Sports Physiotherapy NZ Oct 2011 newsletter

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BULLETIN SPNZ EXECUTIVE COMMITTEE President Secretary Treasurer Website Bulletin Committee

Dr Tony Schneiders Michael Borich Dr Gisela Sole Hamish Ashton Angela Cadogan Mark Cartman Bharat Sukha Jim Webb

EDITORIAL ASSISTANTS Nicola Thompson David Rice

SPECIAL PROJECTS Wayne Fausett Monique Baigent Nathan Wharerimu Amanda O’Reilly

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LINKS Sports Physiotherapy NZ List of Open-Access Journals SPNZ Research Reviews Asics Apparel and order form

Welcome to the October 2011 edition of the SPNZ Bulletin.

Welcome to the October edition of the SPNZ Bulletin. Heraclitus (c.535 BC - 475 BC), the Greek philosopher, is renowned for his quote ―nothing endures but change‖ and so it is that we announce another positive step forward for Sports Physiotherapy New Zealand with the unveiling of our new logo.

Since our announcement last year of our new name, we have been working hard behind the scenes to develop a logo that matches the new name and still encompasses our continuing vision to be the best provider of sport, orthopaedic and exercise medicine information to physiotherapists in New Zealand. In developing the new logo we drew inspiration from our previous insignia and consulted widely with the membership early on. We received some very positive and useful feedback which led to further development of logo options which we have since worked on with our graphic/web designer Elliot Sullivan. With continuing input from the entire executive, Elliot has transformed our old logo into the one that appears above which also comes with a number of different options and layouts of the same theme that we can use on different media, backgrounds, and promotions.

Another exciting change is the move to our new website URL: www.sportsphysiotherapy.org.nz. We hope that you will find the time to visit our website and yes, we are in the process of redesigning this as well, which could only make Heraclitus super proud of SPNZ at the moment. In the meantime, and in between the final rounds of the Rugby World Cup, enjoy this latest issue of the Bulletin of which editor, Angela Cadogan, has done another fine job of putting together.

Ka kite ano

McGraw-Hill Books and order form

Tony Schneiders

Asics Education Fund information

President SPNZ

Physiotherapy NZ IFSP JOSPT NZ Research Reviews

CONTACT US

In this edition: 

FEATURE: Sports Medics—Experiences of undergraduate physiotherapy students

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SPNZ Sideline Safety Workshop

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Article review: Accuracy of the Ottawa ankle rules for detecting ankle and mid-foot fractures

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Research reviews: Sideline emergency management

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Latest journal publications: JOSPT and International Journal of Sports Physical Therapy. and more.......

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

ISSUE 5 l OCTOBER 2011

www.asics.co.nz

www.medical.formthotics.co.nz

IN THIS EDITION

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To locate a page quickly, click on the ‘pages‘ symbol at the top of the pdf reading panel at left of screen and select the required page.

LATEST NEWS

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SPNZ—new logo SPNZ Symposium 2012 Advanced Practitioners (Sports and Orthopaedic) database IFSPT News International Journal of Sports Physical Therapy - current edition and subscription details

2012 SPNZ SYMPOSIUM

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Update and Call for Papers

FEATURE

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SPORTS MEDICS—Experiences of Undergraduate Physiotherapy Students How well would you respond to the sudden collapse, seizures and lack of pulse in a young soccer player? Two University of Otago physiotherapy students were faced with this situation, responded and were instrumental in the survival of this player. Read more on page 5.

CLINICAL SECTION SPNZ—Sideline Safety Workshop

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Article Review: ―Accuracy of the Ottawa Ankle Rules to Exclude Fractures of the Ankle and Midfoot: A Systematic Review.

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RESEARCH SECTION Sports Physiotherapy NZ Research Reviews:

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Emergency Sideline Management: 

Sideline and event preparation for the management of sudden cardiac arrest in athletes

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ECG as part of the pre-participation screening programme

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Evaluation of the patient with extremity trauma: An evidence-based approach

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Safety and efficacy of attempts to reduce shoulder dislocations

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Therapeutic musculoskeletal injection. What is current practice? What is the evidence?

Journal of Orthopaedic & Sports Physical Therapy: Volume 41, October 2011

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International Journal of Sports Physical Therapy: Volume 6, No 3

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Other Research Reviews:

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Bone Health Reviews Sports Medicine Reviews Foot and Ankle Reviews Rehabilitation Reviews

CONTINUING EDUCATION

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SPNZ WEBSITE INFORMATION

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ADVERTISING - Neuromagnetics Course

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CLASSIFIEDS - Positions vacant and physiotherapists wanted for cycling event

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LATEST NEWS New SPNZ Logo SPNZ have developed a new logo.

In December last year, ―SPNZ‖ was voted as the new name to replace NZSOPA. Since then much work has been done, and many versions of new logos have crossed the desk of the SPNZ Executive.

We hope you like the new look!

SPNZ Symposium: Prevention, Practice, Performance.

Sebel Trinity Wharf Hotel, 17th & 18th March 2012.

Dr Jill Cook (Monash University) has been confirmed as our keynote speaker. Jill‘s presentation topics will cover: 

Can we prevent tendon injuries?

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Is the clinical presentation of tendinopathy correlated with pathology?

Hear from other invited speakers on a range of topics relevant to sports and orthopaedic physiotherapists including quadriceps inhibition in knee osteoarthritis (David Rice), labral injuries of the hip (Mr Matt Brick), Functional Movement Screening (Dr Tony Schneiders) and ethical considerations in sports physiotherapy (Dr Lynley Anderson). Also confirmed are Dr Dale Speedy (Sports Physician), Caryn Zinn (sports nutritionist) and Richard van Plateringen (sports podiatrist).

Put the date in your diary and we look forward to seeing you in Tauranga next year. More updates will be available as they become available on: www.nzsopa.org.nz/symposium.html

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Advanced Practitioners (Sports & Orthopaedic) database.

We would like to establish a database of SPNZ Advanced Practitioner members.

SPNZ are occasionally contacted by physiotherapists, medical and allied professionals and members of the public seeking physiotherapists with advanced or specialized skills in the area of sports or orthopaedic physiotherapy. We would like to create a database of our Advanced Practitioner members so that we can direct these enquiries to appropriately skilled physiotherapists. If you currently hold Advanced Practitioner membership status with the NZCP (―Sports & Orthopaedic‖ tag), and consent to your contact details being made available in response to enquiries, please send your details to the SPNZ Secretary mborich@ihug.co.nz and include the following information:     

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Name Address Phone contact details Email address Area of specialist practice (specific sport, body region, specific injuries, age groups, programmes etc) Professional sporting involvement (if any): (sport and level)

International Federation of Sports Physical Therapy (IFSPT) News Keep up to date with IFSP News.

The IFSPTnewsletters are available to download in .pdf format from the website http://www.ifsp-world.org/. For the current newsletter, click on the following link: September 2011.

International Journal of Sports Physical Therapy The IJSPT journal is available to purchase for individual members.

To view contents of the current issue click here or see page

Call for papers.

The education committee is currently looking for speakers for long (30 min) and short (15min) presentations that will fit the direction of the symposium. If you are inter ested in presenting please submit an abstract and brief CV to: Hamish Ashton (Symposium Chairman) help@nzsopa.org.nz

The current issue contains a number of high quality articles including ―Functional Movement Screen TM - normative values in a young, active population‖, by SPNZ President Dr Tony Schneiders from the University of Otago. Other articles include a review on conservative management of patellofemoral pain, the predictive ability of upper limb functional tests for softball throw distance, and rehabilitation guidelines for exertional compartment syndrome.

SPNZ members 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 2011 is €20.

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SPNZ Symposium 2012

PREVENTION, PRACTICE, PERFORMANCE Sebel Trinity Wharf Hotel Tauranga March 17th and 18th 2012.

Speakers confirmed: KEYNOTE SPEAKER Dr Jill Cook - Monash University, Australia INVITED SPEAKERS Mr Matt Brick—Orthopaedic surgeon Dr Dale Speedy—Sports Physician Dr Lynley Anderson—University of Otago Caryn Zinn - Sports nutritionist Richard van Plateringen - Sports podiatrist More information as it becomes available: www.sportsphysiotherapy.org.nz/program.html

CALL FOR PAPERS

―Prevention, Practice, Performance‖ Sports Physiotherapy New Zealand hosts biennial symposiums to portray the breadth of knowledge associated with Sports Physiotherapy. The symposiums are largely practically based with presentations having a ‗take home‘ message. The focus is on ―I can use this in my practice tomorrow‖

The education committee is currently looking for speakers for long (30 min) and short (15min) presentations that will fit the direction of the symposium.

If you are interested in presenting please submit an abstract and brief CV to: Hamish Ashton, Symposium Chairman help@nzsopa.org.nz

SPNZ is now on Facebook Check us out at:

www.facebook.com/SportsPhysiotherapyNZ Website Gems Links to Video clips

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FEATURE SPORTS MEDICS Experiences of Undergraduate Physiotherapy Students

How would you respond to the sudden collapse, seizures and lack of a pulse in a 19-year old during a soccer game?

Two second-year physiotherapy students from Otago University were faced with exactly this situation. In this feature article, Gisela Sole provides a summary of interviews with these two students, who performed CPR and were instrumental in the players survival. Gisela also provides reports from other students of their experiences on the sidelines as ‘sports medics‘, as well as an overview of the sports medic training, and other relevant issues facing physiotherapists who attend sporting events.

Introduction Each year hundreds of physiotherapists and physiotherapy students attend sports games, events and tournaments, and are frequently the only medical personnel in attendance. In addition to physiotherapy skills, the sports physiotherapist must also possess basic first aid and emergency management skills in order to manage the many medical situations that arise from sports participation.

Sports Medic Training for Physiotherapy Students University of Otago physiotherapy students complete a Sports Medic course at the beginning of Year 2 as a terms requirement for the paper PHTY255 Physiotherapy Clinical Practice. This course entails at least 14 hours of lectures and 6 hours of practical labs, the latter focusing in taping, splinting and wound management. After completion of a written test, students are awarded a Sports Medic certificate, and they can choose to volunteer in this capacity with local teams. The restricted role of the sports medic is made clear to them, and the requirement to introduce themselves as such to the teams, not as physiotherapy students, is emphasised. Those that volunteer for a team are more likely to continue doing this at Year 3 level, with a handful also continuing into Year 4, dependent on their clinical placements.

Sports Medics in Action Most medics work with rugby, soccer or rugby league teams and a small number with netball. This includes

University and high school teams, as well as local premier teams. The students may be aligned with a team for the whole season, alternatively might work with them only during specific tournaments or events. For example, one of our current Year 2 students, Fabian Law, volunteered to work at the USA vs Canada ice hockey game, and had the opportunity to spend time in the American players‘ box. Although Year 2 sports medics are often paired with Year 3 medics, they occasionally have to work by themselves. However, with the Dunedin Sports Injury Clinic (DSIC) available on Saturdays, there is assurance that injured players can be referred whenever needed. Further, the sports medics normally have telephone numbers for physiotherapists if these have to attend to games at other locations. During weekly practice sessions, physiotherapists are often on site working with more elite teams, being available to supervise the medics directly or indirectly.

Otago University Sports Medic Experiences I have interviewed volunteer students involved as sports medics about their experiences and various stories emanate. Although the sports medics‘ main role focuses on immediate management of injuries, taping and massaging, they may also be involved with decision making regarding referrals for further assessment and return to play, particularly if a player is injured during matches/ games. A sharp learning curve is experienced within the first few weeks of starting as sports medic. The medics reported that, in general, their advice it taken seriously by most coaches and players. However, they occasional

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FEATURE SPORTS MEDICS face the pressure when a player insists on returning to sports, or when expectations are set by coaches, particularly in rugby.

Shoulder Dislocations For those working with rugby teams, a high number of shoulder dislocations are seen. Although it is well known that they should not attempt to reduce these, rather refer them to the DSIC or Emergency Department (ED), they have found that these may be reduced ―by chance‖. For example, Camille Gurung was making a rugby player with a dislocation comfortable in the car to take him to DSIC, resulting in a spontaneous reduction. Nina Barker related an incidence when a rugby player with a previous dislocation insisted on playing. After being taped by another team member (knowing that Nina would refuse to do this), the player went onto the field but rather sheepishly had to discontinue within 5 minutes and ask her to take him to the DSIC due to a re-dislocation, with a subsequent immediate referral to ED. Nicole McMahon observed a player incurring a complete anterior ankle dislocation of the tibia at the ankle during a game. The game was cancelled, and fortunately the St John ambulance was on site to provide immediate management and transfer him to ED. Concussion The medics also appear to encounter a relatively high frequency of concussion. Nina had to deal with concussion by two team mates who had run into each other, both loosing consciousness. This was momentary for one of them but the other player remained unconscious for about 5 minutes and the St Johns ambulance arrived within acceptable time to take him to ED. Nina learnt from this incidence that immediate management does not always go according to plan. This match had been well-attended by spectators who were eager to help and arrived at the players before she and her colleague were able to. By the time she reached them, the more seriously injured player had been turned into the recovery position without consideration for a possible cervical injury.

Cardiac Events Fabian Law and Courtenay Kay encountered a more serious situation: they were attending to a soccer game when they observed a 19-year old player collapsing. Their first thoughts were that he had re-dislocated his shoulder, however realized very quickly that this was a different situation, noting that he had lost consciousness as they raced towards him. Fabian could not open the airways due to seizures and could not find a pulse. They started with cardio-pulmonary compressions and continued with these until the ambulance arrived 15 minutes later. The player thankfully survived and underwent a coronary artery by-pass within a couple of weeks. Fabian experi-

enced that ―you just go in and do what you have to do‖.

He also found himself in the position of having to communicate with the parents of the player from the North Island, and having to debrief the soccer team the following morning. Fabian and Courtenay‘s maturity and ability throughout the procedures were commended by many team members, the coach, the St John‘s team and, of course, a very grateful player.

Benefits of Sports Medic Experience The medics mentioned many benefits of being involved in this role while being a physiotherapy student. They perceived growing confidence while dealing with various aspects throughout the year, transferring to improved performance as a student. They gain courage to face the unexpected and to communicate assertively with sportspeople, coaches, and other members of the team. They experienced that the sports people were willing to give helpful feedback about their skills, while also learning that some of the players had their own ideas about how they should be taped, and some coaches about readiness for return to play!

Involvement throughout a season allowed the medics to follow injuries for a longer period than the physiotherapy clinical placements normally allow. They also have the opportunity to see ―non-textbook‖ cases, such as a player who initially presented with mechanism of injury, signs and symptoms indicative of a medial collateral ligament injury, instead being confirmed with a later MRI as a distal hamstring tear but intact ligament. The overall practical experience remains the main benefit, as Emma Stewart mentioned that ―nothing can prepare you for the actual practice‖. The actual involvement on the field and on the sidelines was their most valuable learning experience, reinforcing the knowledge that students learn to be practitioners while being exposed to ―real life‖ clinical practice.

The medics expressed their appreciation for the sports physiotherapists that they have worked with, finding them approachable, knowledgeable and excellent role models to aspire towards. Similarly, the contribution by Mr Graeme Harvey, coordinator of the DSIC, is highly valued by them, and also by the School of Physiotherapy. Many thanks to all members who are involved in the development of our future colleagues.

Dr Gisela Sole.

Senior Lecturer, Associate Dean Undergraduate Studies School of Physiotherapy, University of Otago Acknowledgements Thank you to Emma Stewart, Camille Gurung, Candace Wheatley, Tom Hoffman, Fabian Law, Ashleigh Spratt, Nicole McMahon, Nina Barker, Rebecca Brown and Courtenay Kay for sharing their stories.

CLINICAL SECTION

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SPNZ SIDELINE SAFETY WORKSHOP Sports Physiotherapy New Zealand recently ran a Sideline Safety Workshop for third year physiotherapy students at AUT University. Physiotherapy students are often asked to assist as sports games and events, and a basic knowledge of medical issues, injury prevention, strapping and acute injury management is required until formal physiotherapy training is completed. Hamish Ashton from the SPNZ Executive presented the course to and this was well received. Hamish has provided a short report about the course.

In September SPNZ ran a four hour sideline safety workshop for 3 rd year physiotherapy students from AUT. This was aimed at providing the students some guidelines on what to do and what not to do when working with sports teams.

Physiotherapy students are often present on the sideline of sports games and events, where they provide a valuable service and gain both knowledge and experience, helping to develop an interest in sports medicine. However as they are not supervised they are present in a sports medic capacity, and can not use the term physiotherapist until fully qualified.

The course covered the role as a sports medic including dealing with general health issues of the players. It then went on to look at the various components of injury prevention including general preparation, warming up, the use of appropriate equipment, and warming down. This was followed by an introduction to injuries from a functional anatomy perspective.

After a couple of videos identifying how hard it was to predict an injury from the sideline, the assessment and treatment principals of TOTAPS, RICE and HARM were then covered, along with a section on concussion management. By the end of theoretical section the students had an understanding of where their knowledge limits were – a key point in remaining safe on the sideline.

The course then finished off with a session on strapping. This session introduced the students to different styles of strapping from the two different perspectives of the tutors.

Hamish Ashton Sports Physiotherapist

Our thanks to USL for providing the tape for the strapping session.

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CLINICAL SECTION ARTICLE REVIEW Accuracy of the Ottawa Ankle Rules to Exclude Fractures of the Ankle and Mid-foot: A Systematic Review.

Lucas M Bachmann, Esther Kolb, Michael T Koller, Johann Steurer, Gerben ter Riet

Differentiating between a severe ankle sprain and an ankle or foot fracture on the sideline of a sports field, or in the clinical can be challenging. This article reviewed a number of studies in which the Ottawa Ankle Rules had been used to assess its‘ value as a screening tool for ankle and mid-foot fractures.

ABSTRACT Objective: To summarise the evidence on accuracy of the Ottawa ankle rules, a decision aid for excluding fractures of the ankle and mid-foot.

Design: Systematic review.

Data sources: Electronic databases, reference lists of included studies, and experts.

Review methods: Data were extracted on the study population, the type of Ottawa ankle rules used, and methods.

Sensitivities, but not specificities, were pooled using the bootstrap after inspection of the receiver operating characteristics plot. Negative likelihood ratios were pooled for several subgroups, correcting for four main methodological threats to validity.

Results: 32 studies met the inclusion criteria and 27 studies reporting on 15 581 patients were used for meta-analysis.

The pooled negative likelihood ratios for the ankle and mid-foot were 0.08 (95% confidence interval 0.03 to 0.18) and 0.08 (0.03 to 0.20), respectively. The pooled negative likelihood ratio for both regions in children was 0.07 (0.03 to 0.18).

Applying these ratios to a 15% prevalence of fracture gave a less than 1.4% probability of actual fracture in these subgroups.

Conclusion: Evidence supports the Ottawa ankle rules as an accurate instrument for excluding fractures of the ankle and mid-foot. The instrument has a sensitivity of almost 100% and a modest specificity, and its use should reduce the number of unnecessary radiographs by 30-40%.

Reference: L Bachmann, E Kolb, M T Koller, J Steurer, G ter Riet. British Medical Journal 2003;326:417 Introduction Ankle sprains are one of the most common injuries seen by sports physiotherapists involved in many sports including netball, basketball, rugby union, rugby league and soccer. The differentiation between a moderate or severe sprain and an ankle fracture can be clinically challenging, particularly in the acute stages of injury. In many cases, different management pathways exist for soft-tissue ankle sprains and foot or ankle fractures, with detection of a fracture often resulting in periods of immobilization and non weight-bearing to optimize healing. To help differentiate soft-tissue injury from bony injury, medical practitioners including physiotherapists often seek further imaging investigations such as x-rays to help screen for (rule-out) or to detect (rule-in) a bony injury. The use of x-ray to aid in the diagnostic process, while providing useful information in many cases, also involves exposure to radiation, additional cost to the health care system, and to the patient, and also adds to the resource burden in radiology departments, particularly in hospital emergency departments.

The balance between the ability to rule-out an ankle frac-

ture with the use of x-ray, and optimizing radiology resource utilization is necessary to ensure that ankle and foot fractures are not missed, and that health care funding and resources are used appropriately.

In medicine, clinical prediction rules are being increasingly reported in the literature. CPRs are tools designed to aid in clinical decision making by statistically combining clinical findings to improve the accuracy of diagnosis, prognosis, or prediction of response to treatment for individual patients. Earlier diagnostic prediction rules in the medical literature focused upon conditions for which the consequences of missing a particular condition were serious, such as myocardial infarction, diabetes, alcoholism and substance abuse. Other prediction rules were aimed at reducing the use and spending on hospital services by targeting investigations more appropriately at those patients more likely to have the condition. More recently clinical prediction rules for the diagnosis of musculoskeletal pathology have been reported, among them the Ottawa ankle rules.

In 1992, the Ottawa Ankle Rules were developed outlin-

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CLINICAL SECTION ARTICLE REVIEW CONTINUED... ing a specific set of clinical features that were highly sensitive for the detection of mid-foot and ankle fractures among those presenting to a hospital emergency department.

Ottawa Ankle Rules.

The Ottawa ankle rules are designed to rule-out either a mid-foot or ankle (malleolar) fracture, meaning these clinical features are able to detect the majority of patients with these fractures, and very few will be missed: Detection of an ankle fracture: 



the inability to walk four steps (immediately after the injury or at the emergency department) localised tenderness of the posterior edge or tip of either the lateral or medial malleolus (four spots).

Detection of a mid-foot fracture: 

the inability to walk four steps (immediately after the injury or at the emergency department)



localized tenderness of the navicular or the base of the fifth metatarsal

This systematic review aimed to evaluate the accuracy of the Ottawa ankle rules across a range of studies in which

these were used to identify mid-foot or ankle fractures.

Methods The systematic review included studies in which the Ottawa ankle rules had been used to assess for an ankle or mid-foot fracture. Quality assessment of all studies was conducted by the authors, and although no specific quality assessment tool was used, all studies were evaluated for methods of data collection, patient selection, blinding and prevention of verification bias, and description of the instrument and reference standard.

Statistical methods Pooled negative likelihood ratios (NLRs) were calculated for differing categories of methodological quality. (NLR = how many times more likely it is to find a negative result among people with a fracture (1 - sensitivity) than among those without. Ideally this would be around 0.00, and guidelines suggest a NLR less than 0.20 to be of diagnostic significance). Pooled sensitivities were also calculated (ability to rule-out a fracture when the Ottawa rules are negative). To assess sources of variation, results were stratified according to different clinical sub-groups, and study design.

Results A total of 1085 studies were identified, and 32 studies were identified that satisfied the study inclusion criteria. Sixteen studies involved assessment of ankle fractures, 11 involved assessment of mid-foot fractures, and 10 involved overall accuracy of the rules and included a combination of both assessments. The majority of studies were conducted in adult populations presenting to hospital emergency department.

Results of pooled analysis Twenty seven studies were included in the pooled analysis (ankle n=12; mid-foot n=8; combined rules n=10).

Of these studies that collectively included 15, 581 patients, only 47 patients (0.3%) returned a falsenegative result.

Sensitivities were consistently high but ranged from 99.6% (95% confidence interval 98.2% to 100.0%) in studies on application of the rules within 48 hours of injury to 96.4%

CLINICAL SECTION

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ARTICLE REVIEW CONTINUED...

(93.8% to 98.6%) in studies of combined assessment.

The specificities ranged from 47.9% (interquartile range 42.3%-77.1%) in studies with a prevalence of fracture below the 25th centile of all studies to 26.3% (19.4%34.3%) in studies of combined assessment.

unless the clinician shares the patient's cultural background. The subtlety of palpation technique might explain some of the large variation in false positive rates—the percentages of patients who apparently indicated pain (or were unable to walk four steps) but had no fracture.

Negative likelihood ratios ranged from 0.8 for ankle or foot rules, to 0.17 for combined rules (ankle and foot).

The NLR was also lower (better) when the rules were applied within a 48 hour period (0.06), compared with later than 48 hours (0.11). However, studies investigating Ottawa ankle rules for adults presenting within a 48 hour period were scarce.

The authors also discuss other evidence which reports that although clinicians widely recognised the test as a decision tool, its use, and the resulting change of clinical behaviour was limited. Clinicians would logically aim to minimise the number of missed fractures and would therefore maximise sensitivity at all costs. Fear of a bad professional reputation or litigation might be an explanation. In contrast, a health insurer would be interested in the optimal balance between sensitivity and specificity of the instrument.

Therefore, the practical question from the health authorities' point of view is, how should the instrument behave in order that clinicians will use it? The authors put forward a proposed outline of how this could be evaluated.

Discussion The authors summarised the accuracy of the Ottawa ankle rules for excluding fractures of the ankle and mid-foot in patients presenting to emergency departments with an acute ankle sprain. Less than 2% of patients in most subgroups who were negative for fracture according to the Ottawa ankle rules actually had a fracture meaning the rules were highly sensitive and missed very few fractures.

As a clinical tool, the Ottawa ankle rules are calibrated towards high sensitivity, rather than specificity, hence the results of this review focused on the sensitivity of these rules. High levels of sensitivity mean when the Ottawa rules are negative, the clinician can be confident there is no fracture. When the NLR is low, the clinician can be confident that the likelihood of patients having a fracture in whom the Ottawa ankle rules are reported to be negative, is very low.

Specificity, however, is an indicator of the number of false-positive results (those patients in whom the Ottawa rules were reported to be positive for a fracture, but who did not acutally have a fracture). Thus specificity is an indicator of the number of unnecessary radiographs that may be avoided with this decision rule. The variability in the specificities, which ranged from 10% to 79%, was surprising, and the authors hypothesised that differences in clinical skills, interpretation of the test, and experience of staff may have influenced the ability to correctly classify the rules as being negative based upon the clinical examination.

In addition, the expression of pain, which is crucial for the interpretation of the test, was cited as a possible explanation for the variable specificity (false-positive rate). The authors point out that pain may have a cultural dimension which could result in a higher false positive rate among patients with a relatively vivid expression of pain or a higher false negative rate among stoical individuals,

Immediate access to radiography may further trigger requests for radiographs and all studies included in this review were conducted in hospital settings where radiology services are presumably readily available. So far the usefulness of the Ottawa ankle rules as a decision tool in primary care has not been assessed and the authors recommend that dissemination among general practitioners and people supervising sports activities may therefore be pertinent.

Conclusion Although the Ottawa rules may not have been validated in primary care or sporting settings, they represent simple clinical tests that would be well within the capability of all physiotherapists. To apply these in clinical practice, and particularly on the sideline at sporting events would fit with the context in which these rules have been investigated, particularly when applied within 48 hours of injury. While clinical prediction rules are not intended to replace clinical reasoning, they do provide a reasonable guideline with high sensitivity for a malleolar or mid-foot fracture.

RESEARCH SECTION

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SPNZ PHYSIOTHERAPY RESEARCH REVIEWS

EMERGENCY SIDELINE MANAGEMENT In keeping with the feature article in this edition of the SPNZ Bulletin, the Special Projects Group have summarised a range of articles relating to management of some common injuries and medical issues encountered by sports physiotherapists.

Reviews by Wayne Fausett, Monique Baigent, Nathan Wharerimu and Amanda O‘Reilly

www.nzsopa.org.nz/resources.html

Update on sideline and event preparation for management of sudden cardiac arrest in athletes K. G Harmon & J. A Drezner (2007). Current Sports Medicine Reports; (6): 170-176.

Article Summary This review summarizes the current American guidelines for emergency management of cardiac arrests in athletes.

Sudden death in athletes occurs approximately once every 3 days in the United States. Unexpected cardiac death is the leading cause of death in young athletes, and in approximately 55% to 80% of sudden cardiac death cases the athlete is asymptomatic until the cardiac arrest.

Protocols should be put in place to prepare for such an event, with a cohesive and coordinated emergency response plan. 91% of National Collegiate Athletic Association Division I institutions have defibrillators with an average of four in each of these institutions. Only 25 to 54% of schools however have a defibrillator on the grounds. This is likely to increase further as 13 states now have laws or legislation requiring defibrillators in high schools.

In 2000 the American Heart Association came up with four important steps to follow in this situation. 1) early recognition of the emergency and activation of emergency medical services ; 2) early cardiopulmonary resuscitation (CPR); 3) early defibrillation; and 4) early advanced life support. Survival rates of 50% to 74% have been reported with witnessed collapse, immediate bystander CPR, and defibrillation within 3 to 5 minutes.

Clinical Significance As a sports physiotherapist it is important to have an updated knowledge of CPR. Each year over 1000 people in New Zealand will suffer a cardiac arrest outside of hospital (St John, 2011). Being prepared can make a difference, having an automated external defibrillator can increase the chance of survival by up to 40% when dealing with a sudden cardiac arrest. Knowing whether your sports ground has access to a defibrillator and identifying and administering early CPR could save a life.

RESEARCH SECTION

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SPNZ PHYSIOTHERAPY RESEARCH REVIEWS CONTINUED…..

ECG as part of the preparticipation screening programme: an old and still present international dilemma.

C Hevia, M.M Fernandez, J.M.A Palacio, E.H Martin, M.G Castro, J.J Rodriguez Reguero. (2011). British Journal of Sports Medicine; 45: 776-779 Article Summary Systematic pre-participation screening of competitive athletes was implemented by law in Italy in 1982. This screening has proven efficacy in preventing sudden cardiac deaths related to sports but it is not routinely practised internationally.

The aim of this study was to determine the prevalence of abnormal findings during routine cardiovascular examination.

1220 young athletes (mean age 23 years, 96% male) of different sports disciplines underwent a cardiovascular examination. This involved a personal and family history, physical examination in addition to a resting 12-lead ECG. Those with positive findings were referred for additional tests such as echocardiography, 24-hour ECG and/or exercise stress test. Ninety (7.4%) athletes were referred for further tests. Eight cases were diagnosed with left ventricular hypertrophy, one with athlete‘s heart, one with hypertrophic cardiomyopathy and six required further evaluation as the echocardiograph findings were not sufficient to confirm or exclude diagnosis of cardiomyopathy.

Clinical Significance The findings of a normal ECG during pre-participation screening can be regarded as reasonably reliable evidence to exclude the presence of potentially lethal cardiac disease. Neither history nor physical examination raised suspicion in any of the eight cases that were referred on for echocardiogram; therefore it seems reasonable that a 12-lead ECG may be a useful technique for identifying athletes with suspected underlying heart disease.

Note: The September 2011 International Journal of Sports Physical Therapy contains an article titled ―The use of cardiopulmonary resuscitation and the automated external defibrillator in the practice of sports physical therapy.‖ The abstract for this article is available by clicking on the link and would be worth a read for those who attend sports fixtures with no other medical support. If you want to subscribe to this journal to access full-text articles, see page 3 of the Bulletin for details.

Evaluation of the patient with extremity trauma: An evidence based approach D Kaufman, J Leung (1999) Emergency Medicine Clinics of North America;17 (1): 77-95 Article Summary This literature review aimed to establish the validity of clinical decision rules used to determine if an x-ray should be ordered following extremity trauma. It provided evidence based clinical guidelines on the radiographic evaluation of patients in the emergency department. The authors also summarised previous work on the topic then reviewed and evaluated data that were specifically concerned with x-rays of the ankle with particular reference to the Ottawa Ankle Rules.

Evidence is strongest for selective use of ankle, foot, and knee radiography guided by use of screening criteria that have been carefully developed and tested. The authors recommend that clinical decision rules be included in the algorithm for evaluation of blunt trauma to the ankle and knee.

Clinical Significance The main drive behind establishing and researching clinical decision rules with regards to fractures of the extremity is to reduce medical treatment cost, emergency waiting room times and exposure to unnecessary radioactive exposure.

Establishing fool proof clinical decision rules is a particularly big topic in the USA. This is due in part to the legal repercussions that can occur if one decided not to refer for an x-ray and it was discovered to be fractured later. This article explores the topic in depth and provides clear guidelines for making the decision whether to refer on or not. From a physiotherapist perspective it is comforting that there is evidence based research to back the decision whether or not to refer an ankle injury for x-ray. See the in-depth review of the Ottawa Ankle Rules in the Clinical Section of this Bulletin for guidelines on how these are used in clinical practice.

RESEARCH SECTION

Page 13

SPNZ PHYSIOTHERAPY RESEARCH REVIEWS CONTINUED…..

Safety and efficacy of attempts to reduce shoulder dislocations by non-medical personnel in the wilderness setting.

J. Ditty, D. Chisholm, S.M. Davis, M. Estelle-Schmidt (2010). Wilderness and Environmental Medicine; 21: 357-361 Article Summary This study reported success and complication rates for attempted reduction of dislocated shoulders by non medical people in the outdoor setting. 56 of 112 responses to an online survey described shoulder dislocations in the outdoors, with 39 reductions by non‑medical personnel were attempted at the scene of injury, with a success rate of 72% (28/39). Median time to reduction at the scene of injury was 5 minutes, compared to 135 minutes for those reduced at a medical facility. Other than pain during the reduction attempt, there were no reports of serious complications associated with a reduction attempt. 79% (31/39) of dislocations occurred during whitewater kayaking, and 18% (7/39) had suffered prior dislocation to the same shoulder. The authors concluded reduction of dislocated shoulders at the injury scene by nonmedical personnel can be safe and effective.

Clinical Significance There is considerable debate whether reduction for dislocated shoulders should be attempted at the scene of injury by non-medical personnel, or should reduction only be attempted by trained medical staff once appropriate investigation has been completed. The sooner a dislocated shoulder is reduced, the easier it is to reduce, and the benefits of early reduction include decreased pain and muscle spasm, and a decreased risk of neurovascular compromise. However, these benefits could be outweighed by any possible iatrogenic injury during the reduction attempt ie. if a fracture is present. This study has obvious methodological flaws (data collected retrospectively, therefore subjected to recall bias; no way of verifying if the reported injury was actually a dislocated shoulder), which were acknowledged by the authors. Despite these shortcomings, attempted reduction of dislocated shoulders by non-medical personnel appears a relatively safe procedure. Lastly, the data suggest whitewater kayaking is a high risk activity for shoulder dislocation, and clinicians working in this sport are advised to screen participants to identify those at risk.

Therapeutic musculoskeletal injection: What is current practice? What is the current evidence?

J. Peters (2010). Minnesota Medicine; 93 (12): 8-11 Article Summary This article summaries current literature around injectable agents, and reviews their use and effectiveness. Injectable agents can be used to reduce pain/inflammation and facilitate/induce healing when first-line treatments (RICE, analgesia, physiotherapy) have proved ineffective. Corticosteroids have a potent anti-inflammatory action, and have been used for many years to treat joint and soft-tissue conditions. Steroid injections offer a pain-free ‗window‘, and it is essential follow up the injection with appropriate rehabilitation to prevent recurrence. Risks associated with corticosteroids injection include skin depigmentation, fat necrosis, and infection. An alternative to steroid injection for OA is intraarticular injection of hyaluronic acid, which has been shown to offer longer-term pain relief. A course of hyaluronic acid injections is expensive compared to steroid injections, which may explain their lack of popularity here in NZ. Plateletrich plasma and autologous blood injections are 2 approaches to treating degenerative soft-tissue conditions. The proposed mechanism of action is the potentially beneficial bioactive factors present in platelets, and there are potentially less serious side effects with these therapies. Sclerotherapy, using agents such as polidocanol, has potential to benefit degenerative soft tissue conditions such as tendinopathies, by inhibiting the neovascular response. Prolotherapy involves injection of a hyperosmotic dextrose solution, again to induce a healing response in degenerative soft tissues.

Clinical Significance: Although early results are encouraging, there is a lack of consistent, high quality, prospective research to support the use of some of these injectable therapies. As clinicians, a good working knowledge of the efficacy of injection therapy is necessary, because although physiotherapists are not responsible for administering injectable agents, we are often asked about them or responsible for providing follow up care post injection.

RESEARCH SECTION

Page 14

JOURNAL OF ORTHOPAEDIC & SPORTS PHYSICAL THERAPY

October 2011; Volume 41, Issue 10 Did the NFL Lockout Expose the Achilles Heel of Competitive Sports?

Gregory D. Myer, Avery D. Faigenbaum, Chad E. Cherny, Robert S. Heidt Jr., Timothy E. Hewett

Change in Knee Cartilage Volume in Individuals Completing a Therapeutic Exercise Program for Knee Osteoarthritis Jason D. Woollard, Alexandra B. Gil, Patrick J. Sparto, C. Kent Kwoh, Sara R. Piva, Shawn Farrokhi, Christopher M. Powers, G. Kelley Fitzgerald

Treatment of Patients With Degenerative Cervical Radiculopathy Using a Multimodal Conservative Approach in a Geriatric Population: A Case Series Steven W. Forbush, Terry Cox, Eric Wilson

Biomechanical and Clinical Factors Related to Stage I Posterior Tibial Tendon Dysfunction Melissa Rabbito, Michael B. Pohl, Neil Humble, Reed Ferber

Who Needs ACL Surgery? An Open Question

Reliability and Diagnostic Accuracy of the Lachman Test Performed in a Prone Position Edward P. Mulligan, Jordan L. Harwell, William J. Robertson

Screening the Lumbopelvic Muscles for a Relationship to Injury of the Quadriceps, Hamstrings, and Adductor Muscles Among Elite Australian Football League Players Julie A. Hides, Cassandra T. Brown, Lachlan Penfold, Warren R. Stanton

Evoked Spinal Reflexes and Force Development in Elite Athletes With Middle-Portion Achilles Tendinopathy Hsing-Kuo Wang, Kwan-Hwa Lin, Yu-Kuang Wu, Shyh-Ching Chi, Tifany Ting-Fang Shih, Yung-Cheng Huang

Lynn Snyder-Mackler, May Arna Risberg

Proximal Femur Fracture in a Patient Referred to a Physical Therapist for Knee Pain The Effect of Therapeutic Exercise and Mobilization on Patients With Shoulder Dysfuction: A Systematic Review With Meta-analysis Tracy J. Brudvig, Hetal Kulkarni, Shalvi Shah

Identifying Individuals With an Anterior Cruciate Ligament-Deficient Knee as Copers and Noncopers: A Narrative Literature Review Yonatan Kaplan

Roberto Sandoval

Osteochondritis Dissecans Jonathan C. Sum, George F. Hatch

CIRNE III Abstracts: Congresso Internacional de Reabilitação Neuromusculoesquelética e Esportiva

Page 15

RESEARCH SECTION

Volume Six, Number Three

Table of Contents Differences in change scores and the predictive validity of three commonly used measures following concussion in the middle school and high school aged population.

Authors: Barlow M, Schlabach D, Peiffer J, Cook C Management of acute sports injuries and medical conditions by physical therapists: assessment via case scenarios.

Authors: Cross PS, Karges JR, Salsbery MA, Smith D, Stanley EJ A pilot survey on injury and safety concerns in international sledge hockey Authors: Hawkeswood J, Finlayson H, O‘Conner R, Anton H The influence of heel height on sagittal plane knee kinematics during landing tasks in recreationally active and athletic collegiate females.

Authors: Lindenberg KM, Carcia CR, Phelps AL, Martin RL, Burrows AM The navicular position test – A reliable measure of the navicular bone position during rest and loading.

Authors: Sporndly-Nees S, Dasberg B, Nielsen R, Boesen M, Langberg H Electromyographic analysis of gluteus medius and gluteus maximus during rehabilitation exercises.

Authors: Boren K, Conrey C, LeCoguic J, Paprocki L, Voight M, Robinson K

CASE REPORT Shoulder pain and dysfunction secondary to neural injury.

Authors: Brown KE, Stickler L

CLINICAL COMMENTARY Post-activation potentiation: an introduction Authors: Lorenz DS

Click on the article title to go to the abstract.

See page 3 of the Bulletin for details on how to subscribe to the IJSPT journal.

Journal subscription enables access to full text of all articles.

Integration of strength and conditioning principles into a rehabilitation program Authors: Reiman MP, Lorenz DS

CLINICAL SUGGESTION Cervicogenic headaches: an evidenced-led approach to clinical management.

Author: Page P The use of cardiopulmonary resuscitation and the automated external defibrillator in the practice of sports physical therapy.

Author: Smith D, Hoogenboom B

Page 16

RESEARCH SECTION RESEARCH REVIEWS Register (FREE) and download the latest ―NZ Research Reviews‖

http://researchreview.co.nz

Studies in this issue:

Studies in this issue:

 Oral bisphosphonates and risk of atypical fractures

 Simulation training improves foot ulcer management

 Denosumab reduces new fractures in high-risk postmenopausal women

 Paracetamol use, fractures and BMD  SC denosumab preferred over oral alendronate  Hip structure analysis of bisphosphonate users  Strontium reduces fracture risk in postmenopausal osteoporosis

 Ankle tourniquet pain control in forefoot surgery  Foot orthoses for plantar heel pain  Foot biomechanics in diabetes mellitus  Guidelines for managing foot-related RA problems  Implementing feedback during gait retraining  Nonoperative therapy for adult-acquired flatfoot  Extracorporeal shockwave therapy in Achilles tendi-

 Vitamin D guidelines

nopathy

 Denosumab improves bone strength: preclinical data

 ESWT vs hyperbaric oxygen therapy in diabetic foot ulceration

 Sclerostin inhibits formation

Studies in this issue:

Studies in the latest issue include:

 Exercise and type 2 diabetes  Identifying patellofemoral pain patients likely to benefit from foot orthoses

 Rotator cuff tendinopathy: pathology and related management

 A–Z of nutritional supplements: part 13  Foot orthoses and gait

 Keep exercising in multiple sclerosis  Peer support promotes physical activity in heart disease.

 Evidence-based cognitive rehabilitation.

Knowledge brokering in children‘s rehabilitation organisations.

 Goal Management Training for executive functioning

 Kinesiotape and calf function, pain and motoneuronal excitability

 Impact of footwear on gait

deficits.

 Aphasia worsens quality of life after stroke.

http://www.researchreview.co.nz

Page 17

CONTINUING EDUCATION

Upcoming courses and conferences in New Zealand and overseas in 2011 and 2012. www.nzsopa.org.nz/calendar.html LOCAL COURSES & CONFERENCES When?

What?

Where?

More information

20-21 October

National Community Physiotherapists Conference

Nelson

pam.blair@xtra.co.nz

30 October

PAANZ: Ear Acupuncture

Dunedin

www.paanz.org.nz

5-6 November

NZMPA: Wrist and Hand, and Review of Upper Christchurch Quartile Pathologies

www.nzmpa.org.nz

5-6 November

Southern Physiotherapy Symposium 6

Registration information

5-6 November

Movement Analysis and Motor Control Retraining Tauranga for the Lumbar Spine

jenlochray@hotmail.com

9 November

Setting the standard: Best Practice for the Assess- Auckland ment and Management of Chronic Pain

Registration information

10 December

NZMPA: Lumbar Spine Revisited

Registration information

10-11 December

Movement Analysis and Motor Control Retraining Tauranga for the Sacroiliac Joint and Pelvis.

jenlochray@hotmail.com

Sports Physiotherapy NZ

Sebel Trinity Wharf,

www.nzsopa.org.nz

‖Prevention, Practice & Performance‖

Tauranga

2011

Queenstown

Dunedin

2012 17-18 March

INTERNATIONAL COURSES & CONFERENCES When?

What?

Where?

More information

2011 19-22 October

Australian Conference of Science and Medicine in Freemantle, Perth Sport

ACSMS Conference

27-30 October

Australian Physiotherapy Association 2011 Confer- Brisbane ence

physiotherapy.asn.au/ conference 2011/

10-12 ber

Novem- Discover the Sports Pelvis—LJ Lee

Sydney

physiohealing.com.au

Quebec, Canada

www.ifomptconference.org

2012 30 Sep - 5 Oct

IFOMPT 2012: Rendez-vous of Hands and Minds

Page 18

SPNZ WEBSITE SPNZ MEMBER SECTION

www.sportsphysiotherapy.org.nz/members1.html SPNZ Member Login Your email address is that which you supplied to Physiotherapy NZ. Your password will be sent to you by SPNZ and can be reset to a password of your choice by clicking on ―Reset Password‖.

MEMBERS SECTION: Copies of all clinical article reviews and SPNZ Research Reviews that appear in the SPNZ Bulletin editions will be placed in the new ―Resources‖ section, as well as an updated list of Open Access Journals. These will be available for

SPNZ‘s Research Reviews

Clinical Article Reviews



Osteoarthritis



Barefoot running and the minimalist shoe debate



Injuries in Cricket



Bench pressers‘ shoulder—overuse tendinosis of pectoralis minor



Medical Exercise



Blood clots and plane flights



Sport and the Disabled Athlete.



Heat acclimatization guidelines for high school athletes



Management of hamstring injuries—issues in diagnosis



Sideline evaluation of bone and joint injury



Occular injuries in basketball and baseball



Clinical and MRI features of a cricket bowlers side strain

List of Open Access Journals (full text available to all members) 

AND MORE...

Sports physiotherapy

Quick Links to Members Section Resources Copies of SPNZ‘s Research Reviews, a list of openaccess journals (full-text available), clinical article summaries and other sports physiotherapy related articles.

Book Reviews Book reviews on sports physiotherapy topics

Snippets Vacancies

Quick sports physiotherapy tips

Sports Team Positions and Clinic Positions available Calendar Clinical Forum Got a clinical question and want advice from members?

Calendar of upcoming courses and conferences

ADVERTISING

Page 19

Neuromagnetics Workshop Got patients with pain? This is for you!

9.00am – 3.00pm November 19th Venue: St Chads Church, 38 St Johns Rd, Meadowbank, Auckland

Presented by Doug Edwards, N.Z.R.P. Pain systems often become too sensitive, causing us pain that provides no benefit. Learn how to shut down the pain pathway using Neuromagnets Neuromagnets main applications - acute pain, chronic pain, chronic dysfunction

Who uses Neuromagnets?

Physiotherapists – acute pain, chronic pain, dysfunction / imbalance Sports Teams – acute pain, soft tissue injuries, musculoskeletal conditions

YOU! Start using this ground breaking, simple and effective technology before everyone else!!!

During this workshop learn some of the secrets of pain mechanisms, and be introduced to neuromagnets: what they are and how they work. Make them a part of your business.

Cost: $200.00 pp Places are strictly limited – book now!!

For more information contact: doug@neuromagnetics.co.nz Your opportunity to start changing people’s lives – one pain at a time This page may contain paid advertisements. Content is not necessarily endorsed by SPNZ.

Page 20

CLASSIFIEDS POSITION VACANT BAY OF PLENTY

Keen in working in a dynamic multidisciplinary physio clinic in combination with a sports massage therapist and a fitness trainer?

We use hands on physiotherapy combined with rehab and exercise training to fully meet our patients needs.

Move to the sunny BOP and be supported with continuing education and work alongside staff with postgraduate qualifications and international sports experience.

Sports experience preferable.

Contact Jacinta on Jacinta@buretaphysio.co.nz or (07) 5761860.

PHYSIOTHERAPISTS WANTED FOR EVENT

CYCLING: Great Escapade New Zealand Gisborne to Taupo 544km ride 18 - 26 February 2012 The Great Escapade is for riders seeking a supported touring holiday in the best riding destinations.

Enjoying the fantastic scenery and holiday experience by the seat of your bike in New Zealand. We take care of the planning and you take care of the riding.

Secure your spot on this amazing ride by 30 October and you'll receive bike transport to and from NZ valued at $300, as a bonus offer.

Download the complete brochure at: https://www.bv.com.au/file/file/Great%20Escapade/Great% 20Escapade%20NZ%20E-brochure.pdf

Physiotherapists --Would you like to ride? Come with us and ride FREE. We need three Physios to help on the Care Team.

The Care Team (Medical Team) supports the riders with rest stop first aid and a medical clinic at campsite. We like to offer a massage and physio service for the riders.

We would expect physios to work about 2 -3 hours a day in return for a complimentary ride pass.

If you are interested please ring Dr Chris Davenport Care Team Director 0425 708 382 or email on careteambv@gmail.com