ISSUE 2 l APRIL 2013
BULLETIN FEATURE TOPIC: 100 Years and Beyond: Advances in Surgery for Amputees www.spnz.org.nz SPNZ EXECUTIVE COMMITTEE President
Dr Angela Cadogan
Dr Gisela Sole
Website & IT
Dr Tony Schneiders Bharat Sukha Jim Webb David Rice
EDUCATION SUB-COMMITTEE Chelsea Lane
Dr Grant Mawston
Dr Gisela Sole
Welcome to the April 2013 Edition In this Edition: EDITORIAL: 100 YEARS OF PHYSIOTHERAPY by Dr Angela Cadogan
FEATURE: Osseointegration: New Developments in Surgery for Amputees with Physiotherapist Andy Strang
CLINICAL SECTION Article Review: Immediate effects of a new microprocessor-controlled prosthetic knee joint: A comparative biomechanical evaluation
SPECIAL PROJECTS Monique Baigent
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LINKS Sports Physiotherapy NZ List of Open Access Journals Asics Apparel and order form McGraw-Hill Books and order form Asics Education Fund information IFSPT
RESEARCH SECTION SPNZ Research Reviews: The next 100 years of Physiotherapy: new technology and evidence based practice
RESEARCH PUBLICATIONS JOSPT: April 2013, Volume 43, Number 4
IJSPT: Volume 8, Number 2 April 2013
SPORTS HEALTH A Multidisciplinary Approach Vol. 5, No 2 March/April 2013 Health Research Reviews
Asics Report: Product Review Tigreor 5
CONTINUING EDUCATION CALENDAR
Michael Borich (Secretary) 26 Vine St, St Marys Bay Auckland email@example.com
EDITORIAL 100 YEARS OF PHYSIOTHERAPY By Dr Angela Cadogan
With the 100 Years of Physiotherapy celebrations just completed in Dunedin, I have taken the time to reflect on some of the pertinent historical points within our profession, including those that have shaped the Sports Physiotherapy SIG. A huge thanks to Michael Borich who compiled much of the history on SPNZ, which can been seen in its entirety on the PNZ 100 Years of Physiotherapy website.
History of the Physiotherapy Profession 1912 Dr WE Herbert returned from a trip to Europe and, impressed by what he had seen at the Robert Jones’ clinic in Liverpool, he brought the value of physiotherapy to the attention of the British Medical Association who passed a resolution that the University of New Zealand be approached with a view to inaugurating a massage training course. “Massage” was later to be defined (Masseurs Registration Amendment Act, 1924) as: “the use by external application to the human body of manipulation, remedial exercises, electricity, heat of light for the purpose of curing or alleviating any abnormal condition of the body; or the use for such purpose of any other method of treatment that may be recognised by the Governor General in Council as an approved method of performing massage but does not include the internal use of any drug or medicine, or the application of any surgical of medical appliance except in so far as the application of such appliance is necessary in the use of aforesaid of manipulation, remedial exercises, electricity, heat, light or other approved method”. 1913 A two-year training course was approved in February 1913 consisting of 6 months study of anatomy (taught in the Medical School) and physiology (taught in the Home Science Department) and, following the provision of evidence of another 6 months training in massage and ‘medical electricity’ at one of the country’s major hospitals, the Government granted a certificate of proficiency in massage. 1913-1915 The original curriculum was further developed, and covered an 18 month course of study with a triple qualification in massage, medical electricity and medical gymnastics (as was the case in England at the time). The first class consisting of 5 women were examined in August 1914 (all passed). The University of Otago surrendered its official connection with the new school and the Otago Hospital Board accepted the responsibility of founding a Training School in Massage. This meant students were not able to be ranked as “university” students. However the Hospital Board was not given ‘free-field’ in this endeavour. The inspector-general of Hospitals expressed strong disapproval of this action and threatened that any financial loss on the school would be charged against the individual members’ private accounts. 1920 The Massage Bill (originally introduced to the House of Representatives in 1913) was finally passed in September 1920, and came into force in 1921. 1930’s and 1940’s The appointment of a Miss L. Roberts to the Director of the School of Massage (a university position) and the training, curriculum and organisation being in the hands of a committee of ‘medical men’ and University Professors, saw the course become again affiliated with the University of Otago. The finances were however, still controlled by the Hospital Board, and the registration of trained masseurs was controlled by the State (the Health Department, and under it by the Massage Council).
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The number of applications continued to grow with over 40 applicants for the 1938 intake from which 20 were selected. Preference was given to ‘matriculated’ students and those with higher educational standards. It was noted by ML Roberts in 1938 that “the physique of the candidate is not always as robust as could be wished but a means of getting a better selection is under consideration”. Exactly what that was is unclear. Just as in medicine, a scientific and orderly system of training grew from an old method of apprenticeship. 1970’s The second School of Physiotherapy was established in Auckland, with the first course run by the Auckland Institute of Technology in 1973. In a guest Editorial in the New Zealand Journal of Physiotherapy in May 1973 Glen Park spoke of how the Government had firmly excluded the possibility of vocational courses being set up within a University. However she saw some hope that the growing university-technical institute relationship would lead to cross crediting. Post-graduate education began in 1975 in limited formats and continued to grow through the 1970’s. 1990’s The Auckland Institute of Technology gained University status and a Masters Degree in Health Science (including a Masters Degree in Sports Physiotherapy) was offered from 2000.
History of Sports Physiotherapy 1970’s During this time, the first buds of professional sport were sprouting and, in 1978, Peter Stokes headed a Wellington group of physiotherapists who realised the need for sports-specific physiotherapy skills in preparation for the increasing levels of accountability professional sport would place on the ‘sports physiotherapist’. They arranged their first weekend course in 1979 attended by 33 participants. 1980’s This group applied for formal recognition as a SIG by the Society (NZSP) in 1980 and this was granted at the Society’s AGM in 1981. After a couple of years running out of Wellington the administration of the group moved to Christchurch. Unfortunately this was not a successful move with the group eventually folding and all monies raised donated to the Society’s Scholarship Trust Fund. 1990’s Professional sport increased exponentially in the 1990’s and high performance sporting practice was becoming more commonplace in both professional and amateur sport. Sports funding also increased dramatically, and along with this came more accountability for producing results in the sporting arena. Following an advertisement placed in the NZSP 1995 March Newsletter, a second group began operating in April 1996 with formal notification and eventual acceptance at the 1996 New Zealand Society of Physiotherapists AGM to form a Sports and Orthopaedic Special Interest Group. At this time preliminary meetings were held in Auckland and Christchurch to discuss the administrative details and to establish a foundation membership list. With an initial membership list of 80 in October 1996, educational meetings were held in Auckland every 8 weeks and occasionally in Christchurch and Palmerston North. In 1997 the group held its inaugural AGM and the first executive committee was established, led by Graeme Nuttridge. At the Society’s 1997 AGM the Sports and Orthopaedic group was now officially recognised as the “New Zealand Sports and Orthopaedic Physiotherapy Association” (NZSOPA). 2000’s The International Federation of Sports Physical Therapy (IFSPT) was officially recognised as an official sub-group of CONTINUED ON NEXT PAGE.
[100 Years of Physiotherapy continued….. CONTINUED FROM PREVIOUS PAGE. the World Confederation for Physical Therapy (WCPT) in 2003, and NZSOPA was accepted as a full member of the IFSPT in 2006. Today, Tony Schneiders (SPNZ executive member) is an elected Board member of the IFSPT. Dr Tony Schneiders led NZSOPA through the 2000’s, a time that saw a name change of the group to Sports Physiotherapy New Zealand (SPNZ), rapid growth within the SIG, and also rapid growth in high performance (professional and amateur) sport resulting in many more positions within sporting organisations becoming available to physiotherapists. Up until this time, selections for high performance physiotherapy positions in sport were largely based upon opportunity and availability, however the increasing demands for specific, advanced level sport physiotherapy services saw many physiotherapists go off-shore for post-graduate training, or seek sport specific continuing education within New Zealand, and sporting organisations becoming increasingly interested in the credentials of their physiotherapy applicants. 2010’s Dr Angela Cadogan took over as President in 2012. Following many years of planning and preparation the finishing touches are now being applied to structured Level 1 and Level 2 Sports Physiotherapy modules. SPNZ is also working on the development of a Sport Physiotherapy Code of Conduct to provide guidance on situations involving the competing demands of competitive sport and duty of care to the patient. PNZ is co-sponsoring the project and we look forward to presenting this to our membership for discussion during 2013. 2013 and Beyond: Since 1913, advances in technology have revolutionised every aspect of physiotherapy from the way we meet (Skype), communicate (email), administer (electronic management systems), store, transfer and acquire information (internet and phone ‘apps’), learn (webinars and podcasts), access research (electronic databases and file downloads) and educate patients (iPads). The world is now a smaller place, allowing increased accessibility to international experts allowing much faster dissemination of new and important advances within the profession. Compared with our counterparts 100 years ago, we now truly live in the information technology age. The profession has come a long way since our beginnings as ‘Trained Masseurs’, with New Zealand recently becoming the first country in the world to achieve a regulated Physiotherapy Specialist scope of practice, reflecting national and international recognition and value of physiotherapy services, and a public and health sector need for advanced level skills. This now provides a structured career pathway within the profession to recognition of those with specialist level knowledge, skills and leadership abilities. In Sports Physiotherapy, from our opening membership of 80 we can proudly state that our membership has grown ten-fold with membership as of December 2012 at over 800. Sports Physiotherapy has become one of the largest clinical interest areas within the profession and, as the demands of high level sport increase the accountability and need for specific advanced scope physiotherapy practice in the sporting arena, we look forward to leading the way in this growing area within the profession. The World Health Organisation global health priority of reducing the disease burden resulting from physical inactivity also provides sports and exercise medicine specialists, including sports physiotherapists with an important role to fulfil in the promotion and prescription of physical activity in the coming decades. The past has been exciting, but we look forward to an even more exhilarating future with the support of the SPNZ membership, PNZ and the many volunteers that tie our group together.
100 Years of Physiotherapy The University of Otago School of Physiotherapy Centenary Celebrations. Read a history of the University of Otago School of Physiotherapy, and the professions’ first 100 years on the PNZ website, and read a summary of the history of Sports Physiotherapy in the Editorial in this Bulletin.
Sports Physiotherapy Code of Conduct The first draft of the Sports Physiotherapy Code of Conduct is nearing completion. A draft of the Sports Physiotherapy Code of Conduct will soon be circulated to the profession and other interested parties for consultation and comment. Dr Lynley Anderson has been working on this document along with a working party from SPNZ (Dr Angela Cadogan, Dr Tony Schneiders and Michael Borich), with support from Physiotherapy New Zealand. When completed, this document will provide valuable guidance for sports physiotherapists as they negotiate the muddy waters of competitive sport where the desire for success often conflicts with the duty of care to the patient. We will send all SPNZ members a copy of the draft document when it is ready for circulation and welcome any feedback.
SPNZ Educational Courses SPNZ Level 1 Course Development is almost complete. The SPNZ Education Committee have been working on development of Level 1 and Level 2 Sports Physiotherapy courses, with the development of Level 1 courses almost complete with courses due to be run throughout 2013. See the separate page in the Bulletin for more detail. The Immediate Care and Sports Trauma Management Course was held in Auckland on 7th April, with excellent feedback, and many attendees commenting they would like more on this important area of sports physiotherapy. SPNZ maintain its’ commitment to providing SPNZ members with preferential registration at reduced rates for these courses, and members will be notified several weeks before advertising goes out to the general PNZ membership.
Health Research Reviews New Research Reviews available. The Research Reviews Website now includes reviews on Travel Medicine (16 issues) and will shortly be adding reviews on Wound Care. You can register online and download these research reviews free of charge. See more Research Review titles for sports medicine, physical activity, orthopaedics and health in the Research Publication Section of this Bulletin.
SPNZ Website Upgrade and Public Resources The 'find a sports physiotherapist' is now live on our website. It is split into regions for easy searching and lists can be altered to be searched by first name, last name, town and key sport. This feature has been designed to allow you as Members of SPNZ to promote yourself to your colleagues and the public. For those who have not viewed it click here to access it. As we develop more public information we will start promoting the website to the public, funders and other interested parties. If you haven't sent me your details they can be added by filling out the form here As mentioned this is for you to promote your interests and expertise and not that of your clinic so please fill the form out as clearly as possible.
International Journal of Sports Physical Therapy - Individual Subscriptions Available The IJSPT journal is available to purchase for individual members. SPNZ members interested in subscribing to this journal can purchase an individual subscription through the journal directly. To purchase a subscription go to the IJSPT website, and click on “subscriptions”. Subscription rate for 2013:
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SPNZ Member Benefits Remember to take advantage of the full range of SPNZ member benefits:
FREE online access to JOSPT (value approx. USD$275)
FREE Editions of the Quarterly APA “Sports Physio” Magazine
25% Discount on all McGraw-Hill book publications
Funding Support for continuing education and research (Asics Education Fund).
Substantial discount, Advanced Notice and preferential placing on SPNZ Educational Courses.
Access to website with clinical and relevant articles.
Sports Physiotherapy Forum to discuss ideas and ask questions
Bi-monthly SPNZ Bulletin featuring Activity, Course and information updates.
FREE classified advertising in the SPNZ Bulletin
SPNZ is now on Facebook
Check us out at:
www.facebook.com/SportsPhysiotherapyNZ Website Gems Links to Video Clips Online interviews of interest
SPNZ COURSES SPNZ Level 1 Courses 2013 IMMEDIATE CARE & SPORTS TRAUMA MANAGEMENT (1 day course) Waitakere Hospital, Auckland 7th April 2013. Presented by:
Dr Rob Everitt, Dr Duncan Reid and Stephanie Vos.
Sudden cardiac death and basic life support
Head/facial trauma Spinal injury Transfer and hand-over procedures
Infection/disease transmission Medical emergencies Anaphylaxis Fractures and dislocations
We are currently investigating the possibility of running another course in 2013.
Advance Notice of Upcoming Courses: PROMOTION & PRESCRIPTION OF PHYSICAL ACTIVITY & EXERCISE (2 day course) Location: Date:
Auckland (AUT University) 22nd & 23rd June 2013 (PUT THE DATE IN YOUR DIARY) (More details to follow. Members will be advised as soon as registrations are open)
A course covering the health benefits and assessment of physical activity levels, and the principles of prescription of physical activity and exercise. Content includes:
Health benefits of physical activity and exercise Assessing levels of physical activity Risk factor screening Physiological effects of disuse on the musculoskeletal and cardiovascular system
Components of neuromuscular performance Aerobic functional capacity testing Assessment of strength, power and endurance Principles of exercise prescription
More details will be sent to members as soon as they are available.
SIDELINE MANAGEMENT (2 day course) Details: Location:
South Island (location TBC)
July/August 2013 (exact date TBC)
NB: This course may also be run in the North Island late in 2013 depending on demand. A course for sports physiotherapists working on the sideline at sports games or events. This course will give you the basic tools you need to manage teams and individual athletes from pre-event preparation, to post-event recovery. Presenters include nurse, experienced sports physiotherapists, hand therapist and radiologist.
Pre-event warm-up Strapping Acute injury assessment and management (including fingers/hands and Sports First Aid and Wound Care
Acute injury management and referral Concussion assessment, management and return-to-play criteria Pharmacology and Standing Orders Ethics and Professional Issues in Sports Physiotherapy
Return-to-play decision making
More details will be sent to members as soon as they are available.
FEATURE OSSEOINTEGRATION: NEW DEVELOPMENTS IN SURGERY FOR AMPUTEES PHYSIOTHERAPIST - ANDY STRANG By Andy Strang BPhty, PGCertHealSci (Clin rehab)
Andy Strang graduated from Otago in 2002. He has ten years of experience in physiotherapy and has been working with Amputees on and off since his first position on ward 1A at Princes Margaret Hospital in Christchurch as a new graduate. He has been working over the past year with the Osseointegration clients that he will discuss for us and among other interests has spent time working with rock climbers, travelling to Sydney with the New Zealand sport climbing team for the World Champs in 2010.
What's your physiotherapy background Andy? Well, let’s consider this discussion more about the working athlete, rather than the traditional type of athlete that is of interest to most sports physios. Major achievements for me are working alongside people who are simply getting back on their feet again. When I started 10 years ago I was working with elderly clients who had lost a limb from peripheral vascular disease and might be lucky to return home. More recently I have been working with people who lost their limbs in the Canterbury Earthquakes and are rebuilding and redefining their lives. Recently there has been a groundswell of interest in a procedure called Osseointegration. The catalyst for this was when TV3 screened a feature on a Nelson amputee undergoing a relatively unknown technique in April 2012. He had to travel to Australia to have this surgery completed. In Australia there are not one but two differ-
ent surgical methods offered. Rather than using a traditional socket prosthesis, a metal implant is surgically implanted and the body is then given time to “osseointegrate” to form a direct bond between implant and bone. There is an abutment protruding from a stoma at the distal end of the stump and the leg is attached directly to the abutment. It’s an exciting time as there is the possibility of this surgery being performed by NZ surgeons for the first time this year. There are four amputees from New Zealand who have had this procedure performed in Australia and both methods have been used: the original Swedish method and a more modern German method. The original Swedish procedure is called Osseointegrated Prostheses for the Rehabilitation of Amputees (OPRA). The Osseointegration process was discovered in 1952 by Per-Ingvar Brånemark of Sweden inadvertently following experiments on rabbits. The method in its current form has CONTINUED ON NEXT PAGE.
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been used in Sweden, the UK, Hungary, France and Spain. The German Procedure is known as the Integral Leg Prosthesis (ILP) method and is offered in Germany and Australia. The OPRA method is a threaded rod that is screwed into a tapped femur. The ILP procedure is a bang-in method that is very similar to modern hip replacement techniques and with similar technology. How did you become involved in your current role? My role with Osseointegrated patients really happened largely by chance. I was working within a large multidisciplinary team and we had the resources to manage complex patients. All of a sudden there were young, relatively fit and healthy people who had lost one or both of their lower limbs in the Canterbury earthquakes. I had some experience working with amputees and a team was cobbled together to manage their rehabilitation. Initially the prostheses that we were using were the traditional Ischial containment socket (ICS) type prosthesis with silicone liners. We started on a “stumpy” which is a fixed pylon prosthesis and very short. As balance and strength build you add height to the pylon and then finally when there is enough height then a knee can be added. Following the TV3 feature, a client became interested in the procedure and opted to have it done on both legs. Things happened very quickly and now we are about 8 months down the track since the first procedure was completed. If I was completely honest, ACC contracts had a lot to do with it as well and other very experienced clinicians were sidelined with politics. I have been very fortunate and grateful to have their assistance along the way. My role is developing at present and we are learning a lot both from our own experiences and from the teams in Australia. In particular Cathy Howells and Sarah Benson, both Physiotherapists in Sydney have been a massive resource and local support has been from Jetje Bullion at the ALC in Christchurch. Can you describe your role with your team/clients? I am a small player in a big team. There is the client, their family, surgeon, prosthetist, OT, seating specialist, nurse, GP, psychologist, anaesthetist, pain management physician..... You get the point. My role is to gauge a person’s overall fitness and capability as an amputee, strengthen muscle, reduce or prevent contractures, assess and train balance and propri-
oception, manage pain issues. I liaise closely with the prosthetist and often attend prosthetic fittings and adjustments. As I see clients regularly, often I might pick up on infection issues, medication problems, mood changes, sleep issues etc so a lot of my time is spent talking with the client and liaising with other clinicians that might be able to better deal with those things that crop up. What are your specific tasks/responsibilities? This is an interesting and developing area. The past few months have been a frantic period of information gathering and learning from overseas experience. My first role was actually to prepare a client for the Australian team in Sydney currently performing a version of the German ILP method of this surgery. A key area was the reduction of hip flexor contractures and core strengthening. Cardiovascular fitness on circuit training machines was used to help reduce BMI. Essentially you want the client to be in the best shape of their life – given the circumstances – before the surgery. I have been lucky to work with very motivated clients and a lot of the drive has come from them. Maybe my role is to focus the energy that they have on the areas that need the most attention and give them the tools they need to manage the process independently as well away from the clinic environment. We are currently working on post surgical protocols. It really depends a lot on the surgical method as the two methods have vastly different timeframes associated with them. The OPRA method you are looking at 6 months or more until full weight bearing. The ILP method is closer to 2 months until full weight bearing. It is likely that a version of the faster and more modern ILP method will be used in New Zealand initially. I will be involved in pre surgical conditioning, following loading protocols to safely begin weight bearing through the implant, and developing cardiovascular, core and upper limb strengthening programmes. The loading protocols are very strict as you must not overload the implant. You start with a short peg leg attachment and load through a scale. We will start at 20kg of load 30 minutes twice daily. If all goes well you can add up to 5kg of load per day until 50% of body weight is registered on the scale. It will then be time for gait training in the parallel bars which will include learning about a new knee and foot set up.
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Green Prescriptions continued….. CONTINUED FROM PREVIOUS PAGE. What are the common client issues you are dealing with? The above knee amputee who has sufficient femur residuum length is the most likely type of amputee to have this operation. At last count there were 26 amputees who had undergone the ILP procedure in Australia. Four New Zealanders have had the procedure, three of them with the ILP method. The cause of amputation is most likely to be from trauma, followed by cancer. The technique can also be used on trans-tibial amputees and also in the arm but is not commonly done internationally. It is not necessarily for high functioning amputees either as very low K level (scale which describes amputee function) amputees actually have the most to gain. The Australian experience has been very positive in this regard with K0 to K2 users shifting up to K1 to K3 levels following the surgery. K3 and K4 users are already functioning quite highly and might notice other benefits such as improved comfort from not wearing their socket prosthesis, better temperature management from allowing the skin in the thigh to breathe, less skin infection or abrasion. With short residuum lengths there is the possibility of undergoing leg lengthening prior to Osseointegration. The leg lengthening is used to add sufficient length to a short femur for the implant to be able to fit. This process is being discussed at present as a way of increasing femur leverage. Short stumps have the added problem of lacking good distal muscle attachments and it may still be very difficult to get good control of the limb. Watch this space! What do you think are the key elements in successful outcomes for your clients? Client selection has been a recurring theme in the international experience as the first step in a successful outcome. There are no well defined criteria and each team working with these clients has a different opinion. This also makes it hard to compare surgical methods and “success rates” as one team may be willing to take a risk on a client where another team with an inferior technique is extremely conservative with client selection, and might get a better outcome on paper. Which team is doing better? Pain management is critical and having experienced pain management physicians and anaesthetist in the team is a must. Having knowledge of nonpharmacological management techniques is just as im-
portant and often the clients will come up with novel ways of managing pain, both acute and persistent. The pain management strategies developed by the NOI group (Sydney, Australia) are constantly developing and are applicable to amputees. Building trust, both in the prosthetic components, and also with the challenges that you present to the clients. The new Genium knee from Otto Bock is a major development, and provides a level of safety and confidence not seen in previous knee joints. We are currently managing the first client in New Zealand to be using this knee and there are likely to be other amputees who will benefit. The knee has a microprocessor that is responding to input from accelerometers and a gyroscope within the knee. It responds by changing hydraulic resistance within the knee to facilitate the desired movement or to resist knee collapse in a stumble situation. It’s fantastic to watch a knee move so naturally and to observe the increase in confidence that this offers. It even allows for a natural loading response with a 4 degree flexion on heel strike which can be unnerving for users initially as this would have indicated a collapse with their previous knee. Being patient and having a long term view. There have been as many setbacks as there have been gains and you have to try and take a step back and look at the big picture. Getting caught up in day to day issues means you often lose sight of the big goals. Being a full time prosthetic user is a big ask for a bilateral above knee amputee and accepting that there are limitations The main team is the surgeon, anaesthetist and nursing staff initially. This is then broadened to include the prosthetist, physio, OT and psychologist. How do you integrate/work with the team with respect to injury prevention or rehabilitation? We spend a lot of time on email and on the phone discussing problems as they arise. As we are developing our knowledge the more we communicate about an issue the better. In an ideal world there would be a dedicated facility where everyone is on site but this is not feasible with the small number of clients that are being managed at present. Are you involved in performance aspects for your clients? I hope I haven’t excited too many physiotherapists who are working with amputee athletes.... Osseointegration
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patients can’t run! At this point there are no track athletes using this method as the implants and interface are not yet strong enough to cope with the huge loads although this is clearly an area for future development. Limb suspension and component strength is a major issue for athletes and you hear stories of sprinters going through tens of thousands of dollars worth of components in the search for something that will handle the load. David Howells, an Australian Prosthetist working with sprinters once told me a story about an athlete he was working with. The guy destroyed eight knees, some of them only lasting a few seconds before exploding on the track, until settling on something that would last. It’s much easier to replace an exoskeletal component than it is to replace an Osseointegration implant, or to wait while fractured bone heals. The energy consumption of an amputee is much higher than that of an able bodied person given the same task. For a bilateral above knee amputee, walking is estimated at between 200 and 300% higher energy consumption than an able bodied walker. We recently completed a 6minute walk test for a bilateral above knee osseointegrated amputee and achieved 280 metres, the equivalent of 2.8 km/hr. This is double the pre op score, but still less than an age equivalent able bodied person. Everyday living is performance activity and optimum conditioning is necessary just to complete ADL’s, go to work and enjoy a social life. One client has taken up hand cycling and is looking at competing in the New York marathon in November this year. So although the Osseointegration is not going to help on the hand cycle there are still a number of performance issues that are managed alongside this process.
ing issues (the procedure is likely to cost around $80,000 per implant), and that is not including the Genium knee which is a further $90,000 per knee. Add in a foot, the cost of fitting and adjustment and the rehab hours and there is a sizable cheque to write out. Another challenge is making the transition from a clinical environment with parallel bars and nice flat floors, to a real world environment that has bumps and steps and slopes and all manner of obstacles. It is a real eye opener to walk around with an amputee who is operating at their performance limit and seeing how simple obstacles you would not normally notice becoming major challenges. Our world is not very disability friendly and it is discouraging when access to your local cafe is so difficult that it easier not to go. I guess it also motivates you to overcome the obstacles as well and seek solutions that are novel. What are the key attributes you feel are required for your area of work?
Being a team player is important, especially if you are operating in isolation you need to be on the phone or email or in the car when things need to be sorted.
Being flexible and incorporating new ideas.
Moving on and taking a fresh look at a problem when things are not working.
Being brave enough to ask for help! It has been a huge learning experience and the more inclusive you can be with as many people as possible the better. My experience pales in comparison to others who work in this field and I have been expertly guided along the way.
Surrounding yourself with the right people and being supportive as a team member to work with the client is imperative.
What are the major challenges in your work? The biggest challenges are probably still to come. We are gearing up to start managing clients to have this surgery in New Zealand and a lot of work has, and still needs to be done. Besides the obvious challenges of the surgery and recovery itself, there are cost and fund-
By Andy Strang BPhty, PGCertHealSci (Clin rehab)
ARTICLE REVIEW Immediate effects of a new microprocessor-controlled prosthetic knee joint: A comparative biomechanical evaluation Bellmann, M., Schmalz, T., Ludwigs, E., & Blumentritt, S. (2012). Immediate effects of a new microprocessor-controlled prosthetic knee joint: A comparative biomechanical evaluation. Archives of Physical Medicine and Rehabilitation, 93, 541-549. doi:10.1016/j.apmr.2011.10.017 A good prosthesis can help an above-knee amputee to participate in their community without major limitations walking and navigating stairs and ramps. This is a cross-over study with repeated measures investigating the biomechanical effects of the new microprocessor-controlled prosthetic knee joint. Microprocessor-controlled prosthetic knee (MPK) joints are well-established in rehabilitation after above knee amputation. The C-Leg has demonstrated improved function and safety leading to improved quality of life. The C-Leg is closely aligned to physiologic gait and has shown a decreased fall rate in amputee patients. The Genium prosthetic knee is a new model; it utilizes new algorithms and sensors in order to achieve improved dynamic stability and control. The new functions integrated into the Genium include a stance function that blocks the flexion direction when the user is standing still; switching to walking mode automatically as soon as the user moves. A fixed flexed position of 4째 in the late swing phase which helps to prepare for initial contact; simulating normal gait. Integrated stairs function allowing stair ascent step-overstep instead of the conventional step by step process where the contralateral limb takes the load and the stiff prosthesis is lifted to the same step. Non microprocessor-controlled prosthetic knee (NMPK) and other MPK joints, including C-Leg do not offer a separate stair function. Eleven men, mean age 37, with unilateral transfemoral amputation were recruited. The subjects were experienced C-Leg users and could execute all C-Leg functions. No participant had previous experience with the Genium. The group of subjects were representative of transfemoral amputees with a high activity level capability. The C-Leg and the Genium were compared for alignment, kinematics and centre of pressure in four different tasks. These were level walking, level walking with small steps, walking on stairs and a ramp and standing on a decline. Ascending stairs with the C-Leg was conducted in the conventional step to method. With the Genium, the subjects ascended stairs step-over-step using the integrated stairs function. Force plates and cameras permitted recording of gait biomechanics of both prosthetic and contralateral sides. Improved biomechanical outcomes were demonstrated by the Genium: lower ground reaction forces at weight acceptance during level walking at various velocities, increased swing phase flexion angles during walking on a ramp, and level walking with small steps. Maximum knee flexion angle during swing phase at various velocities was nearly equal to the contralateral leg for Genium. The Genium had a mean maximum knee flexion angle of 46.1째 compared to 41.7째 with C Leg in swing phase. Step-over-step stair ascent with the Genium knee was more physiological as there was a more equal load distribution between the prosthetic and contralateral sides and a more natural gait pattern. When descending stairs and ramps, knee flexion moments with the Genium tended to increase. During quiet stance on a decline, subjects using Genium accepted higher loading of the prosthetic side knee joint, reducing same side hip joint loading as well as postural sway. The comparison between the C-Leg and the Genium shows immediate biomechanical advantages with the Genium during various daily ambulatory activities. This may lead to an increased participation in their community and a more diverse range of activities available to people with above-knee amputations. Results showed that use of the Genium facilitated more natural gait biomechanics and load distribution during quiet stance on a decline, walking on level ground, and walking up and down ramps and stairs. This increased functionality is represented in this study by direct comparison with the C-Leg, whose benefit has been demonstrated in numerous scientific studies. A natural gait is characterized by symmetrical movements. It is often seen however, that active transfemoral amputees make longer steps with the affected side. With the Genium, this asymmetry is reduced due to 4째 preflexion at initial contact, resulting in increased step length symmetry. Only a small number of transfemoral amputees are able to ascend stairs step-over-step with NMPK and most MPK joints. The Genium is the first prosthetic knee joint to allow this functional activity due to its integrated stair function without additional actuators. The function can be activated by a slight conscious residual limb movement that is also possible within the walking cycle without interruption of the on-going movement pattern. This article therefore recommends the Genium prosthesis as a technological advancement on previous models and a superior means of ambulation for above knee amputees. Reviewed by Monique Baigent BHsc (Physiotherapy)
SPNZ RESEARCH REVIEWS
THE NEXT 100 YEARS OF PHYSIOTHERAPY: NEW TECHNOLOGY AND EVIDENCE BASED PRACTICE www.sportsphysiotherapy.org.nz/resources
Botulinum toxin injection to facilitate rehabilitation of muscle imbalance syndromes in sports medicine D. M. Cullen, J. J. W. Boyle, P. L. Silbert, B. J. Singer & K. P. Singer Disability and Rehabilitation, December 2007; 29(23): 1832 – 1839 Article Summary Intramuscular injection of Botulinum toxin (BT but also known as Botox) to produce reduction of focal muscle overactivity, and localized muscle spasm and spasticity, has been utilized therapeutically for almost two decades. This has mostly occurred in neurological conditions associated with conditions like cerebral palsy or spinal cord injury induced spasticity. Botulinum toxin results in chemical denervation of the overactive muscles but is also reported to be short lived. However during the time of reduced muscle overactivity allows for facilitation and rehabilitation of the synergistic or antagonistic underactive muscles. The review examines and hypothesizes that muscle imbalance also seen (albeit to a lesser degree) in patients with neurologically normal muscle, where an imbalance exists producing a faulty movement pattern such as in the athletic population, potentially could also be selectively managed with BT treatment. Using examples such as the imbalance found in patellofemoral syndrome where the overactivity found in vastus lateralis is too powerful for an underactive vastus medialis to function and subacrominal impingement as a result of overactive rhomboids, levator scapulae and pectoralis minor preventing optimal use of middle and lower trapezius and serratus anterior from working to provide normal scapulohumeral rhythm. The review outlines where BT treatment has been already successfully used such as with recalcitrant cases of piriformis syndrome where other avenues of conservative treatment have been unsuccessfully trialed. Clinical Applications Physiotherapists working with athletes would require a comprehensive understanding of normal movement patterns, ability to diagnosis abnormal motor patterns and to re-educate more appropriate movement strategies. Therapeutic management of co-impairments may include stretching of tight soft tissues, specific re-education aimed at isolation of the non-dominant weak muscles and improvement in their activation, ‘unlearning’ of faulty motor patterns, and eventual progression onto functional exercises to anticipate gradual return to sporting activity. This article is highlighting that there is potential use of intramuscle injection of BT therapy in carefully selected cases where effectively all else has failed, hypothetically providing short term reduction of focal muscle overactivity, and may facilitate activation of relatively ‘inhibited’ muscles and assist the restoration of more appropriate motor patterns. The article outlines a case study where vastus lateralis was injected with BT, 12% cross sectional area (CSA) was reduced as a result, effectively allowing vastus medialis to start contracting optimally following a period of rehabilitation. Reducing the CSA by 12% in any muscle may also have a detrimental effect as well, specifically as there have been no studies done on dose and administration parameters in the sporting population, nor have there been any longitudinal studies to assess for long term complications, indicating that BT treatment in the sporting population is very much in its infancy.
Reviewed by Kate Polson MHSc(Hons); Dip Phty, Dip MT, MNZCP; MNZSP
SPNZ RESEARCH REVIEWS
The next 100 years of Physiotherapy: new technology and evidence based practice continued... www.sportsphysiotherapy.org.nz/resources
Recent advances in sports medicine Peter D Brukner, Kay M Crossley, Hayden Morris, Simon J Bartold and Bruce Elliott Med J Aust 2006; 184 (4): 188-193
Article Summary This article summarises a range of advances in the understanding of pathophysiology, diagnosis and management of hip injuries, patellofemoral pain, anterior cruciate ligament injuries and acute chondral defects, with a focus on sports related injuries. Previously hip joint abnormality was attributed to osteoarthritis. Magnetic Resonance Imaging and hip arthroscopy have shown that labral injuries, chondral injuries, rim lesions, synovitis and tears of the ligamentum teres are all common causes of hip, groin and low-back pain. X-Ray, arthrography and conventional MRI have all been shown to be inadequate in diagnosis. Fast spin-echo proton-density weighted MRI sequences taken in the plane of the hip joint have been shown to be more accurate. Intra-articular injection of local anaesthetic combined with examination pre and post injection can be useful in determining the origin of pain. Hip arthroscopy is an effective diagnostic tool and is effective therapeutically for recent traumatic labral injury (evidence level IV) but less so for chronic hip pain. Patellofemoral pain (PFP) is characterised by individuals with delayed onset in activity of Vastus Medialis Obliquus (VMO), relative to the lateral quadriceps. The multimodal physiotherapy programme described by Jenny McConnell has been supported by five systematic reviews of randomised controlled trials. Further research suggests hip muscle strength is reduced in PFP and most multimodal interventions now include a component of hip strengthening and control exercises. Anterior cruciate ligament (ACL) injuries are three times as likely to occur in women as in men. Nueromuscular training decreases the incidence of ACL injuries in females (evidence level III). Hamstring and patellar tendon grafts appear to show no difference in outcomes (evidence level III-I). Acute Chondral defects are treated by microfracture and autologous chondrocye implantation. The effect of tissue engineering techniques is still under investigation. Research in sports biomechanics may take the form of analysing movement to identify variables crucial to successful performance, identifying power sources and causes of injury. Research in this area has been aided by advances such as the optoreflective motion analysis system and software models that capture and track marker movement. The data from these investigations linked with data from other professionals will create a team approach to research to optimise performance and reduce injury. Clinical Applications Advances in the understanding of the pathophysiology, diagnosis and management of sports injuries means treatment can now be more evidence based rather than relying on an empirical basis. Innovations around imaging, biomechanical analysis, tissue engineering and gene therapy offer exciting therapies for the future. This article provides an interesting summary of advances around management of four common clinical syndromes associated with the lower limb and contains a useful reference list. Reviewed by Aveny Moore Dip Phys, Adv Dip Phys (OMT), Dip MT
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The next 100 years of Physiotherapy: new technology and evidence based practice continued... www.sportsphysiotherapy.org.nz/resources
Physical game demands in elite rugby union: a global positioning system analysis and possible implications for rehabilitation Coughlin G, Green B, Pook P, Toolan E, Oâ€™Connor S (2011). Journal of Orthopaedic and Sports Physical Therapy 41: 600-605. doi:10.2519/jospt.2011.3508 Article Summary The evolving nature of the game of rugby union has given rise to a bigger emphasis on skill acquisition and physical conditioning. The increase in the physical nature of the game has placed more importance on the sports medicine staff to develop injury prevention and management strategies. One way of doing this is to monitor and evaluate the physical demands of training and games on the players using global positioning system (GPS). By doing so appropriate conditioning and rehabilitation programmes that suit the players can be established. The objective of this study was to determine the physical demands on players during an international rugby union game using GPS. This study had two participants; 1 forward and 1 back. They each had a GPS devise strapped to their back which recorded velocity, time, position, distance and direction as well as the number and magnitude of impacts. Locomotion data and an accelerometer in the device measured the number of impacts (measured in gravitational force (G)). The results showed that the back covered a greater distance than the forward during the game, and that they spent more time in the higher intensity running and maximalâ€“speed running zones than the forward. The forward however, sustained considerably higher number of impacts and total body load (the sum of the number of impacts multiplied by the level at which they occurred) than the back; but the back had a greater percentage of total body load in the severe (10+ G) level. Both players covered similar distances at the higher intensity speed zone (18-24.1km/h) but the back had a higher total distance and higher than average speed than the forward. This is consistent in most games where backs cover greater distances in open play running and sprint more often. This is the first study that has reported on the body loads sustained in tackles and scrums. The highest proportion of injuries are sustained during tackling and risk factors for these injuries have been indentified in previous studies. The back had more loads of over 10G, indicating the nature of the collisions in this position. This study reiterated the link between GPS data with video analysis and its assistance in the identification of mechanisms of injuries. This in turn benefits the player as the physical demands of the game can be established. GPS is also being used in the correlation of total distance run and prematch/postmatch muscle damage markers.
Clinical Implications Players are required to recover quicker from competitions and injury; they also have to contend with the increasing physical demands of the game and the higher intensities of play. Medical staff can use GPS data to devise a position specific rehabilitation programme suited to the playersâ€™ individual needs and therefore get them match fit quicker. GPS is going to become an integral part of the sports medical team and undoubtedly more research will include it in the future. Reviewed by Charlotte Raynor MPhty, PGDipPhty, BSc (Hons), NZRP, MNZSP
JOSPT April 2013, Volume 43, Number 4 www.jospt.org
Coming soon in the May 2013 issue of JOSPT: EDITORIAL Whatâ€™s in a Name? Using Movement System Diagnoses Versus Pathoanatomic Diagnoses RESEARCH REPORT With Online Videos Clinical and Morphological Changes Following 2 Rehabilitation Programs for Acute Hamstring Strain Injuries: A Randomized Clinical Trial RESEARCH REPORT With Online Videos Efficacy of Thrust and Nonthrust Manipulation and Exercise With or Without the Addition of Myofascial Therapy for the Management of Acute Inversion Ankle Sprain: A Randomized Clinical Trial RESEARCH REPORT The Feasibility of a 3-Month Active Rehabilitation Program for Patients With Knee Full-Thickness Articular Cartilage Lesions: The Oslo Cartilage Active Rehabilitation and Education Study RESEARCH REPORT With Online Videos The Influence of Varying Hip and Pelvis Angle on Muscle Recruitment Patterns of the Hip Abductor Muscles During the Clam Exercise RESEARCH REPORT Translation, Cross-cultural Adaptation, and Clinimetric Testing of Instruments Used to Assess Patients With Patellofemoral Pain Syndrome in the Brazilian Population RESEARCH REPORT Using Functional Magnetic Resonance Imaging to Determine if Cerebral Hemodynamic Responses to Pain Change Following Thoracic Spine Thrust Manipulation in Healthy Individuals MUSCULOSKELETAL IMAGING Venolymphatic Malformation of the Proximal Gastrocnemius Muscle in a Girl MUSCULOSKELETAL IMAGING Comminuted Fractures of the Femoral Neck and Scaphoid CLINICAL PRACTICE GUIDELINES Shoulder Pain and Mobility Deficits: Adhesive Capsulitis
International Journal of Sports Physical Therapy Volume 8, Number 2 April 2013 IJSPT April 2013 ORIGINAL RESEARCH Sex differences in rectus femorus morphology across different knee flexion positions. Functional testing to determine readiness to discontinue brace use, one year after ACL reconstruction. Relationship between core strength, hip external rotator strength, and star excursion balance test performance in female lacrosse players. A comparison of two taping techniques (Kinesio and McConnell) and their effect on anterior knee pain during functional activities. Weekly running volume and risk of running-related injuries among marathon runners. Ankle dorsiflexion range of motion influences dynamic balance in individuals with chronic ankle instability. The reliability and concurrent validity of measurements used to quantify lumbar spine mobility: an analysis of an iPhone application and gravity based inclinometry. Upper body push and pull strength ratio in recreationally active adults. CASE REPORT The use of trigger point dry needling and intramuscular electrical stimulation for a subject with chronic low back pain: a case report. Functional progression and return to sport criteria for a high school football player following surgery for a lisfranc injury: a case report. CLINICAL COMMENTARY Classifying running-related injuries based upon etiology, with emphasis on volume and pace. Pre-participation screening: the sports physical therapy perspective. Shoulder posterior internal impingement in the overhead athlete. CLINICAL COMMENTARY â€“ DIAGNOSTIC CORNER Glenohumeral instability and glenoid bone loss in a throwing athlete. CLINICAL COMMENTARY â€“ ON THE SIDELINES Sideline assessment and return to play decision making for an acute elbow ulnar collateral ligament sprain.
A Multidisciplinary Approach Volume 5, Number 2 (March/April 2013) EDITORIAL A Safe World for Kids SPORTS PHYSICAL THERAPY Reliability of a New Stabilized Dynamometer System for the Evaluation of Hip Strength Effect of Subject Restraint and Resistance Pad Placement on Isokinetic Knee Flexor and Extensor Strength: Implications for Testing and Rehabilitation ATHLETIC TRAINING Accuracy of Calendar-Based Methods for Assigning Menstrual Cycle Phase in Women PRIMARY CARE Grade III Liver Laceration in a Female Volleyball Player Glenohumeral Joint Injections: A Review Concussion in Sports Stress Fractures of the Pelvis and Legs in Athletes: A Review ORTHOPAEDIC SURGERY Allograft Replacement for Absent Native Tissue Non-FOOSH Scaphoid Fractures in Young Athletes: A Case Series and Short Clinical Review Current Concepts in Examination and Treatment of Elbow Tendon Injury
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ORTHOPAEDICS AND HEALTH
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Foot and Ankle
Hip and Knee Surgery
Mental Health– Behavioural Disorders
Sports Medicine Travel Medicine Wound Care
ASICS releases its 6th edition of the Tigreor with the ongoing
the heel counter further enhances ASICS attention to detail
technological advancements that it is known for. Six years ago
and is a standout feature in overall fit. As in previous models
ASICS used its running shoe science to make break through
there is a lateral support sleeve on the inside of the boot upper.
changes never seen before in football, all aimed at changing
This links into the laces which when pulled gives the boot an
the mindset behind boot design. Tigreor 6 continues the lega-
added feel of support and enhances the fit of the boot. The
cy with features designed to improve speed, comfort and per-
ASICS football range has a removable solyte sock liner making
fitting any orthotic type a breeze. A Kangaroo leather upper completes the many features that have made Tigreor one of
Football is similar to middle distance running/sprinting and
the most comfortable boots on the market.
requires the majority of movements to be performed on the toes at quick speeds. To assist faster transition to the toes
The Tigreor outsole is available in both stud (4:2 configuration)
Tigreor 6 has a 10mm gradient built into the boot from heel to
and moulded versions for maximum traction on all playing
toe (HG 10mm). Research has also shown a higher pitch in
surfaces. The moulded version has conical moulded studs
the heel helps unload the joints of the lower limb and this pre-
that are well positioned to reduce blistering and pressure on
vents injuries to the Achilles and hamstrings. The moulded out-
the balls of the feet whilst releasing easily from the turf and
sole has different densities in the rear and forefoot making the
resisting unnecessary loads on the knee e.g ACL ruptures.
vamp more flexible under the toes, improving acceleration and speed. The rear of the outsole maintains torsional stability
This seasons model maintains ASICS leadership in tech-
required when breaking before a cutting movement or for the
nical performance, dropping the weight and improving flexi-
stabilising leg when kicking the ball.
bility in the forefoot. Tigreor 6 is packed with intelligent features designed to protect the player from injury without
Comfort has always been a standout feature of the Tigreor
sacrificing comfort. Packing so much into a boot you would
range and with a Solyte midsole (ASICS premium cushioning
think the weight of the boot would increase affecting perfor-
material) stud protection is maintained whilst keeping a plush
mance (a 100g increase in weight has a 1% energy cost).
underfoot feel on different surfaces. The new heel counter is
Surprisingly Tigreor with its many features has maintained
not as rigid allowing the boot to accommodate most heel
a low weight profile making it the most technical performing
shapes and prevents the all too common blistering seen in
boot on the market. The boot will suit the elite and non-elite
poorly designed boots. The ample padding on the inside of
players and those looking for features designed to protect against injury.
CONTINUING EDUCATION CALENDAR
Upcoming courses and conferences in New Zealand and overseas in 2013. http://www.sportsphysiotherapy.org.nz/calendar.html
LOCAL COURSES & CONFERENCES When?
See Physiotherapy NZ Website
More information Click Here
INTERNATIONAL COURSES & CONFERENCES When?
30 August 2013
Johannesburg, South Africa
30 Aug- 1st Sept 2013
The Leuko Tape Sport Physiothera- Gauteng, South py Congress Africa
2 Sept 2013
Cape Town, South Africa
25-26 Oct, 2013
Glasgow Sports Conference
8-9 Nov 2013
Salzburg Sports Physiotherapy Symposium
Nov 15, 2013
SportFisio 11th Annual Conference
http://r20.rs6.net/tn.jsp? e=0014PUpTeosLp3nXXroB4ozWJ Pfo1LkxFMNv3yvQ3ZJB0Mwz91nQFceMRLKAyUn0m7WgpdAohUiZdrLKteP2j Xs8MJYrbtBKEu1YG4olSxupZCw0 AmCawW85Lv0XEuD65j
Dec 5-7th, 2013
Team Concept Conference
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