February 2014 bulletin by Sports & Exercise Physiotherapy NZ

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ISSUE 1 l FEBRUARY 2014

BULLETIN FEATURE TOPIC: Tennis: Factors Influencing Injury and Performance 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 Dr David Rice Chelsea Lane Kara Thomas

Welcome to the February 2014 Edition In this Edition: EDITORIAL: By Dr Angela Cadogan

LATEST NEWS

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Sports Physiotherapy New Zealand AGM The SPNZ AGM for 2013 will be held at the Millennium Hotel, Rotorua on the weekend of 15 th and 16th March during the 2014 Symposium â&#x20AC;&#x153;Exercise Across the Lifespanâ&#x20AC;?. Official notification along with more details will be provided as they become available.

SPNZ Farewells Dr Tony Schneiders This year marks a changing of the guard for SPNZ. Dr Tony Schneiders is leaving SPNZ after 17 years on the Executive (12 of them as President) to take up a new role as Professor and Discipline Leader-Physiotherapy at Central Queensland University. Tony has made a significant contribution to this organisation during his time as President, and in his role as the International Federation of Sports Physical Therapy (IFSPT) Board Member and representative. He oversaw significant growth in the SIG, which has grown considerably in numbers and, with the structures he put in place, has seen a growth in the profile of sports physiotherapy in New Zealand, and a corresponding increase in sports-specific physiotherapy education. He has personally contributed significantly to the sports physiotherapy body of knowledge in the areas of sports screening, and concussion, and we know he will continue with these research activities in his new role and will hopefully continue to present his research at our biennial symposia. We would like to thank Tony on behalf of all SPNZ members for his contribution over the years, and we wish him, and his family all the best for their move across the ditch.

Sports Physiotherapy Code of Conduct Dr Lynley Anderson and the SPNZ working party are pleased to announce that consultation on the Sports Physiotherapy Code of Conduct has been completed, and the final document will soon be available on both the SPNZ and the Physiotherapy New Zealand website. The document clearly states the standard of professional conduct that SPNZ will promote and expect from our members when working as Sports Physiotherapists in any capacity. This is a living document that will be reviewed at appropriate intervals and will provide guidelines for the professional conduct of physiotherapists working in the sporting environment where the desire for sporting success often conflicts with patient welfare. We recommend anyone working in the area of sports physiotherapy to read this document, and we welcome and encourage anyone working in the area who has questions regarding ethical questions or specific situations to contact SPNZ.

Thank You to Our Contributors As we begin 2014, I would like to take the opportunity to thank all the physiotherapists who have contributed to putting the SPNZ bulletins together over the past year. As is the case with all of our "feature" contributors too, these physiotherapists already lead busy lives, juggling sports commitments with business and family demands while attempting to maintain their own health and fitness. I am grateful for their enthusiastic support and particularly wish to thank Charlotte Marshall (previously Raynor) for her enthusiastic help and wish her well with her new career in Melbourne. Go well. Aveny

SPNZ SYMPOSIUM 2014

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3rd Sports Physiotherapy Symposium

Sport and Exercise Across the Lifespan Rotorua March 15-16th 2014 Confirmed Key Note Speakers: Professor Craig Purdam - Head of Physiotherapy Australian Institute of Sport Mary Magarey - Specialist APA Sports & Musculoskeletal Physiotherapist

Other Great Speakers Include: Dr Ben Speedy - Exercise and the older Mr Andy Stokes - Shoulder surgery through the ages person Rod Corban - Sports Psychologist

Dr Tony Schneiders - Concussion

Erica Hinckson - Exercise in children

Dr Lynley Anderson - Sports ethics

Last chance to register Provisional programme now available on the Symposium website. Register at: www.spnz.org.nz/symposium

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MEMBERS ’ BENEFITS

There are many benefits to be obtained from being an SPNZ member. For a full list of Members’ Benefits visit http://sportsphysiotherapy.org.nz/benefits/ In each Bulletin we will be highlighting individual member benefits in order to help members best utilise all benefits available.

ASICS BENEFITS Asics Education Fund

http://sportsphysiotherapy.org.nz/members/education/

SPNZ has funding for Members who wish to attend courses or conferences that are relevant to the field of Sports Physiotherapy for the furtherance of education in Sports Physiotherapy. It is available twice yearly. Applications close March 31st and August 31st.

OBJECTIVES OF THE SPNZ EDUCATION FUND 

 

For grants to members of the SPNZ, a SIG of the NZSP, who wish to attend courses or conferences that are relevant to the field of Sports Physiotherapy for the furtherance of education in Sports Physiotherapy. For grants to members of the SPNZ who wish to undertake research in fields relevant to Sports Physiotherapy For such other purposes in the opinion of the majority of the Approval Committee as shall be for the education or benefit of the members of the SPNZ.

Asics Shoes and Apparel

http://sportsphysiotherapy.org.nz/members/asics-information/

Asics provides footwear and clothing to Members at a reduced rate. These are available directly from Asics. There is a order form in the Members section of the website. Find a style, size and colour you want, fill out the form and send it off

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FEATURE PHYSIOTHERAPIST - CAROLE DOHERTY

SENIOR DIRECTOR, SPORTS SCIENCES AND MEDICINE DEPARTMENT, WOMEN’S TENNIS ASSOCIATION By Carole Doherty Grad Dip Phys MCSP, Grad Dip, Academic and Practical Physiotherapy in Sport.

Carole graduated from St Mary’s Hospital London in1985. She has 20 years experience in sports physiotherapy and 18 years in her current position. She is currently Senior Director, Sport Sciences and Medicine Department, Women’s Tennis Association (WTA) She has also had sports physiotherapy experience with soccer UK.

ABOUT THE WTA The WTA is the global leader in women’s professional sport with more than 2,500 players representing 92 nations competing for a record $96 million in prize money at the WTA’s 53 events and four Grand Slams in 32 countries. The WTA is a membership organisation and is the administrative body for women’s professional tennis, servicing players ranked from number 1 in the world to approximately 200. The headquarters is located in St Petersburg, Florida, and is comprised of many departments from: communications, marketing, and operations to sport sciences and medicine (SS&M). The SS&M department is made up of a head of department (non clinical role), eight full-time/ nine independent contractor specialists sports physiotherapists, six massage therapists, player welfare officer and a coordinator of the department. To oversee the medical care provided to the athletes there is a team of medical advisors that include an orthopaedic sports medicine doctor, internal medicine/sports medicine doctor and a sports dietician. The department also has medical consultants to advise on an as needed basis. These include a podiatrist (specialising in tennis), psychologist, sports dermatologist, tennis bio-mechanist, hydration specialist and a physiologist. At every WTA event and Grand Slam the SS&M department of the WTA provides the WTA sports physiotherapists and massage therapists. These therapists are part of the “team” as described above with local massage therapists sometimes utilised as well. Each event provides a local tournament physician, who is required to have a sports medicine background. A training room is set up, standardised supplies are shipped into the event and the therapist’s hand carries the more specialised equipment. Each event is required to meet a tournament standard in regards to the facility, equipment and performance food provided; this ensures that the athletes are serviced to the highest level. How did you become involved in your current role? I joined the WTA in 1996. I was working in a sports medicine clinic which was based in a tennis club in London; and had completed my post graduate sports medicine diploma at the London hospital. I was also involved with a local soccer team providing pitch coverage, training sessions and clinics. My first sporting love has always been tennis, having played from an early age and being a fan of the game. I applied for a position with the WTA, had an interview with the head of the SS&M department during Wimbledon, and was offered some independent contractor work. This involved providing coverage at a number of International Tennis Federation [ITF] events in Europe. I absolutely loved the job and when I was offered a full time position with the WTA I snapped it up! In my early days with the WTA I worked 23 events in a year and was involved in the initiation and implementation of many of the WTA SS&M programs that exist today. Over the course of the past 18 years my role has changed considerably and I am now in a management position.

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Physiotherapist - Carole Doherty continued… CONTINUED FROM PREVIOUS PAGE. What are your roles in working with this team? I am Senior Director of the WTA SS&M department. This involves overseeing and running the daily operations of the department and includes the following:  

Building and managing the annual budget for the department. Yearly staff scheduling. Full time employees work 10-16 events and when they are off the road they have an administrative role - coordinating a program. Independent contractors work eight – ten events a year.  Source and manage all supplies that are provided to the staff and to the tournaments.  Recruitment of staff.  Oversee the staff, staff training/orientation/program management and daily onsite operations.  Assist with the overall strategic planning of the department.  Develop and manage policy and procedures for the department.  Travel to eight events in the year providing clinical coverage to the athletes and clinical instruction to the staff. I have a large administrative role, which I am able to do from my home office in Whangarei and I have a couple of trips a year to the headquarters in the USA

What are your specific tasks/responsibilities: 

Between competitions/events

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In preparation for competitions/events

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During competitions/events

The uniqueness of working in the professional women’s tennis means that we see the players when they are "in competition". The WTA players travel internationally to compete and may play matches every day while at a tournament. The WTA staff who take care of the players are physiotherapists who are called “Primary Health Care Providers” (PHCP). This best describes our onsite role, being the first medical practitioner the athletes will come to. Athletes who require first aid, emergency care, health or medical services seek the advice and treatment from the PHCPs and Tournament Physicians. This service is carried out through a comprehensive evaluation and treatment plan, which emphasizes manual therapy techniques and functional therapeutic exercise. We arrive on site at a tournament the day before the event starts. We set up a training (treatment) room and begin providing treatment from that day to the end of the event. We are on call to the athletes 24/7 and therefore have our first aid/court kits with us at all times. The athletes know that they can call on us at any time of the day or night, if they are sick. Once the tournament starts we arrive on site one hour prior to the start of matches and are there up to an hour after matches have finished. A typical day would involve match prep, taping, dynamic warm ups, nutrition/hydration advice through-out the day. We may be called to court to evaluate an injury/illness. Under the rules, we are allowed the evaluation to be “within reasonable time, but with best efforts not to exceed three minutes”. If we deem the injury/ illness to be treatable then we are allowed to take a three minute medical time out (MTO). If the injury/illness falls out of our scope of practice we can call the tournament physician to the court. These moments are where excellent clinical reasoning skills are needed and then seamless execution of the treatment choice. The MTO rule is primarily there for safety of play. The main job of the PHCP is to assess if the player is safe to continue and if so, decide what treatment interventions are going to help the athlete the most. We are very involved in the athletes post match care and recovery, this includes cool down techniques, static stretching, nutrition and hydration advice, cool pool, massage, etc. If athletes are carrying injuries we will treat those as necessary. Our emphasis is on prevention of injuries and much of our time is spent on education. We keep our athletes up-to date with the latest trends in sports medicine prevention by distributing monthly “Physically Speaking” topics. We track each athlete’s physical health through our Sport Specific Physical Examination and design individualized programs to meet our athletes’ training goals while targeting injury prevention based on the physical examination results. CONTINUED ON NEXT PAGE.

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Physiotherapist - Carole Doherty continued… CONTINUED FROM PREVIOUS PAGE. On a daily basis the PHCPs can offer a wide range of services to the athletes. These include: 

Athlete’s Assistance program that provides athletes with educational and preventive strategies to enhance their on-court performance and cope with the challenges of professional tennis. Assistance can be accessed through monthly education topics, the Athlete Assistance phone services and website, and via trained on-site staff.

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Functional Biomechanical Assessment. We offer comprehensive assessment of the athlete’s functional biomechanics, which may include foot mechanics, stroke mechanics, and the relationships between biomechanics and functional sport-specific movements. Based on results of the assessment, individual treatment plans are created to address an athlete’s functional biomechanics.

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Equipment Assessment. This service is provided for WTA athletes who require equipment intervention such as custom orthotic devices, shoe evaluations and recommendations for high performance clothing. The SS&M team incorporates the assessment of various aspects of equipment in relation to injury prevention and performance. Our team consults with outside experts and works with equipment manufacturers to provide input into the design of shoes and equipment specific to the elite female athlete’s needs.

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Nutrition and Hydration Program. Athletes can access the WTA sports dietician advisor and hydration consultant who provide nutrition and hydration assessments to the athletes, as well as advising tournaments on menu plans for the best performance foods offered to the athletes. Supplements may also be provided, when necessary. USANA Health Sciences Inc provides high quality pharmaceutical grade, dietary supplements with a guarantee of purity from banned substances.

Obviously, communication between the SS&M team members is paramount and this is achieved by using a confidential web based medical documentation system. Each athlete care treatment plan is well coordinated and communicated to all team members. Follow-up services are offered to all athletes to ensure continued care throughout the year, both on and off the road. This follow-up is conducted by the WTA SS&M team which directly coordinates the appropriate care for an athlete or communicates with the athlete’s personal medical team to streamline the health management of the athlete and ultimately provide the most comprehensive care. What are the types of injuries you commonly see? The WTA season runs from the beginning of January through to the end of October and is played on predominantly three different surfaces: hard court, clay and grass. The calendar was designed on the principles of Periodization, considering: athletes building their base, pre competition, peaking in competition and recovery breaks. The calendar follows a structured geographic flow, as well as, different surfaces being grouped together. Each surface requires a certain amount of physical adaptation as the properties of the surface vary. This results in common injuries seen on each surface. Grass courts are very fast, the ball bounces low and can be unpredictable and as a result we see more wrist injuries particularly on the non dominant side. There is more chance of hitting the ball late, as the surface is fast and also if players are not getting low enough and not bending their knees it means they compensate with dropping their wrists more into ulna deviation. This may result in injury to the TFCC and or the ECU tendon/retinaculum. If the ball is constantly being hit late or the player has to adjust to an unpredictable bounce, the wrist is forced into excessive extension this can result in ulnacarpal impingement causing bone bruising. Another compensation we may see with the low bouncing ball on grass is low back injuries due to players reaching for the low ball. Clay courts are slow and the ball bounces higher, the rallies are a lot longer on clay, and the balls can get heavy especially if the courts are damp. Players slide on clay and we commonly see more thigh injuries particularly adductor strains due to the sliding and then the quick change of direction. We may also see repetitive overuse injuries of the CONTINUED ON NEXT PAGE.

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Physiotherapist - Carole Doherty continuedâ&#x20AC;Ś CONTINUED FROM PREVIOUS PAGE. upper limb, due to the longer rallies and the balls getting heavy. Hard courts are hard and not so forgiving, and thus we see more joint type injuries â&#x20AC;&#x201C; so back and knee injuries are common. Obviously, environmental factors must be considered; for example, if it is very windy, this has an impact on ball toss during the serve, which may lead to shoulder injuries and abdominal muscle strains. Heat is another environmental factor where we have put safety rules in place and focus our education and intervention efforts on preventative measures as they relate to heat illness conditions.

What have you found to be the key elements of success in dealing with these injuries? The key to success is prevention by education and intervention. Regarding surface change we have developed specific therapeutic exercise protocols whereby athletes can prepare for the new surface prior to making this transition. In hot conditions the PHCPs are extremely proactive with the management of the athletes from the time they arrive in the country of the tournament and begin acclimatization. They are educated and reminded re their hydration/nutrition strategies before, during and after their matches and practices. Cooling techniques are advised, pre match cooling, during and after match cooling. They are advised on the most appropriate clothing to wear, light coloured and of wicking material. The athletes are encouraged to change their clothing as the rule permits at the set change. They are also advised to take advantage of the Extreme Weather Conditions Rule (EWCR) if it is in place, which allows for a 10 minute break between the second and third sets if the temperature is at or above 30.1 degrees C. (For more details see below). The 10 minute break permits them to leave the court and go to a cool room; where they can use a cool pool, cool shower, and change their clothes, while rehydrating. During the 10 minute break they are not allowed coaching or to be treated. The PHCPs are allowed to standby and advise them on what they should be doing during this time.

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Physiotherapist - Carole Doherty continued… CONTINUED FROM PREVIOUS PAGE. WTA EXTREME WEATHER CONDITION RULE OVERVIEW The WTA Extreme Weather Condition Rule allows for a 10-minute break between the second and third set when the Heat Stress Index is at or above 30.1 degrees Celsius/86.2 degrees Fahrenheit or the Apparent temperature reaches 93 degrees Fahrenheit /34 degrees Celsius. Only one of the players participating in the match needs to request the 10-minute break for the rule to be implemented. The HEAT STRESS INDEX is a measure, which factors together the air temperature, the humidity and the radiant heat (or the temperature that is radiating off the court). This is measured by the HEAT STRESS MONITOR, which is placed on the court. The Heat Stress Monitor readings are taken 30 minutes prior to match play, at designated times throughout the day, and just before the last match/start of night matches. In the event that during the day there is a sudden change in weather conditions, as determined by this periodic monitoring, the Extreme Weather Condition Rule may be put into effect at any time on all courts, including matches already in progress. If there is a change in weather conditions and the Rule is lifted, those matches already in progress will be completed under the Extreme Weather Condition Rule. The WTA adopted the Extreme Weather Condition Rule in 1992. In 1996, the ITF and WTA recognized Heat Related Conditions as treatable. This allows a Medical Time Out to be taken for the treatment of any heat-related illness. The WTA Sport Sciences and Medicine department annually reviews the latest scientific findings. And as such, the most recent heat related field research, published by the American College of Sports Medicine, was applied to the 2011 WTA Extreme Weather Condition Rule.) Who else is involved in the ‘support team’ that you communicate with regarding athlete status? As tennis is an individual sport, each athlete usually travels with a certified coach and sometimes a certified fitness trainer. Once we have the written permission given to us by the player we can discuss injuries/injury prevention and management with her team. How do you integrate/work with the trainer/coach with respect to injury prevention or rehabilitation? Once a player has been through her physical and if there are some highlighted follow ups in regards to injury prevention, then we would sit down with the player and the coach/fitness trainer and discuss recommendations, which may include detailed specific exercise programs. This multi-disciplinary approach, with the coach, is critical particularly when a technique/biomechanical component are involved. Are you involved in performance aspects for this athlete/team? Elaborate (if appropriate). As stated before there are many services we offer to the players and as best we can, and if appropriate, we try to involve the athlete’s team as much as possible. What are the major challenges in working with this sport/athlete/event? The athletes are always in competition. This brings certain challenges especially when dealing with an injury which is load related i.e. tendonopathy. We are participating in research with Jill Cook, Australian Physiotherapist, on this topic at present, which may prove to be very beneficial. What are the key attributes you feel are required to work with elite level athletes? A professional physiotherapist working with elite level athletes must be a team player, possessing qualities of loyalty, accountability, ethics and trustworthiness. Working in professional sport is a life style choice; you need to be passionate about what you do and absolutely love the job. And of course, an excellent clinician who has great clinical reasoning skills and the ability to work well under pressure. As Billie Jean King, the founder of the WTA says, "Pressure is a privilege"!

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ARTICLE REVIEW Relationships Between Biomechanics, Tendon Pathology, and Function in Individuals With Lateral Epicondylosis Chourasia A, Buhr K, Rabago D, Kijowski R, Lee K, Ryan M, Grettie-Belling J, Sesto M (2013). Relationships Between Biomechanics, Tendon Pathology, and Function in Individuals With Lateral Epicondylosis. Journal of Orthopaedic and Sport Physical Therapy 43: 368-378. doi:10.2519/jospt.2013.4411 ARTICLE REVIEW Lateral Epicondylosis (LE) is a prevalent and costly musculoskeletal disorder of the common extensor tendon. It is characterised by degeneration of the tendon and patients frequently report pain at the lateral aspect of the elbow. Functional problems can occur due to biomechanical and sensorimotor deficits related to LE. These functional deficits may interfere with occupational tasks and activities of daily living. Treatment of LE remains challenging as the pathophysiology of LE is not well understood and therefore LE is prone to recur. The common tendon origin in individuals with LE is usually thickened and shows increased signal intensity on MRI. The greatest signal abnormality is usually found at the origin of the extensor carpi radialis brevis from the lateral epicondyle of the humerus. The areas of increased signal intensity usually correspond to areas of mucoid degeneration and neovascularisation on histopathologic analysis. Tendon changes due to LE show an increased amount of fibroblasts, vascular hyperplasia, and disorganised collagen. Pain associated with LE may be due to changes in the nervous system as a result of neuronal tissue changes, nociceptive and non-nociceptive processes. Although tendon pathology, pain system changes and motor impairments due to LE are considered related, their relationship has not been investigated thoroughly. The object of the study was to evaluate the relationship between self-reported pain and function and measures of tendon pathology and biomechanics in individuals with LE. Secondary analyses evaluated the relationships between biomechanical and tendon pathology measures. This information may provide a better understanding of the effects of LE on function and its association with biomechanical measures. METHODS Twenty-nine participants with LE were recruited. Diagnostic criteria for LE included the presence of lateral elbow pain for more than three months, tenderness on palpation over the lateral epicondyle and/or extensor mechanism and pain present on at least 2 of the following provocation tests: resisted extension of the wrist or fingers; resisted supination; and passive stretch of the wrist extensors or supinator muscles. Two participants were excluded because they reported concurrent upper extremity injury and data from one participant was excluded because of an instrument malfunction. Twenty-six people were eligible; 11 had unilateral symptoms and 15 had bilateral symptoms. Self-Reported Measures Patient-Related Tennis Elbow Evaluations (PRTEE) Questionnaire: A condition-specific questionnaire that asses both elbow pain and function. It has good test-retest reliability and consists of 5-item pain subscale and a 10-item subscale. Visual Analogue Scale: All participants were asked to rate their average lateral elbow pain intensity for the previous week Biomechanical Measures These included pain-free grip strength; rate of force development and electromechanical delay. Only the results from the affected arm were used for the correlation analyses reported in the paper. In bilateral symptom participants only the results from their most affected arm were used. Pain free grip strength: Valid and reliable measure and commonly used in research and clinical assessment of LE. Rate of force development: A multiaxis profile (MAP) dynamometer was used. Participants were instructed to squeeze the handle as quickly as possible without pain following a visual stimulus. It also provides a measure of grip -free strength but due to the different handle geometry compared to the baseline dynamometer, the grip strength values are different.

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ARTICLE REVIEW CONTINUED... Electromechanical Delay: This was measured using the MAP dynamometer force output and the raw electromyographic (EMG) signal from the extensor carpi radialis muscle. The time between the onset of muscle activation based on the change in EMG signal intensity and the onset of force as measured with the MAP dynamometer is considered the electromechanical delay. Tendon Pathology Measures For those participants with bilateral symptoms, ultrasound was conducted on the most affected arm and MRI bilaterally. For the correctional analyses used in the paper they used results from the more affected arm. When both arms were equally affected the results from the dominant arm were used. Three participants did not complete the ultrasound assessment and 1 participant declined the MRI scan. In total 22 elbows results were available. MRI: A semiquantitative grading scale (from grade 0-3) was used to estimate the severity of the chronic degeneration and pathologic changes in the common extensor tendon origin. Ultrasound: Images were obtained of the common extensor tendon origin in orthogonal planes, long and short axis. The authors used two published scales of neovascularity and hypoechogenicity to grade the severity of LE-specific structural changes of the elbow (graded 0-3) RESULTS PRTEE Questionnaire All partial correlation coefficients were in the expected directions with negative correlation coefficients indicating that higher PRTEE scores were associated with lower grip strength and rate of force development. Positive partial correlation coefficients between PRTEE scores and electromechanical delay indicated that higher PRTEE scores were associated with higher electromechanical delay. Secondary Associations Higher grip strength was found to be associated with higher rate of force development. The greatest correlation occurred between grip-free strength-MAP and pain-free grip strength-Baseline. Imaging measures showed the strongest correlation was that observed between neovascularity and MRI score. There was no statistically significant association between the biomechanical and the ultrasound imaging measures. DISCUSSION The authors found that the biomechanical measures of grip strength and rate of force development were associated with measurements of self-report pain and function on the PRTEE. However there was no statistically significant association between imaging measures (ultrasound and MRI) and measurement of self-reported pain and function. The rate of force development was highly correlated with the PRTEE and it had a higher correlation with the PRTEE than pain-free grip strength. In previous studies by the authors they found the rate of force development was significantly reduced in those with LE compared to matched controls. To perform activities of daily living, a threshold level of strength is required. Greater strength beyond the threshold alone may not necessarily improve function. However a faster rate of force development helps in reaching the threshold strength levels faster and may have a greater contribution towards function. These findings can impact on physical therapy interventions. Whereas resistance training activities for the forearm muscles as well as grip strength activities are common therapy interventions; exercises that address deficits in grip strength may not necessarily address the deficits in rate of force development. The ability to rapidly produce force is most affected by exercises that incorporate a velocity dependent component and not solely resistive strengthening. Unfortunately specific velocity-dependent training in LE has not been studied, although other muscle tendon groups have. MRI was also found to be more sensitive with all participants showing LE. Whereas hypoechogenicity was not observed in 7/23 participants tested. The authors also concluded that the severity of ultrasound and MRI results does not correlate with clinical symptom severity and function. The authors acknowledge that the results of this small single cohort study cannot be applied to patients with acute LE. Larger studies with an emphasis on participants with varied duration of symptoms will increase the generalisability of the study and therefore the relationship between biomechanics, tendon pathology and function of people with LE can be ascertained. Reviewed by Charlotte Marshall MPhty, PGDipPhty, BSc (Hons) Physiotherapy, NZRP

RESEARCH SECTION

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Tennis: Factors Influencing Injury and Performance www.sportsphysiotherapy.org.nz/resources Precooling Methods and Their Effects on Athletic Performance: A Systematic Review and Practical Applications Ross, M., Abbiss, C., Laursen, P., Martin, D., & Burke, L. (2013). Precooling Methods and Their Effects on Athletic Performance: A Systematic Review and Practical Applications. Journal of Sports Medicine, 2013 (43), 207-225. doi: 10.1007/s40279-012-0014-9 Article Review: Precooling is a popular method of avoiding heat-induced fatigue and enhancing performance in a hot environment. Different methods of achieving precooling include external and/or internal (ingestion) application of cold modalities including air, water and/or ice, immediately before exercise. Due to convenience, comfort and effectiveness, cold water and ice have become the preferred methods for use in competition settings. This systematic review sourced 55 studies reviewing the different types of methods and their effectiveness in reducing initial body temperature, decreasing the rate of heat gain during exercise, and improving performance. Immersion in water and the application of iced garments to the skin have been the most common strategies used to precool athletes. These techniques are most useful for improving performance in endurance sports. The most utilised techniques involve 30-min whole-body immersion in tepid (30–22°C) water, or part-body immersion of non-active body parts to cooler (10–18°C) water temperatures. The major advantage of water immersion is that heat loss to water (*4.2 kJ/kg C) is approximately four times greater than air at the same temperature (*1.0 kJ/kg C). Prolonged, intermittent exposure to cold (0–5°C) air has been shown to reduce skin and core temperatures. The majority of studies using cold air exposure as a precooling technique have reported enhancements to exercise protocols, including an increase in cycling and running endurance. This is however a less accessible means of pre cooling for an athlete. Ice vests can provide effective cooling from 15–65 min of application; however they are difficult in a sporting environment to keep cold and transport. Alternatively 5-20 minutes of iced towel application can be just as effective, prepared by rotating the placement of towels that have been dunked in an ice-slurry and wrung dry. This has been shown to improve rowing performance and running distance in trained athletes. Precooling via the ingestion of cold beverages provides the benefits associated with cooling while co-ingesting nutrients. The pre- or mid-exercise ingestion of a large (1 L) bolus of cold (4°C) fluid has been associated with improved endurance performance. Substantial cooling power is added if this liquid is served in the form of a slushie. The ingestion of ice has been shown to not only increase exercise capacity, but may also allow the athlete to achieve a higher rectal temperature at the point of exhaustion. Furthermore, preliminary data indicates that a sensory effect of a stimulus in the mouth that is perceived as cold (i.e. menthol used as a mouth wash) can improve exercise performance, without changes in body temperature. The cold sensation of a periodic 19°C menthol mouth rinse during exercise has been shown to enhance cycling capacity by 9% (5 min), through increasing ventilation by 8 L/min and a 15% reduction in cardiopulmonary rating of perceived effort. Clinical Significance / Applications Finally, the combination of external and internal precooling strategies can be used to enhance cooling effects and can be applied sequentially or concurrently. The combination of external and internal strategies has been shown to significantly reduce core temperature and improve performance and mental concentration. Especially in those athletes who compete in events of 60–90 min duration. Examples of two external precooling strategies being applied sequentially include cool water immersion followed by wearing an iced garment. Alternatively, external plus internal cooling strategies that can be applied concurrently include the ingestion of a cold or ice beverage while wearing an iced garment. Reviewed by Monique Baigent BHsc (Physiotherapy)

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Tennis: Factors Influencing Injury and Performance continued… www.sportsphysiotherapy.org.nz/resources The Sony Ericsson WTA Tour 10 year age eligibility and professional development review Otis CL, Crespo M, Flygare CT, Johnson PR, Keber A, Lloyd-Kolkin D, Loehr J, Martin K, Pluim BM, Quinn A, Roetert P, Stroia KA, Terry PC (2006). The Sony Ericsson WTA Tour 10 year age eligibility and professional development review. British Journal of Sports Medicine 40:464-468.

Article Summary: Concerns have long existed over the participation of adolescent athletes in professional sport. To decrease the risk of negative medical, psychological and developmental effects many sport governing bodies have introduced age limits and professional development programmes (PDPs). This review article investigated the use of an age eligibility rule (AER) and professional development programmes (PDPs) for female tennis players on the Sony Ericsson WTA tour. The review was conducted 10 years following the introduction of the AER, and involved four components: a literature review, surveys, oral testimony and statistical analysis of players’ careers. The literature review concluded that there are physiological risks associated with adolescent growth and development in young athletes who train and compete at elite levels. These risks can be increased by a variety of things including: training errors, poor coaching and parents/coaches who drive the young athletes too hard. This can lead to injury, burnout and dropout. Psychological risks were also noted, and were associated with many factors including: competition, stressors, expectation and loneliness. Surveys were completed by 628 people, consisting of current and former WTA players, members of the WTA tennis community (e.g. coaches, parents, officials), and sports science and medical professionals. The responses to the survey strongly supported the principles underlying the AER as they felt it allowed player growth and development and protected players from burnout and injuries. They also overwhelmingly supported the use of the PDPs. One of the sections of the survey related to the factors that caused stress for the athletes and interestingly the factor that was identified and the main causer of stress was injury. When analysing players’ careers, following the introduction of the AER and PDPs, players have made their professional debut earlier, have increased their career longevity and there has been fewer premature retirements. Clinical Applications: This article shows that there are both physiological and psychological risks associated with young athletes who train and compete at an elite level. But it has also shown that these risks can be managed and/or prevented with the use of AERs and PDPs. Therefore, if we are involved with a sport that has the potential for young athletes to train and play at elite levels. then these types of programmes should be considered and/or implemented. Also, as injury was identified as the top cause of stress for the athletes in this study it emphasises the importance of our job when working with young elite athletes. Reviewed by Greg Usherwood MPhty, BPhEd

RESEARCH SECTION

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Tennis: Factors Influencing Injury and Performance continued… www.sportsphysiotherapy.org.nz/resources

Epidemiology of musculoskeletal injury in the tennis player Geoffrey D Abrams, Per A Renstrom, Marc R Safran. Br J Sports Med 2012 46: 492-498 Article Summary Tennis is played by millions of people worldwide. Participation like any sport, places players at risk for musculoskeletal injury. This article reviews the epidemiology of tennis specific injuries and risk factors for sustaining injuries. Injury prevalence has been reported as ranging from 0.4-3 injuries per 1000 hours played across all levels of players. Most injuries occur in the lower limb, and involve the ankle or thigh. These injuries are more commonly acute injuries whereas upper limb and trunk injuries tend to be of a chronic nature. Prevalence of ankle, elbow, knee, back, hip, tennis leg, shoulder and stress fracture injuries are discussed. Interestingly tennis elbow was found to have a prevalence of only 1.3%. Studies reviewed showed that risk factors to consider for tennis specific injuries were: volume of play, grip position, court surface and hypothetically racquet mechanics. Once players were partaking in greater than 3 hours/week of tennis there was a positive correlation with volume of tennis played and increased rate of injury. Certain forearm injuries were associated with particular grip types used. Studies comparing grass, hard surface and clay have shown risk of injury is less on the clay surfaces. Different racquet mechanics have reduced forearm vibration which has been hypothesised to contribute to the development of ‘tennis elbow” though no study has been able to establish a definite link. Clinical Applications When treating the tennis player particularly with a chronic injury further discussion and assessment is warranted with respect to volume of play, grip position used, and court surface. Age, sex and skill level do not appear to have any association with injury rates.

Reviewed by Deborah Nelson BPhty, PGD Musculoskeletal

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RESEARCH PUBLICATIONS

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JOSPT www.jospt.org JOSPT ACCESS All SPNZ members would have been sent advice directly from JOSPT with regards to accessing the new JOSPT website. You will have needed to have followed the information within that email in order to create your own password. If you did not follow this advice, have lost the email, have any further questions or require more information then please email JOSPT directly at jospt@jospt.org in order to resolve any access problems that you may have. If you have just forgotten your password then first please click on the “Forgotten your password” link found on the JOSPT sign on page in order to either retrieve or reset your own password. Only current financial SPNZ members will have JOSPT online access.

Current Issue February 2014 EDITORIAL Does One Size Fit All When It Comes to Exercise Treatment for Achilles Tendinopathy? RESEARCH REPORT Exercise Only, Exercise With Mechanical Traction, or Exercise With Over-Door Traction for Patients With Cervical Radiculopathy, With or Without Consideration of Status on a Previously Described Subgrouping Rule: A Randomized Clinical Trial PERSPECTIVES FOR PATIENTS Neck and Arm Pain: Mechanical Traction and Exercises Prove an Effective Treatment RESEARCH REPORT Effectiveness of the Alfredson Protocol Compared With a Lower Repetition-Volume Protocol for Midportion Achilles Tendinopathy: A Randomized Controlled Trial RESEARCH REPORT Association Between Centralization and Directional Preference and Functional and Pain Outcomes in Patients With Neck Pain RESEARCH REPORT Differences in Neuromuscular Control and Quadriceps Morphology Between Potential Copers and Noncopers Following Anterior Cruciate Ligament Injury CLINICAL COMMENTARY Uncertainty in Clinical Prediction Rules: The Value of Credible Intervals CASE REPORT Trigger Point Dry Needling as an Adjunct Treatment for a Patient With Adhesive Capsulitis of the Shoulder CLINICAL COMMENTARY Clinical Rehabilitation Guidelines for Matrix-Induced Autologous Chondrocyte Implantation on the Tibiofemoral Joint RESEARCH REPORT Immediate Effects of 2 Types of Braces on Pain and Grip Strength in People With Lateral Epicondylalgia: A Randomized Controlled Trial MUSCULOSKELETAL IMAGING Fractures Through the Base of the Second and Third Metacarpals

ASICS

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ASICS REPORT SHOE REPORT—GEL-LYTE 33 VERSION 2

As you may know the 33 series shoes were aptly named after the 33 joints in the foot and were created to provide athletes with a lightweight trainer to complement their standard trainer in the kit bag. The ASICS GEL Lyte 33 v2 is the second edition to the Lyte 33 range and is designed for the neutral runner. A more supportive shoe in this series, the ASICS GEL Super J33, is due for release later in the year. The main aim of this genre of shoe is not to replace the structured shoes that have been a staple in the footwear market these last 20 years but more as an aid used to ‘mix up’ the running week with a less structured shoe. By doing so a runner would be able to provide a different stimulus to the body and as a result create better ‘adaptation’ and take away the repetitive impact of wearing the same shoe day in, day out. This is similar to a runner using off road terrain, or a cross fit athlete varying their exercises each week as an alternative stimulus to the muscles and brain as a means to improve strength and balance. The Lyte 33 v2 is set on a 6mm pitch using stack heights of 17-11mm (heel – toe). This creates an immediate increase in shoe flexibility and promotes a smoother ride from heel contact through propulsion. The sub-talar joint (STJ) is one of the primary joints around which pronation and supination occur. As such the inclusion of Fluid Axis, the name given to a new ASICS midsole geometry based on the sub-talar joint (STJ) axis of the foot, allows the shoe to greater compliment natural motion of the foot. How does it facilitate this? The Lyte 33 recognises the importance of the STJ as evidenced by a groove embedded in the rearfoot midsole/outsole that runs in the same direction as the STJ axis. By altering the position of this axis a shoe can be designed to be more supportive (Super J33) or neutral (Lyte 33). Fluid Axis then links into Guidance Line, a groove that decouples the medial and lateral portions of the shoe and functions to reduce surface tension, making it easier to plantarflex the foot and reach propulsion quicker. This assists in moving the foot from midstance to propulsion, unloading muscles and improving gait. A two layered midsole consisting of SpEVA (top), ASICS premium cushioning material, and a firmer EVA underlay combine to prevent deformation and breakdown whilst maintaining a cushioned feel when landing on the heel or forefoot. A GEL unit situ-

ated in the rearfoot provides further cushioning should a heel strike occur. The forefoot relies on the 11mm dual density foams for cushioning when heel strike is not occurring. This season the Lyte 33 upper has less structure and is aimed at both reducing weight, via having fewer material overlays, and feeling more natural on the foot. The heel counter has been removed to provide more freedom whilst the outsole has been de-constructed with only key areas having Asics High Abrasion Rubber (AHAR) for durability. The Gel-Lyte 33 is a shoe that hits the mark on many levels. With a 17-11mm platform and dual layered foam it will last the distance and still maintain it’s cushioning. Fluid Axis, Guidance line, multiple flex grooves and flexible heel counter work together to produce a natural feel which will suit the efficient midfoot/ forefoot runner but still provide good cushioning and decoupling in the heel to manage heel striking on uneven terrain or when muscles fatigue. The GEL-Lyte 33 is versatile and suits those who like to ‘mix up’ their training during the week, the Lyte 33 can be used for short/recovery runs or speed/tempo sessions whilst a more structured trainer can be used for the longer runs where more protection is required. Individuals are different and how each adapts determines the end result. Some will enjoy the new feel, while others will take longer to adapt. The GEL-Lyte 33 is not too big a step when moving into a lightweight trainer and with time and correct use steady adaption develops. The Super J33 due for release later in the year is a similar shoe for the overpronator looking for a less structured shoe to vary their training. Runners who have enjoyed ASICS’ neutral and supportive models can now consider the GEL Lyte 33 and Super J33 as lightweight options with the same ASICS fit and feel they have always enjoyed

- Happy Running!

FORERUNNER SEPEMBER 2013

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AWARDS SECTION SPNZ STUDENT RESEARCH PRIZE OTAGO UNIVERSITY RECIPIENT 2013 This is a summary of the research project by Ms Northcott, Gillespie, Due, and Mr Lim and Chiu, as partial fulfilment towards their BPhty degree. For further information, please contact Gisela at Gisela.sole@otago.ac.nz .

Age-related changes of the glenoid labrum: a narrative review Jaimee Northcott, Nichole Gillespie, Laura Due, John Lim, Peter Chiu Supervisor: Dr Gisela Sole, PhD, FNZCP Centre for Health, Activity and Rehabilitation Research, School of Physiotherapy, University of Otago, New Zealand

INTRODUCTION Injuries to the glenoid labrum have been extensively described in the literature since the mid-1980s1, 2 and can be incurred through a traumatic incident, such as falling on an outstretched arm, or develop insidiously. 3 With the recent emergence of sophisticated imaging processes and availability of arthroscopy, it appears that there has been an increased reported incidence of labral repairs. For example, increases have been reported up to 464% from 2002 to 2010 in New York State4 and a national increase of 105% from 2004 to 2009.5 When diagnosing musculoskeletal conditions, it is important to consider normal anatomic variations of implicated structures and also the age-related changes in these structures. The goals of this narrative review were thus, to determine the normal variations of the glenoid labrum and the natural changes it undergoes with age. A number of common variations were found for the superior labrum. 6-8 The first variation involved the presence of the sub-labral foramen, defined as a sulcus between the anterosuperior portion of the labrum and the glenoid articular cartilage.6, 7, 9-11 Smith et al.12 confirmed this observation with MRI which found that the sub-labral foramen most likely being part of a degenerative reorganization process. The second variant recorded was the presence of a thickened “cord-like” middle glenohumeral ligament (MGHL). In comparison, the normal MGHL is classically described as flat, or “sheet-like”.7 The third variation noted has been termed the “Buford complex”, characterized by the complete absence of labral tissue at the anterosuperior aspect of the labrum, in conjunction with a cord-like MGHL.7 It is thought that these anatomical variations may cause glenohumeral biomechanical alterations and may predispose the shoulder to other associated abnormalities.7 Across the literature it was clearly evident that the glenoid labrum is circularly attached to the glenoid rim, with no irregularities up until the age of 10 years. 6, 9 Changes to the labrum already appear in the second decade, evident as fissures, detachments or tears, increasing in severity and number with age. Pfahler et al. 9 showed that these lesions start superiorly and anterosuperiorly and eventually progress to involve the whole circumference of the glenoid cavity. Between the ages of 30-50 years, tears and defects begin to develop at the superior and anterosuperior aspect of the glenoid labrum. After 30 years, there may be some loosening of the upper part of the labrum which increases in age. After 50 years it was noted that the labrum becomes thinner and absent in some areas. 13 The glenoid labrum is inconsistently fixed to the glenoid rim in the person over 60 years of age. 9 A study by Miniaci et al.14 evaluated the MRI findings of the labrum in both shoulders of asymptomatic professional baseball pitchers without significant prior shoulder injury. Results show that 45% of the throwing shoulders and 36% CONTINUED ON NEXT PAGE.

AWARDS SECTION

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CONTINUED FROM PREVIOUS PAGE.

of the non-throwing shoulders of young pitchers had a SLAP lesion. There was no significant difference between the throwing and non-throwing shoulders of the individual athletes. Compared to a non-athletic population however, the incidence of SLAP lesions in the professional baseball pitchers is high. Training and conditioning in baseball players frequently involves both upper extremities. It has been postulated that this increased activity and stress from such training lead to the increased incidence in SLAP lesions in the non-throwing shoulder.14 CLINICAL IMPLICATIONS The clinician assessing a patient with a shoulder disorder needs to decide whether labrum abnormalities should be considered the pathological source of the patient’s symptoms or whether they are “normal” age-related variations. This review has found that normal anatomical changes of the labrum are common, starting much earlier than usually considered, namely the second decade, increasing with age. While a sublabral recess was found to be common in the older population, it was suggested that if it was located anterior to the head of the biceps tendon, it should be considered a normal variant. A Type II SLAP lesion is diagnosed when the sublabral recess extended posterior to the biceps tendon.11 For throwers, the high incidence of labral abnormalities demonstrated on MRI by Miniaci et al. 14 indicated that only a small percentage of these have “normal” labra and those authors suggested that the mere presence of abnormalities do not confirm symptomatic pathological findings. Caution is thus needed when interpreting findings of these with imaging or arthroscopy. Results from several studies indicate that changes to the glenoid labrum are of minimal clinical relevance if the person examined is clinically asymptomatic. Such changes should be considered a normal and age-dependent physiologic process.9 Assessment of injuries of the labrum is further challenged by low accuracy of many of the diagnostic procedures. For imaging of the labral capsule ligamentous complex, magnetic resonance arthrography (MRA) has been suggested to be most accurate.15 However this procedure has also been shown to have low sensitivity of 65% for glenoid labrum tears subsequently confirmed with arthroscopy in young patients with anterior shoulder instabilities. 16 Further, most of the clinical tests for the labrum lack sufficient accuracy. 17-19 Considering labral lesions to contribute towards a patient’s symptoms is thus complicated by two main issues: lack of accuracy of diagnostic tests and also lack of clarity what may entail “normal” changes. If there is doubt regarding the possible association between symptoms and signs of labral abnormalities, it could thus be suggested that a conservative approach should be used in the first instance, such as treating the impairments associated with the patient’s shoulder pain. Only if these are not successful, should further interventions, such as surgery, be considered. CONCLUSION Findings of this review indicate that there is a need for more specific classification systems for the anatomical variations of the labral region. Only after the normal anatomic patterns of the labrum are understood, can true pathologic variants be appropriately identified. The literature clearly demonstrates an increase in the grading of tears and structural defects with age, starting in the second decade. Emphasis throughout the literature was placed on the fact that the mobile and loosely attached superior labrum is not always to be considered as abnormal, unless there is an irregular or detached labrum. Based on these findings, initial management of patients with shoulder pain considered to be associated with labral changes should be conservative, before considering surgical repair. References available on request

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CONTINUING EDUCATION CALENDAR

Upcoming courses and conferences in New Zealand and overseas in 2014. For a full list of local courses visit the PNZ Events Calendar For a list of international courses visit http://ifspt.org/education/conferences/

LOCAL COURSES & CONFERENCES When?

What?

Where?

3rd SPNZ Symposium Rotorua SPORT AND EXERCISE ACROSS THE

Rotorua

2014 15-16 March 2014

LIFESPAN 1-2 March 2014

Kinesio Taping - KT 1 & 2 Auckland

Auckland

4 April 2014

Optimising 3D Biomechanics, The Pelvic and Lumbar Spine - Assessment & Treatment

Auckland

4 April 2014

Retraining Optimal Dynamic Function of the Hip Region

Auckland

8-9 March 2014

KT1&2 Christchurch

Christchurch

14 March 2014

SPNZ Immediate Care and Sports Trauma Management Course

Rotorua

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 full list visit the APA and SPA Events Calendar Course

City

Begin Date

End Date

Tendinopathy Pain, Pathology and Management

Camberwell, VIC

5/3/2014

Sports Level 1

Warners Bay, NSW

8/3/2014

9/3/2014

Sports Taping

North Ryde, NSW

8/3/2014

SPA/SMA Club Warehouse Evening Lecture Series

Homebush Bay, NSW

13/3/2014

Shoulder Labral Injuries in Sport

Kent Town, SA

14/3/2014

The Sporting Elbow, Wrist and Hand

Woodville South, SA

15/3/2014

The Thoracic Spine in Sport

Camberwell, VIC

15/3/2014

Sports Level 2

Silverwater, NSW

28/3/2014

30/3/2014

Sports Level 1

Camberwell, VIC

29/3/2014

30/3/2014

Sports Level 2

Bruce, ACT

4/4/2014

6/4/2014

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