August 2013 bulletin by Sports & Exercise Physiotherapy NZ

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ISSUE 4 l AUGUST 2013

BULLETIN FEATURE TOPIC: Hips: the Cutting Edge - From Physiotherapy to the Operating Theatre and Beyond www.spnz.org.nz SPNZ EXECUTIVE COMMITTEE President

Dr Angela Cadogan

Secretary

Michael Borich

Treasurer

Michael Borich

Website & IT

Hamish Ashton

Committee

Dr Tony Schneiders Bharat Sukha David Rice Chelsea Lane Kara Thomas

EDUCATION SUB-COMMITTEE Acting Chair:

Dr Angela Cadogan

Chelsea Lane

Dr Grant Mawston

David Rice

Welcome to the August 2013 Edition In this Edition: EDITORIAL: by Dr Angela Cadogan

SPNZ SYMPOSIUM 2014

LATEST NEWS

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Sports Physiotherapy Australia Ratify Closer Working Relationship With Sports Physiotherapy New Zealand SPNZ members can now access APA/SPA courses at membership rates SPNZ have been in negotiations with Sports Physiotherapy Australia (SPA) and their parent body the Australian Physiotherapy Association (APA ) over the last 6 months and can now announce that we have successfully engaged in a symbiotic relationship with Sports Physiotherapy Australia on a wide range of issues including continuing professional development which allows each group reciprocal access to the others educational courses, APA/SPA webinars/podcasts and conferences at local domestic rates. This means that you as a member of SPNZ will be treated as a SPA/APA member when you register for, and attend these courses. SPNZ members can now search for events via the APA website. https://www.physiotherapy.asn.au/APAWCM/LearningDevelopment/event_search.aspx To register, SPNZ members should download a registration form and forward it to the relevant branch office. Add your PNZ number and state you are a SPNZ member on the form. https://www.physiotherapy.asn.au/APAWCM/Learning%20and%20Development/LD9_EventRegistrationForm_Writable.pdf

Membership Survey Thanks to all our Members who filled in the Membership Survey. We had just over a third of our members respond which is fantastic. The exec at their next meeting will go over the results and try to implement the suggestions so we can deliver you an even better service. Remember at anytime you have thoughts regarding ideas for the future or ways to improve what we do feel free to contact the exec. The winner of the draw is Rebecca Dodson. Michael Borich our secretary will be in touch shortly with regards to getting you your prize. Thanks again for your support

SPNZ Website Upgrade and Public Resources Find a Physio now live The 'find a sports physiotherapist' is now live on our website. It is split into regions for easy searching and lists can be altered to be searched by first name, last name, town and key sport. This feature has been designed to allow you as Members of SPNZ to promote yourself to your colleagues and the public. For those who have not viewed it click here to access it. As we develop more public information we will start promoting the website to the public, funders and other interested parties. If you haven't sent me your details they can be added by filling out the form here As mentioned this is for you to promote your interests and expertise and not that of your clinic so please fill the form out as clearly as possible.

SPNZ Member Benefits Remember to take advantage of the full range of SPNZ member benefits: 

FREE online access to JOSPT (value approx USD$275)

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FREE Editions of the Quarterly APA “Sports Physio” Magazine

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25% Discount on all McGraw-Hill book publications

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Discount on ASICS shoes and clothing

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Funding Support for continuing education and research (Asics Education Fund).

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Substantial discount, Advanced Notice and preferential placing on SPNZ Educational Courses

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Access to website with clinical and relevant articles

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Sports Physiotherapy Forum to discuss ideas and ask questions

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Bi-monthly SPNZ Bulletin featuring Activity, Course and information updates

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FREE classified advertising in the SPNZ Bulletin

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SPNZ COURSES SPNZ Level 1 Courses 2013 Advance Notice of Upcoming Courses:

SIDELINE MANAGEMENT (2 day course) Location: Burwood Hospital Physiotherapy Department Burwood Hospital Christchurch

Dates: Saturday 2nd November and Sunday 3rd November 2013

A course for sports physiotherapists of all levels of experience working on the sideline at sports games or events. This course will give you the basic tools you need to manage teams and individual athletes from pre-event preparation, to post-event recovery.

Presenters: Fiona de Jongh (Registered Nurse) Chelsea Lane (Titled Sports Physiotherapist) Dr Tony Schneiders (Physiotherapist—Sports-related Concussion) Hand Therapist (TBC) Dr Mark Coates (Radiologist) Dr Angela Cadogan (Sports Physiotherapist)

The Course Will Cover:    

Sports First Aid and Wound Care Pre-event warm-up Strapping Acute injury assessment and management (including fingers/hands and basic splinting)

    

Return-to-play decision making Acute injury management and referral Concussion assessment, management and return-to-play criteria Medications and Standing Orders Ethics and Professional Issues in Sports Physiotherapy

Please Note: Places will be limited to 24 participants. Further details will be sent to SPNZ members in the upcoming weeks including course cost and registration details. SPNZ members will receive advanced notification when Registrations open for this course.

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IFSPT REPORT

International Federation of Sports Physical Therapy (IFSPT) Report IFSPT website Member Countries of IFSPT Australia, Austria, Bulgaria, Cyprus, Denmark, Finland, Germany, Greece, Hong Kong, Ireland, Italy, Japan, Luxembourg, Netherlands, New Zealand, Nigeria, Norway, Portugal, South Africa, Spain, Sweden, Switzerland, Turkey, United Kingdom, United States of America Early next month the IFSPT executive and delegates from up to 23 countries throughout the world will meet in Cape Town, South Africa for the 2013 IFSPT General Meeting. This is the first time that the General Meeting is being held in the Southern Hemisphere and it is being supported by the South Africa Sports Physiotherapy Group who are allowing IFSPT to hold a symposium preceding their Biannual Sport Physiotherapy Congress in Centurion, Gauteng. The General Meeting will then be held at the Cape Royale Hotel in Cape Town along with another symposium hosted by IFSPT. The IFSPT symposia feature presentations from the IFSPT executive and other leaders in their field of Physiotherapy from Switzerland, USA, United Kingdom, Denmark, Turkey, Australia, and New Zealand. Topics covered will include current concepts in knee, shoulder, and elbow rehabilitation, taping interventions (incl. kinesiotaping) to prevent and rehabilitate sports injuries, the FIFA 11+ football prevention program and side-line concussion assessment and management. Obviously the logistics of getting the symposia organised in two venues with different speakers in a distant country is quite a challenge and luckily we have the help of Craig Smith from the IFSPT executive who‘s past experience includes being the lead physiotherapist for the South African cricket team for 11 years . Besides Craig’s managerial and organisational skills, he has many stories to tell about his involvement at international level cricket including the time they ran out of players due to injury and he was put on the field in a test match against Australia. He had the ignominy of the Australian Captain Steve Waugh come up to him and ask “what the hell he was doing on the field”! While the upcoming General Meeting and Symposia have taken up much time there is still work happening around the edges. Recently Peter McNair as chair of the IFSPT Research subcommittee sent out a worldwide survey to member countries in order to determine the state of affairs in each country as it related to research activities, requirements, and funding opportunities now and in the future. Understanding this will go some way in helping IFSPT determine the support and leadership it can offer to member countries in this area. Look out for the next e-news from the IFSPT for further details on activities and happenings within the organisation. As SPNZ representative to IFSPT and a member of the executive board, I would love to receive your feedback regarding the work IFSPT are doing so please don’t hesitate to contact me at any time to discuss.

Ka kite ano

The current IFSPT Executive Committee:

Tony Schneiders

Craig Smith, South Africa; Bente Andersen, Denmark; Tony Schneiders, New Zealand; Maria Constantinou, Australia; Gordon Eiland, USA; Nicki Phillips, UK; Mario Bizzini, Switzerland

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FEATURE GETTING “ HIP” : RECENT ADVANCES IN HIP SURGERY – A PHYSIOTHERAPY PERSPECTIVE PHYSIOTHERAPIST - MADELINE HERNON

Madeline Hernon graduated from Otago in 1986 and achieved her PGDipManipPhyty (Otago) in 1992. She has worked as a Joint Arthroplasty Product Specialist for the past year after 25 years experience working in sports physiotherapy. Madeline has been fortunate to have previously travelled as a physiotherapist with the NZ Team to the 2000 and 2004 Olympics, Commonwealth Games 1998, and as lead physiotherapist to Youth Olympic Festival 2007, and World University Games 2007. She has toured internationally and extensively through Europe, Asia and Australasia with NZ Basketball, NZ Athletics, and NZ Netball and has lectured internationally on behalf of the International Olympic Committee. She has also been physiotherapist to Alinghi and Prada America’s Cup Teams.

How did you become involved in your current role? Physio is a great stepping stone to a myriad of careers. Recently I have changed career paths from owning a chain of Physio clinics to working for a medical company. This company recently acquired another company for $23 billion, making it the largest medical company in the world Working within a corporate is very different and I love it. My role is basically selling and supporting our Hip, Knee and Shoulder Arthroplasty range to surgeons. What are your roles in this job?  Sales and support to surgeons of our portfolio, includes the specific instrumentation that the surgeon will use.  Ensuring that the surgeon has provision of all the instrumentation required for surgery - this may include up to 100 instruments.  Also that the specific implants that they wish to utilise are provided. For a knee replacement typically four implants for the one operation are required – femoral and tibial components, the polyethylene insert between and the patella. At least 72 components will be required to be present at the operation, from a choice of at least 300 implants. I am also present in theatre to respond to any queries regarding the surgical technique instrumentation or implants on the spot.  Education is a huge priority in this field, both in my being highly trained and in providing surgeons with educational opportunities. So travelling to support surgeons and also to be trained internationally is also part of the role.  Arthroplasty is an area requiring extensive research and development. Our new knee, just launched is reputed to have cost over one billion dollars in development costs. Research to support your products with excellent clinical heritage is paramount.

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FEATURE

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Getting “ Hip ” : Recent Advances in Hip Surgery – a Physiotherapy Perspective continued….. CONTINUED FROM PREVIOUS PAGE. Can you tell us about any recent surgical or conservative innovations that our clients may be offered prior to hip joint replacement surgery? What is the current stance on the success of resurfacing? Current thought is that labral tear repairs of the hip are thought to assist in future-proofing the hip joint, saving many hip joints from requiring replacement as the joint surfaces will continue to be protected. Surgical repair of the Labrum increases in numbers. While labral repairs increase in numbers, there has been complete abandonment of hip resurfacing or indeed of the use of very large heads over the size of 40, or indeed the use of metal heads with a metal liner. Resurfacing was utilising large heads and large acetabular cups and liners, without a stem on the head. The benefit being greater joint mobility, decreased invasiveness and lower dislocation rates. However, the use of metal heads and metal liners has resulted in increased wear and significant numbers of patients with metallosis and consequentially requirement of removal of these joints. Patients typically, presenting with pain, high chromium levels and increased inflammatory markers. The use of metal heads and metal liners as a combination (metal on metal) has now stopped.

Bilateral hip replacements

A stem white head liner and cup Here is a hip joint as used for resurfacing Note no stem – these have been discontinued What are the current criteria for proceeding to hip joint replacement surgery? What is current advice for young (i.e. 50) clients needing surgery? Pain, with changes on X-ray is the major determinant in hip surgery, with younger and younger patients presenting for surgery. Typically patients with OA are in the older age groups presenting and with younger patients presenting with dysplasia, or inflammatory arthritis such as Rheumatoid Arthritis. Currently the life of a hip replacement is expected to be at least 20 years. However, with newer improved materials used in the implants the expectation is growing towards 30 years. However, a hip replacement in a patient of around 50 may indeed require a revision operation in later years. Patients are presenting earlier and earlier to surgery and CONTINUED ON NEXT PAGE.

FEATURE

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Getting “ Hip ” : Recent Advances in Hip Surgery – a Physiotherapy Perspective continued….. CONTINUED FROM PREVIOUS PAGE. patients in their 50s are commonplace as ability to live a more enjoyable and active life is possible. In the younger patients surgeons will usually use a cement-less stem over a cemented stem. As less bone as removed in the cement-less as no cement mantle is required around the stem. Always thinking ahead of possible revision. Bone is the surgeon’s currency. Once spent – it is gone. The head for a younger patient would be typically ceramic or metal. The ceramic being coupled with a ceramic or polyethylene liner. The metal head with a polyethylene liner. Advances in the polyethylene liner manufacturing is such that we moving from minimum thickness in these from 6.1 mm to 3 mm. Meaning that a smaller cup may be used also and less bone removed from the acetabulum. Can you highlight any factors that seem to influence outcomes? The greatest reasons for revision of a hip replacement are loosening or dislocation. Therefore the surgeon’s expertise in placement of the implants is critical, with correct tightness of the soft tissue structures being vital. Loosening is usually secondary to osteolysis occurring which can be a direct effect of particles being released from the implants. Hence implants that are thoroughly tested and have good registry results internationally are vital. How essential is physiotherapy involvement with: Prehab: Pain cannot be relieved by physiotherapy at this late stage and joint range is not critical, what is important is the awareness of correct gait and strengthening of the glutei and quads prior. However, I have not seen any research that demonstrates a difference in long term outcomes due to preoperative physiotherapy intervention. Immediate post op: This is vital mobilising the patient post operatively the day following surgery. With gait reeducation, reinforcement of the precautions that should be taken and the contra indications. Ensuring that patients are actively mobilizing, with strengthening of the glutei and quads in particular. After discharge: Physiotherapy is not commonly used post operatively. Pain is usually the main reason for surgery. Once this is abolished, the patient mobilises at a much greater rate and does not see a need for physiotherapy intervention. What are the current guidelines around return to activity and sport? This is a very grey area. Avoidance of hip dislocation (commonly by a combination of hip flexion past 90 degrees, adduction with internal rotation) is definitely required. However, all surgeons will advise patients differently, often due to the specific age of that patient, their bone quality, the implants used and their health. I know of patients skiing four months post operatively and patients returning to running within the same time frames. The return to activity should be encouraged. But there is no data of which I am aware demonstrating the long term effects of running, etc. on hip joint replacement survival rates. It is all anecdotal. Each case needs to be specifically determined with their specialist. Who else is involved in the team that you work with? My team involves the surgeons and hospital staff that I liaise with. In the operating theatre the scrub and circulating nurses. At my work base the team who put the specific instrument and implant requests together. My colleagues throughout New Zealand who perform the same job as me - of which 75% are physios! And being a corporate we have a large managerial structure and support from marketing, international research and educational teams. What are the major challenges in working in this role? A surgeon’s knowledge is obviously based on years and years of learning. To be able to hold a knowledgeable discussion on surgical technique, the implants that may be used and a patient's pathology can be challenging, but extremely interesting. What are the key attributes you feel a physiotherapist brings to this role? Physios are people people. We are very deeply involved in seeking successful outcomes for patients and their ability to enjoy life. We are inspired to learn and extend our knowledge. We already have a huge foundation of knowledge from where we can grow a further wealth bank of knowledge. Physios are outcome orientated and to achieve this highly organised individuals. We also work well in teams - a critical factor in this job.

CLINICAL SECTION

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ARTICLE REVIEW Clinical Diagnosis of Hip Pain Plante M, Wallace R, Busconi B (2011). Clinical Diagnosis of Hip Pain. Clinical Sports Medicine 30:225-238. ABSTRACT This article reviews the evaluation of the hip including the clinical history and physical examination. Of all the major joints, the hip remains the most difficult to evaluate for most orthopaedic clinicians. Before the advent of MRI and hip arthroscopy, osteoarthritis was the major diagnosis associated with this joint. A recent study estimated that more than 25% of the population will develop symptomatic hip arthritis before the age of 85. As our understanding of hip pathology evolves, and arthroscopic and other minimally invasive operative techniques continue to improve, the focus is shifting towards earlier identification of hip pathology. Risk factors for the development of arthritis are now well established and include femoral acetabular impingement (FAI), labral tearing, developmental dysplasia, and slipped capital femoral epiphysis (SCFE). Emerging treatment options may address these conditions in the early stages and prevent or slow the progression of hip degeneration. This article is really a list of all the tests relevant to the hip and gluteal region. It has limitations in that many tests are described, however there is little evaluation of how useful or limiting a test maybe, they failed to list sensitivity and specificity for any of the tests or to really look at the strengths and weaknesses associated with some of the testing. However the article is useful to read in terms of a being a comprehensive guide to examination of the hip region, although further reading would be recommended. The take home message from the article is the importance of determining, if possible, whether the problem is intra or extra-articular in nature. The authors stress the importance of identifying intra-articular pathologies, as early management of these problems may lead to a decreased chance of developing osteoarthritis at a later time. History As all physiotherapists know, the importance of a thorough subjective examination is vital in working towards a differential diagnosis. This is emphasized in the article. The examiner should look at getting a thorough history. Particular emphasis is placed on location of the pain as this can help locate the pathological structure. Intra-articular pathology presents as groin pain, which can radiate as far as the knee. Pain going distal to the knee is more likely to come from the lumbar spine, gluteal region or thigh muscles. Athletic pubalgia can be indicated with pain in the lower abdomen and/or the adductor tubercle. Sports history is important either current or past, as many sports are associated with specific problems in the hip region. Questions to try and decide if the problem is mechanical or inflammatory in origin are also important. Objective Exam Upright Examination In the upright examination the authors suggest that you look at evaluating gait, pelvic alignment and single leg stance. Looking specifically for antalgic gait, exaggeration of normal pelvic rotation, and Trendelenburgâ&#x20AC;&#x2122;s sign indicating abductor weakness. Leg length is also looked at, particularly looking if it is real or apparent. The patient should also be asked to describe where the pain is when standing. The â&#x20AC;&#x153;C-signâ&#x20AC;?, (when the patient holds their hand in the shape of a C with the thumb above the greater trochanter and the index finger over the groin), is commonly associated with intra-articular pathology. Palpation Palpation is important, especially thinking about what structures are located where and what tenderness in that area may represent. The iliac crest, ASIS and medial to the ASIS, AIIS, pubic symphysis and ramus, greater trochanter and ischial tuberosity are all important bony landmarks and tendon insertion areas to palpate.

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CLINICAL SECTION

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ARTICLE REVIEW CONTINUED... CONTINUED FROM PREVIOUS PAGE. Range of Motion The authors state it is important to look at range of motion in both seated and supine positions. Reduction in hip internal rotation is particularly indicative of intra-articular pathology. Femoral anteversion is measured in prone with the knee flexed to 90 deg. When testing range of motion it is important to stabilise the pelvis to make sure there is not compensatory movement in the lumbar region. Special Tests. A range of special tests were described, although it was hard to know when to use them and how to interpret the results as no guidelines were given as to their sensitivity or specificity, and some of the descriptive text was hard to follow. In view of this it would probably be prudent to do further reading around the use of the tests described. Extra-articular pathology. The article does a good summary of the extra-articular pathologies that can be present around the hip region, along with tests used to identify these. Extra-articular pathologies to be aware of in this region are:  Sacroiliac joint; tests recommended for this is FABER, Gaenslen’s test and posterior pelvic pain provocation test.  Pubic Symphysis; pubic symphysis stress test and the lateral pelvic compression test.  Contractures; Ober’s test (ITB), tripod sign (Hamstrings), Ely test (Rec femoris), Phelps test (Gracilis).  Snapping Hip; evaluate whether it is an internal or external cause.  Nerve Root Compression; femoral nerve traction test.  Sports Hernia; Resisted sit-up test.  Referred Pain; other structures can refer to the hip region, it is important to keep these in the back of your mind, e.g. femoral or inguinal hernias, gastrointestinal causes, renal problems, and gynaecologic problems.

SUMMARY This article is a good overview of the tests commonly used to evaluate pain in the hip region. It is important to try and work out the source of the pain, because this will dictate the treatment or if further testing is required. Unfortunately this article did not go into any use of imaging studies or indeed which ones would be indicated with certain positive tests. From an Orthopaedic point of view it is important to try and separate out if the problem is intra-articular or extraarticular because early detection of intra-articular pathologies may reduce the risk of degenerative changes occurring later on. Techniques for managing intra-articular pathologies surgically have greatly improved recently. Thorough subjective and comprehensive objective examinations are important in differential diagnosis in the hip region, where there are many sources of symptoms. Weaknesses in this review included a lack of justification for the tests they advocated/described, and also many of the references were greater than 10 years old, and there have been many developments and studies in this region over the last few years. As clinicians it is a good refresher of tests we can use in this area, however more reading would need to be done to truly understand the testing and why it is justified. References can be provided on request.

Reviewed by Karen Carmichael BSc, BPhty, M(SportsPhysio)

SPNZ RESEARCH REVIEWS

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Hip Surgery, Pre and Post Operative Physiotherapy: Does it Make a Difference? www.sportsphysiotherapy.org.nz/resources

Surgical Treatment of Femoroacetabular Impingement: A Systematic Review of the Literature Clohisy, J. C., St John, L. C., & Schutz A. L. (2010). Surgical treatment of femoroacetabular impingement: A systematic review of the literature. Clinical Orthopaedics Related Research, 468, 555–564. doi: 10.1007/s11999-009-1138-6 Article Review Surgical management of femoroacetabular impingement (FAI) is becoming more popular; however the literature surrounding its efficacy is still disputed. This review investigates hip impingement surgery its outcomes, complications and causes of failure. FAI is the occurrence of abnormal femoral head and acetabulum abutment, resulting in damage to the articular cartilage and/or the labrum. FAI is commonly classified into three forms cam, pincer and mixed impingement deformity. These deformities initiate a cascade of degenerative, intra-articular events including disruption of the labrochondral junction and potentially the development of secondary osteoarthritis (OA). Eleven studies were reviewed with a mean follow up of 3.2 years. The current evidence regarding FAI surgery is relatively small, single-surgeon studies including retrospective case series and comparative designs. There were 496 cases of FAI amongst the studies. Across the articles techniques used to treat FAI were: periacetabular osteotomy, acetabular rim trimming, proximal femoral osteotomy, femoral osteochondroplasty and relative neck lengthening. Surgeries done supplementary to FAI repair were Microfracture, chondroplasty and partial labral resection/ recontouring. With such a variety of surgical procedures it is difficult to compare these results. The Merle d’Aubigne´-Postel score was the most commonly used clinical outcome measure (four of 11 studies). The average improvement in this questionnaire was between 2.4 to 5 points. Other questionnaires used were the WOMAC osteoarthritis index (three studies) and the nonarthritic hip score (three studies). These outcomes had mean improvements of 7 to 20.2 points and 14 to 31.3 points, respectively. Factors associated with a good outcome and increased satisfaction included no or mild secondary osteoarthritis, labral refixation for treatment of labral pathology, young age, and limited cartilage damage. Failure was defined as either residual pain, conversion to a total hip arthroscopy (THA) or worsening OA, failure was seen on average in 4.4% of patients. Conversion to THA was reported in 0% to 26% of cases. Radiographic osteoarthritis progression was reported in five studies and noted in 0% to 33% of cases. Factors associated with surgical failures and conversion to THA included more advanced preoperative osteoarthritis, advanced articular cartilage disease, older age, and more severe preoperative pain. In general, major complications were uncommonly reported yet occurred in 0% to 18% of the procedures. These included avascular necrosis, femoral head-neck fracture, loss of fixation requiring reoperation, trochanteric nonunion, failure of labral refixation, inadequate osteochondroplasty requiring surgical revision, deep infection, and symptomatic or clinically important limitation of hip motion from heterotopic ossification. Symptomatic hardware requiring removal was the only moderate complication reported. None of the studies reported minor complications. Current evidence regarding FAI surgery is poor. Results however do show pain relief and improved function in 68– 96% of post-surgical patients over short-term follow-up. Long-term results have not yet been published and are needed to determine durability and impact on OA progression. Patients with more advanced OA, articular cartilage disease, older age, and more severe preoperative pain do not show good results from this surgery and should be considered for either a conservative approach or a THA. In younger patients with less articular cartilage and bony degeneration surgical outcomes were positive, even more so if combined with a labral repair.

SPNZ RESEARCH REVIEWS

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Hip Surgery, Pre and Post Operative Physiotherapy: Does it Make a Difference? continued……..

www.sportsphysiotherapy.org.nz/resources

The reporting of complications was variable. There were major complications of up to 18% of patients in one study; however the mean risk was 2.7% of patients. In general, impingement procedures are reported to be relatively safe, with minimal risk for major perioperative complications. The impact of impingement procedures on a long-term basis has not yet been researched and the role of nonsurgical management needs more evidence. Future clinical trials are needed to determine the relative efficacy of long-term nonsurgical and surgical treatment.

Reviewed by Monique Baigent BHsc (Physiotherapy)

The Relationship of Sporting Activity and Implant Survivorship After Hip Resurfacing Le Duff M.J & Amstutz, H.C. (2012). Journal of Bone and Joint Surgery. 94:911-8

Article Summary The ability to return to recreational activities is a main reason why surgeons and patients select hip resurfacing arthroplasty as the treatment of choice for end-stage osteoarthritis. Some studies have been published looking at participation in sports at short-term follow-up after hip resurfacing however there were limitations with these studies. This study aimed to correlate the Impact and Cycle Scores with the survivorship of the procedure in a large cohort of patients with a longer-term follow-up period. The Impact and Cycle Scores look at the frequency of participation and the duration of typical sessions for up to three sporting activities chosen from an extensive list. To calculate the Impact component; activities were rated on the basis of the predominant type of displacement involved, multiplied by frequency and duration. To calculate the Hip Cycle component; activities were rated on the number of hip cycles per unit of time, multiplied by frequency and duration. A total of 445 patients were included in the study group and completed at least one survey between one and five years after resurfacing prostheses. Surveys were performed at a mean of 1.9 years after surgery and at a mean follow-up period of 10.2 years. Results from the study showed that after adjustment for femoral component size, BMI and femoral defect size; a 10point increment on the Impact Score corresponded to a 37% increase in the risk of revision, while a 10-point increment in the Hip Cycle Score increased the risk of revision by 22%. Clinical Applications: At the current level of studied follow-up period; high impact activities may be more detrimental than activities requiring a larger number of hip cycles per unit of time. If patients with end-stage osteoarthritis are thinking of having a hip Arthroplasty, it is important for surgeons to educate patients with respect to high levels of sporting activity on the basis of the presence of additional risk factors. As Physiotherapists we may see patients prior and after surgery. It is just as important for us to educate patients regarding the same risk factors and assist them with altering their recreational activities if required.

Reviewed by Amanda O’Reilly BPhty (Otago)

SPNZ RESEARCH REVIEWS

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[title] continued…….. Hip Surgery, Pre and Post Operative Physiotherapy: Does it Make a Difference? continued……..

www.sportsphysiotherapy.org.nz/resources

Hip Resurfacing: Not Your Average Hip Replacement Scott Siverling & Ioonna Felix & S. Betty Chow & Elizabeth Niedbala & Edwin P. Su Curr Rev Musculoskelet Med (2012) 5:32–38 DOI 10.1007/s12178-011-9103-x

Article Summary Hip resurfacing (HR) has become a widely used surgical intervention for younger patients requiring hip joint arthroplasty. As the number of aging population is expected to increase, so is the incidence of OA hip expected to increase. Total Hip Joint Replacement (THJR) has limitations in the younger population specifically due to the life of the joint replacement being limited, younger patients placing greater and prolonged stress on the prosthesis. HR however is offered now to younger more active patients and it is the expectation that they will return to an active lifestyle, inclusive of light running. While case reports have been published describing rehabilitation programs following HR, there has yet to be established rehabilitation guidelines. This article outlines a guideline protocol for post HR management based on case reviews, current evidence for treatment of hip pathologies and clinical experience.

Clinical Applications: The article divides the rehabilitation protocol up into three phases and gives outlines of healing timeframes, goals and exercise strategies. Whilst the table below indicates guidelines for progression from a timeline perspective, this is naturally tempered with preoperative function and individual patient ability. The key point outlined in the article repetitively was that patients are progressed when they can achieve the strength and exercise tolerance to allow them to manage harder exercise prescription, the timeframe of the phrases outlined are a guide only. Due to the nature of surgery providing a large femoral ball component the joint is considered to be stable, early and pain free movement is encouraged. Despite this if the patient is advanced prematurely or the exercises are painful, tissue healing can be disrupted and exacerbation of pain will occur. It is recommended that manual therapy in some situations can be used but this is also to be done after consultation with the surgeon to determine that the healing tissue can tolerate manual therapy procedure. Whilst stretching is recommended into directional loss, it is also recommended that stretches and manual therapy only restore what is functionally needed. The authors used the Lower Extremity Functional Scale Score as the outcome measure (LEFS). Main complications to watch out for are fracture neck of femur (premature loading) and ongoing soft tissue dysfunction such as iliopsoas and posterior gluteus medius tendinopathy and greater trochanter bursitis. On the following page is a table summary of the phases and exercise prescription guidelines.

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SPNZ RESEARCH REVIEWS Hip Surgery, Pre and Post Operative Physiotherapy: Does it Make a Difference? continued…….. Clinical Applications continued:

Table 1 Rehabilitation goals and treatments per phase Phase I 0-4 weeks

Phase II 2-12 weeks

Phase III 3-6 months

GOALS:

GOALS

Promote healing Normalise gait pattern WBAT with appropriate assistive device Manage stairs Independent home exercise programme

Normalise gait w/o assistive device progress to walking 2 miles Increase hip flexibility Independent HEP Return to 80% of prior function 10 resisted side-lying abduction with 4/5 grade Single leg stand 5 sec with control Pain free ADL LEFS score of 50+ TREATMENT RECOMMENDATIONS: Cardio: resistive Bike/ swimming/elliptical if gait normal promote normal neuromuscular activity of the lumbopelvic function Progress Hip ROM: Stretches such as Thomas stretch, child’s pose/ quadruped rock/ seated figure-4 posture stretches. Manual therapy may be used to promote improved ROM, e.g. mobilizations with movement to promote hip flexion Strengthening: emphasis on hip extensors and abductors, leg press (1/3 body weight), bilateral squats/activities, progress to unilateral as able Proprioception: Bilateral→unilateral End phase initiate activity specific drills but not full participation in sport

Full hip AROM pain free Ability to return to patient specific functional / recreational activities Return to 90% of prior function 10 single-leg squats without deviation LEFS score of 70-80

TREATMENT RECOMMENDATIONS: Transition from crutches to 1 crutch or cane Initiate cardio: stationary upright bike Initiate proximal strengthening: bridge, core exercises Balance retraining with double limb support Pain free hip ROM: Heel slides, single knee to chest, modified Thomas position NB: other than caution with weight bearing (no single leg stance exercises and pain dictated) there are no restrictions with range of motion

TREATMENT RECOMMENDATIONS: Progressive AROM as appropriate Single leg exercises in weight-bearing position Multi planar actiivties Dynamic balance activities i.e. Bilateral→Unilateral Activity specific training / gradual return to approved sports Golf : Approach shot Long drive Initiate Racquet Sports: Match Play Running: terrain # miles NB: avoidance of impact activities such as running for 6 months post surgery

Reviewed by Kate Polson MHSc(Hons); Dip Phty, Dip MT, MNZCP; MNZSP

SPNZ RESEARCH REVIEWS

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[title] continued…….. Hip Surgery, Pre and Post Operative Physiotherapy: Does it Make a Difference? continued……..

www.sportsphysiotherapy.org.nz/resources

Effect of Pre-operative Physiotherapy in Patients With End Stage Osteoarthritis Undergoing Hip Arthroplasty PE Ferrrara, A Rabini, L Maggi, DB Piazzini, G Logroscino, G Maglioccheti Lombi, E Amabile, G Tancredi, AG Aulisa, L Padua (2008) Clinical Rehabilitation, 22: 977-986 Article Review Current management guidelines for osteoarthritis confirm the effectiveness of strengthening exercises and general physical activity to optimise functional status and reduce pain, although a lot of patients do progress to requiring surgery. Research is non-conclusive when analysing pre-operative physiotherapy strengthening in hip joint replacements, with results ranging from not useful, little benefit, to faster functional recovery, reduces amount of assistance and support post operatively, and reduces patient anxiety. The aim of this study is to measure changes in impairment, pain and quality of life in patients with end stage hip osteoarthritis pre and post hip replacement after partaking in preoperative physiotherapy. Patients were recruited from the waiting list of an orthopaedic department and had been diagnosed with end stage osteoarthritis. Each study participant was evaluated at one month before surgery, the day before surgery, and 15 days, 4 weeks and 3 months post-surgery. Patients were randomised into control and study groups. Objective measures taken were: 

muscles strength of hip abductors and quadriceps



ROM of hip abduction and external rotation



Barthel Index, to measure disability



Quality of life using SF-36



Impairment using Western Ontario and McMaster Osteoarthritis Index (WOMAC)



Pain using VAS

The study group attended a pre-operative physiotherapy programme involving group and individual sessions for 5 days/week. Following surgery both groups performed a 4 week inpatient rehabilitation programme. The study group attended a pre-operative physiotherapy programme involving group and individual sessions for 5 days/week. Following surgery both groups performed a 4 week inpatient rehabilitation programme. As expected the study group showed significant improvements after one month of pre surgery physiotherapy, in keeping with the current guidelines. At 3 months post op both groups showed a significant improvement in all outcome measures, however the study group had a significantly lower VAS and higher hip external rotation when comparing the two groups. Clinically this study shows that pre-operative physiotherapy programmes do not reduce impairment or improve quality of life following hip joint replacement. Physiotherapy has an important role in the conservative management of hip osteoarthritis.

Reviewed by Deborah Nelson BPhty, PGD Musculoskeletal

RESEARCH PUBLICATIONS

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JOSPT September 2013 www.jospt.org

CLINICAL COMMENTARY A Biomechanical Perspective on Physical Therapy Management of Knee Osteoarthritis RESEARCH REPORT Read for Credit Quiz Effectiveness of Dry Needling for Upper-Quarter Myofascial Pain: A Systematic Review and Meta-analysis BRIEF REPORT A Novel Device Using the Nordic Hamstring Exercise to Assess Eccentric Knee Flexor Strength: A Reliability and Retrospective Injury Study RESEARCH REPORT Clinical, Physical, and Neurophysiological Impairments Associated With Decreased Function in Women With Carpal Tunnel Syndrome RESEARCH REPORT Reliability and Validity of the Dutch Version of the International Physical Activity Questionnaire in Patients After Total Hip Arthroplasty and or Total Knee Arthroplasty RESEARCH REPORT Hip Joint Torques During the Golf Swing of Young and Senior Healthy Males RESEARCH REPORT Younger Patients Report Greater Improvement in Self-reported Function After Knee Joint Replacement MUSCULOSKELETAL IMAGING Posterior Dislocation of the Elbow MUSCULOSKELETAL IMAGING Chronic Low Back and Left Lower Extremity Pain in an Elderly Woman CLINICAL PRACTICE GUIDELINES Ankle Stability and Movement Coordination Impairments: Ankle Ligament Sprains

RESEARCH PUBLICATIONS

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International Journal of Sports Physical Therapy Volume 8, Number 4, August 2013 IJSPT International Journal of Sports Physical Therapy - Individual Subscriptions Available The IJSPT journal is available to purchase for individual members. SPNZ members interested in subscribing to this journal can purchase an individual subscription through the journal directly. To purchase a subscription go to the IJSPT website, and click on “subscriptions”. Subscription rate for 2013: 

Individual

$60 (USD)



Student

$35 (USD)

ORIGINAL RESEARCH Reliability and Validity of Functional Performance Tests in Dancers with Hip Dysfunction The Effect of Double Versus Single Oscillating Exercise Devices on Trunk and Limb Muscle Activation The Reliability of the Modified Reverse-6 Taping Procedure with Elastic Tape to Alter the Height and Width of the Medial Longitudinal Arch The Effect of Kinesio® Tape on Vertical Jump and Dynamic Postural Control No Association Between Q-Angle and Foot Posture with Running-Related Injuries: A 10-Week Prospective FollowUp Study SYSTEMATIC REVIEWS Diagnostic Accuracy of Physical Examination Tests of the Ankle/Foot Complex: A Systematic Review A Proposed Evidence-Based Shoulder Special Testing Examination Algorithm: Clinical Utility Based on a Systematic Review of the Literature Return of Normal Gait as an Outcome Measurement in ACL Reconstructed Patients. A Systematic Review. CASE REPORT Popliteus Strain with Concurrent Deltoid Ligament Sprain in an Elite Soccer Athlete: A Case Report Differential Diagnosis of Deep gluteal Pain in a Female Runner with Pelvic Involvement: A Case Report Residents Case Report: Deep Vein Thrombosis in a High School Baseball Pitcher Following Ulnar Collateral Ligament (UCL) Reconstruction CLINICAL COMMENTARY A Phased Rehabilitation Protocol for Athletes with Lumbar Intervertebral Disc Herniation CURRENT CONCEPTS REVIEW Balance Training for the Older Athlete CLINICAL COMMENTARY: ON THE SIDELINES The Role of the Sports Physical Therapist: Marathon Events

RESEARCH PUBLICATIONS

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SPORTS HEALTH

A Multidisciplinary Approach Volume 5, Number 4 (July/August 2013) Sports Health EDITORIAL The Boston Marathon Tragedy Letter to the Editor Concentric and Eccentric: Muscle Contraction or Exercise? Letter to the Editor and Response SPORTS PHYSICAL THERAPY Adductor Pollicis Longus Strain in a Professional Baseball Player: Case Report and Review of Thenar Pain Rehabilitation of Low Back Pain in Golfers: From Diagnosis to Return to Sport ATHLETIC TRAINING Neck Strength Imbalance Correlates With Increased Head Acceleration in Soccer Heading The Incidence of Injury Among Male and Female Intercollegiate Rugby Players PRIMARY CARE Exercise-Associated Hyponatremia in an Ultra-Endurance Mountain Biker: A Case Report Comparison of the Effect of Medical Assistants Versus Certified Athletic Trainers on Patient Volumes and Revenue Generation in a Sports Medicine Practice Action in the Event Tent! Medical-Legal Issues Facing the Volunteer Event Physician Muscle Injuries in Athletes: Enhancing Recovery Through Scientific Understanding and Novel Therapies ORTHOPAEDIC SURGERY Paget-Schroetter Syndrome: A Review of Effort Thrombosis of the Upper Extremity From a Sports Medicine Perspective A Rare Cause of Foot Pain With Golf Swing: Symptomatic Os Vesalianum Pedisâ&#x20AC;&#x201D;A Case Report Development and Validation of the Elbow Demand Rating Scale Suprascapular Nerve Entrapment Due to a Stenotic Foramen: A Variant of the Suprascapular Notch Return to Sport Following Shoulder Surgery in the Elite Pitcher: A Systematic Review IMAGING The Practical Uses of Ultrasound in a Clinical Setting to Diagnose Thrombosis of the Ulnar Artery Society News

RESEARCH PUBLICATIONS

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Taylor & Francis Online Research in Sports Medicine An International Journal Volume 21, Issue 3, 2013 www.tandfonline.com SELF-REPORTED CONCUSSION SYMPTOMS AND TRAINING ROUTINES IN MIXED MARTIAL ARTS ATHLETES Christopher J. Heath & Jennifer L. Callahan THE EFFECTS OF ANKLE KINESIO® TAPING ON ANKLE STIFFNESS AND DYNAMIC BALANCE Shirleeah D. Fayson, Alan R. Needle & Thomas W. Kaminski MUSCLE ACTIVITY WHILE RUNNING AT 20%–50% OF NORMAL BODY WEIGHT John A. Mercer, Bryon C. Applequist & Kenji Masumoto EPIDEMIOLOGY OF INJURIES IN THE ELITE LEVEL FEMALE HIGH SCHOOL LACROSSE PLAYER Cheryl Hall, Karen Friel, Michelle Dong, Lauren Engel, Lauren O'Boyle, Andrea Pasquarella, David Serkes, Kathryn Smith, Lauren Stoebe & Danielle Valle METABOLIC RESPONSES DURING POSTPRANDIAL EXERCISE Jie Kang, Emily Raines, Joseph Rosenberg, Nicholas Ratamess, Fernando Naclerio & Avery Faigenbaum EFFECTS OF A LOW VOLUME INJURY PREVENTION PROGRAM ON THE HAMSTRING TORQUE ANGLE RELATIONSHIP Fernando Naclerio, Avery D. Faigenbaum, Eneko Larumbe, Mark Goss-Sampson, Txomin Perez-Bilbao, Alfonso Jimenez & Chris Beedie INSPIRATORY AND EXPIRATORY RESPIRATORY MUSCLE TRAINING AS AN ADJUNCT TO CONCURRENT STRENGTH AND ENDURANCE TRAINING PROVIDES NO ADDITIONAL 2000 M PERFORMANCE BENEFITS TO ROWERS Gordon J. Bell, Alex Game, Richard Jones, Travis Webster, Scott C. Forbes & Dan Syrotuik EFFECTS OF TWO DIFFERENT TRAINING METHODS IN WOMEN WITH FIBROMYALGIA SYNDROME Déborah de Araújo Farias, Ariel Arnon de Oliveira Abrahão, Mateus Rossato & Ewertton de Souza Bezerra ACCURACY OF FIELD METHODS IN ASSESSING BODY FAT IN COLLEGIATE BASEBALL PLAYERS Jeremy P. Loenneke, Mandy E. Wray, Jacob M. Wilson, Jeremy T. Barnes, Monica L. Kearney & Thomas J. Pujol

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RESEARCH PUBLICATIONS

Health Research Reviews Register (FREE) and download the latest “NZ Research Reviews”

http://researchreview.co.nz SPORTS MEDICINE AND PHYSICAL ACTIVITY

ORTHOPAEDICS AND HEALTH

Diabetes and Obesity

Bone Health

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Hip and Knee Surgery

Pharmacy

Mental Health– Behavioural Disorders

Rehabilitation

Pain Management

Sports Medicine Travel Medicine Wound Care

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ASICS ASICS REPORT - INJURY CORNER This issue's Injury Corner is the third in a series on mid foot injury.

The midfoot is a common site for inflammatory tendon injury, with the tendons of tibialis anterior, extensor digitorum longus, flexor hallucis longus and the peroneal tendons most commonly affected. It is important to differentiate tendinitis, the most commonly used term for tendon injury, from peritendinitis and tenosynovitis. Tendinitis is an histopathologic classification referring to acute or chronic inflammation within tendon tissue. Peritendinitis refers to acute or chronic inflammation affecting the paratenon tissues, whilst the term tenosynovitis (also known as tenovaginitis) describes inflammations within the synovium of the tendon. Since inflammation readily affects the well-vascularised tissue of the peritendinous structures, tenosynovitis and peritendinitis occur more commonly than tendinitis which is relatively rare. Tenosynovitis can only occur in areas where a true tenosynovial exists. Malmivaara et al (1995) have made an association between a history of rheumatism and the development of tenosynovitis, Tenosynovitis is similar to peritendinitis and typically produces a crackling sound during tendon movement and palpation. Deposition and adhesion of fibrin exudate within the tenosynovium is likely to produce this crepitation. Extensor Tenosynovitis Tenosynovitis of the extensor tendons and the distal portion of the tendon of tibialis anterior are relatively common in sport. Both the tibialis anterior and extensor digitorum longus muscles act as prime antigravity muscles and function to prevent foot slap at the contact phase of gait. These structures are therefore quite susceptive to overuse injury. In addition the location of the dorsal foot tendons renders them liable to irritation from tight or inappropriate shoe lacing or lace eyelet placement. Tenosynovitis may also be triggered by midtarsal joint dorsal hyperostoses and excessive pronation elongated the anterior tibial tendon which is reported as a predisposing factor to tenosynovitis. Tenosynovitis of these structures presents as swelling over the midfoot, with hyperemia, warmth and pain to palpation. In addition, obvious crepitus of the tendons may be present throughout active recruitment, and the patient may complain of a sensation "like sandpaper" rubbing as the digits are moved through dorsiflexion and plantarflexion. This is secondary to the presence of serous fibrin exudate. Tenosynovitis of the extensor tendons responds well to conservative treatment, which will include NSAID's, ICE, physiotherapy, resistance strengthening exercises, padding and orthoses. Careful assessment of athletes footwear is required, with alteration of lacing systems as necessary. FORERUNNER DECEMBER 2012

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CONTINUING EDUCATION CALENDAR

Page 24

Upcoming courses and conferences in New Zealand and overseas in 2013.

For a full list of local courses visit the PNZ Events Calendar

LOCAL COURSES & CONFERENCES When?

What?

Where?

3rd SPNZ Symposium

Rotorua

More information

2014 15-16 March 2014

See Physiotherapy NZ Website

Click Here

INTERNATIONAL COURSES & CONFERENCES When?

What?

Where?

More information

30 August 2013

IFSPT Symposium

J o h a n n e s b u r g , http://ifspt.org/education/ South Africa conferences/2013-ifspt-general-meetingand-congresses/

30 Aug- 1st Sept 2013

The Leuko Tape Sport

Gauteng, Africa

2 Sept 2013

IFSPT Symposium

Cape Town, South http://ifspt.org/education/ Africa conferences/2013-ifspt-general-

25-26 Oct, 2013

Glasgow Sports Conference

Glasgow

8-9 Nov 2013

Salzburg Sports Physiotherapy Salzburg Symposium

http://spowww.sbg.ac.at/ssps2013/ index.php?id=95

17-20 Oct, 2013

APA Conference. New Moves

Melbourne

http://www.physiotherapy.asn.au/ Conference2013

15 Nov. 2013

SportFisio 11th Annual

Bern, Switzerland

http://r20.rs6.net/tn.jsp? e=0014PUpTeosLp3nXXroB4ozWJPfo1 LkxFMNv3yvQ3ZJB0Mwz91nQFceMRLKAyUn0m7WgpdAohUiZdrLKteP2jXs8 MJYrbtBKEu1YG4olSxupZCw0AmCaw W85Lv0XEuD65j

Las Vegas

http://www.spts.org/education/teamconcept-conference

2013

Physiotherapy Congress

Conference

5-7th Dec , 2013

Team Concept Conference

South http://www.sport-physio.co.za/

Page 25

APA CPD Event Finder

SPNZ members can now attend APA SPA (Sports Physiotherapy Australia) courses and conferences at APA member rates. This includes all webinars and podcasts (no travel required!). To see a list of courses and conferences visit the APA and SPA Events Calendar To register, download a Registration Form and forward to the relevant Branch Office (listed on the

Search for more courses, conferences, webinars and podcasts on the APA and SPA Events Calendar

Page 26

CLASSIFIEDS POSITION VACANT HAMILTON FULL TIME PHYSIOTHERAPIST POSITION Great Opportunity Available for an Enthusiastic and Motivated Physiotherapist to Join Our Team!

We are looking for a full time musculoskeletal physiotherapist to work in our long standing, busy and dynamic accredited private practice. We treat a variety of clientele, from acute, sports, post-operative and general musculoskeletal conditions to more chronic and complex cases. We have two additional clinic sites at the university and a private school. We work with Sports Teams: Hillary Scholar Athletes, Waikato Senior Menâ&#x20AC;&#x2122;s University Rugby Teams, Rugby 7s, Unicol Soccer, Senior Club Netball & Track. Coaching and Mentoring is an Essential Part of our Physiotherapy Practice. We hold a regular In-service Programme which includes guest speakers. A Top Rate Remuneration Package available including up to $1000. per year funding for courses and development. Flexible start date. To join our team e-mail your CV to: performanceplusphysio@xtra.co.nz Or mail to: Melissa Gilbertson Practice Director PERFORMANCE PLUS PHYSIO LTD 280 Peachgrove Road, Hamilton. Phone: 078551788 www.performanceplusphysio.com

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