SEPNZ December 2017 bulletin by Sports & Exercise Physiotherapy NZ

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Issue 6 December 2017

Feature Guest feature: Osteoarthritis of the Knee Special Report ASICS Sports Medicine Australia Conference

FEATURE TOPIC: Osteoarthritis

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SEPNZ Members’ Page Welcome to Sports & Exercise Physiotherapy New Zealand SEPNZ EXECUTIVE COMMITTEE President

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Contents FEATURE TOPIC: Osteoarthritis

SEPNZ MEMBERS PAGE See our page for committee members, links & member information

EDITORIAL By SEPNZ President Hamish Ashton

MEMBERS’ BENEFITS Re-join SEPNZ

FEATURE

In this issue:

Guest Feature : Osteoarthritis of the Knee

SPECIAL REPORT ASICS Sports Medicine Australia Conference

SPRINZ Implementing Individualised Exercise to Better Manage Chronic Illness Within a Multidisciplinary Team Setting

CLINICAL SECTION- ARTICLE REVIEW General Practitioners’ Perspectives on a Proposed New Model of Service Delivery for Primary Care Management of Knee Arthritis: a Qualitative Study

Effect of Physical Activity and Dietary Restriction Interventions on Weight Loss and the Musculoskeletal Function of Overweight and Obese Older Adults With Knee Osteoarthritis: a Systematic Review and Mixed Method Data Synthesis

CONTINUING EDUCATION Sports Performance and Prevention Conference

ONLINE SURVEY Otago University

RESEARCH PUBLICATIONS BJSM Volume 51, Number 24, December 2017

CLASSIFIEDS Situations Vacant

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Editorial Hamish Ashton, SEPNZ President Seasons Greetings to you all and to your families. 2017 has been a year of changes but in some cases not obvious outcomes. We have a new government, but at this stage no real insight as to what is going to change with ACC or the health system. We have decided to go ahead with what could be some of the biggest changes to PNZ since it became our professional body, but as yet, no picture of what these may look like. In both cases we are likely to find some answers in the New Year. With regards to PNZ, the working group has received some detailed information from the branches, SIGs and PNZ office and is compiling this for it to be reviewed as a starting point for a new model. At present there looks to be a meeting in February to review this information and take the next step. We will keep you informed on this process as it happens. I can’t emphasise enough the importance of reading and commenting on any, and all, information that comes out in this process as this will affect you as a physiotherapist. We are listening to feedback so make sure we receive it. For our SIG the big thing was our name change. Since the inception of Sports Physiotherapy New Zealand, our aims and objectives have included exercise for health and well being for all, and not just the elite sportsperson. Our new name now reflects this. All health research currently coming out emphasises the value of exercise for health and wellbeing. Physiotherapists should be key to this and we as the sport and exercise group should be well placed to lead the way. However, to do this we need continue to work on updating our knowledge and putting into practice sound treatment principles, or we will find there are numerous other types of practitioners putting up their hands to do this. At present we are slowly rebranding the website and other materials. For convenience, the web, Facebook, and Twitter addresses will remain the same. The abbreviated web address will however be sepnz.org.nz (this is already accessible) with spnz.org.nz being dropped over the next year. I will shortly add to our members section the new logos for those of you that use them on their webpages to update. If you do use them, do as “Member of SEPNZ” as we cannot be seen to endorse members or their clinics. We also had our symposium later in the year than normal. In hind sight, with a look at the packed CPD calendar for that time of the year it was possibly not the

best move. Our next one is likely to return to the early part of the year. Planning will be starting shortly so if there is anyone you want to hear let us know. As a number of you are aware, we had to cancel a couple of courses at the end of the year. We apologise to those affected by this. These were the first times we have had to do this, and as a result the process had some hiccups. The education committee and the SEPNZ exec have both just met to discuss this to improve things going forward. What we aim to do next year is give much better notification of our courses. Sometimes due to the timetables of external lecturers this is not possible, but we will make a strong endeavour to do so. This will give us a much better opportunity to get sufficient registrations for all the courses to go ahead. Also after much debate and feedback we have decided to drop the prerequisite of doing the Level One Promotion and Prescription of Physical Activity and Exercise Course for the level two courses. However, to gain the certificate you will still need to do all the courses. You will now be able to do any of the courses as 'stand alone courses' and in any order. However, Level Two courses will require a greater level of understanding of exercise prescription theory and we strongly recommend you do the Level One Promotion and Prescription of Physical Activity and Exercise to help give you a good grounding and understanding of the principals of exercise prescription. We will put a suggested reading list up on the website over the next couple of months. I would like to personally wish you all a Merry Christmas and a happy and prosperous New Year. Thanks to my exec and all the members that have contributed to our SIG over 2017. A special thanks must go out to Aveny and her team for putting together these bulletins. They are by far the best I have seen from any group here in NZ or even overseas. A special thanks, also, to the education committee for all their hard work. Finally, a reminder that we as an exec are here for you. We appreciate any feedback, ideas or ways we can improve what we offer to you as the members. Hamish

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Members’ Benefits

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Don’t forget to tick SEPNZ when you renew your PNZ Membership all this for just $80 • Regular SEPNZ sports bulletin newsletters by email including clinical updates, latest research, and clinical interviews

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Feature GUEST FEATURE : OSTEOARTHRITIS OF THE KNEE By Bronwyn Harman Bronwyn Harman is a musculoskeletal/sports physiotherapist and lecturer at the School of Physiotherapy, Auckland University of Technology. She teaches across the undergraduate physiotherapy programme and is the Musculoskeletal Physiotherapy Team Leader. Bronwyn completed the Advanced Diploma of Physiotherapy (orthopaedic manual therapy option) in 1990, a certificate in Tertiary Teaching in 2009, a Postgraduate Diploma in Health Science (Musculoskeletal) in 2010 and a Masters of Health Science (Hons) in 2014. Bronwyn has been a member of New Zealand Manipulative Physiotherapists Association (NZMPA) for more than 25 years with extensive clinical experience in musculoskeletal physiotherapy and orthopaedic rehabilitation. She is currently a tutor for NZMPA. She is also a member of the American Society of Shoulder and Elbow Therapists and recently presented at their conference in New Orleans. Her area of research interest is in rehabilitation following orthopaedic surgery and she has presented her research both nationally and internationally. In her spare time she loves to ski and is trying to learn to surf to keep up with her three grown children! Introduction Osteoarthritis (OA) of the knee affects millions of people globally and is a leading cause of disability (Cross et al., 2014; Peat, McCarney, & Croft, 2001). The increasing ageing population will result in a large rise in the number of people affected by OA in New Zealand with a resultant increase in people requiring total knee arthroplasty surgery (Hooper, Lee, Rothwell, & Frampton, 2014). The economic cost of OA is high which will place further burden on healthcare systems (Puig-Junoy & Ruiz Zamora, 2015). Osteoarthritis is not just a disease affecting the articular cartilage, it is an inflammatory and biomechanical whole organ disease, which affects the entire knee joint (Loeser, Goldring, Scanzello & Goldring, 2012). Classification Criteria for Knee OA The classification criteria, endorsed by the American College of Rheumatology includes three different classification criteria: clinical; clinical and radiographic and clinical and laboratory (Altman et al., 1986; American College of Rhematology, 1986). The clinical criteria include knee pain and at least three of six of the following: age over 50; stiffness less than 30 minutes; crepitus; bony tenderness; bony enlargement; no palpable warmth (Altman et al., 1986). The clinical and radiographic criteria include the presence of osteophytes on x-ray, whereas the clinical and laboratory criteria include synovial fluid signs of OA and blood tests to rule out the presence of rheumatoid factor or an elevated erythrocyte sedimentation which would be indicative of rheumatoid arthritis (Altman et al., 1986).

(Kellgren & Lawrence, 1957). The original KL classification criteria ranges from Grade 0 with no osteoarthritis to Grade 4 (large osteophyte; marked narrowing of joint space; severe sclerosis and definite deformity of bone ends) indicating severe osteoarthritis (Kellgren & Lawrence, 1957). There are also alternative descriptions of the original KL scale, which can seem confusing, however there is moderate agreement between the original description and the alternatives (Schiphof et al., 2011). Classification of osteoarthritis radiographically with a Grade 2 (definite osteophytes and possible narrowing of joint space) or more has been used for inclusion in clinical studies (Messier et al., 2013; Paterson, Nicholls, Bennell, & Bates, 2016). Recent guidelines however have indicated however that imaging is not necessary for people who have a typical presentation of OA of the knee (Sakellariou et al., 2017). If a patient who was over the age of 50, presented with knee pain, stiffness for less than 30 minutes, crepitus and they had bony enlargement as in Figure 1. they would fit the clinical criteria for knee OA.

Are X-Rays Necessary to Diagnose Knee OA? The most widely used radiographic classification system for knee OA is the Kellgren Lawrence scale (KL)

Figure 1. Right knee with bony enlargement with varus deformity due to OA

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Feature GUEST FEATURE : OSTEOARTHRITIS OF THE KNEE continued... There is also considerable discord between radiographic changes and clinical symptoms, with some people with radiographic OA having no pain and others having pain with few radiographic changes (Bedson & Croft, 2008). Inclusion criteria in recent studies on knee OA have used the clinical criteria only rather than the clinical and radiographic criteria (Chang et al., 2017; Dobson et al., 2017). Further investigations, such as x-rays are recommended if there is an atypical presentation or the presence of red flags (Sakellariou et al., 2017). Weight bearing plain films should be undertaken before referring to an orthopaedic surgeon for surgical opinion if the patient has failed conservative treatment for osteoarthritis. There is some evidence that patients with less severe radiographic OA and more widespread hyperalgesia who undergo total knee arthroplasty benefit less from surgery (Wylde et al., 2017). Magnetic resonance imaging (MRI) has also been shown to detect tibio-femoral arthritis however the European League Against Rheumatism guidelines on the use of imaging still recommend conventional plain radiography be undertaken as a first step before other modalities are used (Sakellariou et al., 2017; Schiphof et al., 2014). What do the latest guidelines recommend for the management of knee OA? Several guidelines have been developed for the management of knee OA which include pharmacological and non-pharmacological management (Fernandes et al., 2013; Hochberg et al., 2012; McAlindon et al., 2014; National Institiute for Health Care and Excellence, 2014). Pharmacological management is usually tiered, starting with paracetamol before commencing non-steroidal antiinflammatories and then opioid medication for more severe refractory pain (National Institiute for Health Care and Excellence, 2014). Non-pharmacological management should be the first line of treatment before pharmacological management with guidelines recommending education, aerobic and strengthening exercises as well as weight loss management (Fernandes et al., 2013; Hochberg et al., 2012; McAlindon et al., 2014; National Institiute for Health Care and Excellence, 2014). Both aerobic and strengthening exercises are recommended for people with knee OA as they are less physically active than aged matched healthy controls and their quadriceps strength is reduced by up to 20% prior to joint replacement surgery (de Groot, Bussmann, Stam, & Verhaar, 2008; Harman, 2012). Strengthening exercises have a beneficial effect on pain, function and quality of life (Brosseau et al., 2017b). Physical inactivity is a known risk factor for chronic diseases associated with increased mortality (Nocon et al., 2008). The

recommended level of physical activity for adults by the American College of Sports Medicine is 150 minutes of moderate level physical activity per week (Haskell et al., 2007). Aerobic exercise also has a significant effect on pain function and quality of life (Brosseau et al., 2017a). Obesity is a risk factor for the development of OA and for a minimal clinically important improvement in knee function a weight loss of more than 7.7% is required with knee OA (Atukorala et al., 2016). The effect of the combination of diet and exercise has been explored in one systematic review which indicated that the quality of evidence for the benefit of combining exercise and dietary interventions in obese or overweight adults with knee OA is unclear (Alrushud, Rushton, Kanavaki, & Greig, 2017). Only three studies were included in the review and while risk of bias across the studies was not deemed high, meta-analysis was only able to be undertaken for one outcome measure (the sixminute walk test) at 6 months follow up from two studies (Alrushud et al., 2017). There is a need for further high quality randomised controlled trials to investigate the efficacy of combined treatment however one of the studies in that review demonstrated that the combination of diet and exercise facilitated more weight loss than the exercise group and less pain and better function than diet or exercise alone (Messier et al., 2013). Management of OA should involve a multidisciplinary team aimed at education, self-management and behaviour change strategies for exercise and weight loss. This can be difficult to implement with the traditional pharmacological and surgical approach (Ferreira de Meneses, Rannou, & Hunter, 2016; Hunter, 2017). The Mobility Action Programme developed by the Ministry of Health is a good start as multidisciplinary management is available through this programme (Ministry of Health, 2017). Currently in New Zealand though there are no clear guidelines for the co-ordinated management of knee OA (Jolly, Bassett, O'Brien, Parkinson, & Larmer, 2017). Key Messages • The clinical criteria is acceptable for diagnosis • X-rays are not necessary unless there are red flags, an atypical presentation or the patient has failed conservative management. • The core treatments that the guidelines recommend are education, self-management, exercise and weight loss • A

multidisciplinary

management

recommended References available upon request.

approach

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Special Report ASICS SPORTS MEDICINE AUSTRALIA CONFERENCE Langkawai Island, Malaysia 25-28 October 2017 Three months ago I received an email letting me know that I’d won the Sports Physiotherapy NZ survey prize of an all expenses paid trip to Langkawi Island for the 2017 Asics Sports Medicine Australia Conference. What a big surprise! The conference was a magnificent 4 day feast of learning, on beautiful, tropical Langkawi Island. The luxurious resort accommodation was 5 star and Asics were faultless hosts.

Lecture: The latest Research in Sports Nutrition based on a study looking at long distance race walkers, one group high carbs, and another low carbs. The low carb group used more oxygen to stay at the same speed. The high fat, low carb group were slower, so a diet high in carbs had the better outcome. For more information view Burke et al. 2017. J Physiology 595 (9) 2785-2807. The day was topped off with a welcome reception held on the beach in front of the conference venue accommodation- a full buffet feast of Malaysian specialities and more... words cannot describe the opulence.... Some take home points of interest are outlined below, hopefully there are enough snippets of information to be of help and to maybe inspire you to consider going to the next Sports Medicine Australia Conference: Running re-education: a practical guide to clinical intervention- By Dr Andrew Franklyn-Miller “ There are characteristics of running that obey the principals of segmental coordination from a biomechanical loading perspective which are evidenced based and remain fairly constant from person to person...” People with running pain may have poor segmental patterning; the little muscles are doing too much, so the big muscles need retraining to do the big jobs. Dr Andy presented four teaching cues with the aim of increasing hip flexion and a vertical shin in order for avoiding overload of gastrocnemius and tibialis anterior muscles and excessive forefoot running. The cues facilitate changes in joint angles (kinematics) which change load distribution (kinetics) for the treatment of pain associated with running. The kinematic changes result in kinetic changes, resulting in increased work of proximal muscles and so strengthening of back, gluteal and hamstring muscle groups is part of the rehabilitation.

The key note speakers included Dr Louise Burke (OAM), Dr Philip Ainslie, Dr Wendy Brown, Dr Andy Franklin-Miller, Dr Patria Hume, Dr Jeremy Lewis, and Dr Danny Green. In addition there were over 100 papers presented by some world class health professionals.

Piston-vertical pistoning of the foot to reduce over stride, make the tibia more vertical and to increase the hip flexion angle in order to avoid overloading tib ant and gastrocs. -Kinetic effect-increased ground reaction force, load transfer to hip extensors.

Day one consisted of registering, a 5 hour sightseeing trip including a spectacular ride up the world’s steepest cable car and a walk across the sky bridge. Then I attended a meeting hosted by Asics discussing the brand, followed by Prof Louise Burke’s Refshauge

Oranges- imagine oranges under mid foot and squashing them (barefoot training, until mastered) with the aim of avoiding forefoot running (50% of runner’s forefoot run). -Kinetic effect-increased ground reaction force, CONTINUED ON NEXT PAGE

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Special Report ASICS SPORTS MEDICINE AUSTRALIA CONFERENCE continued... Langkawai Island, Malaysia 25-28 October 2017 load transfer to hip extensors. 3.

Hot coals- foot off the ground as quickly as possible, reducing the knee flexion angle and the plantar flexion angle and increasing the cadence (helps reduce achillies and anterior knee pain). -Kinetic effect-increased ground reaction force, load transfer to hip flexors/extensors.

Chin on the shelf, keep chin horizontal with the aim of reducing the forward lean of the torso. -Kinetic effect- to redistribute anterior load posteriorally and proximally

Some points•

No optimal level of cadence: eg short people fitting into a fast marching cadence get CECS/tib ant pain.

•

Cues are for the change of the recruitment of muscles and loads on muscles to reduce pain, so the aim is to alter the running style but it is not a method of everyone running the same way.

•

Use the cues for 20seconds when running, concentrating on one cue at a time.

•

Use with a walk to run programme-such as walk 4 minutes run 1 minute repeat 5x, building up over several weeks.

•

The aim is to change segmental load patterns (and co-ordination as this is often poor in runners) , so need to strengthen as well- 3x per week- some suggestions- goblet dumbbell squat, rack pull progressing to dead lift, tip toe walk with weight, lunge up to box.

•

With adolescent female knee pain, strengthening before altering running style.

Exertional lower limb pain: a biomechanical approach to load distribution in running. Dr Andy Franklyn-Miller. The incidence of lower limb injury in runners is estimated between 19-78%. Increased risk factors are female, run less than 2x per week or more than 5x,and history of injury (what caused the original injury and if not corrected, then the original problem could still be the problem). Symptoms of chronic exertional compartment syndrome (CECS) are a diffuse burning pain+/- parasthesia with

exercise in the anterior and possibly posterior compartments, symptoms worsening with exercise, may be bilateral, pain on passive stretch post exercise. The pain could be from a variety of causes so it could be a biomechanical overload syndrome. By increasing the speed, the ground contact time decreases, which reduces the forces. Gait retraining is aimed to reduce the symptoms of anterior exertional leg pain: change from anterior torso lean to vertical shin, reduce ground contact time, transition from a rear foot strike to a mid foot strike, hip flexion angle increased. Results showed a reduction in pain score with these modifications. The aim is for big muscles to do the big jobs: in summaryno pathological evidence for CECS, surgical outcome is poor, change in conditions trigger it, gait changes can change symptoms so could be muscle overload. Assessment- previous ankle injury, ankle everter strength, squat (not deep), heel raise, bent knee heel raise (is FHL used to keep sling in foot? Weak FHL= over activation of tib post) hop, sustained single leg squat; to increase dynamic assessment, hop on mini tramp. Look proximal to distal to identify weaknesses. Treatment- 6-8 weeks of twice daily strengthening is recommended (eg single leg bridge for strengthening gluteus+ hams, wall squat, heel raise- encourage weight through 1st ray not lateral foot, heel raises, bent knee heel raise, squat, lunge, step up lunge, progress to mini tramp- catch ball as hop off mini tramp, kick ball, hop on off, sideways etc); address tight structures, coordinate lower limb kinetic chain, Progress exercises- do to fatigue, need to overload. Weighty Issues: Wendy Brown/Louise Burke discussed an Australian study looking at 40 000 women, since 1996. BMI> 25 associated with almost all chronic diseases and symptoms. Younger women today are gaining more weight faster. The proportion of obesity/overweight was 21% in 1996 and 45% in 2008. Older women have reduced physical activity with increasing illness and injury. Another study presented during the conference demonstrated a strong relationship between lower body muscle power and balance among older adults so it is important for the older age group to maintain resistance training to maintain muscle mass and function and to maintain balance leading to prevention of falls. Women are more likely to remain healthy if they have a university degree, low alcohol consumption and have moderate to high physical activity. They are less likely to be healthy if they are separated/widowed, smoke, high sit time, high energy intake and use the oral contraceptive CONTINUED ON NEXT PAGE

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Special Report ASICS SPORTS MEDICINE AUSTRALIA CONFERENCE continued... Langkawai Island, Malaysia 25-28 October 2017 pill. Identify early weight gain- limit to less than 1 kg per year. Perpetual dieters gained the most weight. Conclusion- high physical activity is the best for our health. Recommendations from the presenter were one hour of physical activity per day and physical exercise needs to be regular and taken seriously. If you have > 7-8 hours per day of sitting time there is an increased mortality risk. Increase sitting leads to increased weight which leads to increased sitting which leads to increased weight and chronic disease. Standing up is not sufficient; reducing sitting does not impact on fitness. As the father of occupational medicine, Bernadino Ramazzini stated in 1700- “ when the body is not kept moving the blood becomes tainted, its waste matter lodges in the skin, and the condition of the whole body deteriorates”. Poster presentation – aim to increase advice to older adults-World Masters level athletes were found to tend to focus on the stretches and do less strengthening, education is recommended re strengthening is the biggest protector against injury. Concussion “Risking head trauma in Australian Rules Football”- a player suffering a concussion is 8x more likely to report depressive symptoms in the initial 2 weeks following the injury. An increase total number of head knocks increases the depressive symptoms. Conclusion: increase the awareness to players and educate players around emotional symptoms following concussion. Diagnosis and return to play symptoms based consensus statement: Initial period of 24-48 hours of relative physical and cognitive rest is recommended before RTS progression. 24hr minimum break between each progression, if any symptoms worsen during exercise, go back a step. If symptoms last >10-14 days in adult, >1 month in children, refer athlete to healthcare professional with expertise in the management of concussion. Stage 1- symptom limited activity, stage 2light aerobic exercise-walk, stationary cycling, slow to medium pace, no resistance, stage 3- sport specificrunning drills, no head impact, stage 4- non- contact drills harder training drills, progressive resistance training, stage 5- full contact practice, following medical clearance, stage 6-RTS. Reporting of concussion-like symptoms is influenced by psychosocial/lifestyle factors such as alcohol and sleep. The Shoulder- the dilemma of diagnosis- Dr Jeremy

Lewis The shoulder is the most mobile joint in the body and is able to move the fastest of any joint in the body. The problem that occurs as we age is underuse of the shoulder. Often an older person still has shoulder pain one year after the initial injury, so it was suggested that health professionals should consider giving patient’s the long term skills to manage their shoulder pain, as medical staff would if someone came in with diabetes. The diagnosis is confounded by referred pain from the cervical and thoracic regions and psychosocial factors (such as level of education, > than 1 year of symptoms) which influence outcomes more than physical factors. A stiff shoulder could be adhesive capsulitis, OA, locked dislocation or osteosarcoma. Is the pain nociceptive or central? Pain doesn’t correlate with the degree of the tear. Shoulder Pain and Disability Index and the quickDASH/DASH were recommended as the best shoulder assessment tools. With functional and dynamic assessment of the shoulder, remember the energy transfer system, so keep in mind proximal strengthening as part of the rehab. Have caution with special tests in regards to pain-they are not that specific (“The ‘empty’ and ‘full can’ tests do not selectively activate supraspinatus” Dr Lewis. Dr Lewis states that people with shoulder pain may have inflammatory chemicals in the bursa that stimulate the nociceptors, discrediting the “special tests”, so have patient specific special tests- such as lifting a jug, gym ball push-up. “ As with LBP imaging research, there is a poor correlation between changes seen on imaging and shoulder symptoms” (Dr Lewis). Dr Lewis reports that approximately 50% of people have surgery on tissue that doesn’t require it. He also wants us to challenge the thought that static posture is the cause of the painthere is “no evidence to support definitive scapular posture with impingement syndromes” (Dr Lewis). There is also no evidence that we can make a long term change to posture. The study by Lewis et al 2017 found acupuncture was no more beneficial than exercise alone in the treatment of subacromial pain syndrome. Dr Jeremy Lewis suggests returning to advice, education, health literacy, health initiatives and aiming for 3000-4000 MET per week (MET= metabolic equivalent of a task – the energy cost of a task) 1 MET=O2 consumed at rest. So the daily equivalent requirement is 10min CONTINUED ON NEXT PAGE

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Special Report ASICS SPORTS MEDICINE AUSTRALIA CONFERENCE continued... Langkawai Island, Malaysia 25-28 October 2017 climbing stairs, 15 min vacuuming, 20min running, 20 min gardening, and 25 min walking/running. Rotator cuff- Dr Jeremy Lewis No significant difference in outcomes between open and arthroscopic repair of a full thickness tear of the rotator cuff. At two year follow up, SLAP type1 repairs and biceps tenodesis were no more effective than sham surgery (same rehab) (not relevant for young high level athletes). Exercise is as effective as surgery for subacromial impingement syndrome at 1,2,4 & 5 yr follow up. Exercise reduces the need for surgery by up to 80%. For rotator cuff partial thickness tears <75%, exercise is as effective as surgery. Atraumatic full thickness rotator cuff tears- exercise reduces the need for surgery by up to 75% at 2 year follow-up. It was suggested maintaining and gradually building a high base line of workload as high base line load strength may reduce the risk of injury but high increase in load in one week increases the risk of injury. Reduced external rotation strength and obvious scapular dyskinesis reduces the increase in load a handball player can tolerate before an injury occurs. Non traumatic injuries are caused by inappropriate loads including training and sports. Energy transfer from lower limbs: a 24% decrease at the hips requires a 34% increase at the shoulder. Preventing overuse shoulder injuries in a cluster randomised study looking at 660 elite handball athletes found 28% lower risk of shoulder problems following a 3x per week exercises as part of warm upincorporating glenohumeral movement, thoracic mobility, external rotation strength, scapular and kinetic chain strength. Corticosteroid injections give small and transient pain relief in rotator cuff tendinosis (metaanalysis) and may accelerate tendon degeneration. Should we monitor growth and maturation as risk factors for injury? Patria Hume When growing, there is a reduction in co-ordination and an increase risk of injury. Watch the number, frequency and magnitude of impacts when growing. The author recommended measuring growth by measuring from the greater trochanter to the tibial plateau. There are variable rates in growth and maturation (11-13 yrs in females, 13-15 yrs in males), so measuring is a more reliable method. When sudden grow is occurring; measure every 3 months. The author advised not to stress the athlete by measuring too frequently but it may be useful to explain a reduction in performance, aches and pains etc. Can we reduce injury risk in rugby codes? Prof Patria Hume

Only 4% of NZ population participate in rugby and 50% of the population are inactive, so we need to encourage sport participation but continue with interventions that reduce injury and reduce the effects of injury. • Injury incidence is higher than most other sports • Injury rates vary by participation level, age, sex and country • Knee ligaments, hamstrings, head/neck most frequent injury • Concussion is frequent • Tackles and scrums frequent causes of injury Concussion is linked to dementia, depression and suicide, although there may be confounding factors such as alcohol/drug use. Rugby union has the highest concussion ACC claims. “The impact of concussions on long term balance, cognitive brain function, long term musculoskeletal and cardiovascular health in athletes requires further targeted research”. So from provincial New Zealand to a fine resort on beautiful Langkawi Island, listening to world class speakers, experts in their field; what is my advice to other clinicians? Aim high and go to conferences it is a wonderful opportunity to network and meet inspiring people, glean the latest information and challenge your thinking. Thank you to SEPNZ, Asics and SMA for providing me with this wonderful experience. By Therese Gray Extra: ATI- interesting study looking at 25 people who received autologous tenocyte injection (tenocytes removed cultivated, injected back into the CET) for treatment of common extensor tendinopathy (following 6 mths unresolved symptoms and failed conservative management), 88% returned to work after 2 months, 90% had reduced pain at rest.

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SPRINZ IMPLEMENTING INDIVIDUALISED EXERCISE TO BETTER MANAGE CHRONIC ILLNESS WITHIN A MULTIDISCIPLINARY TEAM SETTING By Matt Wood Matt Wood was recently invited to speak at the annual Sports Physiotherapy Symposium on the role individualised exercise can play in assisting people manage their chronic illness and how clinical exercise physiologists can work within the current healthcare system to achieve this.

The benefits of exercise in improving the quality of life for people living with most forms of chronic illness or disease has been widely discussed, researched and accepted as a valid means of symptom management. What is less accepted is the method of prescribing exercise to these people. A targeted approach seeking to match exercise prescription to an individual’s specific needs and abilities (individualised exercise) is seen to give the most benefit, as compared to a generic prescription approach. While individualising exercise to each person’s unique circumstances seems common sense there are varying levels of “individualised” prescription occurring depending on the practitioners skill set, access to testing equipment, funding and time. This then poses the challenging question of what constituents true exercise individualisation and how to apply this in a real world setting to achieve the best results for our patients. The current gold standard to exercise testing and prescription is a Cardiopulmonary Exercise Test (CPET) using gas analysis (and ECG if required). This method allows a clinical exercise physiologist (CEP) to safely monitor a comprehensive range of key physiological measures in real-time which provide the capability of detecting the smallest worthwhile training effect. This translates into giving the CEP the ability to accurately prescribe threshold based exercise parameters and achieve a true individualised auto-regulatory exercise prescription regime. In addition it removes the potential for reliability test – retest errors associated with other widely used field based tests i.e. 6MWT. Unfortunately in the New Zealand setting this is a relatively new and underutilised method for prescribing exercise. A big challenge facing the expanding CEP profession is integrating their services with the existing health care professionals and promoting a coordinated multi-disciplinary approach to improve the health outcomes of people living with chronic illness. This is particularly apparent with the interactions between physiotherapy and CEP. Physiotherapists see a wide

range of patients, including those who may have undiagnosed conditions or multiple risk factors. This puts their profession in a pivotal position to screen and inform patients about the potential treatment options available. A collaborative approach between these professions would encourage a higher uptake of patients undergoing a CPET, which will ultimately lead to a more specific treatment regime and better health outcomes. Ultimately, a coordinated approach between all health care providers which provides each patient with a customised and individualised exercise treatment regime delivers the best short and long term health outcomes. Exercise should not be viewed as a one size fits all approach when managing chronic illness. Rather it should be seen as a specific intervention which needs to be prescribed based on the unique presenting symptoms and physical abilities of each patient. This in turn improves exercise adherence and self-efficacy which results in a greater improvement to overall quality of life. Clinic Brief: The Human Potential Clinic (HPC) bridges the gap between the medical community and fitness industry. This unique Clinic specialises in providing Clinical Exercise Physiology services to the greater Auckland region. The role of the clinic is to provide evidencebased, advanced exercise assessment and prescription for people living with a wide range of risk factors and medical conditions including cardiovascular disease, cancer, metabolic conditions and mental health conditions. Matt Wood Bio: Matt Wood is a lecturer at AUT University in the School of Sport and Recreation and manager of the AUT Human Potential Clinic that provides clinical exercise physiology services. Matt’s current research interests involve the optimisation of exercise prescription for people living with chronic disease

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SPRINZ

IMPLEMENTING INDIVIDUALISED EXERCISE TO BETTER MANAGE CHRONIC ILLNESS WITHIN A MULTIDISCIPLINARY TEAM SETTING continued...

By Matt Wood Referral Process The Human Potential Clinic currently operates as a private clinic and is not tied into the public health system. This means that patients do not require a formal referral from a G.P or specialist to attend and can book an assessment through our website or phone. However it would be useful to have a referral letter with accompanying relevant medical history. Costs for this service range from $100 for an exercise advice and consultation assessment through to $249 for a full cardiopulmonary assessment with breath by breath gas analysis and ECG monitoring. Normally we will discuss with you the most appropriate form of assessment that you require. Website: http://www.autmillennium.org.nz/clinics/human-potential-clinic/ Email: hpc@autmillennium.org.nz Phone: 09 921 9999 etxn 7848

Clinical Section - Article Review GENERAL PRACTITIONERSâ&#x20AC;&#x2122; PERSPECTIVES ON A PROPOSED NEW MODEL OF SERVICE DELIVERY FOR PRIMARY CARE MANAGEMENT OF KNEE ARTHRITIS: A QUALITATIVE STUDY *Rachel Nelligan1 *Jenny Setchell2 * Lou Atkins3 *Kim L. Bennell BMC Family Practice series- open, inclusive and trusted 2017 18:85 https://doi.org/10.1186/s12875-017-0656-7 Effective management of people with osteoarthritis (OA) requires development of new models of care, and successful implementation relies on engagement of general practitioners (GPs). Semi-structured telephone interviews with GPs were conducted to elicit perspectives on a remotely delivered service to support behavioural change and self-management for patients with knee OA. GPs expressed concerns about potential for confusion, incongruence of information and advice, disconnect with other schemes, loss of control of patient care, lack of belief in the proposed service, resistance to change through lack of knowledge about the service, and reluctance to trust other health professionals to deliver the standard of care. GPs also recognised the potential benefits for patients.

Osteoarthritis (OA) is a major cause of pain and disability. The knee is one of the most commonly affected joints and pain from OA knee can lead to severe disability and loss of function as the disease progresses.[4] Clinical practice guidelines for knee OA emphasise non-surgical, non-drug treatment with particular core management around exercise, weight loss, and education. Optimal care requires patients to

be empowered to self-manage with long term behavioural and lifestyle changes. Barriers have been highlighted to recommended optimal care and are exacerbated for people with multiple morbidities, mobility issues, language barriers and geographical challenges. An Australian model for primary care management of knee OA includes a multi-disciplinary team of health CONTINUED ON NEXT PAGE

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Clinical Section - Article Review GENERAL PRACTITIONERS’ PERSPECTIVES ON A PROPOSED NEW MODEL OF SERVICE DELIVERY FOR PRIMARY CARE MANAGEMENT OF KNEE ARTHRITIS: A QUALITATIVE STUDY continued... professionals using a remote delivery option to provide ongoing ‘care support’. The GP refers the patient to the ‘care support team’ after an initial consultation and this team will have expertise in current best practice for managing knee OA. Since GPs refer patients to the care support team successful implementation relies on GP acceptance and engagement. This paper is a study to identify GPs’ perspective on potential barriers and facilitators to engagement with the proposed model to support knee OA management. Data was collected by semistructured telephone interviews and analysed using interpretive thematic analysis described by Braun and Clark [42]. Findings were them organised into the APEASE (affordability, practicability, effectiveness, acceptability, side-effects/safety and equity) framework. The study used qualitative methodology to understand the factors that could influence GPs’ engagement with a proposed new service model that would support care for patients with knee OA. Many GPs were concerned about the effectiveness however this may reflect inaccurate or inadequate knowledge of the evidence for effectiveness of treatment options for OA. There were mixed perceptions about the need for such a service. Research would suggest that this reflects a lack of understanding about the differences between self-management programs and other practice nurse, allied health and community services [43]. GP’s may perceive the need of their patients differently to their actual needs focusing on pathology and treatment rather than pain and fear of disability [21].Lack of a perceived need for the service may also demonstrate lack of awareness that the current service is failing to deliver optimal care to patients with knee OA [3,46,47]. Lack of trust related to familiarity, credibility and perceived sustainability was identified as a major potential barrier. Having a personal relationship with the ‘care support team’ was seen as important to facilitate communication and develop trust. Change that challenges existing practice is not always welcome [45]. Resistance from GPs due to concerns about other health practitioners encroaching on their area, the conflict with the business model of GP practice and that they were too busy to embrace a new initiative were identified [45]. There were concerns about GPs losing control of their patients’ care and the potential for

the care provided by the remote team to be inconsistent with their own management. Sustainability of the program would also affect their engagement [49]. Individual, professional autonomy and maintaining a level of control of patient care is important for GPs and need to be supported during service changes [50]. Most GPs believed their patients would either fail to attend, fail to change their behaviour, feel they did not fit in or become anxious to the information promoting selfmanagement. Clinician acceptance of a new service has been shown to be the most important driver of change in primary care initiatives [45,51]. GPs generally have negative attitudes towards managing knee OA [19,20,21,22]. In most cases the concerns raised by GPs seemed legitimate, in particular trust. Practical solutions to their concerns may help alleviate their some resistance. Proactively creating opportunities to interact directly with personnel at an early stage would help build familiarity and relationships. Education to build GPs’ knowledge and confidence about recommended primary care management of people with knee OA should be provided. Successful implementation of any new model of service delivery in primary care relies on engagement by GPs. This study identified several issues related to engagement with the main negatives being concerns about potential for confusion, incongruence of information and advice, disconnect with other schemes and initiatives, reticence by GPs to embrace the proposed service due to perceptions of loss of control of patient care and lack of belief in need and benefits, resistance to change because of lack of familiarity with the procedures and the personnel, and reluctance to trust their skills and abilities. GPs also recognised the positives of extra support, and improved access to health professionals with specialist knowledge. This article highlights that effective management of people with chronic disease, in particular knee OA, relies on engagement of GPs. The issues identified can be used to develop possible strategies to improve engagement and up-take of a remotely-delivered ‘care support team’ model by GPs. By Pip Sail, physiotherapist

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Clinical Section - Article Review EFFECT OF PHYSICAL ACTIVITY AND DIETARY RESTRICTION INTERVENTIONS ON WEIGHT LOSS AND THE MUSCULOSKELETAL FUNCTION OF OVERWEIGHT AND OBESE OLDER ADULTS WITH KNEE OSTEOARTHRITIS: A SYSTEMATIC REVIEW AND MIXED METHOD DATA SYNTHESIS Alrushud, AS, Rushton AB, et al

The authors of this paper undertook a review of the research that had been undertaken to assess the effectiveness of combining an exercise and a weight loss programme on the functional and pain status of knee osteoarthritis (OA) sufferers - over 55 years old with a BMI more than 25kg/m2. Obesity is considered an important risk factor for knee OA progression with the goal of weight reduction allowing better function and reduction of pain. One of the limitations of this research is that only three eligible papers were found that had followed randomised controlled trials (RCTs) researching the above parameters and each of those papers included trials conducted by the same research group. Interestingly the comparator/control group in two of the papers described the participants as being part of an exercise group (1hour, three times a week), while in the third paper the control was instructed on a ‘healthy lifestyle’. The success of an intervention was assessed by functional testing, pain scores, self-reported performance measures, strength testing and biochemical markers. The literature supports intervention primarily of a multidisciplinary nature – combining weight loss advice, exercise encouragement, patient education and pain management. (ref 1,11,14-17) It was difficult for the writers to quantify the impact of the combined approach of weight loss and exercise over the time frames (6, 12 and 18 months) versus either of those interventions alone. Results were varied as to the effectiveness of the combined approach, with some improvements in pain reduction and Quality of Life scores. There was no clear outcome from the research to be able to suggest optimal levels of dietary and exercise interventions for OA sufferers. Results from the combined approach and the exercise or diet alone groups, all demonstrated benefits. What this research did establish is that additional RCTs need to be undertaken to further investigate the specifics of the differing treatment strategies for OA. This would help direct treatment providers to deliver best care for the increasing number of OA sufferers. By Rose Lampen-Smith

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Continuing Education Sports Performance and Prevention Conference The Sports Performance and Prevention Conference is the perfect 1-day event for anyone involved in the NZ sporting industry with responsibility for developing and ensuring the performance, well-being and health of our athletes and sports people. Taking place on Feb 17th 2018, tickets are on sale now www.sppconference.co.nz/register. Don’t miss out.

Online Survey Evaluating the decision-making process for shoulder injuries in primary care

Your help is needed as a registered physiotherapist working in the musculoskeletal area: I am a PhD candidate at the School of Physiotherapy and my topic is: Evaluating the decision-making process for shoulder injuries in primary care I am conducting an online survey, consulting New Zealand registered physiotherapists, on their opinion regarding pre-determined key factors when deciding which patient will benefit from a referral to shoulder surgery. This survey will take approximately twenty minutes, and at the end of the survey there is link to ask about yourself. On completing the survey, you will be able to see your own preferences and if you have further interest in the project I can update you with the results. Physiotherapists that have taken part in the earlier focus groups have been very interested and keen to keep in touch. Click this link for project information sheet and see below for consent form. Karen Taylor PhD Candidate ……………………………………………………………………………………………………………………………………….. CONSENT FORM FOR PARTICIPANTS Ethics: University of Otago D17/223 I have read the Information Sheet concerning this project and understand what it is about. All my questions have been answered to my satisfaction. I understand that I am free to request further information at any stage. I know that:1. My participation in the project is entirely voluntary; 2. I am free to withdraw from the project at any time without any disadvantage; 3. Personal identifying information (email contact) will be destroyed at the conclusion of the project, any raw data on which the results of the project depend will be retained in secure storage for at least five years; 4. There is no risk to participating; 5. The results of the project may be published and will be available in the University of Otago Library (Dunedin, New Zealand) but every attempt will be made to preserve my anonymity. I agree to take part in this project by self-enrolling, via the link to the 1000Minds website and receiving a verification email.

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Research Publications British Journal of Sports Medicine www.bjsm.bjm.com

Volume 51, Number 24, December 2017 CONSENSUS STATEMENTS Evidence-based framework for a pathomechanical model of patellofemoral pain: 2017 patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester, UK: part 3 Christopher M Powers, Erik Witvrouw, Irene S Davis, Kay M Crossley Exercise and pregnancy in recreational and elite athletes: 2016/17 evidence summary from the IOC expert group meeting, Lausanne. Part 4—Recommendations for future research Kari Bø, Raul Artal, Ruben Barakat, Wendy J Brown, Gregory A L Davies, Mike Dooley, Kelly R Evenson, Lene A H Haakstad, Bengt Kayser, Tarja I Kinnunen, Karin Larsén, Michelle F Mottola, Ingrid Nygaard, Mireille van Poppel, Britt Stuge, Karim M Khan EDITORIALS Lessons to be learnt from the study ‘Sham surgery versus labral repair or biceps tenodesis for type II SLAP lesions of the shoulder: a three-armed randomised clinical trial’ Ann M Cools, Dorien Borms The new concussion in sport guidelines are here. But how do we get them out there? Caroline F Finch, Peta White REVIEWS Exercise to prevent falls in older adults: an updated systematic review and meta-analysis Catherine Sherrington, Zoe A Michaleff, Nicola Fairhall, Serene S Paul, Anne Tiedemann, Julie Whitney, Robert G Cumming, Robert D Herbert, Jacqueline C T Close, Stephen R Lord ORIGINAL ARTICLES Sham surgery versus labral repair or biceps tenodesis for type II SLAP lesions of the shoulder: a three-armed randomised clinical trial Cecilie Piene Schrøder, Øystein Skare, Olav Reikerås, Petter Mowinckel, Jens Ivar Brox

http://bjsm.bmj.com/content/

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Classifieds AUCKLAND CITY Bodyreform Musculoskeletal Physiotherapy Private Practice $75,000 - $90,000 a year plus

Position available from December 2017, Grey Lynn

Motivated physio who is keen to learn new skills, in-particular spine-care and rehab of shoulder and hip pathologies. An exciting job opportunity is available for a hard-working and passionate physio to join the Bodyreform team. Modern, warm and friendly rehabilitation clinic, close to the heart of Ponsonby. Gain knowledge and valuable skills learnt from International Physiotherapy specialists (Spine-care and Ultrasound Imaging) In-service, online training, and generous money allowance towards courses. Allowance increases per year of working. Bodyreform Physiotherapists par-take in ongoing external courses, both within NZ and overseas, journal readings, case-study meetings about clients. Team focus and flexibility within work hours are qualities we possess. Generous fund towards education offered by Bodyreform. Successful candidate will learn the use of Real Time Ultrasound Imaging within a rehabilitative setting. You will be required to work with three others, with flexible hours. Alternating start and finish times, with a varied caseload which will include manual therapy, rehabilitation and clinical pilates. Very flexible work schedule leaves you more personal time. Pilates experience would be favourable. In-house training is available. Therapist must also be able to work independently at times, possess confident inter-personal skills and achieve selfdirected learning. We work on a per hour basis, 30/60 minute treatment times. We have a loyal following of clients and referral networks which keeps growing each year. Please contact Sarah 021 751 472, email CV to sarah@bodyreform.co.nz

Proactive Physiotherapists Join an innovative market leading organisation thatâ&#x20AC;&#x2122;s growing! Utilise your expertise to provide a bespoke and holistic service within a MDT Work and build experience across a full spectrum of services Wellington | Tauranga | Palmerston North Weâ&#x20AC;&#x2122;re in full on growth mode with opportunities starting ASAP in Wellington, Tauranga, and Palmerston North! With our holistic and innovative approach to transformational rehabilitation, we're proud to be leading the way in New Zealand! We are the only rehabilitation centre in the country to offer such a broad suite of options across mind, body and spirit. The opportunity Work alongside some of the best as you further develop your clinical expertise, or harness the leadership development opportunities we have available. We're a friendly bunch, where our multidisciplinary team take a collaborative approach ensuring we support each other, and provide our clients with the best possible outcomes. You could be working across our full spectrum of client centred services including: Acute physio, Vocational Rehabilitation and Pain Management, Social Rehabilitation, School Based Clinics and gameday physio for sports teams. Who are we looking for? Results driven physiotherapists, who put their clients at the centre of everything they do Ability to tailor approach to meet individual clients needs Great team player with exceptional people skills Two years' experience minimum, however training is provided across our range of services Interested? Email your application to kate.triplow@proactive4health.co.nz or Kate on 022 6933 647 for more info. Applications close Sunday 17 December

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Classifieds TAURANGA Foundation Sports and Rehabilitation Clinic Sport physiotherapy position • • •

Are you looking for a job working with a fun dynamic and experienced team? Do you want to work alongside other highly qualified physiotherapists, massage therapists, sports physician, dietician, mental skills coach and strength and conditioning coaches? Do you want the opportunity to further develop your skills and work with elite athletes?

We are in need of another high quality sports physiotherapist. Foundation Sports & Rehab Clinic is Tauranga’s leading sports physiotherapy and rehab clinics. Generous appointment times allow for an emphasis on manual/manipulative physiotherapy and exercise prescription encompassing full rehabilitation. We have several clinics across the greater Tauranga area. All of our clinics have great rehab facilities including working as part of aspire Sports Med located within the Bay of Plenty’s leading Health Club “aspire Health and Sports” as well as Mt Manganui’s newest athlete training facility “THE ATHLETE FACTORY NZ” The position is permanent full time, however part time options will be considered for the right person. There will be opportunities to work with various sports codes ranging from amateur to semi-professional. Start date negotiable, ideally Jan-Feb 2018. Remuneration package to be discussed, with various options available, including allowance for CPD. We have a well-established pathway to clinic management for people interested in this. We are looking for a fun, competent, hard-working physiotherapist with high work ethic, excellent communication and enthusiasm who is keen to learn and enhance their clinical skills. At least 3-5 years experience working in sports or private practice preferred, however applicants with any sports physio experience will be considered. All applications will be treated with utmost confidentiality. For more information check out our website www.foundationclinic.co.nz For expressions of interest forward your CV and covering letter to: Craig Newland:craig@foundationclinic.co.nz

AUCKLAND FORM Physio Physiotherapist wanted FORM Physio is a recently established clinic looking for a physio to join the expansion. FORM is located on Sale Street inside a premium boutique medium sized gym - Loft 45. This environment creates a unique setting for progressive rehab and training of clients. Cross Referrals and learnings with resident massage therapists, Exercise specialists and osteopath make for a unique continued learning environment. Client base includes local public, referrals from the gym and strong link to Les Mills clients and local cross fitters and Football clubs makes for a wide variety. With a strong focus on extended treatment time, personalised care, tight referral loops the emphasis is on quality of care. Looking for a physio passionate about our profession and passionate about care. Please enquire if this fits your bill. Phone Rob Lee 021848626 or email: rob@formphysio.co.nz