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SEPNZ BULLETIN
ISSUE 14, APRIL 2020
TELEHEALTH SPECIAL: COVID-19 P5
p10 Covid-19 for Sports and Exercise
p20 2019 Canadian guidelines for physical activity throughout pregnancy
p23 UPCOMING SEPNZ COURSES
www.sepnz.org.nz
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CONTENTS SEPNZ MEMBERS PAGE See our page for committee members, links & member information
2
EDITORIAL: By SEPNZ President Blair Jarratt
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FEATURE ARTICLE: Thriving in a Telehealth Environment
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APP REVIEW: Tabata Timer
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MEMBER BENEFITS: Asics Professional Buyers Program
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SPECIAL REPORT: COVID 19 for Sports and Exercise
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NEW CONTENT: RADIOLOGY: IMAGING IN ACUTE DISTAL BICEPS TENDON INJURIES
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ADDITIONAL ARTICLE: Exercise in Pregnancy and Post Natal Care.
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CLINICAL REVIEW: 2019 Canadian guidelines for physical activity throughout pregnancy.
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UPCOMING SEPNZ COURSES
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RESEARCH PUBLICATIONS: BJSM February 2020 - Volume 54 - Issue 4
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SAM’S GAME
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EDITORIAL So many things have changed since our last Bulletin. We hope you are all adapting to the new way of working. Never would I have imagined the situation the world would be in when I was writing this piece for the last Bulletin, a timely reminder of how things can change so quickly and change we must. For the majority of us, this has been a crash course on Telehealth. It has now become part of the physiotherapist's toolkit for the delivery of our service. It has pushed many of us in a direction that six months ago, we didn't think we could do effectively - challenged our mindset, made us think outside the box. Yes, we are making history at present, and maybe the cloud of COVID brings other silver linings. Along with others this is a special interest group and we have been pushing the "exercise is medicine" mantra for a long time. Never is there a time like the present to embrace the power of exercise. In the past physiotherapy has wandered from this path bringing in other forms and adjuncts. Still, as the literature grows there is an overwhelming wave of evidence behind exercise and the current climate delivery of service, can this now be our saviour? Thankfully we are not alone in this situation, and many resources are being put out by credited sources, and this is a strength of what we do, which is always heartening to see. Even if you have done a plethora of education on Telehealth - the platforms, everyday operation and delivery continue to evolve at a rapid pace and brings new challenges but also a unique learning opportunity. Our feature article from Dr Mark Fulcher on Telehealth is another piece of excellent information. Mark kindly offers some of his learnings and some great practical tips to help us with these consultations. It's important with this new style of delivery that Physiotherapists continue to operate at our usual high standards and continue to prove our weight in gold for the health of our Nation. It is here to stay. Also in this Bulletin, Scott Piece discussed the respiratory implications for COVID 19 his article reads well to the sporting minded therapist with likening the possible outcomes from infection to some of the musculoskeletal conditions we see with shorter to more extended time frame implications. We have another excellent APP review from Emma Lattey, which is practical for a time like this when we can offer solutions to break the boredom of home isolation with spicing up the rehab plan. With the amount of DIY and home exercise going on at the moment, there are bound to be people pushing themselves above and beyond previous thresholds of activity. This can be good to see increased activity, but also as a group, we know that
steepening that curve to load can come with some risks. Auckland radiology group has provided a useful article on distal biceps tendon rupture - not an injury to be missed. Currently, this may mean that your client is referred to an emergency service, but hopefully, you have checked with your local imaging provider to see if essential imaging is available. We round off this edition with a clinical review from Amanda O'Reilly on the guidelines for exercise in pregnancy. The six specific recommendations outlined in her review provide clinically relevant and practical information for us to keep in mind when we are discussing and prescribing exercise throughout pregnancy. Finally—we leave you with “Sam’s Game” an invention by exec member Justin’s 10 year old son to keep us all entertained during lockdown. Also thanks to Olive (12) for the cover picture! If you have been around for long enough, you would know that unfortunately and fortunately for physiotherapy things have been tough in our profession before and this is no different to our current situation. What I do know is we deliver a necessary and valuable service to New Zealanders. As a mentor of mine said: "Adapt or Die" (Kudos Graeme Nuttridge). Like a phoenix to the flame, we will rise out of this and be reborn in some way shape or form, more robust, better and more resilient. Don't devalue your worth. No doubt this time will be a time we will remember for the rest of our lives. Let's make the most of it. Kind Regards Blair Jarratt SEPNZ President The Front Cover original image (and other COVID19 related images) are available under Public License here https://covid19.govt.nz/assets/images/ headers/COVID19_header_stay-home_icononly.jpg and was modified by adding a headset.
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FEATURE ARTICLE
Telehealth Special: Thriving in a Telehealth Environment Dr Mark Fulcher, Sport and Exercise Physician, MBchB, MMedSci, FACSEP
Dr Mark Fulcher is a Sport and Exercise physician based at Axis Sports Medicine in Auckland. Mark has been working via tele-health over the past year and has recently created and implemented a system for the Axis team to continue to operate through the lockdown imposed by the COVID-19 virus. He has recently presented to the ACSEP medical college on the subject of telehealth. In this short piece Mark will highlight some simple and practical suggestions about how to implement a tele-health system at your practice, what administrative challenges this may present and provide tips on how to conduct a high-quality tele-health consult.
How are you coping working in an environment when you are unable to physically touch your patient? The last few weeks have been truly remarkable. The word ‘unprecedented’ has been used widely; however, it is hard for me to find a better adjective. The COVID-19 enforced lockdown has forced us all to substantially change our practice in a world where many of us are unable to leave our own homes and where organised sport does not exist. At our clinic we have moved to a 100% telehealth solution. The speed at which this has happened would probably not surprise you, as I suspect that most of you will have experienced something similar. In a more normal world, the transition to a new method of consulting would have no doubt involved many meetings, extensive research into available technologies and lengthy discussions about how best to proceed. Despite this lack of ‘process’ and a ridiculously short timeframe, I believe that most of us have developed a solution that largely suits the needs of both our clinicians and patients. The overwhelming feedback that I have received from
both my patients and the clinicians I work with is that this telehealth is a medium that they enjoy and in many cases that they prefer over a face to face meeting. It is generally more convenient for both groups, is generally felt to be effective and limits the need for anyone to leave their ‘bubbles’. It would be wrong to suggest that moving to a new method of consulting has been seamless. This has involved lots of hard work from both our clinical and administration teams as well as being a steep learning curve for all of us. In this article I have tried to summarise some of the things that I have learned over the past 18 months or so that I have been offering telehealth consultations, and some things that our practice has learned (rapidly) over the past few weeks. I would also like to try to offer some advice about how you may be able to optimize your telehealth consultations.
I think the key to succeeding with Telehealth is adopting a positive outlook. There are multiple possible sources of frustration with this type of consultation, particularly when it is almost completely new to you. For example, you CONTINUED ON NEXT PAGE >>
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FEATURE ARTICLE have to create a new way of assessing a patient, are unable to deliver all of the different ‘types’ of treatment you would normally have available to you and are constrained by the technology you have to work with. Remaining calm and being flexible are important strategies. For example, if you are unable to connect reliably via a web platform, see what you can achieve via the phone. Asking the patient to try a different device or to move closer to their router may also be strategies that might salvage your consultation. When things are really not working out, ending the consultation and arranging another time to try again might actually be the best strategy.
The selection of a suitable telehealth platform is also an important consideration. Any device, software or service you use for the purposes of telehealth should be secure, fit for purpose and must preserve the quality of the information or image being transmitted. While some consultations can be done over the phone, a more meaningful consultation can generally be achieved with the addition of video. Clearly, whatever platform you choose needs to be secure. Platforms like Facetime, WhatApp and Zoom can all be safely used. An important consideration however, is that these applications link to your own personal phone or email addresses and generally require your patient to also download an app. Custom built platforms like Doxy.me have additional advantages including a waiting room, an ability to send documents securely through the platform as well as the ability to bill the patient. Clearly the best option would be to have the telehealth platform fully integrated directly into your patient management software (PMS). It has been interesting to see many providers scrambling to integrate this technology and to see how it does, or doesn't, work well. At present many of these do not truly link to the PMS and are more of a bolt on. Some platforms genuinely integrate the Telehealth solution into the programme and allow sharing of different types of patient data. In future I think that this type of functionality is going to become an essential requirement of any PMS.
Many patients have never experienced a Telehealth consultation before and are uncertain whether this is something that will be of benefit to them. As a result, I think that it is essential that we all go out of our way to make sure that it is a positive experience for them. This is especially true at present when most practices do not have a full patient load. Consider sending them some information about the consultation in advance. This
might have details about how to logon to the consultation, outline what might happen during the consultation and give suggestions about how they might get the best out of their appointment (for example make sure that they are in a quiet room, that they have the best possible internet connection and that they are ready to attempt a clinical examination). Similarly, make sure that you are prepared. Try to have a professional background behind you and make sure that you are dressed appropriately. During the consultation stay calm if things go wrong and be ‘solution-focused’. At the end of the consultation consider checking-in with the patient to see whether they were happy with the experience and whether there is anything additional that you can do to help. Consent is also a critical part of any consultation but there are some specific challenges associated with Telehealth. For example, a patient may not be in a suitable environment for a medical consultation. This is not something that you may be aware of, given the limited field of view available to you on a webcam. Being clear at the beginning of your consultation about what the session will involve, that you are aiming to conduct a ‘normal’ consultation where you will ask about their health and conduct an examination and providing an opportunity for questions is the minimum we should be aiming for. Being aware of, and following, available best practice guidelines (Allied Health or Medical Council of New Zealand) is critical.
An important consideration, for both the clinician and patient, are the limitations that a telehealth consultation can impose. It is important for the clinician to be acutely aware of these and to acknowledge them to the patient. There are times where telehealth is not appropriate. For example, a patient who you suspect may have ruptured their Achilles tendon will need a physical examination to confirm that the tendon is ruptured. In my opinion, particularly given the consequences associated with a missed diagnosis, this is not something that can reliably be done via Telehealth. In addition, the treatment of this problem requires immobilisation or surgical treatment which cannot be administered remotely. While this patient can be adequately triaged and offered advice, it would be unwise to attempt to make this diagnosis remotely. Similarly, many patients with long-term problems or more significant disability are likely best managed in a face to face consultation. For some of these patients, attempting some initial treatment or rehabilitation is very reasonable with the proviso that at some point in the future their progress will be reviewed in person. In these cases, it is important that this plan is clearly outlined to the patient and that appropriate follow up is arranged.
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FEATURE ARTICLE
It is very easy to focus on the clinical impact that a move to telehealth consultations has on our working life. Making sure that your administrative processes are also updated is critical to the success of this change in process. For example, your administrative staff may need to work a lot harder to convince patients to book an appointment. Making sure that they understand what can be achieved during this type of consultation is very important. Making sure that the phone is still answered during a time of crisis and that your website clearly states that you are open for business is also very important, particularly when many of our businesses rely on organised sport (which is not happening). Basic logistical things like providing a radiology referral, prescription or referral to a medical specialist also become far more challenging. Anticipating, and addressing, these challenges is important to the success of your telehealth practice.
Finally, frequent reflection and adjustment of your processes will greatly enhance positive outcomes for both your patients and your practice. By now I hope that most of you have got to grips with working remotely. One of the next things we all need to be thinking about is when and how we will be able to safely see patients face to face. I think that this is something that we should all be thinking carefully about now. Many sports physiotherapy consultations require direct physical contact and we will all need to consider whether this is appropriate, and how the risks associated with these consultations can be minimised. Social distancing, the use of personal protective equipment and being mindful about the potential risks for both the clinician and patient are all going to be important strategies. I hope that you are all feeling safe and are coping with the various pressures that this strange time brings.
Remember that the sport and exercise medicine community is there to support you and remember to reach out to your friends and colleagues. I look forward to seeing you all, either online or in person, soon.
LINKS: https://www.alliedhealth.org.nz/ uploads/8/8/9/4/88944696/ best_practice_guide_for_telehealth.pdf https://www.mcnz.org.nz/assets/ standards/06dc3de8bc/Statement-ontelehealthv3.pdf
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APP REVIEW
Back to the App... Your App Review Tabata Timer : Interval Timer The app I am reviewing this month is “Tabata Timer “- a simple and well-designed app to plan and time your Tabata or HIIT circuit without a fuss. The COVID19 home isolation situation might all be history by the time this bulletin is published (fingers crossed!) but during this time I have found this an invaluable app for use with my family and patients.
Seller: Size: Version: Category: Compatibility: Languages: Age rating: Copyright: Cost:
What it is used for?
Oleksandr Serhiienko 60.3 MB 3.5.3 Health & Fitness Requires iOS 10.0 or later. Apple and Android. English, Russian, Ukranian 4+ Alexander Sergienko Free. Or you can update to premium $4.99-6.99 per year.
The original “Tabata protocol” was developed by Dr Izumi Tabata and colleagues in a 1996 paper titled Effects of moderate-intensity endurance and high-intensity intermittent training on anaerobic capacity and ˙VO2max. In this research article “Tabata training” is defined as training at the intensity that exhausts subjects during the 7th or 8th sets of 20 second exercise bouts with a 10 second rest between the exercise bouts (Tabata, 2019). Over the years however, variations of the Tabata Protocol seem to be indicated to provide increases in aerobic power that are similar to traditional aerobic training while being less time consuming (Viana et al., 2019).
Who would benefit from this App? The Tabata training protocol was initially used in cardio training and weight control for short track skaters, and over the years this protocol has been widely used to train elite athletes. In my experience however, this style of high intensity training is suited for most people due to its many advantages such as a time-saving training plan, high efficiency, and simple rules. As a result, many forms and variations of Tabata have appeared, and with this app you can design a programme for yourself or your patients using whatever equipment is available!
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APP REVIEW PRACTICAL APPLICATION During the COVID19 lock down I have used telehealth video and phone consultations to assess and treat patients using education, advice, and most importantly exercise prescription. The overwhelming response has been that patients (as able) are keen for any variation to their rehab exercise plans and general daily exercise. I tend to pick 7-8 exercises (cycles) in a circuit set up and perform four sets. It is super easy to input your workout plan into the app and the workout is over in 14-16 minutes! My hope is that people continue to utilise this form of self-directed training once our lives go back to “normal”.
Pros: • This app does all the timings for you with cool sounds to let you know when to start/stop eg. whistle to start and bell to stop. • No fuss, super easy to use app with no annoying ads or promos to upgrade. • Big numbers and a 3 second count in and out of each 20second set.
Cons: •
•
No genuinely bad feedback online and I’ve had no issues at all with app. Muscle soreness the next day!
References Tabata, I. (2019). Tabata training: one of the most energetically effective high-intensity intermittent training methods. J Physiol Sci, 69(4), 559-572. doi:10.1007/s12576-019-00676-7 Viana, R. B., de Lira, C. A. B., Naves, J. P. A., Coswig, V. S., Del Vecchio, F. B., & Gentil, P. (2019). Tabata protocol: a review of its application, variations and outcomes. Clin Physiol Funct Imaging, 39(1), 1-8. doi:10.1111/cpf.12513
OVERALL RATING = 5 / 5
MEMBER BENEFITS
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There are many benefits to be obtained from being an SEPNZ member. For a full list of Members’ Benefits visit http://sportsphysiotherapy.org.nz/benefits/
In each bulletin we will be highlighting individual member benefits in order to help members best utilise all benefits available.
The ASICS Professional Buyers Programme is designed to enable Sport & Exercise Physiotherapy New Zealand members the opportunity to experience our shoes first hand and to assist in referring the most suitable shoe/s to your patients. By registering for the Professional Buyers Programme, you will: ASICS Performance Footwear/ASICS Sportstyle Footwear Receive 4 voucher codes per year, 2 every six months. Each voucher will give you 40% off the retail price of one pair of shoes up to $300 Recommended Retail Price. Vouchers must be redeemed online at www.asics.co.nz Additional Product Offers: Birkenstock Footwear Receive 2 voucher codes per year, 1 every six months. Each voucher will give you 30% off the retail price of one pair of shoes up to $200 Recommended Retail Price.
Vouchers must be redeemed online at www.birkenstock.co.nz Smartwool Socks Receive 2 voucher codes per year, 1 every six months. Each voucher will give you 30% off the retail price for your choice of socks (Recommended Retail Price). Vouchers must be redeemed online at www.smartwool.co.nz
Register Here Full terms and conditions can be found on the Professional Buyers Programme registration page. If you are already a member of the Professional Buyers Programme you will receive your vouchers in July and February. For first time registered member, we run a report at the end of each month which picks up the newly registered members. You should then receive your vouchers by the middle of the following month. REGISTER HERE
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SPECIAL REPORT
COVID 19 for Sports and Exercise Scott Peirce, Physiotherapist, BHSc, PG Cert. Covid-19 started in December 2019, with many unexplained cases of pneumonia in Wuhan, China, and has now quickly spread to most of the world and is a pandemic. The current epicenters of the outbreak are now Europe and North America. Severe cases of Covid-19 share many features with the SARS outbreak in 2003 and the MERs outbreak in 2012 but these outbreaks were quickly contained and eliminated. Many patients with Covid-19 are completely asymptomatic with indications that anywhere from 50% to 88% of cases have no symptoms and can be a major driver of transmission of the disease. The common symptoms from Covid-19 include fever, headache, tiredness and a dry cough. Other common symptoms include aches and pains, runny nose, sore throat and diarrhea. Sputum or mucus production is present in 30% of moderate symptomatic cases. More severe progressions include shortness of breath, pneumonia, and finally Covid19-SARS and death. Thankfully at this time the mortality rate in New Zealand is low compared to international levels. Worst-case scenarios have multiple lock-down periods in a year and a 2-4-year time frame if immunity is not acquired after exposure to Covid-19, or a vaccine is slow in being developed. Currently there are highly divergent reports from people who have caught Covid-19 and have not been hospitalized. A spectrum of presentations exists from asymptomatic, to post viral fatigue states (i.e. inability to walk further than the toilet without getting significant shortness of breath), to headaches and chronic fatigue and mild neurological symptoms. So, given all of that background what are the issues pertinent when thinking about Covid-19 in sports rehabilitation terms? An article from Hull et al 2020 examines some of the issues in Covid-19 in sports in general and in individual cases. Research is needed, and it is unclear whether Covid-19 represents a small, mid or large issue in sports and athletes?
I would frame the question of the size of the Covid19 pandemic like this:
Is Covid-19 the equivalent of a calf sprain, an ACL rupture, or a brain injury / stroke in terms of rehabilitation for athletes? Covid-19 the calf strain? Short term considerations? In many ways Covid-19 is not a big deal for athletes, as many athletes are younger, have good cardiovascular fitness and robust immune systems. This means that If they get sick then they can get better quickly and are unlikely to have many long-lasting symptoms. Key short-term guidelines in athletes includes: •
Actively educating and screening teams and patients for Covid-19 symptoms and sending them for testing when necessary. I have personally had one patient already where testing was clearly indicated but had not been completed (he is being tested today).
•
Delaying the return to training after any upper respiratory tract infection. Typically playing / training after URTI symptoms decrease is ok in normal circumstances. However, in Covid-19, symptoms may decrease at day 5 only to increase again at day 10 with a significant worsening of lower respiratory tract symptoms. An athlete that returns to training too early will be at risk of causing lower airway damage and may lengthen the course of this illness.
•
Avoid anti -inflammatory medications as these present a risk of worsening the disease and increase symptoms of Covid -19.
•
When training be aware of droplets from the respiratory tract in the slip streams and stay 5m -10m apart for running and 20m for cycling. (1.5m in a side by side formation is fine).
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SPECIAL REPORT Covid-19 the ACL rupture? Mid-term considerations
Covid 19 the brain injury / stroke? Long term / severe considerations
Covid-19 and an ACL rupture might be comparable from an interruption to training or timeframe perspective. Many athletes have had their respective seasons cut short, or goals completely removed (Olympics) as international competitions and teambased environments have been shut down. How long will these changes to sports organizations and formats last? Time will tell but the modelling of this pandemic is difficult to predict. Best case scenarios have sporting competition affected for a single season. This will impact on the mental health of athletes who will be unable to compete and may develop anxiety or depression. Para-athletes, age-group athletes with comorbidities, and athletes with respiratory conditions are particularly at risk of Covid-19 and will need guidance on returning to training and management of post viral fatigue states.
For some patients, age group or older athletes and para-athletes there is a real possibility of severe disability or death if they are infected with Covid-19SARS. Significant published risk factors for severe Covid-19 SARS include: hypertension, cardiovascular disease, COPD, diabetes, obesity and other lung diseases. Given that 20% of endurance athletes have some form of airway disease there is a real risk in this group, and a much higher risk in age group athletes.
Key mid-term guideline in athletes includes: •
Be ready to help with athlete’s home rehab and home training via telehealth.
•
If an athlete is returning to exercise after a mild form of Covid -19 monitor closely for signs of reduced exercise capacity and post viral fatigue.
•
Slow progression of training loads post covid19
•
Reduce load to 60-80% to avoid reduced immune function, and to allow for longer-term and off-season fitness conditioning to continue.
•
Be flexible with goals - psychological preparation for changes to schedules and changes in playing / tournament structures is needed. Referral to sports psychologist may be indicated. Be alert for signs of anxiety and depression in athletes.
•
The set up of a good home gym / home rehab facility should be prioritized, so athletes have the ability to be self-sufficient with training.
If an athlete or other patient gets the severe version of Covid-19 SARS – and survives - there are several negative outcomes. There have been reports of reduction in lung capacity and gas diffusion by 20-30% in moderate / severe cases of Covid-19 SARS. This reduced lung function translates into reduced VO2 max and exercise capacity and may be longstanding. Other symptoms include post viral chronic fatigue symptoms and neurological injuries. What can we do for this group? Key guidelines for severe Covid-19 SARS includes: •
Education that post viral fatigue states are common and disability may be significant if the athlete has a comorbidity – so avoidance and increased self-isolation measures are needed in at risk groups.
•
The need for multidisciplinary rehabilitation in severe Covid-19 SARS including respiratory physiotherapy, inspiratory muscle training, neurological rehabilitation, dietician, and psychological support.
Summary There is much uncertainty as to how Covid-19 will affect athletes, and further research is needed. Athletes will need guidance through these changing times, and rehabilitation will be needed for many patients and athletes who have post Covid-19 symptoms and disability.
.
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SPECIAL REPORT References Notes on references: Due to the immediacy of the covid-19 pandemic standard rules of referencing have been ignored by many authors therefore quality published data is lacking at present. Symptoms of Covid-19 https://www.who.int/news-room/q-a-detail/q-acoronaviruses#:~:text=symptoms NSAIDs https://www.bmj.com/content/368/bmj.m1185 Asymptomatic cases https://www.nejm.org/doi/full/10.1056/ NEJMc2009316 https://www.bmj.com/content/368/bmj.m1165 Models of covid-19 https://science.sciencemag.org/content/ early/2020/04/14/science.abb5793.full Anxiety and depression, symptoms in first 2 weeks, immunosuppression Hull et al 2020 https://www.thelancet.com/journals/lanres/article/ PIIS2213-2600(20)30175-2/fulltext Lung capacity changes in severe SARS https://www.dw.com/en/covid-19-recovered-patients -have-partially-reduced-lung-function/a-52859671
PNZ COVID-19 ARTICLES Telehealth Guidelines: COVID-19 Response COVID-19 Business Information and FAQs COVID-19 Member Emails Novel Coronavirus (COVID-19)
Neurological manifestations in Covid-19 https://jamanetwork.com/journals/jamaneurology/ fullarticle/2764549?utm_campaign=COVID19&utm_content=126355592&utm_medium=social& utm_source=facebook&hss_channel=fbp76297933103 Droplets in running https://medium.com/@jurgenthoelen/belgian-dutchstudy-why-in-times-of-covid-19-you-can-not-walkrun-bike-close-to-each-other-a5df19c77d08
Scott Is the co-director of Breathing Works, and the BradCliff Breathing Method which runs education courses for Physiotherapists in New Zealand, Australia and Canada. He is currently completing his research focused on the measurement of the thickness of the diaphragm in people with disordered breathing. Scott has more than 15 years’ experience working in musculoskeletal and hospital settings. Scott loves to run, surf, snowboard, mountain bike and generally get outside whenever he can, as well as enjoying time with his two young children.
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RADIOLOGY
Imaging In Acute Distal Biceps Tendon Injuries. Auckland Radiology Group Below we have a new article piece which will be ongoing in 2020 - Thanks to Auckland Radiology Group for the content! Distal biceps tears usually occur in middle aged men, heavy manual workers or in weight-lifters as a result of a lifting injury or eccentric loading. Treatment can be surgical or non-surgical, however untreated rupture leads to a loss of flexion and particularly supination power.
CLINICAL •
Complete biceps tears are more common than partial. Injury most often occurs distally at the radial tuberosity attachment (tendon detaching from bone)
•
Clinical diagnosis can be simple in complete ruptures with retraction of the muscle belly (Popeye Sign). Imaging is often not required
•
Partial tears may involve only the long or short head components
•
History is important: typically, eccentrically loading the flexed elbow and suddenly feeling something snap with subsequent anterior elbow pain
•
Mid tendon or musculotendinous junction tears (tendon detaching from muscle) are less common. Musculotendinous junction tears are often not surgically managed, as surgery is less successful at this site. Diagnosis of musculotendinous junction tears can prevent unnecessary surgical exploration
•
Rupture can cause an immediate 30% loss in flexion strength and 50% loss in supination strength, which only partially recovers unless managed surgically
Non-operative Management:
In elderly and those not fit for surgery
In those who accept the cosmetic appearance and loss of strength
Surgical Management:
Indicated in those who cannot tolerate loss of supination strength or an altered cosmetic appearance
Outcomes are optimal with surgery performed within 1-3 weeks of injury
Delayed diagnosis beyond 6-8 weeks leads to muscle and tendon atrophy with an increased need for tendon graft or augmentation
Fig. 1 Ultrasound showing a normal distal biceps tendon inserting at the radial tuberosity. •
Variations of injury exist and imaging can help with the diagnosis of incomplete tears or where there is rupture with an intact bicipital aponeurosis, and in these cases the biceps muscle belly may not retract
•
Even with complete tears the elbow can still flex / extend / supinate
•
An ultrasound or MRI may help if the history and examination are atypical, if the patient is not clinically progressing, or as an aid for surgical planning CONTINUED ON NEXT PAGE >>
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RADIOLOGY IMAGING X-Rays •
Usually normal, but will exclude fractures and other radial abnormalities
•
Chronic tendinopathy can cause irregularity and sclerosis at the radial tuberosity
Ultrasound •
Can confirm the tendon rupture and locate the tendon remnant
•
Fluid or haematoma may be seen in a measurable tendon gap
•
On ultrasound the very distal attachment to the tuberosity may be difficult to visualise due to the oblique tendon path. Determining the grade of distal partial tears can be more difficult in muscular patients
•
Ultrasound is operator dependent and most useful when performed by experienced sonographers and radiologists
Fig. 4 Ultrasound showing biceps tendon retraction causing bunching and thickening of the torn tendon stump. MRI •
Confirms biceps tendon rupture and locates the tendon stump, similar to ultrasound imaging
•
MRI provides greater sensitivity than ultrasound for partial and complex tears which may assist surgical planning
•
Multiplanar imaging of bone, cartilage and soft tissues in exquisite detail provides concurrent assessment of other alternative pathology, such as tendinosis, tenosynovitis, brachialis injury as well as ligamentous and osteochondral damage elsewhere in the elbow
Fig. 2 Ultrasound showing normal biceps tendon (white arrows). Fig. 3 Ultrasound: The distal biceps tendon is ruptured. There is fluid and haematoma at the tendon defect (red arrow), and the tendon is retracted proximally (white arrow). CONTINUED ON NEXT PAGE >>
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RADIOLOGY
Fig. 7 Axial MRI showing rupture of the distal biceps. The tendon is absent from the radial tuberosity (red arrow). The bicipital aponeurosis has also torn causing subcutaneous and deep fascia oedema over the medial forearm (blue arrows). OTHER DISTAL BICEPS PATHOLOGIES Imaging may identify other distal biceps pathology including: INSERTIONAL TENDINOSIS (from an acute event or chronic trauma): Fig. 5 Sagittal MR showing rupture of the biceps tendon with the tendon retracted proximally and bunched above the elbow joint line (white arrow). There is fluid in the tendon defect with surrounding oedema (red asterix).
•
the tendon is thickened and or hypoechoic with loss of the normal fibrillary pattern on ultrasound, or shows abnormal signal without tearing on MRI
BICIPITORADIAL BURSITIS: •
the normal bursa surrounds the tendon in supination, and passes between the tendon and radial tuberosity in pronation, allowing tendon glide
•
bursitis can accompany biceps tendinosis and tears or be a stand-alone diagnosis. It typically causes swelling and anterior elbow pain
Fig. 6 Axial MRI showing a normal low signal biceps tendon inserting at the radial tuberosity.
CONTINUED ON NEXT PAGE >>
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RADIOLOGY
BICEPS INSERTION CALCIFIC TENDINOSIS: •
uncommonly seen at the biceps insertion
Fig. 8 Long section ultrasound image showing distal biceps tendinosis and bicipitoradial bursitis. The tendon is abnormally thickened and hypoechoic (red arrows) and there is fluid around the insertion in the bicipitoradial bursa (green arrow).
Fig. 10 X-ray showing deposit of amorphous calcium near radial tuberosity in patient with anterior elbow pain.
Fig. 9 Axial MRI showing thickened biceps tendon with fluid in the surrounding bicipitoradial bursa (red arrow).
Fig. 11 Longitudinal ultrasound image showing calcific tendinosis with deposit of calcium next to biceps insertion.
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RADIOLOGY NERVE IMPINGEMENT SYNDROMES:
SUMMARY AND KEY POINTS
•
•
Many distal biceps tears will not be surgically managed, however early diagnosis is recommended for surgical candidates. Optimal time for surgery is within 1-3 weeks of injury.
•
Imaging is not required in many cases but may assist where:
history and examination are atypical
in diagnosing partial tears or biceps rupture without muscle belly retraction
in identifying alternative causes for symptoms such as tendinosis, bicipitoradial bursitis, or nerve impingement
Radial nerve impingement / cubital tunnel syndrome can be associated with anterior elbow pain
X-rays are helpful for excluding elbow arthropathy or radial head pathology as an alternative cause for pain. Fig. 12 Longitudinal and axial ultrasound images showing a ganglion at the anterior elbow. The radial nerve is displaced (red arrows).
Ultrasound is a good modality for the primary investigation but is operator dependent. MR provides excellent tendon detail for more complex injuries and surgical planning as well as when concurrent bone and cartilage assessment is also required. Author: DR BARNABY CLARK (MUSCULOSKELETAL RADIOLOGIST) AUCKLAND RADIOLOGY GROUP
Fig. 13 Longitudinal ultrasound images of anterior left and right elbow showing normal thickness posterior interosseous nerve (PIN) on left (white arrow), but a thickened right PIN (red arrow) at the margin of the Arcade or Frohse (not shown).
PAGE 19
ADDITIONAL ARTICLE
Exercise in Pregnancy and Post Natal Care Plus One Wellbeing Team Introduction
Larissa Botherway, Juliet Bartholomew, and Kelly Owens are the PlusOne Wellbeing team based in Auckland’s North Shore. Each of them are mums who understand the unique demands that pregnancy and motherhood place on the body. They are all AUT graduates who work closely with other health professionals to ensure the best outcomes for pregnancy and beyond for their patients.
Why is ante important?
and
post
natal
exercise
so
As Physiotherapists we know that exercise is medicine. It is encouraging to see recent Canadian guidelines published in 2019 (ref) noted that there was a positive relationship between physical activity and health benefits in pregnancy. It is interesting to note that no upper limit of exercise was established. So more is not more! One of the recommendations was to continue using the “talk test” where Women should be able to maintain a conversation while doing cardiovascular exercise. We recommend that Women exercise throughout their pregnancy and make modifications as needed. We often see Women who have completely changed their exercise regime when discovering they are pregnant and subsequently sustaining injury. There is no one size fits all and screening for risk factors and pelvic floor problems is imperative. This is also true Postpartum, there is a vast array of options out there for Women and unfortunately we see many Women returning to high intensity exercise too quickly. We hope by providing good education and working with trainers and other Physiotherapists that we can assist these Women to return to their desired activities.
What are the common issues you see in mothers post natally? We see a variety of issues post natally. Most commonly we see Women with concerns about diastasis recti (abdominal separation), pelvic floor issues such as incontinence or sexual dysfunction and pelvic girdle pain. We also see Women who just don’t know where to start, so we are there to provide
assessment and to give them appropriate management which enables them return to exercise. What specific things do you do in your clinic? As well as treating ante and post natal musculoskeletal conditions we have developed a Post Natal Check. This is a comprehensive assessment where we do a musculoskeletal screen including assessment of diastasis recti, a vaginal exam, assessment of scars and a functional real time ultrasound to look at TVA and Pelvic floor. We find patients find the Ultrasound helpful in terms of biofeedback. There is no set standard of checks for Post-natal women in New Zealand and we often see Mums who have never had anyone focus on their recovery as the attention turns to the baby. Considering 1 in 3 Women who have had a baby experience incontinence, working with these Women in the immediate Post Natal period is helpful. We also have a 6 week Post Natal Rehab class. Due to the current situation with Covid-19 we have developed a digital version of this programme. We are also in the process of developing an assessment for those wishing to return to CrossFit/ F45 or higher intensity exercise. We are working with Kirsten Harris of Evexia Performance to cater for these Women. In France, the government subsidise every post natal Women to have access to Physiotherapy. While that may be a way off in New Zealand we do have a great network of Women’s Health Physiotherapists throughout New Zealand passionate about assisting Women throughout this special time. It is important to remember that Pelvic Floor symptoms and pain although common in pregnancy and post natally, should not be considered normal and Women shouldn’t have to struggle through.
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CLINICAL REVIEW
2019 Canadian Guidelines for Physical Activity Throughout Pregnancy.
Michelle F Mottola, Margie H Davenport, Stephanie-May Ruchat, Gregory A Davies, Veronica J Poitras, Casey E Gray, Alejandra Jaramillo Garcia, Nick Barrowman, Kristi B Adamo, Mary Duggan, Ruben Barakat, Phil Chilibeck, Karen Fleming, Milena Forte, Jillian Korolnek, Taniya Nagpal, Linda G Slater, Deanna Stirling, Lori Zehr.
Br J Sports Med 2018; 52: 1339-1346. doi: 10.1136/bjsports-2018-100056
By Amanda O’Reilly Fewer than fifteen percent of women will achieve the minimum recommendation of physical activity during their pregnancy despite the significant affect it has on her health as well as that of her fetus.
throughout pregnancy.
There continues to be uncertainty among some pregnant women and obstetric care providers as to whether prenatal physical exercise may increase the risk of pregnancy complications. The Guidelines Consensus Panel selected thirty-seven (20 rated critical, 17 rated important) outcomes related to maternal, fetal and neonatal health.
1: All women without contraindication should be physically active throughout pregnancy.
In the absence of contraindications (see Table. 1), following the guidelines is associated with a) fewer newborn complications (i.e., large for gestational age), and b) maternal health benefits (i.e., decreased risk of pre-eclampsia, gestational hypertension, gestational diabetes). CONTRAINDICATIONS TO PHYSICAL THROUGHOUT PREGNANCY ABSOLUTE RELATIVE
ACTIVITY
Ruptured membranes
Recurrent pregnancy loss
Premature labour
Gestational hypertension
Unexplained persistent vaginal bleeding Placenta praevia after 28 weeks’ gestation Pre-eclampsia
A history of spontaneous preterm birth Mild/moderate cardiovascular or respiratory disease Symptomatic anaemia
Incompetent cervix
Malnutrition
Intrauterine growth restriction High-order multiple pregnancy (e.g. triplets) Uncontrolled type I diabetes Uncontrolled hypertension
Eating disorder Twin pregnancy after the 28th week Other significant medical conditions
1
Contraindications
A)
Women who were previously inactive. Strong recommendation, moderate-quality evidence.
One hundred and four exercise-only randomized controlled trials (RCTs) were identified. From these studies prenatal physical activity was associated with a reduction in the odds of gestational diabetes mellitus (38%), pre-eclampsia (41%), gestational hypertension (39%), prenatal depression (67%) and macrosomia (39%) without increasing the odds of adverse outcomes such as preterm birth, low birth weight, miscarriage and perinatal mortality. Physical activity during the first trimester did not increase the odds of miscarriage or congenital anomalies however not engaging in physical activity from the first trimester increased the odds of pregnancy complications. Therefore, physical activity should be encouraged throughout pregnancy. B)
Women categorized as overweight or obese (pre-pregnancy body mass index ≥25kg/m2. Strong recommendation, low-quality evidence.
Despite low-quality evidence, there was evidence from RCTs of improvement in gestational weight gain and blood glucose in women categorized as overweight or obese. C)
Women diagnosed with gestational diabetes mellitus. Weak recommendation, low-quality evidence. This is a weak recommendation as the benefit between women who were physically active and those who did not was small.
Uncontrolled thyroid disease Other serious cardiovascular, respiratory or systematic disorder
Table.
Six specific recommendations are provided with corresponding quality and strength of recommendations.
to
physical
activity CONTINUED ON NEXT PAGE >>
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CLINICAL REVIEW
2: Pregnant women should accumulate at least 150 minutes of moderate-intensity physical activity each week to achieve clinically meaningful health benefits and reductions in pregnancy complications.
6:
Strong recommendation, moderate-quality evidence.
Weak recommendation, very-low quality evidence.
The evidence presented demonstrated an association with clinically meaningful reductions in the odds of developing gestational diabetes mellitus, pre-eclampsia and gestational hypertension.
This recommendation is based primarily on expert opinion as there was limited information from RCTs regarding the balance of benefits and harms from physical activities performed in the supine position.
3: Physical activity should be accumulated over a minimum of three days per week; however, being active every day is encouraged. Strong recommendation, moderate-quality evidence. Accumulating more physical activity (frequency, duration or volume) over the week was associated with greater benefits. Physical activity below the recommendations also incurred some benefits. There is a dose-response relationship between physical activity and decreasing odds of pre-eclampsia, gestational diabetes, gestational hypertension and a reduction in depressive symptoms and circulating maternal blood glucose.
Pregnant women who experience lightheadedness, nausea or feeling unwell when they exercise flat on their back should modify their exercise position to avoid the supine this position.
Along with the above guidelines there are safety precautions (Table. 2) and reasons to stop physical activity and consult a healthcare provider (Table. 3) provided by the Guidelines Consensus Panel. SAFETY PRECAUTIONS FOR PRENATAL PHYSICAL ACTIVITY Avoid physical activity in excessive heat, especially with high humidity. Avoid activities which involve physical contact or danger of falling. Avoid scuba diving.
4: Pregnant women should incorporate a variety of aerobic and resistance training activities to achieve greater benefits. Adding yoga and / or gentle stretching may also be beneficial.
Avoid physical activity at high altitude (>2500m) if this is not where you usually exercise / live. Seek supervision from an obstetric care provider if you plan to exercise competitively or significantly above the recommended guidelines. Maintain adequate nutrition and hydration.
Strong evidence, high-quality evidence.
Know the reasons to stop physical exercise and consult a qualified healthcare provider immediately.
Evidence reviewed demonstrated that combining aerobic and resistance exercise during training was more effective at improving health outcomes than aerobic exercise alone. 5: Pelvic floor muscle training (PFMT) may be performed daily to reduce the risk of urinary incontinence. Instruction on the proper technique is recommended to obtain optimal benefits. Weak recommendation, low-quality evidence. The Guidelines Consensus Panel deemed this weak recommendation as pre-natal PFMT is associated with a 50% reduction in prenatal and 35% reduction in postnatal urinary incontinence.
Table. 2 REASONS TO STOP PHYSICAL ACTIVITY AND CONSULT A HEALTHCARE PROVIDER Persistent excessive shortness of breath that does not resolve on rest. Severe chest pain. Regular and painful uterine contractions. Vaginal bleeding. Persistent loss of fluid from the vagina indicating rupture of the membranes. Persistent dizziness or faintness that does not resolve on rest.
Table. 3
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CLINICAL REVIEW
LIMITATIONS IN THE RESEARCH Despite women over the age of thirty-five years of age being considered high risk of prenatal complications there is very limited research targeting the benefits or risks of physical activity in this subgroup. Research does not identify the safety or added benefit of exercising at levels significantly above the recommendations. RCTs prescribed to 7.0 metabolic equivalents as the upper limit. The safety and efficacy of chronic high-intensity physical activity for the mother, the fetus and the neonate are not known. Future research efforts should focus on pregnant women over the age of thirty-five and develop a better understanding of what the upper limit of physical exercise is for pregnant women. Based off this guideline, all pregnant women should be encouraged to participate in physical exercise throughout their pregnancy unless they fall into the contraindication’s category. A full set of references is available on request.
PAGE 23
UPCOMING SEPNZ COURSES
Please note these are the proposed courses for 2020. With the current COVID-19 situation this could also change. Once we are confirmed to go ahead registrations will be open via PNZ. Lower Limb in Sport
Venue and dates TBC This course is for registered physiotherapists who work with individual athletes or teams in which lower limb injury is common. The focus of the course is on pathomechanics and kinetic chain deficits as they relate to injury prevention and performance, diagnosis and advanced rehabilitation of lower limb conditions. By the end of the course you will understand the pathoaetiology of common lower limb injuries, be able to perform key clinical and functional tests, rehabilitate lower limb injury in a number of sporting contexts including football, running and contact sports, and develop individualised return-to-sport programmes.
Promotion and Prescription of Physical Activity and Exercise 22nd & 23rd of August at AUT North This course is suitable for physiotherapists wanting to improve their knowledge and skills in assessment and prescription of physical activity and exercise to use with patients on a daily basis. This course provides a bridge to Level 2 SPNZ courses and important background information for those considering university postgraduate study. The course will provide a combination of lectures, practical demonstrations, practical assessments and case studies and will cover the following topics: Principles of exercise prescription, Promotion and assessment of physical activity, Assessment of neuromuscular performance, Aerobic and functional capacity testing ,Strategies to enhance exercise adherence, Screening for return to sport, Exercise risk screening and goal setting, Physiological effects of disuse and ageing Injury Prevention & Performance Enhancement. 21st and 22nd of November at AUT Millennium This course will provide you with the key skills used in the enhancement of sporting performance and prevention of injury. It covers the analysis of physical, biomechanical and technical needs of sport, identifying key factors affecting performance and injury prevention. You will learn how to assess athletes and implement an individualised programme designed to optimise movement efficiency, performance and minimise injury risk. You will learn how to develop a sport–�specific screening assessment, how to monitor injury rates and target injury prevention strategies within different sporting contexts.
PAGE 24
RESEARCH PUBLICATIONS
British Journal of Sports Medicine April 2020; Vol. 54, Issue 7 ORIGINAL RESEARCH
Sports concussions: can head impact sensors help biomedical engineers to design better headgear? (6 December, 2019)
Does soccer headgear reduce the incidence of sportrelated concussion? A cluster, randomised controlled trial of adolescent athletes (14 May, 2019)
Lyndia Wu
Timothy McGuine, Eric Post, Adam Yakuro Pfaller, Scott Hetzel, Allison Schwarz, M Alison Brooks, Stephanie A Kliethermes
International Olympic Committee consensus statement: methods for recording and reporting of epidemiological data on injury and illness in sport 2020 (including STROBE Extension for Sport Injury and Illness Surveillance (STROBE-SIIS)) (18 February, 2020)
Does disallowing body checking in non-elite 13- to 14-year -old ice hockey leagues reduce rates of injury and concussion? A cohort study in two Canadian provinces(6 September, 2019) FREE
Carolyn Emery, Luz Palacios-Derflingher, Amanda Marie Black, Paul Eliason, Maciek Krolikowski, Nicole Spe ncer, Stacy Kozak, Kathryn J Schneider, Shelina Babul, Martin Mrazik, Constance M Lebrun, Claude Goulet, Alison Macpherson, Brent E Hagel Time before return to play for the most common injuries in professional football: a 16-year follow-up of the UEFA Elite Club Injury Study (10 June, 2019) Jan Ekstrand, Werner Krutsch, Armin Spreco, Wart van Zoest, Craig Roberts, Tim Meyer, Håkan Bengtsson
Few training sessions between return to play and first match appearance are associated with an increased propensity for injury: a prospective cohort study of male professional football players during 16 consecutive seasons (29 August, 2019)
CONSENSUS STATEMENT
Roald Bahr, Ben Clarsen, Wayne Derman, Jiri Dvorak, Car olyn A Emery, Caroline F Finch, Martin Hägglund, Astrid Junge, Simon Kemp, Kari m M Khan, Stephen W Marshall, Willem Meeuwisse, Margo Mountjoy, John W Orchard, Babette Pluim, Kenneth L Quarrie, Bruce Reider, Martin Schwellnus, Torbjørn Soligard, Keith A Stokes, Toomas Timpka, Evert Verhagen, Abhinav Bindr a, Richard Budgett, Lars Engebretsen, Uğur Erdener, Kari m Chamari Improved reporting of overuse injuries and health problems in sport: an update of the Oslo Sport Trauma Research Center questionnaires (14 February, 2020) FREE Benjamin Clarsen, Roald Bahr, Grethe Myklebust, Stig Haugsboe Andersson, Sean Iain Docking, Michael Drew, Caroline F Finch, Lauren Victoria Fortington, Joar Harøy, Karim M Khan, Bill Moreau, Isabel S Moore, Merete Møller, Dustin Nabhan, Rasmus Oestergaard Nielsen, Kati Pasanen, Martin Schwellnus, To rbjørn Soligard, Evert Verhagen
Håkan Bengtsson, Jan Ekstrand, Markus Waldén, Martin H ägglund EDITORIALS #Time2Act: Harassment and abuse in elite youth sport culture (18 March, 2020) Margo Mountjoy #REDS (Relative Energy Deficiency in Sport): time for a revolution in sports culture and systems to improve athlete health and performance (10 January, 2020) Kathryn E Ackerman, Trent Stellingwerff, Kirsty J ElliottSale, Amy Baltzell, Mary Cain, Kara Goucher, Lauren Fles hman, Margo L Mountjoy
http://bjsm.bmj.com/content/54/7 All articles are accessible via our website https://sportsphysiotherapy.org.nz/members/bjsm/
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SAM’S GAME — COVID SPECIAL
PAGE 26
SAM’S GAME — COVID SPECIAL
