SPNZ BULLETIN PAGE
Issue 1 February 2016
Feature Drugs and the Sports Physiotherapist
ASICS Education Grant Closes 31st March 2016 Reminder: Renew your membership now FEATURE TOPIC: Health & Safety SPNZ Bulletin February 2016 Issue
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SPNZ Members’ Page Welcome to Sports Physiotherapy New Zealand SPNZ EXECUTIVE COMMITTEE President
Hamish Ashton
Secretary
Michael Borich
Treasurer
Timofei Dovbysh
Website
Blair Jarratt
Sponsorship
Bharat Sukha Kara Thomas
Social Media
Timofei Dovbysh
Committee
Monique Baigent Justin Lopes
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CONTACT US Michael Borich (Secretary) 26 Vine St, St Marys Bay Auckland mborich@ihug.co.nz SPNZ Bulletin February 2016 Issue
An application form can be downloaded on the SPNZ website sportsphysiotherapy.org.nz.
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Contents FEATURE TOPIC: Health and Safety
SPNZ MEMBERS PAGE See our page for committee members, links & member information
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EDITORIAL By SPNZ President Hamish Ashton
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MEMBERS’ BENEFITS On-line Journals
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FEATURE Drugs and the Sports Physiotherapist by Professor David Gerrard
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PLANET OF THE APPS
In this issue:
My Sprint
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SPRINZ Field monitoring of sprinting power-force-velocity profile before, during and after hamstring injury: two case reports
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ASICS ASICS Product Review —Gel-Kayano 22
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CLINICAL SECTION- ARTICLE REVIEW What is the lowest threshold to make a diagnosis of concussion?
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CONTINUING EDUCATION AUT Applied Human Movement Studies
13
Immediate Care and Sports Trauma Management Course
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Local course and APA CPD Event Finder
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RESEARCH PUBLICATIONS JOSPT Volume 46, Number 2, February 2016
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BJSM Volume 50, Issue 5 March 2016
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CLASSIFIEDS Job Vacancies
SPNZ Bulletin February 2016 Issue
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Editorial Hamish Ashton, SPNZ President Greetings all, and a warm welcome to the start of 2016 though being mid-February it probably can’t classify as a start. With even more bad press for sports over the last few months I recently reflected on my associations I have as a physiotherapist and how that reflects on me as a professional. We had just appeared to be over cycling’s drug issues when we get a huge scandal in FIFA’s management, which seems never ending, and now we have athletics with drug issues. Adding to this is the yearly press from rugby league players, who seem to need to doing something stupid on a regular basis. Though many of the sponsors appear to be sticking by FIFA, Nestlé has talked about, if not already withdrawn, its sponsorship with athletics due to the bad image it may get through being associated with an organisation with these types of issues. So how bad does it really have to be before your reputation gets caught up in the bad press of an associated club, organisation. The answer is probably as grey as FIFA’s ethics committee. I have been associated with numerous sporting clubs and organisations over the years that I have been a sports physiotherapist on the sideline. Until recently I have neither had any issues with the public image of these bodies, nor been aware of any. However, a current club I am with has had three events over a couple of months where behaviour had been affected by alcohol. None of these has made the news media, perhaps because the events weren’t that bad, or possibly because the club doesn’t have a big enough profile to make the media. But it made me think – how does this reflect on me? One of the events in question was a formal affair and I was attending as a judge as well as being a sponsor. After the event I felt I needed to formally disassociate myself from the team as I was embarrassed with their behaviour. Though a number of the audience knew I worked with this team, would this affect their opinion of me? I would hope not, but can you be sure? We are now in a new year and contract negotiations are now underway for the winter season. Should I look for a new team, or stick with that which I worked with last year? What is helping with the decision is that there will be a new committee this year, and there are plans to put in place a code of behaviour for the players. This, if undertaken well, will mean incidents in the future, if they occur, can be dealt with and resolved hopefully without affecting the club’s reputation and by association that of the partners and sponsors, including me. The same principle mentioned above applies to us as an organisation. Physiotherapy as an occupation in New SPNZ Bulletin February 2016 Issue
Zealand has spent many years working to improve its professional appearance and professionalism. As a SIG, we have also worked on improving our professional image and we are keen to develop this further. Doing this will benefit our members. However, there is an adage in health that a good practitioner is a good practitioner, but a bad one reflects the profession. Groups are often judged by the bad apples. The SPNZ Sports Code of Conduct, which was published three years ago, takes steps towards establishing behaviour and expectations of a sports physiotherapist. Having the code gives us a base line of the minimum we expect from our members and gives us the tools to adjudicate on professional standards should issues arise. If you haven’t read it, check it out on our website. It not only helps to protect us as a profession, it also protects you as a practitioner. Another thing we can do to go forward is associate with organisations of good repute. The British Journal of Sports Medicine is one such organisation, and we are pleased to be not only associated with them, but also receive their journal for you, our members. Part of our relationship with them is they wish to promote us as an organisation locally and on the world stage. For those on social media you will notice regular tweets from them including us, as a group, in the message. We also get to promote ourselves via our own BJSM issue which has just been released. Other strong partners we have include JOSPT, Asics, Footscience, and SPRINZ, to name but a few. Over the year I challenge you to work on maintaining and building positive partnerships. These will not only help you as a practitioner develop, but will reflect positively on us as an organisation. This will allow us to provide more for you as our members thereby creating more opportunities for you. Winter is coming, and with it a number of us will be back on the sideline. Not all of us will be on TV but we will still be in the public eye. The All Blacks work on a philosophy. One of their principles is “Be a Good Ancestor” “As the sun shines on you for this moment, this is your time. It’s your obligation and responsibility to add to the legacy – to leave the jersey in a better place. The legacy is more intimidating than any opposition.” Hamish
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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.
Online Journals
Free full text online access to JOSPT JOSPT is one of the top physiotherapy journals in the world. Scholarly and peer-reviewed, JOSPT features the latest evidence-based research and clinical cases in musculoskeletal and sports-related health, injury, and rehabilitation, including physical therapy, orthopaedics, sports medicine, and biomechanics. With 12 issues over the year it strives to offer high-quality research, immediately applicable clinical material, and useful supplemental information in a variety of formats.
British Journal of Sports Medicine British Journal of Sports Medicine (BJSM) is a multimedia portal for authoritative original research, critical reviews and timely debate in sport and exercise medicine (SEM) as well as clinical education and implementation success stories. BJSM’s web, print, video and audio material serves the international sport and exercise medicine community with the journal recognised as a leader in sports medicine social media.
SPNZ Bulletin February 2016 Issue
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Feature Drugs and the Sports Physiotherapist Professor David Gerrard OBE CNZM MB ChB(Otago) FACSP FSMNZ David Gerrard is a physician and Full Professor at the Otago Medical School in the Department of Medicine. His specialty is sport and exercise medicine. David chairs the World Anti-Doping Agency Committee for Therapeutic Use Exemption, is vice-chair of the Sports Medicine Committee for International Swimming (FINA), and a member of the Anti-Doping Advisory Committee for World Rugby. He has more than 80 peer-reviewed publications and book chapters on topics including paediatric sports medicine, sports injury prevention, bioethics and anti-doping in sport. David was a 1964 Olympian and a Commonwealth Games swimming gold medallist who has also been NZ Olympic Team Doctor, Chef de Mission, and Medical Commission member at nine Summer Olympic Games. He remains an avid surfer, loyal Highlanders supporter and advocate of Central Otago Pinot Sport has evolved to embrace standards of professionalism that were simply not invoked in the amateur era. Contracts, collective bargaining, athletes’ unions, agents and drug testing have become part of the contemporary landscape. The sports physiotherapist, as part of the “entourage” of athlete support, must observe accepted standards of professional conduct especially where traditional roles might be challenged. This brief article addresses two areas of clinical responsibility that threaten the scope of physiotherapy practice. These are: 1. Generic supplying or administering of drugs 2. Obligations to the World Anti-Doping Agency Code.(1) In many team settings, and in the absence of a medical opinion, significant responsibility for clinical decisionmaking resides with a physiotherapist. In the majority of cases physiotherapists respect their traditional scope of practice and seek medical endorsement where this is appropriate. However, a reminder to members of the sports physiotherapy community is, from time to time, necessary, well intentioned and, for the most part, well received. The use of performance-enhancing substances and the authority to prescribe drugs is also topical given international events of recent notoriety. Drug misuse in contemporary sport is inescapable.
It is therefore critical to sports physiotherapy practice that ethical and legal boundaries are defined and particular aspects of anti-doping are identified that best serve the athlete while protecting the practitioner. Under the Health Practitioners Competence Assurance Act 2003 (HPCA)(2) sports physiotherapists are obligated to ensure that their patients receive safe and appropriate, evidence-informed treatment that is within their designated scope of practice. Under normal circumstances this does not extend to the supply or administration of medication, however in extraordinary circumstances such as with travelling teams, a physiotherapist may work under Standing Orders for which the Ministry of Health provides unequivocal guidelines.(3) Essentially, a Standing Order is a written instruction by a registered medical practitioner to a physiotherapist enabling the supply and administration of a specified dose of medication for a specific condition over a finite period to an identified athlete. The terms of such an order are not transferrable and no deviation is permitted. However putting aside the formality of Standing Orders, there are situations in which team physiotherapists on tour and without a colleague team doctor find themselves professionally challenged in the area of medication use. The debate over the prescribing rights of physiotherapists has waged over a number of years and CONTINUED ON NEXT PAGE
SPNZ Bulletin February 2016 Issue
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Feature Drugs and the Sports Physiotherapist continued... seems only to have reached conclusion in the UK where certain rights have been accorded under strictly specified circumstances.(4) This is no simple matter to be decided without considerable deliberation, stakeholder engagement and acknowledgement of the limitations inherent in current undergraduate curricula. There are so many factors associated with the administration of medicines that physiotherapists are not clinically or professionally trained to deal with them. There have been suggestions that physiotherapists should be entitled to prescribe and administer simple analgesics, muscle relaxants and anti-inflammatories given their relevance to musculoskeletal practice. In other sectors, those working in respiratory settings advocate the use of bronchodilators and even antibiotics. Clearly these matters are highly conjectural and the subject of ongoing debate.(4) Returning to the setting of the travelling team and the responsibility for administering medications, physiotherapists would do well to refer to excellent commentaries by Lynley Anderson,(5,6) a former physiotherapist and now Associate Professor of Bioethics at the University of Otago. Aside from the complexities of drug interactions, pharmacokinetics and the potential for serious allergic reactions including anaphylaxis, there are also legislative issues of sports anti-doping that physiotherapists must consider. Athletes subjected to doping control in accordance with the requirements of their International Federation or an Anti-Doping Agency may often implicate the physiotherapist in discussions over the legality of certain products including dietary supplements. At international tournaments or events in which athletes are selected for in-competition-testing it is not uncommon for the team physiotherapist to accompany the athlete to doping control. While this is an appropriate support function, the physiotherapist must always be cautious about providing the athlete with an opinion as to the appropriateness of any medication or supplement. The source and constituents of the latter products are notoriously difficult to authenticate and many have been found to contain prohibited contaminants or precursors giving rise to adverse analytical findings – in short, a “positive” doping test with serious consequences including sanction from sport. The role of the sports physiotherapist in the area drug administration and with respect to the potential for
SPNZ Bulletin February 2016 Issue
anti-doping rule violations is presently embodied in legislation with which all practitioners should be familiar. As important members of the sports medical team, physiotherapists should comply with their scope of practice and avoid the temptation to stray into matters closely regulated by anti-doping policy.
KEY POINTS 1. Physiotherapists are valuable members of the athlete “entourage.” 2. The team physiotherapist’s role, irrespective of a doctor’s presence does not alter from the scope of practice articulated in the HPCA. 3. A written Standing Order by a registered medical practitioner is mandatory for a team physiotherapist to administer medicines. 4. The improper supply and/or administration of medicines by any member of the athlete “entourage” is liable to disciplinary action. 5. The WADA Code makes no professional discrimination, applying independent sanction where complicity in drug misuse is proven.
References 1.
The World Anti-Doping Code. WADA, Montreal (2015)
2.
New Zealand Government. The Health Practitioners Competence Assurance Act 2003
3.
New Zealand Government Medicines Regulations (Standing Orders) 2002
4.
Physiotherapists gain new power to prescribe medicines independently after campaigning by CSP. Chartered Society of Physiotherapy press release 24 July 2012.
5.
Lynley Anderson. Physiotherapists administering medications under instruction. Br J Sports Med. 2012; 46(4)
6.
Anderson L. Travelling light – sports physiotherapists administering medications in the absence of a doctor. New Zealand Journal of Sports Medicine 2010;37:38-42
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Planet of the Apps Your monthly App review by Justin Lopes - Back To Your Feet Physiotherapy, SPNZ executive member.
Hey team, For this bulletin an app was suggested to us which was awesome. We always appreciate suggestions. So long as they are constructive. Non-constructive suggestions such as ‘I know this is an app review but have you reviewed the latest ultrasound machine?’ are not particularly helpful. This app, similar to the Ankle app has been produced in a University, and once you get the hang of it can be quite useful, if you are the physio / sports science / conditioner / trainer / dogsbody at your club. It does require some set up though, with poles, a field measuring tape that you can measure up to 40m, a tripod, your client to wear a contrasting coloured shirt to the poles and a trigger finger to ensure you catch the correct timings for the client. After I had tried to use the app I asked Scott R Brown, Doctoral Candidate at AUT Millennium to help with the review as he had used the app regularly.
App: My Sprint Category:
Sports
Updated:
27/11/15
Version:
1.7
Size:
5.9MB
Language:
English and Spanish
Family Sharing:
Yes
Seller:
Pedro Jimenez Reyes
Website:
http://mysprintapp.wix.com/mysprintapp
Rated:
4+
Cost:
$12.99
Requires:
IPhone 6 or above, 6 agility poles or similar, contrasting clothing for the athlete from the pole.
YouTube:
https://www.youtube.com/channel/UCh-zFZGKXKqHO5FQYNm2Y7A
What it is used for:
Assessing power – force – velocity profiles of clients
Where to find it:
Download from Apple store,
Android or Apple or both: Both Features: You can save your users to clubs they belong to. You can measure athletes or your clients Power-Force-Velocity profile. You can also measure the athletes speed in split times in 10, 15, 20, 30 and 40m. By measuring the F-v horizontal profile it allows you to explore force-velocity and power-velocity relationships. Pros: This is relatively inexpensive way of measuring individual force, velocity and power outputs, especially compared to radar guns, force plate embedded tracks or treadmills, or timing gates. For elite athletes, I can see how this app could be useful, however it can also be used to rehabilitate athletes, and anyone who is returning to running from injury, Cons: Needs a tripod (set up 18m from the track, poles, field tape measure and your client to be in contrasting colours to the poles to be effective. You need to record the race in landscape and move your device to ensure you get the whole race in. You also need to start recording in the frame when the client takes their hand off the track to start SPNZ Bulletin February 2016 Issue
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Planet of the Apps App: My Sprint continued... running. You also need to accurately record the splits, and … you also need to also understand the formulas and how to appropriately apply the force-velocity and power-velocity formulas to assist your client. It takes a while to set up the poles. How I use the app: I have used the app with athletes to help give them specific targets to train, however I do not currently have a field measurer, so I have to admit that the feedback I am providing to them may not be entirely accurate (the app use poles that are placed at specific distances to calculate the speed the subject is running at and these are not exactly 10, 15, 20, 30 and 40m due to the angle of view from your device and you need to correct the parallex) and so I do not believe that I have fully maximized how the app can be used, I also have not yet done the SPNZ exercise prescription course and so do not fully understand the equations and I am looking forward to better understanding the power-force-velocity profile once I have done that. Overall Rating: 3/5 (mainly because I don’t really understand how to use it yet!) Addendum by Scott R Brown Fresh off the heels of its vertical power-force-velocity relationship (P-F-V) predecessor My Jump, the My Sprint app (which measures horizontal P-F-V) adds to our collection of the “lab in your pocket” series of scientific apps. My Sprint is a wonderful app for the field with a ton of potential. While the app may not be as easy to use initially as say, Frogger, it does not take a rocket scientist to figure it out. In fact, with a brand new YouTube tutorial to learn the setup (https://youtu.be/65qBaynqu7w, and even more instructional videos on their way) even a technophobe can figure out the basic operation. And as with any new devise, the more experience you have, the more you learn how to use the devise and the more comfortable you become when using it. So at this point you may be asking to yourself, “but what does it do that’s so special?” A fair question indeed. The answer is this, the app (and similarly the radar gun) gives us insight into WHY an athlete may be running faster instead of telling us simply that they are faster via timing splits. By using a ‘simple method’ presented in the literature by Dr Pierre Samozino and colleagues, we are able to break down a sprint effort into its detailed mechanical outputs (i.e. theoretical maximal force [F0] and velocity [V0], ratio of the net horizontal and resultant ground reaction forces [RF] and the rate of linear decrease in RF as velocity increases [DRF]). It is through these details that we are able to gain insight into what mechanical properties are affecting an athlete’s sprint performance (which are also calculated in the app). From that point we can make a more informed training prescription aimed at improving a specific mechanical element; with the ultimate goal of increasing overall sprint performance. And for the sceptics still out there; yes, a validation paper of the app is currently in the peer review process which compares the app to the radar gun (current gold standard) and timing gates (current field measure) during sprint activities. For some additional clarity and perhaps piece-of-mind, the My Sprint app is intended to analyse horizontal P-F-V. As such, athletes that would most likely benefit the greatest from its use are track athletics. On the other hand sports that might not benefit from the app may include volleyball, basketball and athletics (field). These latter sports should use the alternate My Jump app to measure vertical P-F-V. For cross-over sports like rugby and football (soccer) wherein the sport combines elements of both vertical and horizontal force, a combination of both apps would provide the greatest insight. Apart from assisting with exercise prescription and training load selection, a vertical and horizontal athlete profile could be used in determining return-to-sport status should an injury occur. Although this last thought is only a speculation at this time. My final thoughts on the My Sprint app: first, get onto Google Scholar and read Dr Samozino’s “A simple method for measuring power, force, velocity properties, and mechanical effectiveness in sprint running” (don’t be alarmed if / when you get lost or confused in the technical terminology, this is normal); second, purchase the My Sprint app for less than the price of a Subway footlong sandwich; third, watch the YouTube tutorial mentioned above and take notes; fourth, use the app and then continue to use it. If after many practice sessions and several data collections you still don’t understand or like the app, you’ve only lost minimal time and a small financial cost. To put it into context, you’ve probably already wasted the same amount of time reading this article and spent the same amount of money on parking and / or coffee today alone. For further discussion on this App check the SPNZ LinkedIn forum page Click here SPNZ Bulletin February 2016 Issue
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SPRINZ
Field monitoring of sprinting power-force-velocity profile before, during and after hamstring injury: two case reports
By Dr Matt Brughelli A recent paper was published in the Journal of Sports Sciences by several SPRINZ members, including two post-graduate students. The paper included two case reports, one elite rugby 7’s player from New Zealand and a professional soccer player from Spain. Each subject suffered an acute hamstring injury. The rugby player suffered his injury during a maximum effort sprint, which was captured with a Radar Gun. This paper utilized new technology that has only been available for a few years. This technology included a Radar Gun, and a custom-made LabVIEW software program developed at AUT. Currently there are only two software programs in the world that are capable of this specialized analysis. The software program analyses raw data files from the Radar Gun, as the athlete sprints away from the Radar Gun in a straight line. From the velocity signal, the entire force-velocity profile can be established for each athlete. The forcevelocity profile can be thought of as a neuromechanical signature, each athlete has one, and they give information about where on the force-velocity spectrum an athlete should train. In this particular study, the Radar Gun was in use during an acute injury. Thus, information was collected just prior to the injury occurring. This information could be used to gain a further scientific understanding about hamstring injuries that occur during sprinting. The rugby player was performing 10 sprints x 40 metres with 45 seconds rest. Very impressive protocol indeed. This athlete suffered his injury during trial five.
SPNZ Bulletin February 2016 Issue
Thus there were four baseline sprints and one injury sprint. There were also two baseline sprints from the previous day. The interesting finding from the study was that the sprinter had an elevated force output during trail five vs the previous four trials, prior to the injury which occurred at 30.5 meters. For some reason, he had an “over shoot� in force and during the acceleration phase, which was different from the previous sprints. The authors proposed that this over shoot could have been an attempt by the body to anticipate a reduction in maximum velocity that normally occurs during fatigue. The athlete could have unconsciously put more emphasis on the force component in order to compensate. This strategy would have allowed the athlete to produce more power and maximum velocity sooner, but also placed the hamstring under unusually high strain resulting in an acute injury. More research would be needed to confirm this suggestion. It is also interesting to point out that the injury occurred during the late acceleration phase. The authors proposed that this was a very dangerous phase of the sprint as the athletes is still in acceleration (thus muscle tendon units are still producing active force) but is in an upright position (thus the hamstrings are at a greater length due to greater hip flexion). Therefore, the late acceleration phase should be considered in addition to the maximum velocity phase in future research. Dr Matt Brughelli Senior Lecturer - Exercise Science matt.brughelli@aut.ac.nz
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ASICS ASICS Product Review Gel-Kayano 22
Available in standard (D) and wide (2E) widths
In the 1990s it was believed that over-pronation was a strong indicator of injury. The Kayano shoe was conceived during these years and aligned with these scientific findings. The years since have delivered research to challenge this and it was subsequently suggested that pronation wasn’t in fact such a big pre-determiner of injury. The introduction of the barefoot movement injected a complementary perspective. Today we have a much clearer picture. Abnormal pronation is associated with an increased risk of overuse injury (based on a quality systematic review with meta-analysis 2013). The reason we deviated away from this idea in the past was because researchers used multiple ways to define and measure pronation which confused the results. Kayano is an over pronation-focused running shoe which has remained popular through the tumultuous years of running industry change. It has done so because its design is aligned to research principles and it focuses consistently on protection from excessive load. How does Kayano 22 do this? The midsole has a firmer medial density to give resistance to pronation forces at impact and rebound. It starts below the talonavicular joint and finishes prior to 1st MPJ. A medially prominent talonavicular joint is one indicator to excess pronation and placing a resistant force at this region may help manage the load on these joints. Perception of comfort is individual and low comfort levels are associated with higher rate of injury. The Fluid Ride midsole is a combination of two differing types of foam stacked to accommodate comfort and provide postural stability. Visible rear and forefoot Gel are placed to give increased comfort at impact and propulsion. In recent times it was muted that minimalist shoes allow our foot to feel better quality sensory signals by having less bulk underfoot. However a recent study (Zech et al, 2014) suggests that wearing shoes definitely gives SPNZ Bulletin February 2016 Issue
Available in standard (B) and wide (D) widths
postural stability compared to being barefoot, but a minimalist shoe didn’t give better proprioceptive feedback to the foot than a (similar to Kayano) 2160 shoe. We can be confident that the well cushioned Kayano plays a role in protecting the foot but not at the cost of sensory feedback from the ground. The Kayano outsole carries further protective features – a more reinforced Trusstic than previous model. Its 3D upper shape wraps the sides of the midsole to resist transverse and frontal pronation force. It is durable and lightweight in design. The Guidance Line remains and its role is to encourage direction of load centrally through the foot and not to deviate medially or laterally at late midstance pronation phase of gait. Kayano 22 is more refined in the upper. Its External Heel Counter System extends further forward of the medial and lateral sides of the heel. It feels more dominant at initial impact phase than previous model. The upper carries a combination of stitched and heat pressed reinforcing. The stitched network of fabric focuses on the medial and lateral sides of the heel, toward the lacing eyelets. This is an extension of the Heel Counter Collar, linking the heel and ankle joint to give more personalised fit and resistance to excess movement. The pressed overlays give strength to the medial arch region and anterior portion of the shoe, reducing excessive transverse tendency. This resistance is noted particularly when running off camber. Kayano 22 is a modern stability shoe. Its weight is the lowest it’s ever been and is mindful of energy consumption. It holds a number of pronation-protection features and is aware of the connection between excessive pronation to injury risk. It is comfortable underfoot and provides a sophisticated wrap over the foot. Its refinements are subtle but noticeable to the distance runner. It feels like luxury to try on yet provides the unrestricted freedom required of a performance shoe. Printed with permission from ASICS FORERUNNER AUGUST 2015
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Clinical Section - Article Review Whatt is the lowest threshold to make a diagnosis of concussion? Dr Paul McCrory et al. British Journal Sports Medicine 47 (5):268 Abstract The majority of concussions in sport occur without loss of consciousness or frank neurological signs. The pathophysiology of sports related concussion produces a constellation of symptoms, typically most severe within 24-48 hours and diminishing over a period of days to weeks. While difficult to diagnose, athletes suspected of concussion should be removed from play and evaluated thoroughly. Concussion is considered to be among the most complex injuries in sports medicine to diagnose, assess and manage. The majority of concussions in sport occur without the loss of consciousness (LOC) or frank neurological signs. There is no perfect diagnostic test or marker for an immediate diagnosis of concussion in the sports environment. When obvious signs exist (eg. LOC or convulsions) the diagnosis is relatively straight forward; however symptoms and/or cognitive disturbance may be delayed or concussive symptoms may be present but not specific for the injury. Athletes may not recognise the significance of the symptoms or they may be reluctant to report them or they may not endorse the symptoms because they are concussed. Thus the complexity of this injury highlights the importance of a multimodal examination and the potential usefulness in baseline cognitive and symptom scores if team physicians are to determine the ‘minimum’ concussion diagnosis. The Concussion in Sport Group defined concussion as ‘a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces, that may be caused by a direct blow to the head, face, neck or elsewhere in the body with an impulsive force transmitted to the head.’11 In a sporting context concussion historically represents low-velocity injury that causes brain shaking resulting in clinical symptoms which are not necessarily related to a pathological injury. In contrast mild traumatic brain injury (mTBI) is part of a spectrum of injury severity that reflects a pathological injury differentiated by the Glasgow Coma Scale. 13 To fit these injuries into a full spectrum of traumatic brain injury one must include a ‘minimal’ injury subset that falls below the threshold of mTBI at the 6 hour time point. The majority of sports concussions fall into this category. MRS (magnetic resonance spectroscopy) suggests the concept of metabolic vulnerability occurs in brain tissue after any concussive episode.20 During this transient period of altered brain metabolism and function, a second concussive episode of even modest entity may cause significant additional and/or traumatic brain damage. 28 The subjective reporting of symptoms is problematic with athletes being less than honest; either minimising or not reporting their symptoms. It is important that the culture of sports change such that athletes, parents, coaches and healthcare providers understand the significance of unreported, repetitive concussive injury. The first step in evaluating and managing concussion is recognition of injury. ‘The injury may be subtle and not obvious and the mechanism of injury may not even be a single impact but rather combined effects of multiple hits over a short time period (minutes) and magnitude of impact does not necessarily correlate with clinical injury.’41 The symptoms of concussion are one component of diagnosis with the other components including a neurological examination, cognitive assessment and balance evaluation. Sports concussion typically results in a range of acute and delayed symptoms. Common symptoms in the initial minutes post injury include headache, dizziness and some form of mental status disturbance. The most common acute symptoms in the first 24hours include headache, nausea, dizziness, and balance problems, blurred vision or visual disturbance, confusion, memory loss and fatigue. 1,2,43,53-57 In the days following, tiredness, irritability, nervousness or anxiety, sleep disturbance and light or noise sensitivity. It is important to note that there is often variable presentation of symptoms, even in the same athlete, enhanced if they have had multiple concussions. Baseline, pre-injury screening can be influenced by a number of situational factors and is thus often a ‘state’ not a ‘trait’. Also, it has been noted that these symptoms are not specific to concussion. 60 Concussion becomes the default diagnosis and must not be ruled out. Side line tests and symptom scales do not diagnose whether a concussion has occurred rather, they measure physiological, cognitive and psychological and behavioural changes associated with the injury. The diagnosis of concussion is based on a comprehensive assessment of the injury event and the acute SPNZ Bulletin February 2016 Issue
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Clinical Section - Article Review Whatt is the lowest threshold to make a diagnosis of concussion? continued... signs and symptoms at the time, however an evolving pathophysiology may mean it is not possible to make a certain diagnosis in acute stages. The diagnosis of concussion in athletes can be problematic especially if the injury is mild with minimal signs and symptoms and can be compounded by non-compliance of the athlete. Given the metabolic and neuropathological vulnerability in the acute phase, significant risk may exist for all athletes who sustain a concussion. This means we need to have a high degree of clinical suspicion and all head injuries need to be treated as concussion until proven otherwise, a determination that is impossible to make immediately after injury. An athlete who has one or more of the following needs to be assessed thoroughly and treated as a suspected concussion: 1. Physical signs consistent with concussion 2. cognitive or behavioural changes in functioning 3. athlete report of symptoms 4. abnormal neurocognitive and/or balance examination All suspected concussion may have the potential for adverse outcomes. Diagnosing concussion is often not a ‘point in time’ but requires observation over time and exclusion of other conditions that mimic concussion. Between injury suspicion and concussion diagnosis the athlete should be treated as if they are concussed.
By Pip Sail, Physiotherapist
Continuing Education
SPNZ Bulletin February 2016 Issue
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Continuing Education
IMMEDIATE CARE AND SPORTS TRAUMA MANAGEMENT COURSE Appropriate for physiotherapists working at any level of sport. This course will provide you with the skills to assess and manage emergency situations on the sideline or at sports events. It is also a useful update for those already trained in sports trauma management.
COURSE DETAILS Date and Location: Saturday 16th April 2016 Or Sunday 17th April 2016 8:30 am - 5:00 pm AUT Millennium 17 Antares Place Mairangi Bay Auckland Cost (incl GST) SPNZ member:
$450
PNZ member but not SPNZ Non-PNZ
$540 $575
Cost includes course manual, supervised training sessions, morning and afternoon tea and lunch. To register for this course: please contact Physiotherapy New Zealand or go to spnz.org.nz SPNZ Bulletin February 2016 Issue
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Continuing Education Upcoming courses and conferences in New Zealand and overseas in 2015. 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?
5 March 2016
First Aid Course (4 hours) - Valid for 2 years
Napier
2-3 April 2016
KT 1 & 2
Auckland
2-3 April 2016
Advance Upper Body - Dry Needling
North Shore
16 April or 17 April
Immediate Care and Sports Trauma Management Course
North Shore
14-15 May 2016 21 May 2016
BradCliff速 Method Physiotherapy Practitioner Certification Next
Auckland
Beginners Course Acupuncture - Tendinopathy
North Shore
16-18 September 2016 Physiotherapy New Zealand Conference 2016
Auckland
19-20 November 2016
North Shore
Advance Lower Body Dry Needling
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
APA SPA COURSES & CONFERENCES When?
What?
Where?
5 March 2016
The Sporting Elbow, Wrist and Hand
Camberwell, VIC
5-6 March 2016
The Sporting Hip
Silverwater, NSW
16 March 2016
Hamstring Sparing ACL Reconstruction
Eight Mile Plains
16 March 2016
Placebo Treatments
Camberwell , VIC
6 April 2016
Advanced Sports Taping
North Ryde, NSW
16 April 2016
Foot and Ankle in Dance
Kent Town, SA
SPNZ Bulletin February 2016 Issue
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Research Publications 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.
Volume 46, Number 2, February 2016 EDITORIAL Accommodating a Viewpoint VIEWPOINT Fear-Avoidance Beliefs and Chronic Pain RESEARCH REPORT A Comparison of the Effects of Stabilization Exercises Plus Manual Therapy to Those of Stabilization Exercises Alone in Patients With Nonspecific Mechanical Neck Pain: A Randomized Clinical Trial Timing of Physical Therapy Initiation for Nonsurgical Management of Musculoskeletal Disorders and Effects on Patient Outcomes: A Systematic Review Effects of Volitional Spine Stabilization and Lower Extremity Fatigue on Trunk Control During Landing in Individuals With Recurrent Low Back Pain The Effect of an In-shoe Orthotic Heel Lift on Loading of the Achilles Tendon During Shod Walking Exercise and Cognitive Functioning in People With Chronic Whiplash-Associated Disorders: A Controlled Laboratory Study Division I College Football Concussion Rates Are Higher at Higher Altitudes CLINICAL COMMENTARY Rehabilitation Following Meniscal Root Repair: A Clinical Commentary CASE REPORT Conservative Management of Second Metatarsophalangeal Joint Instability in a Professional Dancer: A Case Report MUSCULOSKELETAL IMAGING Identification of Metastatic Lesions in a Patient With Low Back Pain Following a Motor Vehicle Collision
SPNZ Bulletin February 2016 Issue
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Research Publications British Journal of Sports Medicine www.bjsm.bjm.com Volume 50, Issue 5, March 2016 EDITORIALS Are we sports physiotherapists working as a team as well as we could? Hamish Ashton http://bjsm.bmj.com/content/ REVIEWS Great Britain Rowing Team Guideline for diagnosis and management of rib stress injury: Part 1 Guy Evans, Ann Redgrave http://bjsm.bmj.com/content/ Great Britain Rowing Team Guideline for Diagnosis and Management of Rib Stress Injury: Part 2 – The Guideline itself Guy Evans, Ann Redgrave http://bjsm.bmj.com/content/ The training—injury prevention paradox: should athletes be training smarter and harder? Tim J Gabbett http://bjsm.bmj.com/content/ Monitoring the athlete training response: subjective self-reported measures trump commonly used objective measures: a systematic review Anna E Saw, Luana C Main, Paul B Gastin http://bjsm.bmj.com/content/ The incidence of concussion in youth sports: a systematic review and meta-analysis Ted Pfister, Ken Pfister, Brent Hagel, William A Ghali, Paul E Ronksley http://bjsm.bmj.com/content/ Dentofacial trauma and players’ attitude towards mouthguard use in field hockey: a systematic review and metaanalysis Strahinja Vucic, Rosalin W Drost, Edwin M Ongkosuwito, Eppo B Wolvius http://bjsm.bmj.com/content/ ORIGINAL ARTICLES Time to return to full training is delayed and recurrence rate is higher in intratendinous (‘c’) acute hamstring injury in elite track and field athletes: clinical application of the British Athletics Muscle Injury Classification Noel Pollock, Anish Patel, Julian Chakraverty, Anu Suokas, Stephen L J James, Robin Chakraverty http://bjsm.bmj.com/content/ Cognitive and physical symptoms of concussive injury in children: a detailed longitudinal recovery study Louise Crowe, Alex Collie, Stephen Hearps, Julian Dooley, Helen Clausen, David Maddocks, Paul McCrory, Gavin Davis, Vicki Anderson http://bjsm.bmj.com/content/
SPNZ Bulletin February 2016 Issue
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Classifieds WELLINGTON Capital Sports Medicine Physiotherapist
STARTING MID FEBRUARY 2016 Capital Sports Medicine is a busy central city multidisciplinary clinic with a close knit team of physiotherapists, sports physicians, podiatrist, massage therapists, visiting specialists and an enthusiastic front line reception team. It services a wide range of sports people from the elite athlete to the recreational as well as the general public. In our new larger premises on Featherston St. we also offer Pilates out of our purpose built rehabilitation gym. We are looking for a physiotherapist who can work as part of a team, has an interest in Sports Medicine and Manual Therapy The hours are approximately 35 hours a week. We have regular in-service education. You will be working alongside experienced manipulative therapists. The position is available from mid February 2016. Have a look at our website www.capitalsportsmed.co.nz and Facebook page.
Please send your CV to Capital Sports Medicine, PO Box 25607, Wellington or email to office@capitalsportsmed.co.nz. Otherwise call Helen McKendrey or Glenn Muirhead on (04)4995732
HAMILTON Sports Med Physiotherapy Musculoskeletal Physiotherapist—Private Practice Sports Med Physiotherapy is looking for two full- time enthusiastic musculoskeletal physiotherapists to work as part of a friendly team in our busy private practice clinics in Hamilton. An exciting job opportunity has become available in both the Ulster Street and Thomas Road clinics. Sports Med Physiotherapy is a long established clinic and is well equipped having private consultation rooms and a fully equipped gymnasium. Four of our current physiotherapist’s are post-graduate trained and two are presently the physiotherapists for the Chiefs Super Rugby Team and the Paralympic Cycling Team. We have also previously had a long association with the Magic Netball Team and the New Zealand Triathlon Team, hence the calibre of our staff is extremely high. We aim to maintain a very supportive work environment for our staff and you will receive monthly onsite CPD and funding for external courses. The length of our patient appointment times is flexible giving you the ability to individually tailor treatment to benefit your patient. Private practice work experience would be ideal but new graduates are welcome to apply. The clinic uses Gensolve and an understanding of this would be advantageous but not necessary. Candidates must be eligible to work in New Zealand, have an annual practicing certificate and registered with the Physiotherapy board of New Zealand. Remuneration will be based on experience.
Please send a CV with covering letter to malovell@me.com.
SPNZ Bulletin February 2016 Issue
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Classifieds HAMILTON Performance Plus Physiotherapy Physiotherapist position full time and part-time Great opportunity available for an enthusiastic and motivated manual / musculoskeletal physiotherapist to join our team! We are a long standing, busy and dynamic accredited private practice. Our main clinic is situated within a busy central catchment area in Hamilton surrounded by schools, professional business thorough-fare, retirement villages and university. We have two additional clinic sites: one at the University of Waikato and the other at a local private school.
We treat a variety of clientele, from acute, sports, post-operative and general musculoskeletal conditions to more chronic and complex cases.
We work with sports teams: High Performance Sport NZ –Athletics NZ & Rowing NZ provider, Hillary Scholar Athletes, Waikato Senior Men’s & Women’s Senior University Rugby Teams, Rugby 7s, Unicol Soccer, Senior Club Netball & Track.
Coaching and mentoring is an essential part of our physiotherapy practice. We hold a regular in-service programme which includes guest speakers.
Our in-house clinical skill development programme is top rated whether you are a senior physio or junior physio. We create an expert learning and development environment. This is run by two of our senior physiotherapists that have HPSNZ experience at a World stage level with New Zealand’s elite athletes.
A top rate remuneration package is available including up to $2000. per year funding for courses and development. Flexible start date from Feb/ March 2016. Applications: e-mail your CV to performanceplusphysio@xtra.co.nz or mail to: Melissa Gilbertson, Practice Director, PERFORMANCE PLUS PHYSIO LTD 280 Peachgrove Road, Hamilton. Phone: 078551788 or 021 875379 www.performanceplusphysio.com
Wanted! We need some more article reviewers for our bulletin. This is not a big task and a good way to get some CPD points and keep up with the latest research. Contact: Aveny Moore aveny.moore@xtra.co.nz
SPNZ Bulletin February 2016 Issue