sportEX Medicine Journal Issue 60 - April 2014

ISSUE 60 Apr 2014 ISSN 1471-8138

promoting

excellence in

highlights

sports

n latest research news n research analysis n sports triage medical screening

medicine n the tendinopathy continuum n shoulder impingement

contents April 2014 issue 60 publisher/editor Tor Davies tor@sportex.net Art editor DeBBie asher debbie@sportex.net sub-editor alison sleigh Journal watch BoB BraMah subscriptions & Advertising support@sportex.net +44 (0) 845 652 1906 coMMissioning eDiTors Brad hiskins - australia & nZ Whitney lowe - Usa & canada humphrey Bacchus - UK & europe glenn Withers - Worldwide Dr Marco cardinale - Worldwide Dr Thien Dang Tan - Usa & canada Dr Joseph Brence, DPT, coMT, FaaoMPT, Dac Technical aDvisors

steve aspinall Bob Bramah Paula clayton stuart hinds rob granter Michael nichol Joan Watt Prof greg Whyte

Bsc (BasraT), Msc McsP, MsMa Msc, Fa Dip, Mast sTT Dip ssT Dip ssT Bsc (BasraT) McsP, MsMa PhD, Msc, Bsc

Welcome

Apr 2014

This april issue is so literally bursting at the page seams that we’ve had to run onto the inside back cover with one of our articles anD print our new Web Watch page as a loose leaf insert so apologies if it looks a bit weird! We’ve also introduced a new feedback mechanism where your response to our post-issue feedback on which articles you like, will be factored into the payment remuneration equation for authors. it’s all part of our mission to make sure we’re publishing the type of content that you want and that the authors delivering that content get rewarded accordingly. ever since i launched sporteX 15 years ago in July (yikes), it was always about fostering a ‘virtuous circle’ approach across the business. This is one more step in that direction. another new aspect of this issue is an official collaboration with ForwardThinkingPT and the nxtgen institute. nxt gen’s mission is focused on delivering education designed to foster the highest levels of practitioner critical thinking and clinical reasoning. ForwardThinkingPT’s mission is to promote thinking and improved methodology and assist in the delivery of quality, evidence-based reviews to help the average clinician improve their practice.. This aligns perfectly with the sporteX mission to turn evidence into hands on practice. if you are part of an organisation with a similar passion and would be interested in having your own similar section in the journal then get in touch. it could be a one off or a series of contributions.

Finally come and follow me on Twitter - there’s masses of brilliant material out there from all sorts of sources which i tweet regularly @sportexjournals. in the meantime, enjoy spring and of course the new issue.

is published by Centor publishing ltd 88 Nelson road Wimbledon, sW19 1HX Tel: +44 (0)845 652 1906 Fax: +44 (0)845 652 1907 www.sportex.net

Tor davies, physio-turned publisher and sporteX founder tor@sportex.net

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4 Journal watch CoNTeNTs psychosocial aids to recovery 8 21 The tendinopathy continuum reviews in 14 research partnership with the Nxtgen 27 shoulder impingement instutitue The latest key research from this quarter can psychological strategies help your athletes to heal faster?

The progressive nature of tendinopathy and how best to treat it assessing and treating shoulder pain

Turning evidence into practice

To FiNd ouT More AbouT sporTeX VisiT

DISCLAIMER While every effort has been made to ensure that all information and data in this magazine is correct and compatible with national standards generally accepted at the time of publication, this magazine and any articles published in it are intended as general guidance and information for use by healthcare professionals only, and should not be relied upon as a basis for planning individual medical care or as a substitute for specialist medical advice in each individual case. To the extent permissible by law, the publisher, editors and contributors to this magazine accept no liability to any person for any loss, injury or damage howsoever incurred (including by negligence) as a consequence, whether directly or indirectly, of the use by any person of any of the contents of the magazine.

Copyright subsists in all material in the publication. Centor Publishing Limited consents to certain features contained in this magazine marked (*) being copied for personal use or information only (including distribution to appropriate patients) provided a full reference to the source is shown. No other unauthorised reproduction, transmission or storage in any electronic retrieval system is permitted of any material contained in this publication in any form.

The publishers give no endorsement for and accept no liability (howsoever arising) in connection with the supply or use of any goods or services purchased as a result of any advertisement appearing in this magazine.

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online

CLICK ON RESEARCH TITLES TO GO TO ABSTRACT

U ULTRASOUNd EvALUATION Of ACHILLES TENdON THICKNESS IN ASympTOmATICS: A RELIABILITy STUdy. Kharate p, Chance-Larsen K. International Journal of physiotherapy and Rehabilitation. November 2012.

Twenty five healthy patients had their Achilles tendon thickness measurements taken using ultrasonography (SonoSite 180 Plus Ultrasound System) on two occasions, approximately 30min apart; by the same rater who had received only minimal training in the use of the equipment. The intraclass correlation coefficient for intra-rater reliability was found be excellent.

sportEX comment The sooner diagnostic ultrasound machines are cheap enough for every physio to have and their use gets taught as part of the core curriculum at universities the better. BTW you can pick this model up for a couple of grand.

T AddITION Of CERvICAL UNILATERAL pOSTERIOR-ANTERIOR THE mOBILISATION IN THE TREATmENT Of pATIENTS wITH SHOULdER m ImpINGEmENT SyNdROmE: A RANdOmISEd CLINICAL TRIAL. Cook C, Learman K, et al. manual Therapy 2014;19:18–24 Sixty eight patients were randomised into a shoulder treatment plus neck mobilisations or a shoulder treatment only group. The shoulder treatment was individualised according to need and contained elements of manual therapy, self- and externally-applied stretching, isotonic strengthening, and restoration of normative movement. The manual therapy interventions to the neck consisted of grade III posterior–anterior mobilisations, performed in prone for 30 repetitions for 3 sets. The treatment target was the stiffest segment, or the most painful, or if no symptoms in the neck then to C5/C6 or C6/7.

Comparative pain, disability, rate of recovery and patient acceptable symptom state (PASS) measures were analysed over an average of 56.1 days. 86% of the sample reported an acceptable change on the PASS at discharge. There were no between-

groups differences in those who did or did not receive neck manual therapy; however, both groups demonstrated significant within-groups improvements.

On average both groups improved 59.7% for pain and 53.5% for the Quick Disabilities of the Shoulder and Hand Questionnaire (QuickDASH) from baseline. No value was added with the addition of neck manual therapy.

sportEX comment This is a good effort on the part of the authors but it illustrates the difficulty of manual therapy research.

The individual treatment protocols for the shoulder although clinically correct behaviour makes it difficult to make comparisons of the outcomes. Patients with neck pain were excluded so it is not surprising that that there appears to be no benefit to the addition of neck therapy.

ACUTE EffECTS Of INSTRUmENT ASSISTEd SOfT TISSUE mOBILIzATION fOR ImpROvING pOSTERIOR SHOULdER RANGE Of mOTION IN COLLEGIATE BASEBALL pLAyERS. Laudner K, Compton B, et al. The International Journal of Sports physical Therapy 2014;9(1):1 Thirty-five asymptomatic collegiate baseball players were randomly assigned to either a treatment group or a control. The former (n = 17) received one application of instrument assisted soft tissue mobilisation (IASTM) using the Graston® Technique to the posterior shoulder. Measurements of passive glenohumeral (GH) horizontal adduction and internal rotation range of motion were taken.

A significant group-by-time interaction was present for GH horizontal adduction ROM with the treatment group showing greater improvements in ROM (11.1°) compared to the control group (–0.12°). This group also showed significant groupby-time interaction for GH internal rotation ROM (4.8°) compared to the control group (–0.14°).

sportEX comment This treatment involves the use of a shaped metal tool. They can be purchased in the UK for around £350 with extra advanced tools at around another £450. There are training courses available.

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sportEX medicine 2014;60(April):4-7

JOURNAL WATCH

Journal watch NSAI ANd OTHER ANALGESIC USE By ENdURANCE NSAId RUNNERS dURING TRAINING, COmpETITION ANd RECOvERy. Joslin Jd, Lloyd JB, et al. South African Journal of Sports medicine 2013;25(4):101–104 Surveys were given to 27 ultra-marathon runners and 46 marathon, half-marathon and marathon relay runners in the Desert Race Across the Sand race (Colorado to Utah, USA) in June 2011 and the Empire State Marathon half-marathon and relay races in Syracuse, NY, USA, in October 2011. They were asked about their use of common analgesic medications during training, racing and recovery was assessed.

For all the runners and at all stages, non-steroidal antiinflammatory drugs (NSAIDs) were the most commonly used analgesic medication. NSAID use by ultra-marathon runners compared with all other runners was similar during training (59% and 63% respectively) and recovery (59% and 61%), Ultra marathon runners were more likely than all other runners to use NSAIDs during the race (70% and 26%).

sportEX comment Damaged tissue heals in set phases. There has to be an inflammatory stage. If this doesn’t happen the damage will never be repaired [see Tim Watson’s sportEX article on Tissue Healing (sportEX medicine 2006;28;8–12)]. Taking NAIDS in the early stage will affect the process. There are other ways of killing pain.

mUSCULOSKELETAL pAIN AmONG UNdERGRAdUATE LApTOp USERS IN A NIGERIAN UNIvERSITy. Obembe AO, Johnson OE, et al. Journal of Back and musculoskeletal Rehabilitation 2013;26(4):398 The Boston University Computer and Health Survey questionnaire was self-administered to 400 undergraduate laptop users with a usable response rate of 94%. Pain in the shoulder was the most reported musculoskeletal complaint from 268 (75.7%) participants. Elbow pain was the least common complaint from 132 (37.3%) participants. The prevalence of musculoskeletal pain was slightly higher among female students 93 (50.3%) of 185 and highest among students aged between 24 and 26 years: 60 (37.5%). In addition, the prevalence of musculoskeletal complaints was highest among those who used single-strap laptop bags 176 (94.1%).

sportEX comment So laptops are bad for you and carrying them is worse than using them. www.sportEX.net

R REvIEw Of mETHOdS USEd By CHIROpRACTORS TO dETERmINE THE SITE fOR AppLyING mANIpULATION. Triano d JJ, Budge B, et al. Chiropractic & manual Therapies 2013; 21:36 The usual database subjects were searched to find studies looking at the diagnostic reliability and validity of common methods used to identify the site of treatment application. A total of 2,594 titles were screened from which 201 articles met all inclusion criteria. The quality of evidence was ranked using QUADAS for validity and QAREL for reliability and not surprisingly the quality was found to be somewhat mixed. The most convincing favourable evidence was for methods that confirmed or provoked pain at a specific spinal segmental level or region. There was high quality evidence supporting the use, with limitations, of static and motion palpation, and measures of leg length inequality. Evidence of mixed quality supported the use, with limitations, of postural evaluation. The evidence was unclear on the applicability of measures of stiffness and the use of spinal X-rays.

The evidence was of mixed quality, but unfavourable for the use of manual muscle testing, skin conductance, surface electromyography and skin temperature measurement.

sportEX comment This is all about attempting to develop clinical prediction rules for spinal manipulation sites. It seems that the thing that there is most evidence for is to home in on the painful bit.

T EffECTIvENESS Of ExERCISE INTERvENTIONS TO THE pREvENT SpORTS INJURIES: A SySTEmATIC REvIEw ANd mETA-ANALySIS Of RANdOmISEd CONTROLLEd TRIALS. Lauersen JB, Bertelsen dm, Andersen LB. British Journal of Sports medicine 2013;dOI:10.1136/bjsports-2013-092538 Data bases were searched to find papers concerned with reduction of sports injuries. This resulted in an initial 3462 results which were whittled down to 25 relevant trials, including 26,610 participants with 3,464 injuries. Despite a few outlying studies, consistently favourable estimates were obtained for injury prevention via proprioception training, and strength training. Stretching didn’t make a difference, whereas strength training reduced sports injuries to less than 1/3 and overuse injuries were almost halved.

sportEX comment Think about this in evolutionary terms. Go back 50 thousand years or so and picture Henry Homo-Sapiens wandering along his favourite track when he is confronted by a hungry looking sabre-toothed tiger. He doesn’t shout, “stop a minute puss while I have a stretch to warm up before I do a runner or I will do myself a mischief”. No, he either legged it pretty sharpish or he was dinner; therefore, proving beyond doubt that we are programmed to run without stretching in order to survive.

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CLICK ON RESEARCH TITLES TO GO TO ABSTRACT

HEAdING IN fOOTBALL, LONGTERm COGNITIvE dECLINE ANd dEmENTIA: EvIdENCE fROm SCREENING RETIREd pROfESSIONAL fOOTBALLERS. vann Jones SA, Breakey Rw, Evans pJ. British Journal of Sports medicine 2014;48:159–161

Three hundred questionnaires were sent to four players’ associations from two professional clubs in England and two in Scotland.

They were required to complete a self-assessed test of cognition and a Test Your Memory questionnaire.

Further information was collected from respondents in order to analyse the potential effect of a number of variables on cognition.

A total of 138 former professional football players completed and returned the assessment: a response rate of 46%. Of these, 92 met the inclusion criteria. The mean age of those included in the study was 67.45 years (± 6.96), the mean length of the professional playing career was 13.84 years (± 4.67) years. Of respondents, 8.7% were goalkeepers; 30.4% played the majority of their career in defence; 27.2% in midfield positions; and 33.7% in forward or striking position.

Ten of 92 respondents (10.87%)

screened positive for possible mild cognitive impairment (MCI) or dementia. There was no association between low-risk and high-risk playing positions or length of playing career and a positive screening result. Age was a risk factor although this was not significantly different from the population prevalence across age groups.

sportEX comment Professional football provides a laboratory for proving data on the impact of chronic repetitive low impact head trauma through the act of heading. This suggests that once the player retires his (or these days, her) risk of harm is in line with the rest of the population. This might be because changes are reversible or that heading may not be as dangerous as once thought. Consider also that the modern ball is a balloon compared to earlier heavier models.

ImpACT Of SHOULdER pOSITION ANd fATIGUE ON THE fLExION–RELAxATION RESpONSE IN CERvICAL SpINE. Nimbarte Ad, zreiqat m, Ning, x. Clinical Biomechanics 2013;dOI:10.1016/j.clinbiomech.2013.12.003 Thirteen male graduate engineering students without a history of neck pain were recruited.

Motion capture kinematic data and muscle EMG were recorded during neck flexion and extension activity using a Sorensen protocol where the subject lies prone on a table and the head is unsupported dangling off the end. Time to fatigue against gravity was measured with the shoulders in neutral and shrugged and correlated with the other data. The flexion–relaxation phenomenon was observed only in the neutral shoulder position pre- and

post-fatigue. The flexion relaxation ratio decreased significantly post-fatigue in neutral shoulder position but remained unchanged in shrugged shoulder position. The onset and offset angles and the corresponding durations of the silence period were significantly affected by the fatigue causing a post-fatigue expansion of silence period.

sportEX comment According to this study it is estimated that about 67% of people suffer neck pain at some point in their life. Ouch! Those who suffer most are

people whose work activities include static and/or awkward head–neck postures for sustained periods. That includes manual therapists especially if their technique isn’t top notch and users of VDUs, which means all of us. The flexion–relaxation phenomenon is the point at which during flexion the extensors muscles quit and stability is maintained by the ligaments. What all this means in practice is that shoulder position and fatigue affect the load on passive structures, which in turn can lead to problems. So, it’s all about posture. Get that right in the workplace and you will cut down that 67% figure.

EvIdENCE Of dECLINING EmpATHy IN THIRd yEAR OSTEOpATHIC mEdICAL STUdENTS. Caruso Hm, Bernstein B. International Journal of Osteopathic medicine 2013;dOI:10.1016/j.ijosm.2013.10.008 Earlier studies have reported a decline in empathy shown by medical students as they progress through their studies. In this one, 70 third year students at the Philadelphia College of Osteopathic Medicine were given a questionnaire regarding empathy and the results were, as predicted in

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the previous studies, that their empathy levels took a nose dive.

sportEX comment Given that other studies suggest that patients fare better when their clinicians display a bit of empathy this is a disturbing result. The paper

touches on whether or not empathy can be taught. Hanford et al. [PLoS ONE 2013;8(6)] suggest not as it is personality trait based around an ability (or otherwise) to understand others emotions. Maybe it is time that we in the therapy and care industry give a bit more thought to who we are recruiting.

sportEX medicine 2014;60(April):4-7

JOURNAL WATCH

Sp SpORTINESS ANd mASCULINITIES AmONG fEmALE ANd mALE pHySIOTHERApy STUdENTS. dahl-michelsen T physiotherapy Theory and practice 2014;dOI:10.3109/09593985.2013.876692 The purpose of this study was to explore “the gendered importance of sportiness in terms of students’ judgments of themselves and their classmates as suitable physiotherapy students”. It was conducted using observations and qualitative interviews with first year students doing a physio degree in Norway.

‘Sportiness’ is a display of masculinity and is inspired

by Connell’s concept of multiple masculinities.

With it so far? The results demonstrate sportiness as a shared common value among students. There were two main typologies: hypersportiness; and ordinary sportiness.

Apparently male hyper-sporty students

are acknowledged as particularly suitable physiotherapy students and assume a hegemonic position in the student milieu. Female students who adapt hypersportiness have the potential to assume a hegemonic position, but tend not to do so. Female students with an ordinary level of sportiness have no particular problems in being identified as suitable physiotherapy students, whereas male students do encounter such problems.

sportEX comment Norway is clearly very different to England where being sporty is not necessarily a requirement to enter physio school. In fact your esteemed Journal Watch editor was specifically advised not to mention sport on application to British uni’s.

THE EffECTS Of TwO THERApEUTIC pATELLOfEmORAL TApING TECHNIqUES ON STRENGTH, ENdURANCE, ANd pAIN RESpONSES. Osorio JA, vairo GL, et al. physical Therapy in Sport 2013;14(4):199–206 Twenty physically active patellofemoral pain syndrome (PFPS) patients attended three sessions. At the first they recorded baseline measures for Isokinetic strength and endurance, and perceived pain. At the second they were randomly allocated to a McConnell taping technique or a NUCAP Medical Upper Knee Spider ® kinesiology taping technique and tested again. On the third visit they swapped taping technique.

The results were that all the tested measures showed improvement but there was no difference between the taping techniques.

sportEX comment This is kind of an old v. new study. You don’t seem to see an athlete on TV in any sport these days without them having a bit of kinesiology tape stuck on somewhere. You don’t see McConnell tape much but this proves that for patella pain at least there is life in the old ways yet. What this doesn’t answer is how long they stayed on and effective for.

www.sportEX.net

EffECT Of THERApEUTIC INfRA-REd IN pATIENTS wITH NON-SpECIfIC LOw BACK pAIN: A pILOT STUdy. Ansari NN, Naghdi S, et al. Journal of Bodywork and movement Therapies 2014;18(1):75–81 Ten patients (5 men and 5 women; mean age 36.40 ± 10.11 years, range = 25–55) with non-specific low back pain and disease duration of 21.7 ± 11.50 months were treated with infra-red (IR) for 10 sessions, each for 15min, 3 days per week, for a period of 4 weeks. Outcome measures were the Numerical Rating Scale, the Functional Rating Index, the Modified–Modified Schober Test, and the Biering-Sorensen test to assess pain severity, disability, lumbar flexion and extension range of motion (ROM), and back extensor endurance, respectively. Data were collected at: baseline, end of 5th treatment session (after 2 weeks), and at the end of the treatment (after 4 weeks). There were significant effects of IR on all outcomes of pain, function, lumbar flexion– extension ROM, and back extensor endurance.

sportEX comment What goes around comes around. There was a time when the heat lamp was a ubiquitous piece of physio room equipment. Search the back of your departmental storeroom and they are probably still there.

THE mATURE ATHLETE’S SHOULdER. Tokish Jm. Sports Health: A multidisciplinary Approach 2014;6(1):31–35 This is basically a ‘state of play’ article on the mature athlete’s shoulder. A normal natural history of the shoulder includes stiffness, rotator cuff tears and osteoarthritis, all of which can become increasingly more symptomatic as an athlete ages.

It points out that rotator cuff pathology increases with age and activity level. Partial tears rarely heal, and debridement of significant partial tears results in poorer outcomes than those of repair. Repair of partial-thickness tears can be accomplished with completion and subsequent repair or in situ repair. The most successful result for treatment of osteoarthritis in the shoulder remains total shoulder arthroplasty, with more than 80% survival at 20 years and high rates of return to sport. However, caution should be taken in patients younger than 60 years, as they show much worse results with this treatment. Adhesive capsulitis of the shoulder can be successfully treated with non-operative management in 90% of cases.

sportEX comment The authors set the bar for aging at 50 with a banding of above and below this and another for the over 65s, all of which require a slightly different rehab approach. This paper is one of a number in this issue of Sports Health with a focus on the more mature athlete including papers on aging tendons, articular cartilage and hips. It’s well worth getting hold of a copy if you deal with athletes who are getting on a bit.

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It’s all In the mInd

BY Dale ForsDYke Msc, MsMa, MssT

BackgrounD My previous article [sportEX medicine 2014;59(January):10–15] highlighted that psychological dysfunction is both a common consequence of sports injury and a key determinant of injury recovery outcomes. It was highlighted that practitioners should assume that sustaining a sports injury is a significant life event and therefore helping athletes deal with the ‘fall out’ of becoming injured and redirecting thoughts and behaviours seems an important consideration in holistic recovery.

The Integrated Model of Sports Injury (1) theorises that psychological interventions can influence sports injury recovery by affecting the cognitive appraisals made by the athlete throughout rehabilitation thus leading to more adaptive emotional and behavioural responses. According to Harris (2) the practitioner should be adequately skilled to recognise a range of psychological reactions experienced by injured athletes, to have the required skill set to intervene (eg. use basic psychological skills interventions) and to have the ability to recognise the need for referral to an appropriate professional in cases of suspected clinical issues (eg. depression symptoms, substance abuse, eating disorders). To further reinforce the

Psychosocial interventions to imProve recovery As practitioners we all have a range of modalities and tools to treat sport injuries, but how many of us use psychosocial skills to facilitate holistic recovery? There is a growing perspective that sports injury practitioners should be able to use basic psychosocial interventions with athletes as they are usually present immediately after the injury has taken place, and at the time when the levels of pain and confusion experienced by the athlete are at their worst. This article aims to increase knowledge of psychosocial interventions that can be used with injured athletes and provide some basic strategies to be considered in the day-to-day management of sports injury rehabilitation to improve practice.

Box 1: pracTiTioner Tips For creaTing eFFecTive inTeracTions wiTh injureD aThleTes [Adapted from Brewer et al. (6)] n Regularly check perceptions and understanding n Get specific with information and goals to avoid ambiguity n Listen before you fix to understand/empathise with the patient problems n Listen for the ‘but’ to uncover patient fears and concerns n Value patient input as a means of showing respect and improve perception of control n Talk about the expected challenges and difficulties associated with recovery and plan for relapse.

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rationale for a practitioner to use psychosocial interventions, it has been found that faster-healing athletes use psychological strategies more often during rehabilitation than those who subsequently heal more slowly (3).

creaTing an eFFecTive MoTivaTional environMenT Often the essential role of the practitioner interactions and the psychological environment created is under appreciated. Both the rehabilitation environment and interactions between athlete and practitioner should focus on fulfilling the basic psychological needs of the athlete that are often compromised due to sustaining injury (4). An athlete’s basic psychological needs include autonomy, competence, and relatedness. Autonomy refers to the athletes perceptions of choice and control throughout their rehabilitation, competence refers to the athlete feeling like they can achieve and accomplish exercises and tasks, and relatedness refers to the athlete feeling understood and supported by the significant others around them. If these

needs are fulfilled then an effective motivational treatment climate will be created. In a study of 70 participants with sport-related injuries from a range of sports and level of performance, findings revealed that high perceptions of autonomy supportiveness provided by the practitioner led to better clinicbased adherence and attendance at rehabilitation (5). Consequently if the athlete’s psychological needs are not fulfilled then adaptive emotional, cognitive and behavioural responses may become present (eg. fear of re-injury, low self-efficacy and poor adherence). Essentially, being aware of the rehabilitation environment and your interactions with the athlete seeks to improve self-confidence through improving commitment to recovery/ rehabilitation, perceptions of control, and feeling of competence (Box 1).

rehaBiliTaTion proFiling anD goal seTTing Systematic and regular performance profiling (PP) with subsequent goal setting based on the profiling outcomes has been commonly used in performance psychology since the early 1990s. As described in Weston et sportEX medicine 2014;60(April):8-13

EvidEncE Informed informEd practIce practicE evIdence

al. (7), it is thought that advantages of using PP are to: n Raise self-awareness n Help prioritise training focus n Motivate athletes to continually improve n Facilitate setting of individualised goals n Monitor and evaluate sports performance n Enable athletes to take more responsibility for their development.

Box 2: personal anD phYsical FacTors aFFecTing recoverY (D. Forsdyke, 2014)

Although the exact process and people involved in PP varies, it is often as follows: 1. The athlete identifies important physical and psychological demands of the sport/position 2. The athlete discusses the relative importance of each demand 3. The athlete scores themselves on a scale on 0–10 (low–high) against each demand 4. Goals are set to improve demands with low scoring whilst maintaining high score 5. After a set time this is evaluated.

physical factors (0–10)

Confidence Motivation Anxiety Focus Expectations Worry Emotions Identity Adherence Understanding Pain tolerance Social support

Range of movement Strength Stability Coordination Balance Swelling Pain Function Daily activities Sports participation General health Sleep

rehabilitation outcomes. Where the athlete is in terms of the personal and physical factors can be made more objective by using recognised outcomes measures, eg. bilateral functional comparisons, visual analogue scales, and established psychology inventories. A performance profile chart can be completed as a more visual representation of the process for the athlete and allow for stage of healing-based comparison (Fig. 1). The PP should be done ideally within 72 hours of sustaining an injury and again throughout rehabilitation to demonstrate

Within rehabilitation, Taylor et al. (8) highlight that athletes should score themselves (0–10) against physical and personal factors (Box 2) as both together are thought to affect

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personal factors (0–10)

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Figure 1: A performance profile chart.

The physical and personal factors should be placed on the outer ring of the profile. The athlete will need to understand what each of these mean and score themselves out of ten for each factor and display this on the profile. This can then be used to identify concerns, track progress, and set rehabilitation goals.

[Adapted from Butler et al. (15)]

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FASTER-HEALING ATHLETES USE PSyCHOLOGICAL STRATEGIES MORE OFTEN DURING REHABILITATION THAN THOSE WHO SUBSEqUENTLy HEAL MORE SLOWLy

improvement and continually re-focus goals.

There are a number of approaches to goal setting when applied to injury settings; however, the SMARTS method seems the most robust and recognised. This means that all goals set during the rehabilitation process should be: specific to the individual, the injury and the healing process; measurable using reliable outcome

recoverY goals (long term)

levels oF goals

Used to specify the ultimate level of recovery at the conclusion of rehabilitation. Includes physical, psychological, and performance goals.

liFesTYle goals sTage goals (medium term) Consists of objectives for each stage of rehabilitation, thus making recovery goals more manageable.

Includes physical, psycolocical, and performance goals.

In relation to sleep, diet, alcohol or drug use, relationships, work and school.

DailY goals (short term)

TYpes oF goals

These goals are aimed to specify what will be done in each physiotherapy session. Usually not prepared as part of the goal setting, but evolve during the session. Should be clear, and leading towards stage and recovery goals.

phYsical goals Including goals in relation to range of motion, strength, stability, stamina, flexibility, coordination, and other relevant physical parameters.

psYchological goals

perForMance goals

Including goals regarding issues in relation to confidence, motivation, focus, anxiety, and pain tolerance.

Including goals in relation to technical and tactical development, physical conditioning, mental training and return-toform.

Figure 2: Rehabilitation goal setting. [Adapted from Taylor et al. (8); Arvinen-Barrow and Hemmings (9)]

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measures; achievable and realistic so as not to undermine the athlete’s competence; have a time constraint for completion; and be self-determined so that the athlete has some ownership of the goal and adheres to it. Effective goal setting during rehabilitation should include making different levels of goals relating to overall recovery and beyond (long term), stage of healing goals (medium term) and day-to-day aims and objectives (short term) (8).

Adopting a biopsychosocial and holistic approach to rehabilitation means that goals relating to the athlete’s lifestyle such as diet, sleep, work and relationships should also be considered important. The types of goals created should also be considered and altered according to physical, psychological and athletic performance outcomes, with the athlete understanding the purpose of and agreeing to all goals made (Fig. 2). Recording all goals formally and getting the patient to sign and date these may improve the goal adherence and subsequent chance of success.

using iMagerY Can you heal quicker by using imagination? Imagery is cognitively reproducing or visualising an object, scene or sensation as though it was occurring in overt, physical reality incorporating all five senses (10). Broadly, sport imagery tends to serve two main functions, cognitive and motivational, operating on both a specific and general level (eg. motivation-general imagery, motivationspecific imagery). Not only does imagery help regulate emotions and thoughts it also works via mind–body integration. For example recreating events in the mind leads to a psychophysiological and/or psychomotor response also. Within sports injury rehabilitation there seem to be four main types of imagery that can be used to facilitate effective recovery: n Healing imagery – focusing on the specific healing area and tissue healing process, eg. increasing blood flow to the tissues. However, this relies on creating a sound knowledge base with the patient n Pain management imagery – focusing on regulating pain and discomfort as a result of the injury sportEX medicine 2014;60(April):8-13

evIdence Informed practIce

that may become a barrier to recovery n Rehabilitation process imagery – focusing on the challenges of rehabilitation such as adherence, staying positive and overcoming barriers n Performance imagery – focusing on practising correct technique with the absence of injury and pain.

Evidence of the potential beneficial use of imagery comes from a random controlled study of 30 anterior cruciate ligament reconstruction patients that found the imagery treatment group had significantly greater knee strength and significantly less pain and anxiety 24 weeks post-surgery compared with the control and placebo group (11). Using imagery with injured athletes may well speed physical recovery, improve adherence to rehabilitation, enable relapses to be dealt with, regulate negative emotions and maintain/improve self-efficacy through the recovery period (12). This is demonstrated in the following quote from an injured athlete [from Driediger et al. (10)]:

with a positive outcome may reduce anxieties over re-injury associated with return to play and maintain confidence in the healed tissue.

cogniTive reFraMing Sustaining a sports injury and engaging in what can be long slow recovery can be littered with negative and sometimes irrational thoughts. For example an injured athlete feeling that they are never to get better or they will be the weakest link in the team when they return to play. Cognitive reframing is about replacing existing negative, irrational and maladaptive thoughts with more positive, rationale and adaptive ones (see Box 3 for examples).

Practitioners may help injured athletes reframe their negative and often extrinsic perspective by refocusing on the positive and intrinsic reasons for their sport involvement such as ‘a

love of the game’, personal feelings of satisfaction when learning a new skill, the excitement they get from sport participation, and the social benefits associated with sport involvement (4). This technique is not about stopping negative thoughts that will undoubtedly occur in rehabilitation but recognising and using them as a trigger to produce more positive ones. A simple word such as ‘no’ or ‘stop’, or clenching a fist when negative thoughts appear could be a more

“But, while, like physio exercises right after surgery were really painful and you just try not to focus on the pain and you just try to imagine yourself in the future. And how good you’re going to feel when you get through this and you’re actually running and stuff like that.”

An effective sequence to using imagery with an injured athlete includes: (1) educating the athlete so they see this intervention as beneficial to their recovery; (2) assessing the current imagery ability of the athlete and preferred style as more experience and ability in imagining will increase its effectiveness; (3) assisting the athlete in creating vivid, clear and realistic imagery experiences using all five senses with regular practice of these skills; and (4) implementation into the rehabilitation process using it before, during, and after treatment/ exercise sessions and upon return to sport (13). For example, recreating the event that caused the injury initially but www.sportEX.net

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tangible way to deliberately reframe to more positive thoughts. Nippert and Smith (14) refer to channel clicking where the patient is encouraged to switch off the negative/irrational channel or ‘stinkin thinkin’ and use their positive one. What this positive channel looks like would be previously discussed and agreed between athlete and practitioner.

conclusion Just how useful psychosocial interventions are in enhancing both the quality of rehabilitation and the time frame tissue healing takes place over has yet to be fully determined.

The growing body of evidence seems to suggest that interventions have a beneficial role in facilitating holistic sports injury recovery (3,5). Most practitioners will acknowledge they are faced with day-to-day maladaptive psychosocial responses to sports injury rehabilitation but may choose not to use psychosocial intervention based on training needs and areas of expertise.

It is hoped that this article provides some food for thought and by adopting just one intervention covered patients can better recover both physically and psychologically from sports injury.

References 1. Wiese-Bjornstal DM, Smith AM, et al. An integrated model of response to sport injury: psychological and sociological dynamics.

Journal of applied sport psychology 1998;10:46–69 2. Harris L. Perceptions and attitudes of athletic training students toward a

course addressing psychological issues in rehabilitation. Journal of allied health 2005;34(2):101–109 3. Ievleva L, Orlick T. Mental links to enhance healing: an exploratory study. the sport psychologist 1991;5:25–40 4. Podlog L, Dimmock J, Miller J. A review of return to sport concerns following injury rehabilitation: Practitioner strategies for enhancing recovery outcomes. physical therapy in sport 2011;12:36–42 5. Levy AR, Polman R, Borkoles E. Examining the relationship between perceived autonomy support and age in the context of rehabilitation adherence in sport. rehabilitation psychology 2008;53(2):224–230 6. Brewer BW, Van Raalte JL, Petitpas AJ. Patient practitioner interactions in sports injury rehabilitation. In: Pargman D (ed.) Psychological bases of sports injuries, pp.79–94, 3rd edn. fitness Information technology 2007. IsBn 978-1-885693-75-4 (£47.12). Buy from Amazon http://spxj.nl/1dMZa3n 7. Weston NJ, Greenlees IA, Thelwell RC. Athlete perceptions of the impacts of performance profiling. International Journal of sport and exercise psychology 2011;9(2):173–188 8. Taylor J, Taylor S, et al.

Psychological approaches to sports injury rehabilitation. aspen 1997. IsBn 978a 0834209732 (£276.51). Buy from Amazon http://spxj.nl/NoThxc 9. Arvinen-Barrow M, Hemmings, B. Goalsetting in rehabilitation. In: Arvinen-Barrow M, Walker N (eds) The psychology of sport injury and rehabilitation (Chapter 5). routledge 2013. IsBn 978-0415695893 10. Driediger M, Hall C, Callow N. Imagery use by injured athletes: a qualitative analysis. Journal of sports sciences 2006;24(3):261–271 11. Cupal DD, Brewer BW. Effects of relaxation and guided imagery on knee

Box 3: exaMples oF cogniTive reFraMing sTaTeMenTs [Adapted from Podlog et al. (4)] exaMple 1: Negative athlete statement: “I’m concerned that I may let my teammates down if my fitness isn’t what it used to be before the injury.” replace with: Positive athlete statement: “Stop. I’ve worked really hard in rehabilitation to get my fitness to where it is and it will only ever continue to improve with time. Ultimately, what counts is that I get to do something I love and I’m excited to play again.” exaMple 2: Negative athlete statement: “I’m worried about what the coach (or others) will think if my skills and ability aren’t as good as before the injury.” replace with: Positive athlete statement: “Enough. What the coaches think of my skill level isn’t under my control. I know I’ve been practising my skills while injured and my technique has only got better. I am excited that I get to compete again.”

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strength, reinjury anxiety, and pain following anterior cruciate ligament reconstruction. rehabilitation psychology 2001;46:28– 43 12. Green LB, Bonura KB. The use of imagery in the rehabilitation of injured athletes. In: Pargman D (ed.)

Psychological bases of sports injuries, pp.137–141, 3rd edn. fitness Information technology 2007. IsBn 9781-885693-75-4 (£47.12). Buy from Amazon http://spxj.nl/1dMZa3n 13. Richardson PA, Latuda LM. Therapeutic imagery and athletic injuries. Journal of athletic training 1995;30(1):10–12 14. Nippert AH, Smith AM. Psychologic stress related to injury and impact on sport performance. physical medicine and rehabilitation clinics of north america 2008;19:399–418 15. Butler RJ, Smith M, Irwin I. The performance profile in practice.

International Journal of applied sport psychology 1993;5:48–63.

FurTher resources 1. Psychological Bases of Sport Injuries by D. Pargman.

Fitness information Technology 2007. isBn 978-1885693754 (£47.12).

Buy from Amazon http://spxj.nl/1dMZa3n 2. The Psychology of Sport Injury and Rehabilitation by M. Arvinen-Barrow and N. Walker. routledge 2013. isBn 978-0415695893 is (£22.99). Buy from Amazon http://spxj.nl/IDvrM ThE AuThoR Th Dale Forsdyke (MSc, MSST, MSMA, FFhEA) is a lecturer in sports injury management at York St John university and a practising sports therapist. he has dual professional body status with the SST and SMA, and has completed MSc qualifications in both sports science, and sports therapy. Dale has previously written sports therapy programmes and has co-authored the book Foundations in Sports Therapy. he is currently undertaking a PhD looking at the experience and meaning of being an injured athlete.

For correspondence please email d.forsdyke@yorksj.ac.uk, and follow his Twitter account: @forsdyke_dale. sportEX medicine 2014;60(April):8-13

EvidEncE informEd practicE

keY poinTs n it is common that sports injury places the athlete under high levels of psychological distress. n sports injury practitioners are ideally placed to intervene to reduce psychological distress. n it is essential that the practitioner can differentiate between a normal psychosocial response (yellow flags) and a severe psychosocial response (orange flags). n psychological interventions can enhance sports injury recovery. n The interactions between athlete and practitioner are vital in rehabilitation settings. n Try to encourage the athlete to make decisions and take ownership throughout rehabilitation. n addressing the athletes basic psychological needs may lead to better rehabilitation behaviours. n goal setting should be used throughout the rehabilitation process (from injury onset to return to sport and beyond). n The use of imagery in rehabilitation has multiple benefits. n all interventions require the practitioner to educate the injured athlete.

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DISCUSSIONS

n Why do you think practitioners should be able to introduce simple psychosocial interventions? n How could you change your current practice to improve psychological recovery from sports injury? n How might introducing psychosocial interventions benefit your patient groups? n What are the potential barriers to introducing psychosocial interventions with your injured patients? n Create an imagery script for an athlete who is physically healed but anxious about return to play.

continuing education Multiple choice questions This article also has a certificated eLearning test which can be found under the eLearning section of our website. For more information on how to access the test click this link http://spxj.nl/cpdquizzes

thIs quIz Is accessIBle

free

wIth a suBscrIptIon that Includes onlIne access to thIs Journal.

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BY Joseph Brence DpT, coMT, DAc recently, many in the manual therapy community have been questioning the mechanisms of how spinal manipulation works.

While some hold onto the belief that spinal manipulation has more of a biomechanical and structural influence, others believe the effects to be neurophysiological. In a 2011 study published in the journal Spine, Fritz et al. concluded that the mechanisms are likely multifactorial. these researchers reported measuring a decrease in global and terminal stiffness and improved recruitment of the lumbar multifidus following a lumbar manipulation (1). A more recent randomised controlled trial published in Physical Therapy assessed and compared the immediate effects of regional and non-regional spinal manipulation in patients with chronic low back pain (2). this study was necessary to determine if we need to segmentally target vertebrae to get the positive effects that others have found. Let’s take a closer look at what they did and what they discovered.

our regular research reviewer, physical therapist Joseph Brence, reviews research looking into (i) whether the specificity of manipulation is important in the treatment of chronic low back pain, and (ii) the risk factors for falls.

Does specificity of manipulation matter in the treatment of chronic low back pain?

The MeThoDs this study included 148 individuals who had at least a 12-week history of low back pain. they were divided into one of two groups to receive either: (i) a lumbar manipulation (to the painful segments), or (ii) an upper thoracic manipulation (non-regional). Pain, pain pressure thresholds and level of perceived disability (via roland-Morris Disability Questionnaire) were measured by a blinded researcher at baseline and following the intervention.

The finDings the researchers found that there were ‘immediate’ effects in pain and pain pressure thresholds following both manipulations. Furthermore, they found that the degree of reduction did not differ between the two groups. Each appeared to have an immediate 30% reduction in pain intensity.

WhAT This MeAns this study refutes the concept that a biomechanical approach needs to be taken when manipulation is performed to those with chronic low back pain (it further supports the notion that manipulation likely elicits a neurophysiologic response). It also makes one speculate on the idea that the dramatisation of manipulation may elicit non-specific effects (expectations and psychosocial factors) and that environment or interaction may have some effect on outcomes. the cohort tested in this study

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had chronic symptoms. From our understanding of pain neurophysiology (as I have written about in the past), when a tissue is damaged, an output of pain will likely occur to protect it (this leads to an adaptation within the pain pathways). the longer (more chronic) the nervous system reacts to protect the tissue, the more efficient it becomes. this creates a nervous system that is more ‘sensitive’ and eventually, the simple suspicion that a tissue is in danger will cause it to react. A prolonged output of pain can result in a process called central sensitisation, which is due to an augmentation of responsiveness of central neurons to input from unimodal and polymodal nociceptors. this results in a central process of an increased responsiveness to peripheral stimuli, even if they are non-threatening. this study demonstrated that manipulation (even outside of the region of suspected damage), can alter this sensitivity. It appears to make the brain less reactive, demonstrated by the ‘reduced pain’.

LiMiTATions there are, however, limitations to the study: n the researchers used Mitchell’s Test to verify vertebral position and mobility for the regional manipulation.

In a search of the literature, I was unable to find any literature that has validated or found this method reliable.

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research review

n the researchers only assessed ‘immediate’ effects and did not track long-term outcomes. Betweensession changes were not even accounted for. n this study only involved one therapist who applied the interventions. the interactions with this one individual may limit clinical variability and applicability of results. n this study did not assess a combination of manipulation and therapeutic exercise, which is more

likely to occur in clinical practice.

concLusion We must be cautious when interpreting the results from this study. With the manual techniques being performed in isolation, and only immediate effects measured, the applicability to clinical practice is limited. this study does have importance for our understanding of ‘how manipulation works’, but I would be interested to see if it is reproducible.

We shall wait and see.

References 1. Fritz JM, Koppenhaver SL, et al.

Preliminary investigations of the mechanisms underlying the effects of manipulation: exploration of a multivariate model including spinal stiffness, multifidus recruitment, and clinical findings. spine 2011;36:1772–1781 2. de oliveira rF, Liebano rE, et al.

Immediate effects of region-specific and non-region specific spinal manipulative therapy in patients with chronic low back pain: a randomized controlled trial. Physical Therapy 2013;93(6):748–756.

Who is at risk of falling and What can We do about it? inTroDucTion Falls have a large impact on the overall health and quality of life in older adults.

It has been estimated that 30–60% of older, community-dwelling adults experience a fall each year and that approximately half of these individuals experience multiple falls. this number appears to be the highest in those who are 80 years of age and older, and increases as high as 75% in individuals who live in a nursing home (1). Multiple variables have been determined to predict the risk for falling and this article is to provide a comprehensive review of these factors as well as what we can do in an attempt to prevent them.

fALL risk fAcTors A 2010 systematic review by Deandrea et al. (2) set out to analyse the results of 74 prospective studies conducted to assess fall risk factors in older adults. out of these studies, the authors found 31 risk factors to be considered. they concluded that the variables demonstrating the strongest association for fall risk include: history of falls, gait problems, use of walking aids, vertigo, Parkinson’s disease and antiepileptic drug use. the researchers suspected that additional risk factors may be present but are underreported, especially if the associated fall did not result in injury.

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one of the variables found in this study, ‘gait problems’, is a factor that, as physical therapists, we often analyse and treat. But despite this notion, there is currently a lack of uniformity in the diagnosis of gait abnormalities.

So in 2009, Verghese et al. (3) set out to quantify gait markers of falls in older adults, with the ultimate goal of improving diagnostic, gait assessments by the practising clinician. their study included 597 older adults (>70 years old) and baseline measurements of gait speed, cadence, stride length, swing, double support, stride length variability, and swing time variability were taken. the participants were followed over a long period and within 20 months, 226 of the 597 (38%) adults experienced a fall. When analysing the baseline measurements in those who fell, it was found that slower gait speed at baseline (<100cm/s or 2.2mph) was associated with higher fall risk.

Additional fall predictors included: worse performance on swing, double-support phase, swing time variability and stride length variability, even after accounting for cognitive status and disability.

In a third study, researchers set out to determine whether a diseasespecific diagnosis resulting in cognitive loss (such as dementia) is predictive as a fall risk factor, and compared it to measures of global cognition as well as other impairments in specific cognitive

domains (ie. executive function) (4). this systematic review included 27 studies and using an inverse-variance method of data analysis found that executive function impairment, even subtle deficits in community-dwelling older adults, was associated with an increased risk for fall as well as falls resulting in serious injury. A diagnosis of dementia, without specification of dementia subtype or disease severity, was also associated with risk for fall but did not appear to be associated with falls resulting in serious injury.

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TreATing fALL risk So with the above known as risk factors for falling, what can we do about it? Well, the current consensus varies within the research community.

According to a 2008 systematic review published in the British Medical Journal (5), the researchers conclude that our current knowledge and ability to prevent falling is limited. this study assessed research performed on multifactorial fall prevention programmes in primary care, community and emergency care settings, and found the quality of studies in this area not to be high and most trials performed are riddled with methodological flaws.

A Cochrane review (159 trials and 79,193 participants) (6) that assessed the effects of interventions designed to reduce the incidence of falls, found more encouraging results. the researchers concluded that multiple-component exercise programmes performed in a group or home-based setting significantly reduced the rate of falls and risk of falling. In addition, home safety

assessment and modifications demonstrated similar results. Additional variables which showed some effectiveness included: pacemakers (in those with carotid sinus hypersensitivity), the first cataract surgery (additional surgeries did not reduce incidence or risk), gradual withdrawal of psychotropic medications, etc.

In conclusion, we currently have some good guidelines for determining who is at-risk of falling but need additional, quality research to determine how to reduce the risk, as well incidence rates.

References 1. rubenstein LZ, Josephson Kr. the epidemiology of falls and syncope. clinics in Geriatric Medicine 2002;18:141–158 2. Deandrea S, Lucenteforte E, et al. risk factors for falls in community-dwelling older people: a systematic review and metaanalysis. epidemiology 2010;21:658–668 3. Verghese J, holtzer r, et al. Quantitative gait makers and incident fall risk in older adults.

The Journals of Gerontology series a: Biological sciences and Medical sciences 2009;64:896–901 4. Muir SW, gopaul K, Montero odasso MM. the role of cognitive impairment in fall risk among older adults: a systematic

review and meta-analysis. age and ageing 2012;41(3):299–308 5. gates S, Fisher JD, et al. Multifactorial assessment and targeted intervention for preventing falls and injuries among older people in community and emergency care settings: systematic review and meta-analysis.

BMJ 2008;336:130–133 6. gillespie LD, robertson MC, et al.

Interventions for preventing falls in older people living in the community. cochrane Database of systematic reviews 2012; 9:DOi:10.1002/14651858.cD007146.pub3.

Joseph Brence (DPT, FAAOMPT, COMT, DAC) is a physical therapist and clinical researcher from Pittsburgh, PA, USA. He is also a fellowship graduate from Sports Medicine of Atlanta, GA, USA. Joseph’s primary clinical interests involve a better understanding of the neuromatrix and determining how it applies to physical therapy practice.

He is currently involved in a wide range of clinical research projects investigating topics such as the effects of verbalising of pain, the effects of mobilising v. manipulating the spine on body image perception and validation of an instrument which will assess medical practitioners’ understanding of pain. Clinically, Joseph treats a wide range of painful conditions in multiple settings including complex regional pain syndrome, fibromyalgia and chronic fatigue syndrome. Joseph also runs the blog www.forwardthinkingpt.com.

SportS Sport S triage medical Screening and phy phyS Sical therapy management

BY Dr heATher Jennings DpT, scs, cscs, AnD Dr roBerT DuVALL Dhsc, MMsc, cscs

In this issue, the team at the Nxt gen Institute of Physical therapy guide you through improving your management of sudden cardiac arrest, concussion and ankle fractures.

BAckgrounD Medical screening is the process by which a physical therapist uses both subjective and objective examination to evaluate collected data and use clinical reasoning to make a decision as to whether to treat the patient, refer the patient or initiate both treatment and referral (1,2). Medical screening is conducted at the ‘systems level’, which involves identifying ‘red flag’ signs and/ or symptoms (1). red flags can be placed into the following classification

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system: Category I: Factors that require immediate medical attention; Category II: Factors that require subjective questioning and precautionary examination and treatment procedures; and Category III: Factors that require further physical testing and differentiation analysis (3). Physical therapists’ expertise in identifying movement-related dysfunction fulfils the minimum professional requirement to identify pathology falling outside the scope of physical therapy practice (2).

this article will highlight appropriate medical screening and physical therapy management for sudden cardiac arrest (SCA), concussion and ankle fractures.

suDDen cArDiAc ArresT In the sports setting, the time-sensitive nature of appropriately medically screening an injured athlete can mean the difference between life or death.

A common example of this is seen with sudden cardiac arrest (SCA), which is the leading cause of death

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in young athletes during exercise (4,5). the incidence of sudden cardiac death (SCD) in high school and college athletes is estimated to be 1 : 100,000– 200,000 and 1 : 65,000–69,000 respectively (6–8). the American College of Cardiology defines SCD as “nontraumatic and unexpected sudden death that may occur from a cardiac arrest, within 6 hours of a previously normal state of health” (9). the single greatest factor affecting survival is the time interval from the initiation of arrest to defibrillation (10). Factors that may contribute to lower survival rates in young athletes after SCA may be the delayed recognition of cardiac arrest by first responders and therefore delayed initiation of cardiopulmonary resuscitation (CPr) and defibrillation. rescuers may mistake agonal or occasional gasping for normal breathing or falsely identify the presence of a pulse. SCA may also be diagnosed as a seizure because of the presence of myoclonic activity after collapse (11).

In up to 80% of young athletes who remain asymptomatic before sudden cardiac arrest occurs, a fatality will represent the first sign of cardiac disease (12). therefore, this explains the limited power of primary screening based solely on history and physical examination. Some cardiac conditions will present with no abnormalities on a 12-lead electrocardiogram (ECg) and, thus, cardiac arrest due to a nonpenetrating chest injury (commotio cordis) cannot be prevented with screening (12). Mosterd et al. (13) states there are two strategies to prevention, which include timely identification of asymptomatic athletes at increased risk (finding the needle in the haystack), or prompt resuscitation efforts with the use of an automated external defibrillator (AED) (closing the barn door after the horse has bolted). the American heart Association, despite the acknowledged limitations, recommends primary screening in the athletic setting be performed by a healthcare professional who is equipped with the appropriate training, skills and background in order to obtain a history, perform examination and recognise disease (14). Key questions

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thE tIME SENSItIVE NAturE oF APProPrIAtELy MEDICALLy SCrEENINg AN INJurED AthLEtE CAN MEAN LIFE or DEAth for cardiovascular screening should include those that would determine prior occurrence of syncope, chest pain and unexplained shortness of breath with exercise (table 1) (14).

Physical examination key points may include recognition of physical stigmata of Marfan’s syndrome which include arm span greater than height, chest wall deformities, kyphoscoliosis, hyperextensible joints and myopia (14). If unpredictable SCA should occur on the athletic field, access to early defibrillation is essential, with a target goal of less than 3–5 minutes from time of collapse (11). the initial components of SCA management include: early activation of the emergency services, early CPr, early defibrillation and rapid transition to advanced cardiac life support (11). SCA should be suspected in any collapsed unresponsive athlete, treating agonal respiration, occasional gasping, or myoclonic jerking as SCA until proven otherwise (15). An AED should be applied as soon as possible and/or initiate CPr (30 compressions and

two breaths) while waiting for the AED. If AED rhythm monitoring advises a shock, CPr should be resumed immediately after the first shock and rhythm analysis should be repeated every 2 minutes or 5 cycles of CPr, and continue until advanced life support providers take over (Fig.1) (11).

concussion the on-field evaluation of sportrelated concussion is often a challenge given the variability in presentation.

A concussion is a disturbance in brain function caused by a direct or indirect force to the head, face, neck or elsewhere on the body where force is transmitted to the head (16).

A concussion can be suspected in the presence of one or more of the following: symptoms (headache), physical signs (unsteadiness), impaired brain function (confusion), abnormal behaviour (change in personality) (table 2) (17). the initial evaluation is focused on ruling out cervical spine injury and/or more serious brain injury and implementation of the emergency

TABLe 1: keY coMponenTs of cArDioVAscuLAr screening [Adapted from Mcgrew (14)] patient history questions

physical examination

Has the patient experienced:

Key checks include:

1. Previous chest pain or discomfort with exercise?

2. Syncope or near syncope with exercise?

3. unusual, excessive or unexpected shortness of breath and/or fatigue with exercise?

4. A heart murmur or increased blood pressure?

1. Brachial blood pressure in a sitting position 2. Precordial auscultation in supine and standing positions 3. Assessment of femoral artery pulses to rule out coarctation of the aorta 4. recognition of the physical signs of Marfan’s syndrome.

Does the patient have: 1. A close relative who developed significant disability or died before 50 from cardiovascular disease?

2. Anyone in the family with heart conditions such as hypertonic cardiomyopathy, dilated cardiomyopathy, long Qt syndrome, Marfan’s syndrome or arrhythmias?

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action plan (18). An unconscious athlete should be managed assuming they have a coexisting catastrophic cervical spine injury.

Evaluating for more serious brain injury assessment should include cranial nerve function, deteriorating mental status and other signs and symptoms (18). An athlete should be referred to an emergency facility if displaying the following signs and symptoms: worsening headache, very drowsy or cannot be easily awakened, cannot recognise people or places, develops significant nausea or vomiting, behaves unusually and is more confused and irritable, develops seizures, weakness or numbness in arms or legs, slurred speech or unsteadiness of gait (17). once the first aid issues are addressed, an assessment of the concussive injury should be made using the Sport Concussion Assessment tool – 3rd edition (SCAt3) or child SCAt3 (ages 5–12 years). the final decision for appropriateness to play is a medical decision based on clinical judgment.

Although the subcomponents of SCAt2 have been validated separately, SCAt2 itself has not been evaluated and there are limited data on its sensitivity and specificity in diagnosing concussion or determining severity of injury (18). Concussion is often an evolving injury and signs and symptoms may be delayed (16); therefore, the revised uS team Physician Consensus Statement clearly states that there should be no return to play on the same day after a concussion (19). the cornerstone of concussion management involves physical and cognitive rest until acute symptoms resolve and then a graded exertion programme before return-to-play protocol and medical clearance (16).

AnkLe frAcTure Acute ankle injuries are among the most common injuries of the musculoskeletal system (20). In the absence of radiographic evaluation, identifying fractures based on pain

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Athlete is witnessed collapsing

Check patient’s responsiveness tap patient’s shoulder, ask “Are you all right?”

If unresponsive, maintain high suspicion of SCA

Single rescuer Phone the emergency services Fetch AED if easily available use AED and begin CPr on patient

Several rescuers Person 1. Begin CPr Person 2. Phone the emergency services Person 2 or 3. Fetch AED, if available

AED: Apply AED to patient for rhythm analysis

Begin CPR: 1. Check airway and breathing tilt head and lift chin Look, listen and feel for breathing 2. give two rescue breaths Produce a visible chest rise 3. Begin chest compressions Push hard and fast (100/min) Depress sternum by 2.5 to 10 cm Allow chest to recoil Proceed in cycles of 30 compressions and two breaths until AED arrives

Healthcare providers: Check pulse

No pulse

Pulse

Give 1 breath every 5/6 seconds Check pulse frequently

AED/defibrillator arrives Apply to patient for rhythm analysis

Shock advised 1. give 1 shock; immediately resume CPr chest compressions 2. recheck rhythm every 5 CPr cycles minimising interruption to chest compressions 3. Continue until emergency services take over, or patient starts to move.

No shock advised 1. recheck rhythm every 5 CPr cycles minimising interruption to chest compressions 2. Continue until emergency services take over, or patient starts to move.

Figure 1: Management of sudden cardiac arrest [Adapted from Drezner et al. (11)]

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and using percussion and squeeze tests can be misleading, and often produce false-positive or false-negative results (21). Although most patients who present to emergency departments undergo radiography, less than 15% have a fracture of the ankle or foot (22). the ottawa Ankle rules (oAr) is an assessment scheme developed to rule out fracture of the ankle and/or mid-foot, before an extended physical exam [Fig.2] (21,22). oAr recommends X-radiography of the ankle if there is pain in the malleollar zone and any one of the following: n Bone tenderness along the distal 6cm of the posterior edge of the tibia or tip of the lateral malleolus [Fig.2(a)] n Bone tenderness along the distal 6cm of the posterior edge of fibula or tip of the lateral malleolus [Fig.2(b)] n Inability to bear weight both immediately and in the emergency room department for four steps (22). oAr recommends X-radiography of the foot if there is pain in the mid-foot zone and any one of the following: n Bone tenderness at the base of the fifth metatarsal [Fig.2(c)] n Bone tenderness at the navicular bone [Fig.2(d)] n Inability to bear weight both immediately and in the emergency department for four steps (22).

When the oAr is applied within 48 hours of the trauma it has a sensitivity of 99.6% and the rules can be applied to children older than one year with a similar sensitivity (21). During a field evaluation, a tuning fork and stethoscope can be a useful supplement in evaluating potential fractures.

According to Moore (23), the tuning fork is placed distal to the suspected fracture and the stethoscope’s conical bell is placed proximal to the injury on the same bone. After first assessing the uninjured limb for comparison, a diminished or absent sound from the injured limb constitutes a positive result (23). If substantial swelling was present, the tuning fork was placed over the proximal bone, away from the swelling,

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ACutE ANKLE INJurIES ArE AMoNg thE MoSt CoMMoN INJurIES oF thE MuSCuLoSKELEtAL SyStEM and the stethoscope was placed over the swelling. the author notes this method is highly successful with transverse fractures (sensitivity 0.83, specificity 0.80, positive likelihood ratio of 4.2), but not as accurate on avulsion and buckle type fractures (23). After a fracture has been ruled out, a careful physical examination can be carried out.

concLusion the guidelines mentioned above are intended to provide relevant information to medical screening to determine when emergency treatment is needed to prevent sudden death in sports, as well as to properly guide the athlete.

TABLe 2: signs AnD sYMpToMs suggesTiVe of concussion [Adapted from Putukian et al. (18)] category

sign/symptom

Cognitive

n Confusion n Anterograde amnesia n retrograde amnesia n Loss of consciousness n Disorientation n Feeling ‘dazed’ n Vacant stare, inability to focus n Delayed verbal and motor responses. Slurred speech n Excessive drowsiness.

Somatic

n headache n Dizziness n Problems with balance n Nausea/vomiting n Visual disturbances (avoidance of light, burred/double vision) n Avoidance of sound.

Affective

n Mood swings n Irritability n tiredness n Anxiety n Sadness.

Sleep disturbances

n Difficulty falling asleep n Sleeping more than usual n Sleeping less than usual.

In emergency situations, the athlete’s best possible outcome relies on your ability to provide correct and prompt emergency care.

AcknoWLeDgeMenTs the primary author would like to thank her fellowship director and mentors at SportsMedicine of Atlanta for granting the opportunity to research and write this article.

References 1. Advanced medical screening integrated with biomechanical movement based differential diagnosis for physical therapists. Continuing education seminar, sportsMedicine of atlanta. Presented: December 5–6, 2013, Pittsburgh, Pa, Usa 2. Davenport tE, Kornelia K, resnik C. Diagnosing pathology to decide the appropriateness of physical therapy: what’s our role? Journal of Orthopaedic & sports Physical Therapy 2006;36(1):1–12 3. Sizer SS Jr, Brismée JM, Cook C. Medical screening for red flags in the diagnosis and management of musculoskeletal spine pain.

Pain Practice 2007;7(1):53–71 4. harmon Kg, Asif IM, et al. Incidence of sudden cardiac death in national collegiate athletic association athletes. circulation 2011;123(15):1594–1600 5. Maron BJ, Doerer JJ, et al. Sudden death in young competitive athletes: analysis of 1866 deaths in the united States, 19802006. circulation 2009;119(8):1805–1892 6. van camp sP, Bloor cM, et al.

Nontraumatic sports death in high school and college athletes. Medicine & science in sports & exercise 1995;27(5):641– 647 7. harmon K, Asif I, Klossner D, Drezner J. Incidence of sudden cardiac death in NCAA athletes. circulation. 2011;123(15):1594–1600 8. Drezner JA, rogers KJ, Zimmer rr, Sennett BJ. use of automated external defibrillators at NCAA Division I universities.

Medicine & science in sports & exercise 2005;37(9):1487–1492 9. Maron BJ, Ackerman MJ, Nishimura rA, Pyeritz rE, towbin JA, udelson JE. task force 4: hCM and other cardiomyopathies, mitral valve prolapse, myocarditis, and Marfan syndrome. Journal of the american college of cardiology 2005;45(8):1340–1345 10. the American heart Association in collaboration with the International Liason Committee on resuscitation. guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care. Part 4: the automated external defibrillator: key link in the chain of survival. circulation 2000;102(suppl 8):160–176 11. Drezner JA, Courson rW, et al. Inter-

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association task force recommendations on emergency preparedness and management of sudden cardiac arrest in high school and college athletic programs: a consensus statement. Journal of athletic Training 2007;42(1):143-158 12. Corrado D, Drezner J, et al. Strategies for the prevention of sudden cardiac death during sports. european Journal of cardiovascular rehabilitation and Prevention 2011;18(2):197–208 13. Mosterd A, Senden JP, Engelfriet P. Preventing sudden cardiac death in athletes: finding the needles in the haystack or closing the barn door? european Journal of cardiovascular rehabilitation and Prevention 2011;18(2):194–196 14. Mcgrew CA. Sudden cardiac death in competitive athletes. Journal of Orthopaedic & sports Physical Therapy 2003;33(10):589–593 15. Casa DJ, guskiewicz KM, et al. National athletic trainers’ assocation position statement: preventing sudden death in sports. Journal of athletic Training 2012;47(1):96–118 16. McCroy P, Meeuwisse Wh, et al.

Consensus statement on concussion in sport: the 4th international conference on concussion in sport held in Zurich, November 2012. British Journal of sports Medicine 2013;47:250–258 17. Concussion Sport group. SCAt3tM. sport concussion assessment tool – 3rd edition. Group.bmj.com 2013. http://spxj.nl/1cP1DrF. Accessed 17.02.2014.

18. Putukian M, raftery M, et al. onfield assessment of concussion in the adult athlete. British Journal of sports Medicine 2013;47:285–288 19. herring S, Kibler B, et al. Concussion (mild traumatic brain injury) and the team physician: a consensus statement—2011 update. Medicine & science in sports & exercise 2011;43:2412–2422 20. Boruta PM, Bishop Jo, et al. Acute lateral ankle ligament injuries: a literature review. Foot & ankle international 1990;11:107–113 21. Polzer h, Kanz Kg, et al. Diagnosis and treatment of acute ankle injuries: development of an evidence-based algorithm. Orthopedic reviews 2012;4:22–32 22. Bachmann LM, Kolb E, et al. Accuracy of ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ 2003;326:1–7 23. Moore MB. the use of a tuning fork and stethoscope to indentify fractures. Journal of athletic Training 2009;44:272–274.

The oTToWA AnkLe ruLes In general fewer than 15% of ankle x-rays show an abnormality. this is an expensive and very inefficient use of radiography. use of the ottowa rules have been proven to lead to a decrease in radiography waiting times and costs without an increase of missed fractures. they are based on areas of bone tenderness and assessment of ability to bear weight. the rules allow clinicians to determine quickly which patients are at negligible risk of fracture A) posterior edge or tip of lateral malleous 6cm

c) base of 5th metatarsal

malleolar zone 6cm

mid foot zone

B) posterior edge or tip of medial malleous D) navicular

©2012 Primal Pictures Ltd

LATerAL VieW

MeDiAL VieW

Ankle x-ray series is only required if: there is any pain in malleolar zone and any of these findings: 1) Bone tenderness at A (or) 2) Bone tenderness at B (or) 3) Inability to bear weight both immediately and in emergency department.

foot x-ray series is only required if: there is any pain in midfoot zone and any of these findings: 1) Bone tenderness at C (or) 2) Bone tenderness at D (or) 3) Inability to bear weight both immediately and in emergency department.

Figure 2: Ottawa Ankle Rules [reproduced by sportEX, 2012]

THE AUTHORS T Dr Robert DuVall, PT, DHSc, MMSc, OCS, SCS, ATC, FAAOMPT, MTC, PCC, CSCS has clinically coordinated care for more than 15,000 patients before physician intervention. He is ABPTS board certified as an orthopaedic and sports clinical specialist and is a Fellow of the American Academy of Orthopaedic Manual Physical Therapists.

He has obtained Athletic Training Certification and Manual Therapy Certification and was the first physical therapist certified in Primary Care Physical Therapy by the University of St. Augustine where he also completed a post-professional doctorate. Dr DuVall provided physical therapy coverage at the 1996, 2000 and 2004 Summer Olympic Games and is director of the Orthopaedic Primary Care Residency and Manual Therapy Fellowship Programs at Sports Medicine of Atlanta as well as an assistant professor at the Northeastern, Shenandoah, Alabama State and Florida A&M Universities.

Dr Heather Jennings, PT, DPT, SCS, CSCS, USAW-L1SP. Dr Jennings is currently the sports medicine coordinator for Mercy Regional Medical Center, and team physical therapist and strength coach for the Lake Erie Crushers baseball team. Dr Jennings graduated in 2007 from Pennsylvania State University with a B.S. in Kinesiology with a Movement Science Option and 2010 from the University of Pittsburgh with her doctorate in physical therapy (DPT). Heather is a board certified sports clinical specialist (SCS), certified strength and conditioning specialist (CSCS), and is currently a fellow-in-training through the Sports Medicine of Atlanta Manual Physical Therapy Fellowship Program.

The nxtgen institute of physical Therapy is a post-professional physical therapy continuing education residency and fellowship program based in the usA. nxtgen institute in association with foward Thinking pT have partnered with sporteX to produce regular editorial contributions. for more information visit www.nxtgeninstitute.com and www.forwardthinkingpt.com

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sportEX medicine 2014;60(April):14-20

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thE tEndinopathy continuum ExplainEd This article aims to raise awareness of the tendinopathy continuum theory using a medical animation and supportive text linking the science to clinical practice.

by Daniel laWrenCe MCSP

TenDinoPaThy ConTinuuM In the October 2012 issue of sportEX medicine I reviewed the current evidence and theories relating to Achilles tendinopathy (The pathology of midportion tendinopathy, sportEX medicine 2012;54:7â&#x20AC;&#x201C;11). While many theories still abound the one that appears to have gained the most traction, based on its pooling of current knowledge and clinical efficacy, is the tendinopathy continuum proposed by Cook and Purdam in 2009 (1). This article will look at the details of this paradigm using a specifically produced pathology animation and supportive images.

The PaThology It was previously thought that tendon

W

e have learned so much in the last 20 years about tendinopathy; back then we were treating it as an inflammatory condition and using rest, ice and anti-inflammatories as treatment. Today we are better informed of the pathology, especially the degenerative pathology, but there is still much debate about the process from normal tendon to the degenerative state. There is also discussion about the role of inflammation in the early stages of tendinopathy â&#x20AC;&#x201C; again there are several perspectives on this. It is worth noting that there was very little success of anti-inflammatory approaches to treatment in the 1980s and 1990s.

Research today is complicated

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damage was similar to muscle damage; ie. fibres would tear in varying degrees triggering an inflammatory response. The swelling of the tendon and pain was incorrectly assumed to be of inflammatory origin and the term tendonitis was widely used up until a few years ago. Since then the terms; tendinosis, tendinopathy and peritendinitis have become prevalent. Tendinosis refers to a degenerative tendon absent of any inflammatory markers; it also requires microscopic investigation to confirm the degeneration, as this cannot be detected via a basic clinical examination. Tendinopathy is a clinical diagnosis of pain, stiffness and impaired tendon function. Peritendinitis refers to the presence of inflammatory cells between the tendon and its sheath-like outer layers. To confuse the situation

TendinopaThy TendinopaT

by Prof. Jill Cook PhD by the disconnect between tendon pathology and tendon pain, and much is directed at the pathology. There is frenetic activity at the molecular and tissue level and to a lesser extent at the clinical level. Many researchers are looking for a uni-modal treatment to cure the structural changes in tendinopathy; however, we know from clinical practice that changing pain is essential and possible without any change in structure. It is clear that there should be more international collaborations in tendon research, to provide better and consistent direction

based on the clinical presentation of the condition.

ThE auThor Th Professor Jill Cook PhD. Jill is a professor in Musculoskeletal health in the School of Medicine, Nursing & health Sciences, Monash university, australia. Jillâ&#x20AC;&#x2122;s research areas include sports medicine and tendon injury. after completing her PhD in 2000, she has investigated tendon pathology, treatment options and risk factors for tendon injury. Jill currently supplements her research by conducting a specialist tendon practice and by lecturing and presenting workshops both in australia and overseas.

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further it is not uncommon to have a mix of pathologies.

The Three STage ConTinuuM Two Australian physiotherapists proposed that the pathology of tendinopathy could be described as a three stage continuum with limited scope for reversal (Fig. 1) (1).

The three stages were described as follows.

reactive tendinopathy The tendon reacts to acute overload with a short-term, load-adaptive thickening caused by an increased cellular activity and proliferation than in the normal tendon (2). This hypercellularity brings about an increase in the synthesis of large water imbibing aggrecan proteoglycans which push the collagen fibres apart and fatten the overall tendon. These are depicted as feather-like structures in the animation (Video 1). This presents clinically as a thickening of the tendon body, which is often mistaken for an inflammatory reaction. The tenocytes are reported to change shape from a spindle to a rounded structure 22

possibly due to an increase in the surrounding pressure. The change in shape causes a change in behaviour and altered substance production.

The transfer of mechanical force into altered cellular behaviour is known as

Video 1: animation showing the tendinopathy continuum (D. lawrence, 2014)

mechanotransduction.

Within the animation the vertical tubes represent collagen fibrils at a very microscopic cellular level. The small green cells represent a specific proteoglycan called decorin which

by ebonie rio MSC Tendon pain is difficult to manage, especially in-season when there are constant time and performance pressures. Eccentric exercise has limited, if any, clinical application in-season because it is, known to increase pain in the first 2â&#x20AC;&#x201C;4 weeks (1) and to be potentially exacerbating for reactive tendinopathies and insertional Achilles tendinopathy (due to compression) (2).

Furthermore, in the case of very painful presentations, prescribing eccentric exercises may also result in decreased patient compliance and the seeking of alternative options.

Isometric exercise has been shown to significantly reduce tendon pain immediately that is sustained for at least 45 minutes. Also, loading

the quadriceps muscle isometrically resulted in a reduction of excess motor inhibition that is associated with patellar tendinopathy. This caused athletes in the study to produce greater maximal voluntary force than before completing the isometric exercise. The effect is specific to the loaded tendon so clearly there are both top-down and bottom-up effects with isometric exercises. These results were not seen in the isotonic (concentric/eccentric) protocol, which was matched for time under load and rest periods.

This acute study demonstrates a significant pain reduction associated with isometric exercise for tendon pain without a reduction in force production.

We are currently in the middle of a randomised controlled trial to compare isometric and isotonic exercise over 4

sportEX medicine 2014;60(april):21-26

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consists of a protein core and a glycosaminoglycan (GAG) chain which provides a connection, tensile strength and viscoelasticity between the fibrils.

The larger spindle shaped cells are the specialist tendon cells known as tenocytes. These cells maintain the health of the tendon by synthesising new collagen fibres and proteoglycans in the correct quantities. In healthy tendons they are spindle shaped but will be seen to change shape during the animation.

The release of damaging substances, represented as the ‘P’ cells in the animation, is also an important component of the reactive stage, and pain generation is discussed later. The fibre separation is seen clinically as fattened swollen tendon and is not a product of an inflammatory process. Importantly, the animation shows that collagen fibre integrity is largely maintained, which no doubt reflects the reversibility of this stage.

A reactive tendinopathy is often seen in younger athletic patients and can be very painful but has a full repair capacity. The cause of the pain will be discussed within this article.

The reactive tendon is thought to be responding to acute overload by increasing its stiffness and reducing the stress by increasing the overall volume

A REACTIVE TEnDInOPATHy IS OFTEn SEEn In yOunGER ATHLETIC PATIEnTS AnD CAn bE VERy PAInFuL buT HAS A FuLL REPAIR CAPACITy of the tendon within a short space of time.

Stress shielded

Dysrepair If a reactive tendinopathy endures due to persistent overload then the increased protein production continues and a failed healing response is seen within the structure. In the later stages of dysrepair, neovessels will start to show on Doppler ultrasound and an increased production of the weaker, irregular type III collagen will begin. The importance and relevance of the neovessels that are observed developing within tendinopathic tissue remains in question (3). Some authors report that their presence correlates with pain while others clearly do not agree. The infiltrating vessels can be thick walled with a small lumen and are too inferior in quality to achieve much.

The accompanied neural ingrowth, once thought to be a source of tendon pain, consists mainly of sympathetic nerves to regulate the neovessels and does not contain any sensory fibres

unloaded

optimised load

normal tendon normal or excessive load +/- excessive appropriate load + modified individual load factors individual factors

optimised load adaptation strengthen

reactive tendinopathy

Tendon dysrepair

Degenerative tendinopathy Figure 1: The pathology of load-induced tendinopathy (Reproduced from the British Journal of Sports Medicine, Cook and Purdam, 43, 409–416, © 2009 with permission from BMJ Publishing Group Ltd.)

clinical pErspEctivE on isomEtric ExErcisE for tEndon pain weeks during the competitive season to determine the effects on tendon pain and sport participation.

The clinical application of isometrics needs to be specific to the sport.

Whilst isometrics ‘improved’ strength by reducing inhibition, there are some sports where this may reduce precision and thus perhaps pre-activity isometrics may not be appropriate.

However, for others isometric exercises may allow people to remain active.

It is important to remember that the 24 hour response to load is the best gauge of the tendon tolerance to load and load should be progressed in a

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considered manner – interventions that reduce pain should be part of overall load management strategies.

Furthermore, we use isometrics to reduce pain in the early stages of rehab and ensure that people transition into graded and progressive rehabilitation. The exact prescription of how isometrics are completed is not yet known. It is important they are completed out of compression, as the position for insertional Achilles and mid-substance will be different. references 1. Alfredson H, Pietilä T, et al. Heavy-load

eccentric calf muscle training for the treatment of chronic Achilles tendinosis. american Journal of sports medicine 1998;26:360–366 2. Cook JL, Purdam C. Is compressive load a factor in the development of tendinopathy?

British Journal of sports medicine 2012;46(3):163–168.

ThE auThor Th Ebonie rio is in the final year of her PhD investigating tendon pain under Professor Jill Cook. She has a BSc in applied science, BSc (hons) in physiotherapy and a Masters in sports physiotherapy. her clinical experience includes stints at the australian institute of Sport, The australian Ballet, 2006 Commonwealth Games, 2010 Winter olympics, 2010 Youth olympics and 2012 Paralympics.

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(a)

receptor

signalling module

fibres is shown and the animation also shows structural damage and breakages to the GAG chains. The rounder tenocytes begin to synthesise weaker irregular type III collagen. With the advent of time, cellular change has started to cause structural change that is essentially more permanent and less reversible.

Degenerative tendinopathy

signalling cell

(b) local mediator

receptor

target cell

Figure 2: Autocrine (a) and paracrine (b) signalling (sportEX, 2014)

(4). While the full clinical relevance of vascular ingrowth is yet unknown, it does appear to be used as a marker of whether the tendinopathic stage has progressed from a ‘reactive/early dysrepair’ with no neovessel ingrowth to ‘late dysrepair/degeneration’ with evident ingrowth. The potential reversal between the two can also be monitored.

Patients with tendons in an early dysrepair phase often present clinically with ongoing intermittent symptoms.

A limited capacity for full repair is reported.

As the tendon enters the dysrepair phase you will see noticeable structural changes in the animation. The ingrowth of neovessels around the collagen

An ACuTE REACTIVE TEnDOn CAn bE SIGnIFICAnTLy PAInFuL WHILE THE STRuCTuRAL InTEGRITy OF THE TEnDOn REMAInS InTACT WITH A GOOD PROGnOSIS 24

This differs from the reactive and dysrepair stages and is characterised by large changes to the matrix with some areas of reduced cellularity amongst otherwise hypercellular matrix, type I collagen content reduces and is replaced with type III collagen and debris. These patients don’t usually report much pain and may not present clinically unless a reactive tendinopathy is overlaid following acute unaccustomed overload (1). This tendon state has a poor prognosis for structural reversal back through the stages and a rupture is possible with tendon stress. While a structural reversal is unlikely the tendon should still be able to adapt to and tolerate functional loading.

Within the animation the tendinopathic zone of the tendon is shown as a pocket of low cellular content with type III collagen shown in the animation as thinner and more irregular fibrils filling the spaces once occupied by larger more linear type I collagen. The animation also shows the increased propensity of apoptosis (preprogrammed cellular death) amongst the tenocytes.

The animation does not show a full tendon rupture as this is not part of the tendinopathy continuum although a tendon having reached the degenerative phase will not be able to tolerate loading as well as a healthy tendon and the poor structure without associated and somewhat protective pain greatly increases the risk of apparently spontaneous rupture with 97% of ruptured tendons showing degenerative changes that were undoubtedly present before rupturing (5).

These proposed stages of tendinopathy tend to occur with some heterogeneity throughout a single tendon by displaying microscopic zones of differing pathology throughout the tendon.

WhaT abouT The Pain?

The relationship between prognosis and pain does seem to be paradoxical.

An acute reactive tendon can be significantly painful while the structural integrity of the tendon remains intact with a good prognosis. In contrast a degenerative tendon can be structurally weakened without any symptoms of significant pain.

The cause of Achilles tendon pain is unknown and the symptomatic feeling of pain does not appear to consistently correlate with the pathological changes seen under microscopy or more specifically correlate with the presence of the infiltrating tendon neovessels considered to be a main characteristic of the degenerative stage.

In the absence of a standard inflammatory response the tendon pain is likely to be caused by the release of nociceptive substances by activated tenocytes, potentially via an interesting singular or pair of mechanisms called autocrine and paracrine signalling (6).

Autocrine signalling refers to a cellular process whereby a cell releases substances (hormones or chemical messengers), in this case potentially injurious, that then bind to receptors on the same cell and cause cellular effects, ie. the cell damages itself. Paracrine signalling refers to the release of substances, again in this case potentially injurious substances, from one cell, which then affect neighbouring cells. It should be made clear that autocrine and paracrine signalling are simply cell-signalling mechanisms and not automatically problematic or harmful (Fig.2).

Exercise often reduces the pain generated from the tendon, probably as a result of increased tissue tension and neural adaptation; descending inhibition may also play a part in a medium-term pain reduction process.

We should not ignore pain when dealing with Achilles and other tendinopathies, instead we need to consider it only as part of the overall presentation. A daily diary record of morning pain and stiffness and a less regular usage of the Victorian Institute of Sports Assessment [VISA-A (see separate VISA-A subtext)] questionnaire forms a useful assessment tool without the risk of over-assessment. It is usual sportEX medicine 2014;60(april):21-26

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and natural for patients to focus on the increase or decrease in pain but such an acute awareness can lead to unhelpful behaviour such as continuing to exercise in the knowledge that the pain subsides during repetitive loading activity or in some occasions patients have engaged in self-imposed nonweight-bearing (crutches) activities as a form of pain guarding. neither of these responses is helpful and need to be overcome with careful patient education.

Why DoeS The Pain reDuCe WiTh loaDing?

One of the main symptoms of Achilles tendinopathy is morning pain and stiffness which then reduces with weight-bearing activity. Eccentric exercise programmes have also been associated with medium-term symptomatic relief. The reasons for this are not that clear but the suggested mechanisms of structural and cellular change can be more specifically harnessed and utilised for pain relief

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and rehabilitation. It is proposed that the loading of the tendon produces two positive effects: 1. Mechanotransduction. The sustained submaximal non-ballistic loading mechanically stimulates the tenocytes to produce more of the smaller proteoglycans and less of the large water imbibing ones. Coupled with the proposed mechanical extravasion of water from the tendon this simple exercise can achieve some profound results.

2. Sustained isometric fatiguing stimulates descending pain inhibitory pathways. This is suggested to occur via the modulation of pressure pain thresholds. The research at the time of writing had only been extrapolated from fibromyalgia management research (7â&#x20AC;&#x201C;9).

It appears that the careful management of loaded isometric exercises does not use or stress the elastic properties of the Achilles tendon but still offers a loading stimulation.

Figure 3: A one-leg calf-raise isometric hold (sportEX, 2014)

SiMPle iSoMeTriC loaDing for TreaTMenT anD SyMPToMaTiC relief A painful tendon with a suspected tendinopathy should respond to

25

sustained isometric contraction of the gastro-soleus complex by offering a reduction in pain and an improved function for the immediate to mid-term (Fig.3). The isometric exercise can be repeated should symptoms return. Due to the fact that there are no elasticity demands on the tendon the risk of further upset or rupture should be negligible.

Increasing or decreasing load is the chief stimulus that pushes the tendinopathy continuum forward or backwards and appears to be the keystone of successful management.

Continued overload appears to lead to irreversible structural changes and complete rest leads to degeneration from under-stimulation, a fine balance needs to be found and assessed regularly.

SuMMary This article has described the idea that tendinopathy is progressive condition with different stages of severity. As the condition moves through the stages, there is reduced chance of return to full strength because of changes in the tendon at the cellular level.

Isometric loading seems to be a useful treatment, but the condition needs to be managed carefully to avoid overload or under-stimulation.

7. Kosek E, Ekholm J, Hansson P. Modulation of pressure pain thresholds during and following isometric contraction in patients with fibromyalgia and in healthy controls. pain 1996;64(3):415–423 8. Kosek E, Lundberg L. Segmental and pluri-segmental modulation of pressure pain thresholds during static muscle contractions in healthy individuals. European Journal of pain 2003;7(3):251–258 9. Hoeger bement MK, Rasiarmos RL, et al. The role of the menstrual cycle phase in pain perception before and after isometric fatiguing contraction. European Journal of applied physiology 2009;106(1):105–112.

furTher reSourCeS 1. Podcast by Dr Peter Malliaras on Lower limb tendinopathies (Physioedge) (http://spxj.nl/1obmOWP).

2. Podcast by Prof. Jill Cook on Tendons and tendinopathy (Physioedge) (http://spxj.nl/1fyRpma).

DISCUSSIONS

Th auThor ThE Education Director of roCKTaPE uK, Daniel Lawrence is a chartered physiotherapist and lecturer with a first class honours degree in Physiotherapy. having started his career as a personal trainer, he then trained to become a physiotherapist, going on to achieve postgraduate qualifications in both orthopedic Medicine and Education. Daniel has spent much of his working life striving to tie together high quality physical therapy with education in both private and public sectors. he is the founder of South West Seminars, a company which provides training for health professionals. he also works as a lecturer for Plymouth university and as Clinic Manager for Truro College sports department and is actively involved in treating patients on a daily basis. In 2011 Daniel moved to roCKTaPE uK and took up his position as Education Director where he leads regular lectures and seminars, educating physiotherapists, personal trainers, osteopaths and chiropractors. If you wish to attend a tendinopathy or taping course with Daniel please email him on seminars@rocktape.net

n Can you create some clinical models for the three stages of tendinopathy by discussing the stereotypical patient presentations for each stage? n What are the important points to make patients aware of if they have tendinopathy and can you list the points you would put on a patient advice leaflet? n Develop a progressive exercise programme for the Achilles tendon beginning with isometrics and progressing towards full sport participation.

references 1. Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British Journal of sports medicine 2009;43:409–416 2. Parkinson J, Samiric T, et al. Change in proteoglycan metabolism is a characteristic of human patellar tendinopathy. arthritis and rheumatism 2010;62(10):3028–3035 3. Danielson P, Alfredson HK, Forsgren S. Distribution of general (PGP 9.5) and sensory (substance P/CGRP) innervations in the human patellar tendon. Knee surgery sports traumatology and arthroscopy 2006;14:125–132 4. Cook J. Lecture notes 2012.

5. Kannus P, Jozsa L. Histopathological changes preceding spontaneous rupture of a tendon. A controlled study of 891 patients.

Journal of Bone and Joint surgery of america 1991:73:1507–1525 6. Danielson P, Alfredon H, Forsgren.

In situ hybridization studies confirming recent findings of the existence of a local nonneuronal catecholamine production in human patella tendon tendinosis. microscopy research technique 2007;70(10):908–911 26

continuing education Multiple choice questions This article also has a certificated eLearning test which can be found under the eLearning section of our website. For more information on how to access the test click this link http://spxj.nl/cpdquizzes

this quiz is accEssiBlE

frEE

with a suBscription that includEs onlinE accEss to this Journal.

key PoinTS n Tendinopathy is a clinical diagnosis of pain, stiffness and impaired tendon function. n The tendon reacts to acute overload with a short-term, load-adaptive thickening. n a degenerative tendon can be structurally weakened without any symptoms of significant pain. n Sustained isometric fatiguing stimulates descending pain inhibitory pathways. n increasing or decreasing load is the chief stimulus that pushes the tendinopathy continuum forward or backwards and appears to be the keystone of successful management. n Continued overload appears to lead to irreversible structural changes and complete rest leads to degeneration from under-stimulation, a fine balance needs to be found and assessed regularly.

sportEX medicine 2014;60(april):21-26

EvidEncE informEd practicE

BY Dr Chris Norris PhD, MCsP

shoulDer iMPiNgeMeNt Shoulder pain is a common occurrence both in sport and the general public, and one which can be long lasting.

Prevalence is high with 30% of individuals reporting pain in their lifetime, and over 50% complaining that symptoms last beyond 3 years (1). Up to 65% of all shoulder pain can be attributed at least in part to impingement (2). The results of surgical treatment are comparable to that of conservative treatment, but in the long term up to one third of patients are left with persistent pain and disability (3).

To understand this condition we need to look at the anatomy, pathology and management options.

ANAtoMY The arm is attached to the trunk through the shoulder girdle with the scapula resting on the back of the rib cage, and the shoulder held away from the trunk by the clavicle which acts as a strut. As the arm is moved away from the body, movement occurs between the clavicle and breastbone (sternoclavicular joint), clavicle and scapula (acromioclavicular joint), scapula and ribcage (scapulothoracic joint) and the shoulder joint itself (glenohumeral joint). The shoulder offers the greatest range of motion of any joint in the body, and is said to sacrifice stability for mobility. Compared to the hip joint for example, which is also a ball and socket, the shoulder joint has a larger ball (head of the humerus) and a relatively small socket (glenoid fossa), the glenoid fossa being one third the size of the humeral head itself.

The joint is surrounded by a loose capsule with a volume twice that of the humeral head. As the arm moves away from the body movement occurs in a specific sequence throughout the shoulder girdle and upper trunk. This sequence is very precise, and when it breaks down impingement is often the result.

The roof of the joint (coracoacromial arch) is formed by the coracoacromial ligament together with the coracoid process and acromion process. The area below the coracoacromial arch is called the www.sportEX.net

Shoulder impingement Impingement accounts for up to 65% of all shoulder pain, and yet studies have been unable to determine the precise structure which is at fault. This article uses an evidence-based approach to guide clinical practice by looking at anatomy, pathology and function of the shoulder region. By understanding how to optimise shoulder function, treatment of several body regions can be combined to address impingement problems. Rehabilitation is used to target compensatory movements and re-establish optimal shoulder function, and the practitioner is guided through a rehab programme which can be applied to patients immediately. subacromial space officially defined as having the humeral head as its base, and the under surface of the anterior acromion, coracoacromial ligament and

online

the acromioclavicular joint as its roof.

Within the subacromial space there are three structures: the supraspinatus tendon, subacromial bursa and

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Video 1: Anatomy of the shoulder (video online) [developed by sporteX] 27

tABle 1: CAuses of suBACroMiAl CoMPressioN (C. Norris, 2014) intrinsic n Tendon trauma (partial or full thickness tears) n Tendon degeneration n Bursal swelling

extrinsic n Referral from cervical spine n Postural changes to thoracic spine n Altered scapular movement n Altered humeral movement n Tightness of posterior shoulder structures (rotator cuff/capsule) n Altered bony orientation (osteophytes).

long head of the biceps tendon (2).

Subacromial impingement syndrome (SAIS) occurs when the tissues within the subacromial space generate pain or are compressed. Once general medical considerations have been eliminated, mechanical compression may be considered either intrinsic due to changes in the structures within the subacromial space, or extrinsic due to external compression of the space (Video 1) (Table 1).

The height of the subacromial space (acromiohumeral distance or AHD) is between 7 and 14mm in healthy subjects (3). A reduction in AHD may occur at rest, but only measurement taken during active arm elevation is able to demonstrate functional narrowing. MRI studies of AHD have demonstrated smaller distances in the region of 3mm during

online

arm elevation in those with rotator cuff tendinopathy due to SAIS (4).

MoVeMeNt Movement of the arm away from the side of the body is termed the abduction cycle and may be conveniently described in three stages, although the cycle itself is a continuous process (Video 2).

In stage one it is what we donâ&#x20AC;&#x2122;t see as clinicians which is important.

The scapula should remain fixed to the rib cage through action of the scapula stabilising muscles especially the serratus anterior, supported by the trapezius. As the arm moves from the side of the body, the muscle action of the scapular stabilisers fixes the scapula to the rib cage and so the scapula appears to sink into the surrounding muscle mass. There is

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Video 2: scapula movement as the arm moves into abduction (video in online version).

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a very slight upward displacement of the humeral head and this movement should be limited by a synergistic action of the rotator cuff drawing the head of the humerus downwards while the deltoid abducts the arm and draws the head of the humerus upwards.

From the force vectors of the muscles, the infraspinatus and subscapularis are best placed to provide downward displacement of the humeral head in opposition to the upward translation brought about by deltoid action, while the supraspinatus is a more effective compressor, drawing the humeral head further into the centre of the glenoid. Decreased electromyographic (EMG) activity in the infraspinatus and subscapularis together with the middle deltoid has been seen in subjects with SAIS from 30 to 60° abduction (5). The long head of the biceps has been shown to assist in stabilising the head of the humerus in an anterior and superior direction and to decrease pressure within the subacromial space (6). Fluctuations of translation of the humeral head are relatively small in the healthy subject, with movement in the region of 1mm being recorded. The humeral head should remain centred within the glenoid. Where the rotator cuff muscles have reduced activity, or contract too late in the movement, upward displacement of the humerus occurs due to the unopposed pull of the deltoid. Anteroposterior movement of the humeral head varies with values between 0.7 and 2.7mm of anterior translation and 1.5 and 4.5mm of posterior translation being recorded for different ranges of abduction (7).

Increased superior and/or anterior humeral head movement is associated with SAIS, with increased superior translation of 1.5mm and increased anterior translation of 3mm being quoted (2).

Tightness in the posterior capsule induced surgically in cadavers results in an increase in the superior and anterior humeral head translation (8). This finding has been used to justify manual therapy aimed at the posterior capsule, and exercises such as the cross body and sleeper stretch (Figs 1 and 2).

Although these techniques are often effective therapeutically in SAIS, they will probably affect both the posterior sportEX medicine 2014;40(April):27-35

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rotator cuff and capsule as it unlikely that the capsule can be selectively isolated non-operatively (2).

As abduction progresses the greater tuberosity moves closer to the subacromial arch and to prevent the two structures touching lateral rotation of the humerus occurs, and the capsular ligaments relax to allow maximal movement. In addition, to move the subacromial arch away from the approaching humerus the scapula must upwardly rotate during stage 2 of the movement, an action brought about by a force couple between the serratus anterior working in parallel with the upper and lower fibres of the trapezius. The opposite movement (downward rotation of the scapula) occurs through action of the levator scapulae, rhomboids, and pectoralis minor muscles and is a requirement in activities where the body is lifted on the fixed arm such as a dipping action in the gym. If these latter muscles become dominant or are stiffer through tightness, upward rotation of the scapula will occur more slowly, or be more limited in range. Decreased performance in the serratus anterior and lower trapezius has been identified in subjects suffering from rotator cuff tendinopathy due to SAIS, with reduced total EMG activity and onset of activation (3).

The scapula is a relatively flat bone moving on the curved shaped drum of the rib cage. As we move the arm above the horizontal position to draw it overhead upward rotation of the scapula is complete and the scapular is drawn around the rib cage. This lateral movement is only possible if the kyphotic curve of the thoracic spine is reduced to produce a flatter rib cage surface. This action forms stage 3 of the abduction cycle, and will be limited where the thoracic kyphosis is increased (round shouldered posture) or stiffer. In both cases the increased curvature of the thoracic region limits lateral movement of the scapular meaning it is difficult for the subject to lift into pure abduction to draw the arm level with the ear. Instead the arm moves forwards (flexion abduction) towards the side of the face, as a compensatory action.

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PAthologY It is generally considered that compression of the soft tissues between the head of the humerus and the acromion during abduction and elevation causes pain, with the classic impingement test combining abduction and internal rotation (Empty can test) to press the greater trochanter onto the under surface of the acromion, sandwiching any impinging structure between the two.

The classical development of impingement syndrome is of mechanical compression through three progressive phases (9). The condition has been said to begin (stage I) in the younger patient (under 25) with oedema and haemorrhage through persistent overhead activities, leading to deterioration of the tendon and bursa (stage II in the 25–40 year old) to final full thickness rupture and bone spur formation in later life (stage III, over 40 years of age). This progressive pathology has now been challenged (10). If compression of the supraspinatus tendon occurs beneath the subacromial arch, the direct mechanical strain should lead to abrasion to the tendon’s upper surface. However, damage to the inferior (joint) side of the tendon has been found in over 90% of cases (6) in athletes and over 80% of cadavers (11), representing internal impingement (12). The prevalence of partial thickness tears in cadavers has been shown to be roughly 30% with damage to the articular aspect of the tendon or intra-tendon substance (13).

The fibres on the lower (non-acromial) side of the tendon have a smaller cross sectional area than those on the upper surface. The lower fibres are therefore more vulnerable to tensile loading, especially during elevation where tendon strain is increased. Movement of the upper tendon fibres upon the lower may result in intratendinous shearing, giving reaction through physiological failure of the lower tendon fibres rather than injury through external compression (10).

Where external compression is a cause of SAIS, the shape of the acromion becomes relevant. Three types of acromion have been described, flat (type I), curved (type II), and hooked (type III) (14). The suggestion is that rotator cuff tears as a result of SAIS are more common in those with a hooked

Figure 1: Cross body stretch. (Photo credit: C. Norris, 2014)

Figure 2: Sleeper stretch. (Photo credit: C. Norris, 2014)

acromion, justifying the need for surgical removal of the anterior/inferior aspect of the acromion (acromioplasty). However, many asymptomatic individuals have been found to have a curved or hooked acromion, and it has been suggested that the success of acromioplasty may be due to enforced rest following surgery rather than to the surgical procedure itself (10). The shape of the acromion itself may be a secondary rather than a primary effect. Bony spur formation of the acromion seems to be at the insertion of the coracoacromial ligament. A repetitive upward translation force (due to impaired action of the rotator cuff) may create tension at the acromial insertion of the ligament which is smaller than the coracoid side. The ligament may be a source of pain as free nerve ending have been identified within it (10).

The subacromial bursa is innervated by the lateral pectoral nerve 29

and subscapular nerve, and is capable of both nociception and proprioception.

Removal of the bursa (bursectomy) alone gives the same degree of pain relief as bursectomy combined with acromioplasty with no significant differences at 2.5 years follow-up (15).

Changes to the supraspinatus tendon seen in SAIS indicate that the condition is likely a tendinopathy rather than a tendinitis. No infiltration of cells associated with inflammation are seen within tendon in specimens taken during surgery, but increased volume of the tendon seen experimentally may be the result of a reactive phase similar to Achilles or patellar tendinopathy (10). An increased vascular response (neovascularisation) in degenerative areas of the supraspinatus has been noted with Doppler ultrasound (16), suggesting a healing response to microtrauma as is seen in tendonitis in other body areas.

The presence of tendinopathy and increased metabolic response during a reactive phase would suggest that relative rest and graduated loading should form part of the management of this condition.

effective at provoking the subject’s pain, but may be less useful at identifying the pathological tissue responsible for the pain. Traditional passive tests aim to compress the structures within the subacromial space by combining some degree of abduction with internal rotation (Table 2).

With many conditions there can be a poor clinical correlation between pathology and pain, and the shoulder is no exception to this. Some subjects may have pain with few apparent indicators on imaging, while others are asymptomatic in the presence marked bone or soft tissue changes.

Systematic review with meta-analysis of the Neer and Hawkins–Kennedy tests for impingement (and the Speed test for labral pathology) concluded that diagnostic accuracy is limited (17).

The use of clinical tests as symptom-provoking procedures to monitor treatment effect has been proposed for SAIS (1) using the shoulder symptom modification procedure which provides a logical synopsis of common tests and methods from several areas of physiotherapy, such as mobilisation with movement (MWM), exercise therapy, manual therapy, and taping. Techniques in four areas are used (Table 3).

The patient-described outcome is normally that of pain measured on a numerical rating scale (NRS) or visual analogue scale (VAS), with a minimal clinical important difference (MCID) being set at a 30% improvement from baseline to represent a meaningful change (1). Movement range may also be used to assess the effectiveness of a technique.

PAtieNt AssessMeNt

humeral head positioning

Tests used to assess SAIS are

Pressure techniques are used on the

tABle 2: CoMMoN CliNiCAl tests for sAis (C. Norris, 2014) test name

Action

1. Neer’s sign test (Fig.3)

1. Also called the forward flexion impingement test. Stabilise the scapula and grip the arm below the elbow with the other hand. Passively elevate arm into full flexion. Positive if pain is produced at end of passive elevation.

2. Hawkins–Kennedy test (Fig.4)

2. Elbow flexed to 90°, shoulder passively forward flexed to 90°. Take shoulder into internal rotation.

3. Full/empty can test 3. Also called Jobe’s test and the Scaption test. Passively elevate arm to (Fig.5) 90° in scapular plane. Turn hand down so thumb point towards floor for internal rotation (Empty can) and apply resistance to abduction. Repeat with palm up for external rotation (Full can).

Figure 3: Neer’s test. (Photo credit: C. Norris, 2014)

Figure 4: Hawkins–Kennedy test.

(Photo credit: C. Norris, 2014)

tABle 3: shoulDer sYMPtoM MoDifiCAtioN ProCeDure [Adapted from Lewis (1)] Anatomy involved

Mechanical technique

n Humeral head n Scapular position n Cervical spine n Thoracic spine

n Application of mobilisation with movement n Passive stabilisation or modification with or without taping n Neuromodulation procedure to address pain and movement quality n Reduction of increased kyphosis.

Figure 5: Empty can test. (Photo credit: C. Norris, 2014)

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humeral head which are similar to traditional MWM procedures but used with manual pressure, belts or elastic tubing. Either anterior or posterior directed pressure is maintained during the subject’s movement in an attempt to reduce symptoms.

Movements which caused pain during testing may be repeated using minimal resistance to modify symptoms. External rotation and humeral head depression are performed to restrict or modify internal rotation and elevation stresses which traditionally exacerbate SAIS. A posterior glide MWM applied manually has been shown to immediately reduce pain by 20.2% and increase movement range by 15.3% in a group of subjects with anterolateral shoulder pain which restricted shoulder elevation (18). In this study the increase in motion range was not related to change in pain, leading the authors to suggest that joint or muscle mechanisms may be responsible for the movement change rather than pain.

scapular positioning Manual techniques and taping may be used to slightly modify scapular position, as altered scapular kinematics is often associated with impingement symptoms (19). The same scapular modifications may then be used for re-education. Scapular positions of elevation/depression, protraction/ retraction, tipping (also called tilt, representing rotation about a mediolateral axis), and rotation (rotation about an anteroposterior axis) are all compared to the unaffected side and modified if required. Scapular winging may be modified by manual stabilisation or taping, to assess the effect on the subject’s symptoms.

radiculopathy If shoulder pain arises from the cervical spine, manual therapy to this region can affect pain and movement in the shoulder region. Both soft tissue and joint based techniques may be used.

A study that used lateral mobilisations applied to the C5/C6/C7 spinous processes in sitting demonstrated both a reduction in pain (mean 1.3 cm measured in a VAS scale) and increased abduction motion range www.sportEX.net

(mean 12.5° measured using video analysis) in patients with shoulder pain of at least 6 weeks duration (20).

Cervical mobilisation has been shown to increase lateral rotation motion range at the shoulder in subjects with restricted movement in the absence of shoulder treatment (21). Oscillatory mobilisation was given to the C4/5 and C5/6 segments, with lateral rotation range at the shoulder increasing from 0–1/4 range to 1/2–3/4 range. It was suggested that pain referred from the cervical spine to the shoulder resulted in increased muscle tone to the shoulder musculature restricting motion range at that joint. The restricted and/ or painful shoulder movement should be performed and cervical tissue treatment applied to assess change in the shoulder symptoms.

thoracic kyphosis Changes to the thoracic kyphosis have been shown to alter scapular tipping and rotation, and to decrease the amount of elevation at the glenohumeral joint (2). Altering thoracic and scapular posture has been shown to significantly increase shoulder flexion and abduction range in the scapular plane, and to delay the point of onset of pain within the motion range in subjects with SAIS (22). Manual techniques using overpressure and/ or taping may be used to reduce the subject’s kyphosis and movement quality is reassessed. Where thoracic stiffness is present localised manual therapy may be applied, as this has been shown to change impingement signs (Neer, Empty can, Hawkins– Kennedy, and active abduction) in subjects with impingement syndrome (23).

rehABilitAtioN Rehabilitation aims to reduce the subject’s symptoms during aggravating movements and to improve movement quality. Loss of translational control of the humeral head within the glenoid is strongly associated with impingement symptoms, and poor co-contraction of the rotator cuff muscles during the abduction cycle is often found in symptomatic subjects. Over time compensatory muscle strategies are put in place to maintain adequate

65% OF ALL SHOULDER PAIN CAN BE ATTRIBUTED TO IMPINGEMENT function, and as glenohumeral and scapulothoracic movements are optimised, compensatory actions that have become habitual must be identified and reduced. With chronic conditions especially, central sensitisation and altered neuroplastic changes are seen. Central sensitisation occurs when altered processing is seen within the dorsal horn cells of the spinal cord, while neuroplastic changes may include altered representation of the body part within the somatosensory cortex, increased strength of internal neural connections, and reorganisation of neuronal territory (24,25). Motor skill training which is functionally relevant to the patient may help normalise the representation of the body part in the somatosensory cortex and so be instrumental in managing a subject’s pain (26).

Rehabilitation aims to: (i) reestablish muscle co-contraction and translational control of the humeral head, (ii) enhance scapular stability and positioning during the abduction cycle, (iii) reduce habitual compensatory movements and (iv) optimise body segment and whole body alignment, and appropriate movement strategies.

Early rehabilitation begins with the techniques described in the shoulder symptom modification procedure (SSMP), which aim to reduce symptoms in aggravating movements. Isolation movements may be used to reeducation scapular stability and rotator cuff co-contraction during abduction actions. Movements in the scapular plane (30–45° anterior to the frontal plane) are used with ranges below the horizontal to reduce pressure within the subacromial space. Passive or active lateral rotation of the humerus is maintained to distance the greater tuberosity from the anterior aspect of the acromion process.

Hand grip, tactile feedback of the wrist and hand, and closedchain upper-limb actions can all lead to co-contraction of the rotator 31

cuff musculature to initiate the presetting phase of muscle activity in the shoulder. Sensorimotor input may be enhanced by working the scapulothoracic joint and glenohumeral joint in unison, in contrast to isolation movements often prescribed.

Through linked kinetic chains, movement of the whole body contributes to upper limb function.

Fault in one part of the kinetic chain may cause compensation elsewhere in the chain, a feature called link fallout, and rehabilitation should reflect this. Movement and/or stability of the proximal body component is begun prior to the distal, with an emphasis on functional rotation patterns. Throughout the rehab programme the therapist should aim to minimise compensatory patterns in the client, which may be localised to the shoulder and upper limb or appear in other body areas.

Within traditional therapy approaches there is often a focus on isolation actions at the shoulder. Although this approach has a place within the whole programme, if rehab is restricted to isolation actions alone it may fail to restore full function. The use of exercise focusing on a dynamic whole body approach, using both rotator cuff action and scapular stability as part of a kinetic chain movement is likely to produce a better functional outcome.

The use of complex exercise has been shown to be superior to isolation exercise for the rotator cuff using a 6-week programme with subjects training 3 times per week (27). These authors suggested that rehabilitation for the shoulder should begin with isolation actions to stimulate the weaker muscles, and progress to complex actions to give greater overload, an approach also used successfully during the rehabilitation of other body areas (28).

eXAMPle rehABilitAtioN eXerCises The following are example exercises which may be used as part of a structured rehabilitation programme following a full client assessment.

sternal lift (fig.6) Begin with your client sitting on a bench or stool with their feet flat 32

(a)

(b)

Figure 6: Sternal lift start position (a) and end position (b). (Photo credit: C. Norris, 2014)

on the ground. The action is one of thoracic extension (sternal lifting), rather than ribcage expansion (taking a deep breath). Use tactile cueing by placing your hands onto your clientâ&#x20AC;&#x2122;s sternum, or use a pen placed flat against the sternum to show that the sternal plate is angled downwards as the thoracic kyphosis increases, and upwards as the kyphosis reduces. If your client has difficulty isolating the sternal-lift action from deep inhalation, ask them to breathe in, and then lift the sternum as they breathe out. Where they sway their body forwards or backwards ask them to stand or sit with their back pressed up against a wall and perform the sternal-lift action from this starting position. The action is to draw the scapulae down the wall as the sternum lifts upwards.

overhead stretch on gym ball (fig.7) This exercise combines thoracic extension with full range flexion/ abduction at the shoulder. Ask your client to lie over a large (65cm) gym ball. Have them reach overhead with their elbows straight but not locked completely. At the same time encourage their chest to open and thoracic spine to extend. To increase overload, a light dumb-bell may be held between the hands. Where shoulder flexibility is limited, practice the movement close to a wall so the hands rest on the wall rather than overhead.

a

b Figure 7: Overhead ball stretch without weight (a) and with weight (b).

(Photo credit: C. Norris, 2014)

gym ball superman with star arms (fig.8) Have your client lie over a gym ball with their chest on the ball surface, feet apart and on the floor. Their arms should be out to the side in a T shape, hands resting on the floor.

Raise the arms out to the sides (extension-abduction) turning them so the thumbs point to the ceiling (lateral rotation at the shoulder). At the same time perform a thoracic extension movement by drawing the scapulae down and inwards and opening the chest. Raise the head slightly to look sportEX medicine 2014;40(April):27-35

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THE ABDUCTION CyCLE IS CENTRAL TO THE UNDERSTANDING OF THIS CONDITION

Figure 8: Gym ball superman stretch with star arms.

(Photo credit: C. Norris, 2014)

at the floor 1–2m in front of the ball.

Hold the top position for 2–3 seconds breathing normally (do not allow them to hold their breath) and then lower the arms and trunk under control.

Pilates cat paws (fig.11)

Pilates dumb waiter with band (fig.9) Have your client stand with their feet hip width apart, and elbows bent to 90° and tucked into the side of their trunk. For the dumb waiter action, have the palms facing upwards and laterally rotate the shoulders to draw the forearms outwards in an arc away from the body. Pause at the outer range position and then return to the starting position. To increase overload hold a resistance band between the hands and pull outwards against the resistance. Again pause at the outer range point and then move back to the starting position under control.

Abduction with lateral rotation using band (fig.10) Begin by hooking a resistance band

Figure 9: Pilates dumb waiter with band. (Photo credit: C. Norris, 2014)

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it outwards. Their eyes should follow their hand throughout the action as the trunk turns inwards towards the door when the arm is lowered. The second action works the shoulder musculature with the core muscles at the same time. To increase overload on the core, perform the action in single-leg standing so that whole body balance is challenged.

Figure 10: Abduction with lateral rotation using band.

(Photo credit: C. Norris, 2014)

beneath a door using a door stop. This exercise has two parts. For the first part have your client perform an isolation action with the shoulder. Get them to stand with their feet hip width apart and their affected arm away from the door, arm held across the body in adduction taking the slack off the band. The action is a combined movement of abduction and lateral rotation to draw their hand outwards and turn the palm forwards so their thumb moves towards the ceiling.

When they have performed this action several times and are comfortable with it, they can move to part two of the action which is a complex movement combining trunk rotation and arm movement. Now, they stand with their far foot turned outwards (lateral rotation at the hip) and reach downwards towards the door. They then turn their whole body outwards, away from the door as they abduct their arm and turn

This exercise works the scapular stabilisers with the arm in flexion and in closed-chain position (hand on the floor).

Have you client begin in a four-pointkneeling position on a gym mat with their knee beneath their hip and hand beneath their shoulder. Ask them to stabilise their scapula by drawing it down slightly and inwards. Verbal cues such as ‘press your chest outwards’ or ‘push your hand into the floor and make your arm longer’ can be useful, and tactile cues placing your flat hand onto the scapula or using a book placed on the upper thorax are also suitable. The action is to shift the shoulders to the right to take the chest weight over the right hand and to lift the heel of the left hand, leaving the fingers just in contact with the mat. The right scapula must now work hard to remain fixed to the thorax and not wing outwards. Reverse the action taking the weight to the left. Once the action can be performed with good scapulothoracic alignment, have your client progress to

Figure 11: Pilates cat paws.

(Photo credit: C. Norris, 2014)

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IN CASES OF SHOULDER PAIN, THE CERVICAL SPINE SHOULD ALWAyS BE EXAMINED lifting the hand by bending their elbow.

Ensure that the shoulders remain level, and do not allow the shoulder on the lifted side to dip down.

standing band pull (fig.12) Begin with your client standing, shoulders hip width apart. Have them hold the ends of a resistance band in each hand and loop the centre beneath their feet. Adjust the band so it is tight, and encourage them to draw their scapulae down and inwards, at the same time lifting their sternum. Use verbal cues such as ‘open your chest’ and ‘draw your shoulder blades down into the back pocket of your shorts’.

Tactile cues can encourage both movements simultaneously by placing one finger between their scapulae and drawing the skin downwards and another finger on the sternum to draw the skin upwards. Ensure that they do not increase their lumbar lordosis as the lift their ribcage.

single arm row with single leg stand (fig.13) This action combines a shoulder

Figure 13: Single-arm row with singleleg stand. (Photo credit: C. Norris, 2014)

movement with whole body action to provide complex work of overall body balance and coordination. Begin with your client facing a pulley machine or resistance tubing secured to a door frame. Have them take the slack up on the cable or tubing and stand on one leg, establishing their balance.

They should maintain a good upright posture and draw the cable towards themselves moving the shoulder blades downwards as they do so. The action is to stabilise the scapula as the arm moves, but not to overly brace the shoulders or thrust the chest forwards.

The knee of the supporting leg should bend slightly (soften) and the hips are aligned horizontally, Do not allow the pelvis to dip towards the non-weightbearing side.

suMMArY This article has demonstrated how the anatomy of the shoulder can contribute to the pathology of shoulder impingement and has described tests that are useful for assessing a patient’s condition as well as monitoring treatment. The reader will also now be familiar with a number of rehabilitation exercises that can be used in a structured rehab programme.

Figure 12: Standing band pull. (Photo credit: C. Norris, 2014)

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References 1. Lewis JS. Rotator cuff tendinopathy/ subacromial impingement syndrome: is it time for a new method of assessment?

British Journal of Sports medicine 2009;43:259–264 2. Michener LA, McClure PW, Karduna AR. Anatomical and biomechanical mechanisms of subacromial impingement syndrome. clinical Biomechanics 2003;18:369–379 3. Seitz AL, McClure PW, et al. Mechanisms of rotator cuff tendinopathy: Intrinsic, extrinsic, or both? clinical Biomechanics 2011;26:1–12 4. Graichen H, Bonel H, et al. Three dimensional analysis of the width of the subacromial space in healthy subjects and patients with impingement syndrome. american Journal of roentgenology 1999;172(4):1081–1086 5. Reddy AS, Mohr KJ, et al.

Electromyographic analysis of the deltoid and rotator cuff muscles in persons with subacromial impingement. Journal of Shoulder and Elbow Surgery 2000;9:519–523 6. Payne LZ, Deng XH, et al. The combined dynamic and static contributions to subacromial impingement. A biomechanical anaysis. american Journal of Sports medicine 1997;25 801–808 7. Ludewig PM, Cook TM. Translations of the humerus in persons with shoulder impingement symptoms. Journal of orthopaedic & Sports physical therapy 2002;32:248–259 8. Harryman DT, Sidles JA, et al. Translation of the humeral head on the glenoid with passive glenohumeral motion. Journal of Bone and Joint Surgery (am) 1990;72:1334–1343 9. Neer CS. Impingement lesion. clinical orthopedics 1983;70–77 10. Lewis JS. Subacromial impingement syndrome: a musculoskeletal condition or a clinical illusion? physical therapy reviews 2011;16(5):388–398 11. Fukuda H, Hamada K, yamanaka K. Pathology and pathogenesis of bursal side rotator cuff tears: viewed from en bloc histologic sections. clinical orthopedics and related research 1990;254:75–80 12. Edelson C, Teitz C. Internal impingement in the shoulder. Journal of Shoulder and Elbow Surgery 2000;9:308–315 13. Loehr JF, Uhthoff HK. The pathogenesis of degenerative rotator cuff tears. orthopedic translation 1987;11:237 14. Ticker JB, Bigliani LU. Impingement pathology of the rotator cuff. In: Andrews JR, Wilk KE (eds) The athlete’s shoulder. churchill Livingstone 1994. ISBN 0443088470 15. Henkus HE, de Witte PB, et al.

Bursectomy compared with acromioplasty in the management of subacromial impingement syndrome: a prospective randomised study. Journal of Bone & Joint Surgery (Br) 2009;91:504–510 16. Levy O, Relwani J, et al. Measurement of blood flow in the rotator cuff using laser Doppler flowmetry. Journal of Bone & Joint Surgery (Br) 2008;90:893–898 17. Hegedus EJ, Goode A, et al. Physical examination tests of the shoulder: a sportEX medicine 2014;40(April):27-35

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systematic review with meta-analysis of individual tests. British Journal of Sports medicine 2008;42:80–92 18. Teys P, Bisset L, Vicenzino B. The initial effects of a Mulligan’s mobilisation with movement technique on range of movement and pressure pain threshold in pain-limited shoulders. manual therapy 2006;13:37– 42 19. Ludewig PM, Cook TM. Alteration in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement. physical therapy 2000;80(3):276–291 20. McClatchie L, Laprade J, et al.

Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults. manual therapy 2009;14(4):369–374 21. Schneider G. Restricted shoulder movement: capsular contracture or cervical referral – a clinical study. australian Journal of physiotherapy 1989;35(2):97– 100 22. Lewis JS, Wright C, Green A. Subacromial impingement syndrome: The effect of changing posture on shoulder range of movement. Journal of orthopaedic & Sports physical therapy 2005;35(2):72–87 23. Boyles RE, Ritland BM, et al. The short term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome. manual therapy 2009;14:375–380 24. Boudreau SA, Farina D, Falla D. The role of motor learning and neuroplasticity in designing rehabilitation approaches for musculoskeletal pain disorders. manual therapy 2010;15(5):410–414 25. Littlewood C, Malliaras P, et al. The central nervous system – an additional consideration in rotator cuff tendinopathy and a potential basis for understanding response to loaded therapeutic exercise. manual therapy 2013;18:468–472 26. Gibson J. The shoulder: evidence based practice or reinventing the wheel? In Touch (Journal for physiotherapists in private practice) 2011;135:14–21 27. Giannakopoulos K, Beneka A, Malliou P. Isolated vs. complex exercise in strengthening the rotator cuff muscle group.

Journal of Strength and conditioning research 2004;18(1):144–148 28. Norris CM, Matthews M. The role of an integrated back stability program in patients with chronic low back pain. complementary therapies in clinical ractice 2008;14:255–263.

2008;14:255–263 practice

f further resourCes resour 1. Managing Sports Injuries: a guide for students and clinicians (4th edn) by C. Norris. Churchill Livingstone Elsevier 2011. ISBN 0702034738 (£48.44). Buy from Amazon http://spxj.nl/THNgxy www.sportEX.net

KeY PoiNts n impingement accounts for up to 65% of all shoulder pain. n in order to treat shoulder impingement, a thorough understanding of the shoulder anatomy and pathology of the condition is needed. n the shoulder offers the greatest range of motion of any joint in the body, and is said to sacrifice stability for mobility. n Compared to the hip joint, the shoulder joint has a larger ball (head of the humerus) and a relatively small socket (glenoid fossa). n As the arm moves away from the body, movement occurs in a specific sequence; the breakdown of which can often result in impingement. n the classical development of impingement syndrome is mechanical compression through three progressive phases. n the use of clinical tests as symptom-provoking procedures to monitor treatment effect has been proposed for sAis. n rehabilitation aims to reduce the subject’s symptoms during aggravating movements and to improve movement quality. n Within traditional therapy approaches there is often a focus on isolation actions at the shoulder. however, if rehab is restricted to isolation actions alone it may fail to restore full function.

n Describe the abduction cycle n Name and DISCUSSIONS describe the rotator cuff muscles n On a partner, identify the sternoclavicular and acromioclavicular joints

Th AuThoR ThE Dr Chris Norris is a physiotherapist with over 35 years experience. he has an MSc in Exercise Science and a PhD in back pain rehabilitation, together with clinical qualifications in manual therapy, orthopaedic medicine, acupuncture, and medical education. he is the author of 12 books on physiotherapy, exercise, and acupuncture and lectures widely in the uK and abroad. he is a visiting lecturer and external examiner to several universities at postgraduate level. he runs private clinics in Cheshire and Manchester and his postgraduate courses for therapists are on his website www.norrisassociates.co.uk.

continuing education Multiple choice questions This article also has a certificated eLearning test which can be found under the eLearning section of our website. For more information on how to access the test click this link http://spxj.nl/cpdquizzes

thiS quiz iS accESSiBLE

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with a SuBScription that incLudES onLinE accESS to thiS JournaL. 35

webwatch

web watch FacebOOk pages yOu may wanT TO like

@spOrTeXjOurnal’s currenT TwiTTer FavOriTes

physiofacebook - http://www.facebook.com/topphysios - 39k+ followers and a brilliant page set up by one guy in the UK. Well worth a Like.

The sports pT - http://www.facebook.com/TheSportsPT - great Facebook page and equally good to follow on Twitter (see below)

@AdamMeakins (The Sports Physio) - (10.3k followers) @TheSportsPT (The Sports PT) – (6k followers) @BJSM_BMJ (Karim Khan) – (13.4k followers)

linkedin grOups n Evidence Based Physical Therapy (11.3k members) – lots of my contacts are members of this group which describes itself as “a forum for the exchange of dialog around the issues, challenges, and successes in the practice of evidence based physical therapy”. n Sports Medicine Updates (8.5k members) – all sorts of topics relating to sports medicine and quite a bit of interaction from members so worth checking out

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Come and join the discussion at http://sportex.net/blog n TwiTTer – news from around the sports medicine globe https://twitter.com/sportexjournals n linkedin spOrTeX grOup – articles, events, discussions and free resources http://spxj.nl/linkedinwithsportex n Flickr – we publish ALL the images we create for our journals under our Flickr account – for you to use in presentations and in your clinics http://flickr.com/sportex n FacebOOk – we do fun stuff on here mostly but you can also find our email newsletters and other useful sports medicine information http://www.facebook.com/sportEX. net 36

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4 One of the four major ligaments of the knee, for short 6 Technique to revive a person whose heart has stopped breathing 8 They separate vertebrae 9 Indicator of an illness or injury 11 Magistrate, abbr.

12 Informed (2 words) 14 Athletic shoes 16 ___ Bobby Charlton 17 Lady 18 Physical fitness facility 19 Kind of bandage 20 Ability to grasp an object 24 Weight measurement 25 Hand bone 29 Two prefix 30 Liquid used in some massages 31 It’s a vital sign 33 Extreme pain 34 Type of fracture

5 6 7 10 13 14 15

them toward the end of games (2 words) Some vertebrae ____ scan Strengthens, increases (2 words) Type of fruit juice, for short Animal used as a small savings bank Tea in slang Fasten or hold in position,

in a way 21 A restorative massage increases ___ circulation 22 Wound or injury 23 Injury to the finger tip, _____ finger 26 Sailor, abbr.

27 Exercised with weights 28 Become weaker and more tired 32 Period before

dOwn 1 2 3 4

Forearm bone Patient’s prior record Hit hard Football players sometimes suffer from

sportEX medicine 2014;60(April):36