjects (children aged between 10-14 years of age) with acute haemarthrosis had a patella or lateral femoral condyle JOCD and only two were found to have an anterior cruciate ligament (ACL) rupture. This differs from Stanitski et al 3 who found JOCD lesions accounted for
CONTINUED ON NEXT PAGE
PAGE 12
Case Study OCD Case study continued only 7% of the acute haemarthroses in 70 children (aged 7-12 years), with the majority of subjects had sustained a meniscal tear (47% of preadolescents, aged 7-12 years, and 45% of adolescents, aged 13-18 years) and ACL ruptures (47% preadolescents and 65% adolescents). The older population in the Stanitski study may account for some of this difference. A more recent study 4, with a larger study population, found lateral patella dislocations, ACL ruptures and anterior tibial spine fractures, respectively, to be the most common causes to acute haemarthrosis in 117 children aged between 9-14 years. Although all three of the aforementioned studies, 2,3,4, did not report similar pattern in terms of the underlying condition causing the acute haemarthrosis, all agree that imaging is needed to ascertain diagnosis. The earlier studies, 2,3, both advocate for arthroscopic intervention whereas the later Askenberger study4 utilised first plain radiograph, then MRI. The call for arthroscopic surgery in the earlier studies likely predates the generalised use and increased precision in diagnostic ability of, MRI. Looking more specifically at JOCD of the knee, Robertson et al1 recommend plain radiographs in the first instance, including anteriorposterior, lateral, tunnel and skyline views to ascertain diagnosis. MRI is heralded as the gold standard in JOCD imaging due to; higher diagnostic accuracy, clearer depiction of lesion size and location and the ability to follow the progression or healing of the lesion. Recurring haemarthrosis in younger children, especially in the knee, elbow and ankle, although rare, may be indicative of haemophilia and needs to be treated and managed rather differently than a musculoskeletal injury to the young knee.
Conclusion and Reflective Statements Children are not simply younger adults but a special population of their own. Being aware of paediatric conditions and diagnoses is paramount for sport physiotherapists. An acute haemarthrosis in a child’s knee children requires imaging to ascertain underlying condition and ensure correct treatment and management is instigated References 1. Robertson, W., Kelly, B.T. & Green, D.W. (2003). Osteochondritis dissecans of the knee in children. Current Opinion in Pediatrics, 15, 38–44 2. Matelic, T.M., Aronsson, D.D., Boyd, D.W. & LaMont, R.L. (1995). Acute haemarthrosis of the knee in children. American Journal of Sports Medicine, 23 (6); 668-671. 3. Stanitski, C.L., Harvell, J.C. & Fu, F. (1993). Oberservations on acture haemarthrosis in children and adolescents. Journal of Paediatric Orthopaedics. July/ August. 4. Askenberger, M., Ekstrom, W., Finnbogason, T. & Janary, P-M. (2014). Occult intraarticular knee injuroes in children with hemarthrosis. American Journal of sports Medicine, 42(7), 1600-1606.
Authors: Rebecca Longhurst and Sarah-Anne Astwood
With the increase of children seen in private practice by sports physiotherapists, the importance of seeing them as children rather than as little adults can be crucial. Adults and children presenting with the same mechanism of injury and signs and symptoms, may in fact be presenting with very different conditions. As sports physiotherapists we are often the first practitioners to see these patients and we need to be sure we are diagnosing them correctly and refer them on as needed.
What was your original impression of what was going on? What was the process to final diagnosis? In hind sight is there anything you would do differently? Do you have any clinical tips on this injury? For answers to these and further discussion check the SPNZ LinkedIn forum page Click here
PAGE 13
SPRINZ
How much is too much… Do you have any idea of the load your athletes are exposed to? By Kelly Sheerin The battle against overuse injuries in sport has recently taken on a new look. Improvements in wearable sensor technology have made devices lighter, cheaper and more user-friendly. These technological advancements have meant that training load monitoring is increasingly popular in sport to ensure athletes achieve an adequate training stimulus, but minimise the negative consequences of training (injury risk, overtraining). Training load can take many forms, from heart rate, GPS or even power measures from bikes, but until recently this information has been of little use to sports medicine practitioners. In a recent British Journal of Sports Medicine blog, Dr John Orchard [1] proposed hypothetical relationships between training (both under-training and overtraining), injury, fitness and performance. He speculated that both inadequate and excessive training loads would result in increased injuries, reduced fitness and poor team performance. We know that a typical runner will strike the ground more than 1000 times per kilometre, and this repetitive impact loading is thought to play an important role in the pathophysiology of many common injuries. Similar relationships also exist in team sports where explosive jumping and landing activities are involved, such as basketball, volleyball and netball. Most practitioners take the view that any injuries that could be ‘training load-related’ are preventable. However, until recently we’ve lacked the ability to measure training load, making this difficult, if not impossible area to navigate. While still very useful for overall monitoring, trunkmounted GPS units, that have been widely employed for a number of years, may not be effective in monitoring loads experienced by the musculoskeletal tissue of the lower extremities [2]. It is only quite recently that inertial movement sensors (IMU’s) have burst onto the sports scene, and these devices show more promise in this regard. By mounting these devices to locations like the tibia, they enable the collection of real-time and in-game movement related information. The information collected from these sensors can act as a surrogate measure of the loads experienced by the underlying musculoskeletal tissue, which could be potentially useful for guiding clinical decisions.
Now that the measurement challenges are being solved, we need to establish analysis techniques that will provide useful information. For this we can borrow from Bioengineers who have been working in this area for decades. For example, the ‘daily load stimulus’ is a metric of cumulative bone load, which describes the relationship between mechanical load stimuli and skeletal tissue remodelling as a function of the stimulus. This is a product of the magnitude of the loads and the number of load cycles (or frequency) of these loads [3]. SPRINZ researchers and practitioners are actively working in this area to gain a better understanding of how load relates to injury and performance. In collaboration with innovative NZ company IMeasureU, IMU’s are being used with a large number of runners to better understand the loads experienced under different conditions. Additionally, the NZ Breakers are being monitored in all games and training sessions throughout the 2016-2017 season. Lower limb loading information is being fed back to their physiotherapist, to assist in his player management. While there are many questions yet to be answered, you can guarantee that in the next few years, athletes who train and compete without wearable technology will be a rarity. Physiotherapists can, and should, engage in this technology to unlock some of the clinical problems we have experienced for years. References 1. Orchard J. Who is to blame for all the football injuries? Br J Sports Med 2012; June 20, guest blog. http://blogs.bmj.com/bjsm/2012/06/20/who-isto-blame-for-all-thefootball-injuries/ 2. Gabbett TJ. Br J Sports Med 2016;0:1–9. doi:10.1136/bjsports-2015-095788 3. Beaupre GS, Orr TE, Carter DR. An approach for time-dependent bone modeling and remodelingapplication: a preliminary remodeling simulation. Journal of orthopaedic research : official publication of the Orthopaedic Research Society 1990;8(5):662-70
PAGE 14
ASICS
Running smarter to perform better: key considerations to improve your distance running performance. By Chris Bishop Head of Biomechanics, The Biomechanics Lab, South Australia Spring is a great time of year. The sun comes out, the days get longer and the recreational running season starts to ramp up. In my opinion, it is also the most important time of year for health professionals in terms of the advice they can give aspiring runners. In a job where my role is to increase the performance of runners whilst at the same time reducing their running injury risk, I often get asked what makes the elite, well elite?! The answer is simple. Discipline. Day after day, run after run, these athletes realise there are no shortcuts on the road to the podium. It takes tenacity, commitment, and an unresolved will to achieve each goal they set. Yet the difference between those who make it, and those that don’t, comes down to application. In a society with too many choices and too little time, it is natural inclination to revert to old habits and practice what we have always done. This is the easy choice right? It’s hard enough just to get up and out of bed to commence that run, never mind find the energy and thinking power to consider the influence of all potential variables and how they might affect the time we clock. However, the problem is that we are all competitive beasts, with defined goals and we want to achieve our best every time we hit the road. We want to drop minutes not seconds off our times, we want to be more efficient, we want to run further, we want to win. So to achieve those goals that are simply the beauty of human nature, the philosophy I try to translate to all of the runners who visit our lab, is there is more to running than simply running itself. Preparation is everything. Improved performance requires a new insight and approach to running preparation that will force you out of your predictable perceptions, and have you running smarter and better than ever before. Next I detail my five go to strategies.
Use SMART goals (Specific, Measurable, Attainable, Relevant and Time Framed) It is important that runners have a clear understanding of the reasons for them deciding to run. This sounds kind of counter-intuitive, yet the number of runners we see in the lab who have no purpose, who have no goal…they end up lacking motivation and ultimately revert back to sitting on the couch. Helping runners to develop SMART goals creates a purpose and direction for training that also helps with motivation. Further, there is benefit in short term and long term goals. Having a long term goal is important, but creating short term goals that will help an athlete get there is crucial. There is more to footwear choice than colour – think performance optimisation and injury risk. We know runners buy shoes based on looks, price and comfort (and often in that order!). You can’t argue that they are some of the most important factors known. But what happens if I say shoes can improve a runner’s performance and help reduce injury? This has now been confirmed with research. Recent research out of our Gait Lab at UniSA by Joel Fuller says that simply wearing a lightweight shoe can improve running performance by 2% (average 22 sec) over 5kms. Despite this logical benefit, it comes with caution; you put a heavy runner (i.e. > 85kgs) in a light weight shoe and they are twice as likely to get injured than if running in a traditional shoe! What has also been shown to be a good idea in terms of injury prevention is the concept of two shoes. Mixing up your training footwear. Research out of Europe has shown using two different shoes (e.g. lightweight for short distance and speed work and traditional shoes for long runs) in your training mixes up the input signals applied to the body which in turn reduces injury risk. Simple take home message – prescribe/recommend shoes on a protection weight scale, with the right shoe
CONTINUED ON NEXT PAGE
PAGE 15
ASICS Running smarter to perform better continued... being fitted for the individual running in it and the volume included in their program. Oh and it has to be comfortable too! Form over fatigue…at least to start with Too often we see novice runners who are preparing for their first distance running event being more consumed with the concept of running and lasting 40 odd km than whether they can efficiently run 5km’s in the first place, without succumbing to injury. Distance running training imposes a high load on the body, and often a higher load than an individual has ever experienced before. What influences an individual’s personal injury risk is the body’s ability to adapt and handle the repetitive load applied to it. And remember these loads change the quicker we run, the more we run and also depend on the surfaces we run on and the shoes we wear. The simple solution for all runners is that they need an experienced professional to watch them run, screen their body for weaknesses, and iron out any inefficiencies that may also place them at increased risk of injury. Once we have the form sorted, we can then worry about fatigue. In the presence of signs of fatigue (especially on a long run), it is wise to rest or decrease the intensity of your run in order to complete it with good form and technique. Yes, it is possible to undergo advanced testing (e.g. VO2 Max, Lactate Threshold etc.) to understand your physiological profile. The results of these tests provide strategies to assist the runner to identify and train at their optimum physiological condition which in effect, helps improve running performance and reduce the impact of fatigue. Yet remember, no fancy physiological test is a substitute for a poor running technique, and often a gait analysis will provide the insights you need to run further and longer than ever before. Mobility, strength and physical conditioning are the most important factors in reducing running related injuries. To perform, you need to be running. We know that by simply running, you have a 40-70% chance of sustaining a running related injury. There are numerous factors involved in the development of musculoskeletal injury, and often this is isolated as needing optimum strength. However, as health professionals we know that developing mobility (and promoting full range of motion) is just as important as
strength. If an athlete does not have the mobility available to move freely through a required range, strength alone will not save them from injury. In saying this, a stronger body with better movement patterns will be less likely to get injured! And remember there is a lot of factors that influence strength and pure ballistic power is not the be all and end all. The key in any strength program that will be of success for a runner is one that is customised to individual running loads, and aims to improve dynamic strength, control, and core stability during single limb support tasks. And unfortunately for females, the luck of being able to give birth to those darling children requires a little more attention to lumbo-pelvic control. Pilates really is a godsend for runners – the quicker you embrace it, the quicker you will reap the benefits. Mix up your training…and don’t let it be set in concrete. Running programs that use variations in terrain and intensity promote better lower limb control and adaptations. This ultimately helps decrease the risk of injury. It also breaks up those mundane circuit runs and keeps you interested and motivated, no matter the weather. When you and your coach decide it is time to progress your training, this is where we can again be creative. Progression doesn’t mean its always about the distance run - Exercises and programmed runs can be progressed by being performed faster, longer, more often, or with less rest. And don’t forget the magic of rest. Training sessions aimed at recovery and/or injury prevention have better compliance when they are regularly scheduled in to a program. Making them a routine from the start of a program works better than trying to implement them when an athlete begins to break down. So that’s the spiel we give to our runners in our lab. Before things get too specific or complicated, it’s a matter of getting the basics right. It’s about understanding why you run and where you’re running towards. It’s about running correctly and efficiently. It’s about having the right shoes for your program, and preparing and ensuring your training incorporates components to promote mobility, flexibility, strength, dynamic control and endurance. And don’t forget that variation is a good thing! Get all that right, and you will have your patients running better and further than ever before!
Chris Bishop content provided through our support from our SPNZ sponsor – ASICS
PAGE 16
Clinical Section - Article Review Dance Physiotherapy Article Reviews A statistical paper that assessed the results of an anonymous questionnaire to 184 dancers in the USA produced results in line with other groups of dancers. Injuries in professional modern dancers: incidence, risk factors, and management by Shah et al J DanceMed Sci 2012 reported that 82% of dancers suffered between one and seven injuries. The foot and ankle was the most common (40%) with fewer injuries of the lower back (17%) and knee (16%). The rate of injury was only .59 per 1000 hours. With females returning to full dancing at a median of 18 days and males at 21 days. Other statistical findings may not be so relevant to NZ dancers as it related back to Workers Compensation insurance and the practitioners they saw. Following on from the Turnout for Dancers (as reviewed by Pip on next page), a resource paper on Supplemental Training has been produced by the IADMS. (International Association for Dance Medicine and Science). This paper provides an overview of useful conditioning exercises and imagery work for improving a dancers’ turnout. We all understand that muscles find it harder to work when in a biomechanical disadvantage with poor alignment and that good alignment and muscle balance in the lower leg will contribute to stability and control of turnout. The three key areas that dancers need to work on are: 1)Core support and maintenance of a neutral pelvis. Exercises focus on engaging the abdominal musculature with mutifidi and the pelvic floor. Use of therabands and swissballs further challenge the dancer. Stretches of iliopsoas and lumbar extensors are also advocated. 2)Hip musculature to enhance turnout. This primarily involves the deep lateral rotators as well as gluteal muscles. The key components are identifying lateral rotation without clenching the gluteals and then maintaining external rotation through a variety of hip movements. Both external and internal rotators will also need to be stretched. 3)Lower limb considerations. The lower limbs need to be aligned so that the weight of the body is supported evenly throughout the foot. Exercises addressing muscle recruitment and awareness needs to be developed transferring from stance through to travelling. It is important to stress that turnout from the lower leg is not encouraged. A further paper from the IADMS discusses Dance Fitness. This stresses the need to expand the concept of fitness away from formal dance classes and to generate good all round fitness but not distracting from the artistic expression so vital to dance. A specific dance aerobic fitness test (DAFT) has been developed to help gather relevant data on Dancers. Good fitness is key to reducing injury risk and enhancing performance. Emphasis needs to be placed on incorporating all components of a fitness programme. There are: 1) Aerobic, and 2) Anaerobic fitness; 3) Muscular endurance 4) Strength and 5) Explosive Power exercises; 6) Flexibility; 7) Neuromuscular co-ordination skills associated with balance and agility; 8) Assessment of body composition and finally very importantly 9) Rest. Research confirms that students perceived positive physiological adaptations by adding a dance fitness class alongside their regular technical classes. With all supplemental training the main concern is not to interfere with key artistic and aesthetic requirements of dance.
By Rose Lampen-Smith
PAGE 17
Clinical Section - Article Review Turnout for Dancers: Hip Anatomy and Factors Affecting Turnout Virginia Wilmerding, Ph.D. and Donna Krasnow, M.S., International Association for Dance Medicine and Science
www.DanceEducation.org
Introduction
lower limb joints. There are five main anatomical factors:
‘Turnout’ describes the position of the legs in which each leg is rotated away from the midline as observed from the front. ‘Ideal’ turnout has been identified as 18 degrees of external rotation of both legs combined. The anatomy of the hip and pelvis creates limitations of this expectation. The hip is designed more for stability than mobility compared with its upper limb counterpart and thus has a deeper socket and stronger ligaments.
Angle of femoral anteversion (increased anteversion reduces turnout; decreased anteversion or retroversion increases turnout)
Bones of the Hip Joint The pelvis is made up of a fusion of three bones: ilium, pubis and ischium. Each bone contributes to the acetabulum. They are connected anteriorly by the symphysis pubis and posteriorly between the innominate bones by the sacrum. Dense ligaments hold the pelvis to the sacrum creating a slightly mobile junction called the Sacroiliac joint. The femur is located in the acetabulum and has movement in all three planes limited by the capsule and ligaments. Capsule and Ligaments of the Hip Joint A fibrous sleeve of connective tissue encloses the bones of the hip joint. The capsule holds the femoral head in the hip joint and stabilises it. The capsule is reinforced by three major ligaments, each of which is attached to one of the three bones of the hip socket and can be identified by its name. These ligaments become taught in hip extension and therefore contribute to the hip stability in standing. They are lax when the hip is flexed. The iliofemoral ligament extends diagonally across the front of the hip joint and strengthens the front of the hip joint resisting hip extension and inhibiting hip internal rotation. The pubofemoral ligament strengthens the back of the hip capsule, resisting hip abduction. The ischiofemoral ligament resists adduction and medial rotation. Muscles of the Hip that Create Turnout The large gluteus muscles extend and externally rotate the hip. Deep lateral rotators under the gluteals all run laterally spanning the back of the hip joint capsule and the ischiofemoral ligament and attach on or adjacent to the greater trochanter of the femur. Their function is to turn the leg relative to the pelvis by pulling the greater trochanter backwards. When the hip is flexed or abducted Sartorius is initiated and when the hip is extended and in partial turnout the adductors will create additional turnout. Factors affecting turnout Anatomically turnout comes from the hip, knee and
Orientation of the Acetabulum (increased sideways orientation increases turnout) Shape of the Femoral Neck (longer and more concave neck increases range of movement; shorter and less concave limits range of movement) Elasticity of the Iliofemoral ligament (tilting the pelvis forward increases hip flexion creating some laxity in the ligament and allowing greater hip rotation) Flexibility and Strength of the Musculo-tendonis unit (tight muscles restrict turnout thus good stretching techniques will improve turnout) Individual Anatomical Variations Summative contributions of the hip, knee, tibia and foot create turnout. Most dancers do not possess ‘perfect’ turnout without associated adjustment to the rest of the lower leg. At the tibia torsion can occur, medial torsion will adversely affect turnout and contribute to injury risk. The small bones of the foot allow a gliding at the arch and pronation of the foot can give a greater perception of turnout but increases medial stress and injury potential. The injury rate of the foot and ankle complex is the highest of all the joint systems in dancers. Conclusion External hip rotation and turnout are not the same thing. Turnout is presumed to be perfect when each leg is rotated 90degrees laterally. Available external hip rotation coupled with the various contributions of the tibia and foot rarely add up to this ‘magic’ number, there are many considerations of core support and alignment that must be considered to improve turnout. A full set of references are available on request. The three articles I have presented highlight the awareness that in dancers there is a prevalence of hypermobility that needs to be individually assessed and considered when planning a training program, treating the musculo-skeletal system or proposing a career in dance. Anatomically there may be considerable variance even within an individual that can be career limiting or place the dancer at risk for injury.
Review by Pip Sail, Physiotherapist
PAGE 18
Research Publications JOSPT www.jospt.org
JOSPT ACCESS
All SPNZ members would have been sent advice directly from JOSPT with regards to accessing the new JOSPT website. You will have needed to have followed the information within that email in order to create your own password. If you did not follow this advice, have lost the email, have any further questions or require more information then please email JOSPT directly at jospt@jospt.org in order to resolve any access problems that you may have. If you have just forgotten your password then first please click on the “Forgotten your password� link found on the JOSPT sign on page in order to either retrieve or reset your own password. Only current financial SPNZ members will have JOSPT online access.
Volume 46, Number 10, October 2016 EDITORIAL Whiplash Continues Its Challenge Preventable Injuries/Fatalities Due to Distracted Driving: A Call for a Coordinated Action Assessment and Management of Whiplash From the Emergency and Acute Care Setting: Care, Questions, and Future Global Research Needs CLINICAL COMMENTARY Mechanisms and Mitigation of Head and Spinal Injuries Due to Motor Vehicle Crashes Whiplash-Associated Disorders: Occupant Kinematics and Neck Morphology Pharmacological and Interventional Management of Pain After Whiplash Injury Recovery Pathways and Prognosis After Whiplash Injury Advancements in Imaging Technology: Do They (or Will They) Equate to Advancements in Our Knowledge of Recovery in Whiplash? MUSCULOSKELETAL IMAGING Cervical Spine Fracture With Vertebral Artery Dissection Unstable Os Odontoideum RESEARCH REPORT Whiplash Injury or Concussion? A Possible Biomechanical Explanation for Concussion Symptoms in Some Individuals Following a Rear-End Collision An Investigation of Fat Infiltration of the Multifidus Muscle in Patients With Severe Neck Symptoms Associated With Chronic Whiplash-Associated Disorder Are People With Whiplash-Associated Neck Pain Different From People With Nonspecific Neck Pain? Morphology of Cervical Spine Meniscoids in Individuals With Chronic Whiplash-Associated Disorder: A Case-Control Study MicroRNA 320a Predicts Chronic Axial and Widespread Pain Development Following Motor Vehicle Collision in a Stress-Dependent Manner The Traumatic Injuries Distress Scale: A New Tool That Quantifies Distress and Has Predictive Validity With PatientReported Outcomes
PAGE 19
Research Publications British Journal of Sports Medicine www.bjsm.bjm.com Volume 50, Number 19, October 2016 EDITORIALS 2016 international consensus on femoroacetabular impingement syndrome: the Warwick Agreement—why does it matter? Joanne L Kemp, Ian Beasley http://bjsm.bmj.com/content/ Striving for multidisciplinary consensus on the diagnosis and management of patients with femoroacetabular impingement: more evidence is needed David J Hunter, Oliver Marín-Peña http://bjsm.bmj.com/content/ Small-sided football in schools and leisure-time sport clubs improves physical fitness, health profile, well-being and learning in children Peter Krustrup, Jiri Dvorak, Jens Bangsbo http://bjsm.bmj.com/content/ Time to be honest regarding outcomes of ACL reconstructions: should we be quoting 55–65% success rates for high -level athletes? Robert G McCormack, Mark R Hutchinson http://bjsm.bmj.com/content/
CONSENSUS STATEMENT The Warwick Agreement on femoroacetabular impingement syndrome (FAI syndrome): an international consensus statement D R Griffin, E J Dickenson, et.al. http://bjsm.bmj.com/content/ The Copenhagen Consensus Conference 2016: children, youth, and physical activity in schools and during leisure time Jens Bangsbo, Peter Krustrup, Joan Duda, Charles Hillman, Lars Bo Andersen, et.al. http://bjsm.bmj.com/content/ Athletic groin pain: a systematic review of surgical diagnoses, investigations and treatment Darren de SA, Per Hölmich, Mark Phillips, et.al. http://bjsm.bmj.com/content/ Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research? J L Cook, E Rio, C R Purdam, S I Docking http://bjsm.bmj.com/content/
PAGE 20
Continuing Education
PAGE 21
Continuing Education
Classifieds Exciting Physio Opportunity in East Auckland - Multi Award Winning Practice Velca is all about creating positive changes in people’s lives. We do this through ensuring that our people are number one which includes our team as well as our clients. We believe in continually developing our skills through weekly development sessions (team and 1on1) and of course having fun! Our new physiotherapist will be working in a team including: -Physiotherapists -Chiropractors -Massage Therapist -Personal Trainers -Group Fitness Instructors Winners of Howick Best Business Awards in 2013, 2014, 2015 and 2016 -2016: Best Employee, Highly Commended Best Service and Best use of Technology -2015: Highly Commended Best Professional Service and Best use of Technology -2014: Best Professional Service, Best Use of Technology, Highly Commended Best Employee -2013: Best use of Technology and Runner up for Best Professional Service Successful applicants will have great customer service, work ethic and be able to work well in a team environment.
Please take a look at our website for more information: www.velca.co.nz If you are interested in the above physiotherapist position, please send your CV to jesse@velca.co.nz
PAGE 22
Classifieds Do you use ultrasound imaging in your clinical practice? Would you like to use ultrasound imaging in your practice but don’t or can’t? If either is true, we’d like to hear from you! The use of ultrasound imaging (USI) in physiotherapy practice is gaining significant momentum. As training improves and equipment becomes more accessible, more physio’s are enhancing their clinical practice by using USI. We are conducting a survey of New Zealand physios to understand how USI is being used. We’d like to hear from those physiotherapists that are using USI, as to how they use it and what training they have. We also want to hear from those physios who are not using USI to understand the barriers that prevent them from doing so. To participate in this survey you need to be a New Zealand registered physiotherapist. All those who complete the survey can elect to go into the draw to win a SurfacePro tablet valued at $1,400. For more information and to participate in the study, please go to https://www.surveymonkey.com/r/USI-Survey Thanks for your support of our research! Drs. Richard Ellis and Sandra Bassett Auckland University of Technology
HALF MOON BAY, AUCKLAND Marina Physio Locum Musculoskeletal Physiotherapist Dates: 1st December to 24th December 2016 (dates negotiable) Location: Marina Physio, Half Moon Bay, Auckland
A fixed term position for a locum Physiotherapist is available in a busy private practice, located in a Medical Centre. The role would be in a musculoskeletal practice, working with other experienced physiotherapists. Hours and dates are negotiable, but ideally the candidate would fill a full time role. Desired candidates would have experience in private practice and can work independently.
For further information please contact Derek Timmins, either email your CV to derek.timmins@marinaphysio.co.nz or phone on (09) 534 4045 or 021 729383