SEPNZ BULLETIN PAGE
Issue 1 February 2018
Feature Exercise for Health Versus Performance Course Concussion Management NZ Health Role Update
FEATURE TOPIC: Continuing Education
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SEPNZ Members’ Page Welcome to Sports & Exercise Physiotherapy New Zealand SEPNZ EXECUTIVE COMMITTEE President
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Contents FEATURE TOPIC: Continuing Education SEPNZ MEMBERS PAGE See our page for committee members, links & member information
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EDITORIAL By SEPNZ President Hamish Ashton
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MEMBERS’ BENEFITS Publications
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FEATURE
In this issue:
A Comparison of Exercise for Health Versus Performance with Regard to the Basic Principles, Benefits and Risks
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NZ HEALTH ROLE UPDATE Preparing for an NZOC Health Team Role: What is Involved?
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CLINICAL SECTION- ARTICLE REVIEW Likelihood of ACL Graft Rupture: Not Meeting the Six Clinical Discharge Criteria Before Return to Sport is Associated with a Four Times Greater Risk of Rupture
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POST GRAD RESEARCH Best Current Practice in Reducing Injury Risk in Runners By Gait Retraining
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RESEARCH PUBLICATIONS BJSM Volume 52, Number 4, February 2018
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CONTINUING EDUCATION Concussion Management Course
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CLASSIFIEDS Situations Vacant
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Acknowledgement: Thanks to Emirates Team New Zealand for the front cover photo
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Editorial Hamish Ashton, SEPNZ President Hi all and welcome to another year. As I sit here at home with days and nights not dropping below 20°C a thought goes out to our colleagues in South Korea where the temperature is literally dropping to 20 below. On behalf of SEPNZ I would like to wish our winter Olympians and their support staff all the best for the games. Let’s hope our physiotherapists over there have a quiet games. I have just come back from two days in Wellington where we have had the first PNZ changes meeting for the year and the first one since it was voted to continue working on the changes process. In the last PNZ Physio Matters there was a summary of some of the information that was put together from an analysis of the whole organisation. Though the summary is only as good as the information provided, there are some interesting figures. At least 20,000 voluntary hours are put in by committees of the branches and SIGS, the exec, and working committees. There are obviously some dedicated members out there doing their bit for the profession. Though one of the aims of the review is to reduce duplication of services to lessen the load on volunteers, any new model will still need volunteers to keep it working at an affordable cost. People will still have to put their hand up and offer to help. One big aim of the model we are trying to develop is to lessen the load and responsibilities on these volunteers. This will hopefully improve succession planning for the branches and SIGs with more happy to put up their hand. If every physiotherapist put their hand up, just for a short period of time, we would have more support than we probably need. As with many facets of life you get more out of something when you put something in. Another interesting fact is the number of courses we (the greater PNZ organisation) have run over the last 2 years. Over 175 were recorded, and this doesn’t include smaller events such as social gatherings and AGM meetings, or external organisations. Though this appears to be a huge choice and opportunity for us to undertake our CPD, there are regions of the population that still find CPD hard to access, be it through distance or other reasons. This is something we have been aware of during the planning meeting. Over the next few months information is going to become available regarding the new proposed model for PNZ. I urge all of you to read, listen, and engage in what comes out. This is the biggest change ever for PNZ, our professional body. Many hours have been given up to get to where we are currently at, and
personal biases have been put aside to agree on what we think is best for the profession. For this to be successful we need your feedback and support. The SEPNZ exec are having a planning meeting in March. Last year we undertook a membership survey so we will be going though this in detail to look at the suggestions you, as members, gave us. With possible/probable changes happening in the PNZ organisation, we also need to think about future proofing our SIG. What is in current agreement at all levels is, that SIGs will still have a definite role in PNZ and as part of our international bodies such as the IFSPT. Though we have feedback from the survey we are always keen on new ideas so let us know what you want out of us. In March the SEPNZ edition of BJSM is coming out. Each year we get to put together an edition to promote us as a partner organisation. Thanks to Emirates Team New Zealand for providing the cover – a great view of our boat racing against Oracle. In keeping with our usual theme, a selection of papers has been chosen that show aspects of clinical practice. Though research has a place and is important, the transition of this to a clinical application is vital when we are looking to better improve our practice. As mentioned in my BJSM warm up, at a time where everyone is emphasising evidence-based practice, it is important to remember this does not equate to research. True evidence-based practice looks at and assesses all the available research and applies it to the psycho-social-economic and cultural needs of the patient before them, with a sound clinical judgement based on their experience as a clinician. Finally, I just want to mention an upcoming event to look out for. Due to the feedback we had following our roadshow with Karim and Jill 18 months ago we are doing it again with sponsorship by USL, and in partnership with SMNZ. Look out for notification of locations and speakers as we travel the country bringing quality education and speakers to you. Details out very soon.
Hamish
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Members’ Benefits
There are many benefits to be obtained from being an SEPNZ member. For a full list of Members’ Benefits visit http://sportsphysiotherapy.org.nz/benefits/ In each bulletin we will be highlighting individual member benefits in order to help members best utilise all benefits available.
Free immediate full text online access to JOSPT Including educational CPD activities 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 musculo-skeletal 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.
Free immediate full text online access to the British Journal of Sports Medicine including podcasts, and other CPD opportunities 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.
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Feature A Comparison of Exercise for Health Versus Performance with Regard to the Basic Principles, Benefits and Risks Natalie Gallant Exercise, whether for health or performance, carries a multitude of benefits including optimal cardiovascular health(1). The American Collage of Sports Medicine (ACSM) (2) defines exercise as “a type of physical activity consisting of planned structured and repetitive bodily movement done to improve and/or maintain one or more components of physical fitness.’”(p.6.). It is important to be aware that exercise brings inherent risk (1, 2) Consider these risks dose dependent, where at opposite ends of the spectrum too much or too little are of equal harm. In order to minimise risk, attention must be paid to how the exercise is being carried out, the environment in which it is being performed and the population being exercised. If mindful of these risk factors and basic principles of exercise are adhered too, regular exercise has been shown to drastically reduce disability rates and prolong life expectancy to around seven years longer than those of whom are physically inactive.(1, 3) Definitions Health as defined by the World Health Organisation (4) is ‘a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity.’ (p.1.) Ministry of Health guidelines(3) advise all New Zealand adults exercise for health, making it an integral lifestyle choice. Alternatively, performance can be seen as exercising to the best of one’s ability in terms of training and competition for a particular sport. Brukner & Kahn(5) define ‘training’ as ‘the pursuit of activity that will ultimately lead to an improved performance in a given sport.’ (p.139.). Principles The basic principles of exercise are very similar when exercising for health as they are for performance. Aerobic exercise, muscular resistance, flexibility and neuromuscular training are key elements of both.(2) The ACSM refer to the FITT-VP principle(2) which stands for Frequency, Intensity, Time, Type, Volume and Progression. This principle should be specific to each individual and goal orientated. General exercise considerations in order to reduced the potential for overuse and/or injury should include a warm up and cool down pre/post activity and an assortment of exercises.(2) Health For aerobic exercise in health the ACSM recommend a frequency of moderate intensity five plus days/week, vigorous intensity three plus days/week, or a combination of both three to five days/week.(2) Intensity can be defined using the modified Borg Scale,(6) moderate being a rate of perceived exertion (RPE) 4-6, equivalent to a brisk 45-minute plus walk whereby a conversation can be maintained. Vigorous would rate 710 RPE such as jogging to fatigue within about 20 minutes and be unable to hold a conversation. Time
recommendations for moderate intensity exercise are 3060 min/day (>150 min/week), vigorous intensity exercise includes 20-60 min/day (>75 min/week) either continuous or accumulated over a day in greater than 10 minute chunks.(2) Rhythmical, large muscle group exercises including upper and lower limb of moderate intensity and taking little skill to perform are recommended for all adults by the ACSM such as walking, cycling and rowing. A target volume of >500-1000 MET-min/week is required for most adults, volume being the product of frequency, intensity and time. Aerobic exercise can be progressed through small incremental manipulation of frequency, intensity or time.(2) The advised frequency of resistance training by ACSM (2) for health is 2-3 days/week with 48 hours between workouts, working all major muscle groups with single joint exercises post multi-joint. 1-4 sets per muscle group (2-3 minutes rest between sets) with 8-10 repetitions and 8-10 different exercises. The amount of repetitions translates to intensity equivalent to 60-80% of an individual’s one repetition maximum. For progression reps, sets and frequency can be manipulated.(2) Flexibility exercises are performed to improve joint range of motion and are most effective once the muscles are warm and only stretching to the point of tightness. To avoid an acute reduction of strength and power static stretching is to be performed post exercise.(2) Frequency is advised 2-3 days/week, 10-30 second holds, 2-4 repetitions with a volume of 60 seconds total stretching time for each major muscle tendon unit. Progression of flexibility exercises are currently unknown.(2) Neuromuscular exercises involving balance, agility, coordination and proprioception are the final component ACSM advise.(2) ‘FIT’ principles are less specific but believed that 2-3 days/week of 20-30minutes duration and more than 60 minutes per week is beneficial.(2) Performance Basic principles for performance exercise also follow the FITT-VP principle, however performance differs to that of health through its advanced training techniques and specificity in training an athlete to reach their competitive peak. Brukner & Kahn(5) provide four training principles for sport; Periodisation is the first whereby any given year can be broken down into macrocyles, mesocycles and microcycles. Each cycle has focus on one or all elements of conditioning (aerobic and anaerobic fitness, strength and power), pre-competition (emphasis on more technical work), competitive phase (maintaining basic conditioning during competition) and rest (between seasons). Overload is the second principle, which is similar to ‘progression’ but brings about more acute carefully monitored stress in the athlete for sake of CONTINUED ON NEXT PAGE
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Feature A Comparison of Exercise for Health Versus Performance with Regard to the Basic Principles, Benefits and Risks continued... ‘supercompensation’.(5) Specificity in performance tailors the training program to a particular requirement of the athlete’s sport. Rather than working all four key elements of health exercise weekly, specificity in performance can have greater focus toward one element like speed, power, or a particular sport specific skill,(5) such as spin speed of a backhand tennis shot. For purposes of assessment VO2max in a performance athlete would likely be tested using ‘gold standard’ measures in a lab with gas analysis. On the contrary, a basic treadmill test with heart rate monitoring would likely be the option for a cardiovascular health assessment. Similarly as in exercise for health, training for performance needs to be individualised to the athlete and their sport. Performance exercise will not only tailor to the needs of the athlete in terms of tolerance to load and recovery from training sessions, but to a greater extent involve increased depth in understanding the athletes history of training techniques, nutritional needs and psychological profiling whereby relevant experts maybe consulted. Benefits Exercise has a broad spectrum of benefits; most notable is the evidence supporting reduced risk of cardiovascular disease(1, 7, 8) and premature mortality.(1, 2, 9) Strong evidence also exists for lowering the risk of stroke, type II diabetes, high blood pressure, dyslipidaemia, metabolic syndrome and cancer of the colon & breast. (2) Improvements in cardiovascular and respiratory function include increase in VO2max, reduction in heart rate and blood pressure at a given submaximal intensity, increased muscle capillary density, delayed lactate accumulation in the blood and an increase in the threshold during exercise for onset of disease signs/ symptoms such as angina.(2) Reduction in cardiovascular risk factors include reduced systolic and diastolic blood pressure at rest, increased high density lipoprotein cholesterol and reduced triglycerides, a reduction in body fat and intra-abdominal fat, reduced insulin needs along with improved glucose tolerance, reduction in blood platelet adhesiveness and aggregation and a reduction in inflammation.(1, 2) Additional benefits include a reduction in anxiety and depression, better cognitive function, improved physical function, independence and reduced falls risk in older adults and has positive effects on numerous chronic diseases.(2, 3) A specific type of exercise; High intensity exercise training, has also been shown to benefit populations with cardiac risk factors in improving exercise capacity(10) Most notable changes in cardiovascular fitness and strength can be observed in individuals exercising for the purpose of health who were previously sedentary.
Performance athletes also see gains but in comparison training adaptations become less apparent the closer they get to reaching their peak potential. Performance exercise can be more targeted in training a specific aspect of cardio respiratory function such as anaerobic speed intervals in order to prepare the body for encounters in competition.(5) Through focused training and competition, performance athletes have been shown to develop mental toughness, encompassing but not limited to enhanced self-belief, motivation, focus and increased ability to deal with pressure. (11, 12) Other beneficial factors of performance exercise in both elite and non-elite competitors can be observed and nurtured through one of the fundamental principles of Olympism(13) ‘(…) practicing sport, without discrimination of any kind and in the Olympic spirit, which requires mutual understanding with a spirit of friendship, solidarity and fair play. ‘ (p.11.). Risks Risk factors are apparent with all forms of exercise; a participant’s age, smoking status, presence of hypertension, hypercholesterolemia, pre-diabetes, other comorbidities, obesity, or family history of heart disease are such examples.(2) To minimise risk and more specifically, avoid any adverse cardiac events, exercise pre-participation health screening is advised.(14) The ACSM(2) pre-participation screening algorithm can be conducted by a health professional and if medical clearance is warranted a referral should be made to the appropriate health care professional. Self guided evidence based methods such as the Physical Activity Readiness Questionnaire + (PAR-Q+) are also available for those new to exercise (2) and are able to self-mitigate risk. The screening algorithm should be used in both health and performance exercise to gain vital information on the participants / athletes health status. Medications, history of previous injury and concussion are vital factors to be aware of prior to training any participant. Additional recommendations are available and should be adhered to for certain specific exercising populations, whereby risk factors maybe increased, such as those exercising with cardiovascular disease or multiple sclerosis.(2) Musculoskeletal injury can occur in both health and performance exercise, physical activity in itself increases this risk.(15) It is well understood that contact sports such as rugby bring higher risks of injury(16) more so than a controlled environment such as walking on a treadmill for health. Steps can be taken to minimise the risk of any injury during exercise through monitoring the incidence, severity and aetiology in order to then address preventative measures.(17) In performance exercise CONTINUED ON NEXT PAGE
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Feature A Comparison of Exercise for Health Versus Performance with Regard to the Basic Principles, Benefits and Risks continued... individual sports governing bodies should monitor and review their current laws and regulations in order to minimise risk, as such performed by football and rugby union clubs in Europe.(16)
multidimensional team.(19, 21) Collaboration between for example coach, sports doctor, physiotherapist, nutritionist and psychologist may prevent or minimise these overtraining risks.
Overtraining(7) and poor acute: chronic workload ratios (18) have been highlighted as risk factors associated with performance exercise, however if volume and progression principles are not followed overtraining can occur in any exercising population. Research by O’Keefe et al(1) suggest that chronic excessive sustained exercise in some individuals can cause myocardial fibrosis and ventricular arrhythmias. Addiction to exercise has also been reported as dangerous resulting in multiple health issues including endocrine and immune dysfunction. (19) Athletes in performance sport may too be at risk of burnout syndrome, a term described by Cresswell & Eklund(20) as a ‘(a) reduced accomplishment, (b) sport devaluation and (c) physical and emotional exhaustion’ (p.481.). Females participating in performance sport that generally emphasise a lean figure are at risk of the female athlete triad, involving eating disorders, amenorrhea and osteoporosis. (21) Adherence to government guidelines(3) and the ACSM(2) when exercising for health makes it unlikely to succumb to the above risk factors. Risks can also be managed in performance exercise through involvement of a
Environmental factors such at hot or cold temperatures place unacclimatised exercising individuals at risk of heat exhaustion, heat stroke or conversely frostbite or hypothermia.(2) Dehydration for example can affect endurance, cognition and skilled motor performance, which could be detrimental to any population group exercising.(2) Altitude impairs physical performance; illnesses such as acute mountain sickness can be avoided by adjusting the amount and rate of ascent through acclimatisation.(2) Conclusion Although an awareness of risk factors is important to have for safe health and performance exercise, the health benefits as reviewed above vastly outweigh the risks and in some instances maybe life-saving in the long term. Following the basic principles of FITT-VP these risks can be minimised and health or performance gains progressively and safely achieved. References available on request.
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NZ Health Role Update Preparing for an NZOC Health Team Role: What is Involved? BRUCE HAMILTON, JORDAN SALESA, FIONA MATHER Corresponding Author Dr Bruce Hamilton Director of Performance Health High Performance Sport NZ Antares Place Mairangi Bay Auckland NZ Bruce.hamilton@hpsnz.org.nz Introduction 2017 marks the start of a new Olympic cycle, with athletes and sporting organisations refocussing on what it will take to generate medal winning performances in Tokyo 2020. After a period of transition and reflecting the continuous nature of international competition, the New Zealand Olympic Committee (NZOC) has recently completed a recruitment drive for doctors, physiotherapists and massage therapists to participate in a range of international multisport events in 2017 and 2018 - including the Commonwealth and Winter Olympic Games. The NZOC received well over 100 high quality applications for these roles, making the selection process a challenging exercise in discrimination. Charged with determining the selections (BH/ JS), the authors recognise both the privileged role we play in deciding who will attend these prestigious events, and the potential influence our decisions have on careers and life experiences. Unfortunately, there are only limited opportunities to represent NZ as part of the health team at these pinnacle events. This brief manuscript is written with the goal of supporting those who may harbour ambitions of working in the Olympic sports medicine environment.
Background In 2013 High Performance Sport NZ (HPSNZ) and the NZOC collaborated to appoint a joint Medical Lead (subsequently evolving into the HPSNZ Director of Performance Health and NZOC Medical Lead). A unique role among international sporting and Olympic organisations, the goal of this joint appointment was to streamline the health management of the elite athlete,
from the training ground to the international competition arena. Aligned with this appointment, since 2012 HPSNZ has provided sports medicine support to carded Olympic athletes through an increasingly centralised model. By far, the majority of funded athlete programmes are based around either the National Training Centre or Regional Performance centres, where athletes may train, recover and receive comprehensive multi-disciplinary support. Reflecting the centralised approach, the clinical needs of many elite athlete groups are increasingly being met by practitioners supported by HPSNZ to be immersed (albeit to varying degrees) within National Sporting Organisation (NSO) programmes. Working within the centralised HPSNZ structure provides a unique opportunity to practice in a truly multi-disciplinary manner, and to broaden skill sets beyond clinical work alone. However, concurrent with the increasingly centralised delivery model for sports medicine support, there has been a corresponding reduction in opportunities for practitioners around NZ to be routinely engaged with elite Olympic sport. Furthermore, since athletes competing in pinnacle events consistently report the value of having recognisable and trusted practitioners incorporated into the traveling team, international team support opportunities for practitioners not working within the centralised system have potentially declined. As a result, both HPSNZ and the NZOC have recognised that articulating a pathway for sports medicine providers into the arena of sports medicine care for elite athletes is essential to ensure the ongoing availability of high quality, experienced practitioners (Figure 1). Establishing a process that encourages and develops capable and enthusiastic practitioners to choose the care of elite athletes as their career (or as a component of their career) is a crucial element in sustaining the standards of care for elite athletes in NZ, and thereby optimally support athletes at pinnacle events such as the Olympic Games.
Sports Medicine for Elite Athletes There is often animated discussion as to whether providing sports medicine support for elite athletes poses unique challenges in comparison to caring for the “weekend warrior�. It is our contention that while there is significant clinical overlap, operational elements of the two scenarios are distinct and increasingly divergent. Specifically, community based sports medicine support (and in this discussion we will arbitrarily consider this as including physiotherapy and medicine) is typically reactive, time constrained and consultation room based. While interand cross- disciplinary referral is utilised, it is not necessarily the immediate default approach, and funding for services provided is based around either ACC, private health insurance or user pays. In this necessarily business model approach to sports medicine, data collection is often limited to professional and legal requirements, research is rare and the application of novel treatments have both commercial and clinical considerations. By comparison, the provision of centrally funded sports medicine care to elite athletes allows for ease of access and an expectation of inter-disciplinary care. Funding and support is not determined by external funding bodies, and as a result clinical options are determined by knowledge, acquired skills and resource availability. Incumbent in the latter approach is a complex accountability to multiple parties, including the coach, athlete (patient), National Sporting Organisation (NSO), discipline and HPSNZ. While there is significant overlap in required clinical skill sets, the two environments are structurally and organisationally distinct, and success in either environment is characterised by the ability of practitioners to continuously learn and adapt.
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NZ Health Role Update Preparing for an NZOC Health Team Role: What is Involved? BRUCE HAMILTON, JORDAN SALESA, FIONA MATHER
Figure 1. Schematic representation of evolution of individuals involved in Health Team representation at Olympic and Commonwealth Games
Care of the Olympic Athlete at Pinnacle Multi-Sport Events: Core Requirements The clinical care of the elite athlete during international camps and competitions is a relatively unique feature of sports medicine support. The Olympic Games is considered the pinnacle of multi-sport events for athletes (notwithstanding the significance of individual sporting code world cups or world championships), and is often held in similar status by practitioners with respect to their individual career ambitions within sports medicine. Paradoxically, while the Olympic Games is a highly charged and pressured environment, it may not have the challenges that are imposed by many smaller events, where a practitioner of any discipline may often be the sole health care provider and event medical support may be limited. Hence, traveling with elite athletes to all levels of events impose quite distinct demands on practitioners, with unfamiliar environments, conflicts of interest, scope of practice extensions, long working days and clinical isolation all creating challenges that must be adapted too in order to be successful. Like all clinical skills, team travel is a
capability that must be learnt. The health team for a pinnacle multi-sport event such as the Commonwealth or Olympic Games is required to support athletes and support staff through a broad range of potential situations. Critical attributes of team members are found in table one.
PInnacle Event: Team CapabIlIty and FunctIon In addition to the individual capabilities described above, an individual’s
selection and ultimate role within a multisport team is also determined by the overall capability of the health team. Thus, team considerations such as the specific skill set mix, sport specific experience, communication, leadership styles and gender mix, all play a role in the final health team formulation. Furthermore, ensuring an appropriately skilled future team, through careful planning for succession, is a critical function of any multi-sport health team, and this further complicates the team selection matrix (Figure 2). As a result of the large number of individual and team factors implicated in selection, and the extremely limited number of positions available, securing a role at an Olympic or Commonwealth Games team for NZ is challenging (but not impossible). PreparIng for selectIon to an NZOC Health team In 2017, over 120 applications were received for opportunities to be part of the health team for the World University Games, Youth Commonwealth and Olympic Games, Winter Olympics and Commonwealth Games. From this long list, 42 applicants were ultimately interviewed and 39 traveling and reserve positions were appointed. Thus, getting through the initial selection phase is critical, and the following observations are made to assist those wishing to
Table 1. Attributes of individual health team members at a pinnacle multi-sport events Clinical Reasoning for Health and Performance impact
Applied and detailed understanding of specific aspects of individual athlete management, including the impact of illness or injury upon wider performance variables. Established ability to collate multiple clinical and non-clinical factors in the formulation of a management strategy, in a time compressed environment and in the presence of potentially conflicting imperatives
Event experience
Experience and proven capability at an international competition level, preferably multisport event. May be developed through individual sporting federation world championships, or junior events such as youth Olympic and Commonwealth Games.
Proven ability to work in a
Established record of effective inter-disciplinary team involvement in the management of elite athletes
Advanced communication skills
Effective communication of timely, relevant and accurate information to inform multi-disciplinary decision making under pressure of time and conflicting imperatives
Skills under pressure
The ability to remain positive and effective despite the challenging multi-sport environment. The ability to recognise individual limits, work within your scope of practice and respect colleagues.
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NZ Health Role Update Preparing for an NZOC Health Team Role: What is Involved? BRUCE HAMILTON, JORDAN SALESA, FIONA MATHER sustained effect on groups, sports, systems, beliefs and practices? Can you articulate clearly why would this be useful to the NZOC health team?
•
team selection enhance their chance of being involved in future NZOC health teams. • If you are unsure whether to apply – apply. As illustrated above, multiple factors are involved in determining the ultimate team make-up, and you never know what factors may be in play at any given time.
• experience and capabilities
• Be clear and honest on your career aspirations and your motivations. Remember, those selecting the team are interested in what you can do for the team, not just that you are really enthusiastic (which is universal)– it’s about the team, not the individual. • Be clear on what makes you special What can you bring to the team, that differentiates you from other practitioners? While an important part of your application preparation, this should you want to work in this environment, what do you think is going to be needed, and how can you make yourself the best person for that role?
• a difference. Most practitioners are able to provide illustrations of where they have positively influenced an athlete’s outcome term
skills such as team work, collaboration critical observation, problem solving, adaptability and conflict resolution. •More (or less) experience is not necessarily better. What is the quality of what you have been doing and how does it differentiate you from others? For example, having attended 25 conferences may not reflect development or progression of “non-clinical” competencies as much as teaching or lecturing on a few to organisations such as SMNZ, or contributing clinical articles in local educational forums such as the SMNZ journal). • Take opportunities to work with NSO’s and HPSNZ. If you have a passion for a particular sport, look for opportunities to showcase and develop your expertise. HPSNZ is regularly advertising for practitioners to work in the centralised hubs, or travel with teams. In the last year, HPSNZ Performance Health Team has established a sports medicine fellowship for sports physician registrars, internship. • Prepare your curriculum vitae. Ensure that it is up-to-date, does not include typographical errors and does not include multiple colours or fonts! The pieces of your CV that you consider important and relevant to your application should may be all the opportunity you get. • Prepare for the interview carefully by researching and asking questions of those the trap of making assumptions on what may or may not have occurred before. Be primed with examples for a range of potential scenarios that illustrate your strengths and weaknesses.
Conclusion Being a member of the health team in an NZOC multi-sport pinnacle event is both challenging and highly rewarding. Quite appropriately given the nature of the event, membership of this team is highly sought after and given the size of the team, selection is highly competitive. Despite the increasingly centralised approach to the provision of health care to elite NZ athletes, both HPSNZ and the NZOC are committed to supporting the development of practitioners with the right skill set and desire to work with elite athletes. As illustrated above, health team selection involves consideration of multiple factors and is increasingly challenging. Those charged with its selection take the responsibility seriously, recognising the significance of the appointments, and are committed to transparency of process and development of individuals in this inspirational area of work. As with athlete selection, selection to an NZOC pinnacle multi-sport event health team requires years of commitment, sacrifice and hard work. It doesn’t come easy for anyone. However, working at one of the great spectacles, alongside talented and committed colleagues and athletes, makes that hard work worthwhile.
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AUTHOR AFFILIATIONS Bruce Hamilton Performance Health, High Performance Sport NZ NZ Olympic Committee, Olympic House, 350 Parnell Road, Parnell, Auckland 1052 Jordan Salesa Performance Health, High Performance Sport NZ NZ Olympic Committee, Olympic House, 50 Parnell Road, Parnell, Auckland 1052 Physio Rehab Group, 64 Te Koa Road, Panmure, Auckland Fiona Mather Performance Health, High Performance Sport NZ
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Originally published in SMNZ
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Clinical Section - Article Review Likelihood of ACL Graft Rupture: Not Meeting the Six Clinical Discharge Criteria Before Return to Sport is Associated with a Four Times Greater Risk of Rupture Polyvios Kyritsis1, Roald Bahrain1,2, Philippe Landraeu1,Erik Witvrouw1,3 British Journal of Sports Medicine 2016;50:946-951.doi:10.1136 Abstract To evaluate whether a set of objective discharge criteria, including muscle strength and functional tests are associated with risk of ACL graft rupture after return to sport (RTS). Athletes who do not meet the discharge criteria before returning to sport had a four times greater risk of sustaining an ACL graft rupture compared with those who met all six RTS criteria. In addition, hamstring to quadriceps strength ratio deficits were associated with an increased risk of ACL graft rupture. After ACL reconstruction (ACLR) the typical goal is to RTS as soon as possible. To increase the success of RTS, specific criteria have been developed. The most commonly described tests are isokinetic strength tests, functional tests, clinical assessment and related subjective questionnaires. 3,4 Surprisingly to date the main focus has been on non-modifiable factors.7,14-21 In the only prospective study poor neuromuscular control was the biggest risk factor in ACL graft rupture.14 Quadriceps and hamstring strength, poor knee alignment or poor muscular control are predisposing factors14,16,17,19,20 and Paterno et al suggested transverse plane net moment impulse at the hip, dynamic frontal plane knee range of motion, side to side differences in the saggital plane, knee movement at initial contact and deficits in postural stability were associated with greater risk of ACL graft rupture. 14 In this study all athletes completed a rehabilitation program supervised by a specialised team of ACL rehabilitation sports physiotherapists. Rehabilitation was divided in to three phases: 1. early, where the focus was on controlling swelling, restoration of range of movement and activation of the quadriceps and hamstring muscles 2. intermediate, where the focus is on optimisation of muscle strength, neuromuscular control and proprioception. Towards the end of this phase a running progression program was initiated. 3. advanced, sports specific rehabilitation incorporating sports and position specific drills. At the end of this phase an assessment took place before returning to team training. RTS was then based on six discharge criteria, not time based criteria.
Table 1 Discharge tests and criteria used during the study period
Six-part return to sport tests
Discharge permitted when each of these criteria was met
Isokinetic test at 60, 180 and 300°/s
Quadriceps deficit <10% at 60°/s
Single hop
Limb symmetry index >90%
Triple hop
Limb symmetry index >90%
Triple crossover hop
Limb symmetry index >90%
On-field sports-specific rehabilitation
Fully completed
Running t test
<11 s
Criteria were set according to the literature at the start of the study
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Clinical Section - Article Review Likelihood of ACL Graft Rupture: Not Meeting the Six Clinical Discharge Criteria Before Return to Sport is Associated with a Four Times Greater Risk of Rupture continued... Athletes who did not meet the specific discharge criteria before RTS and were not fully discharged from ACLR rehabilitation by the surgeon had a four times greater risk of ACL graft rupture compared to those who passed the RTS criteria. Premature RTS without meeting the specific criteria contributes to an increased risk of ACL graft rupture. This suggests that neuromuscular asymmetries during dynamic movement may not only affect performance but also may be a predictor of the risk of a graft rupture. Also low hamstring to quadriceps strength ratio has been identified as a risk predictor. The hamstring muscles act as agonists to the ACL by resisting the anterior tibial displacement that results from quadriceps muscles forces on the knee. The hamstring strength and the ratio of strength to the quadriceps strength is a factor that may well be applicable to the reconstructed ACL. The current clinical dogma is that RTS should not be permitted within 6 months of reconstruction. 43,44 Grindem and colleagues45 recently reported a 50% reduction in risk of knee re-injuries for each month that RTS is delayed beyond 6 months. In addition to time as a criterion, knee function as evaluated by the RTS tests is a key element in the decision making process.1 The maximum bilateral deficit recommended as acceptable for RTS clearance for functional and strength tests is between 10 and 15%.51,52. A limb symmetry index of 90% in all hop tests and 85% in isokinetic strength tests is recommended. 53,54 It can be considered that meeting these criteria implies good muscular strength and neuromuscular control and therefore ensures safe RTS. Some research data suggests that sufficient hamstring strength and balance between the hamstrings and quadriceps muscles strength should be used as a RTS criterion.40,41,56,57 Given the high incidence of ACL graft ruptures still there remains a concern over the clinical criteria that are used to clear an athlete for RTS. In this study completing the rehabilitation program and meeting the discharge criteria was associated with substantially less odds of ACL graft rupture. Meeting stringent RTS criteria may reduce the risk and this study suggests that a RTS test battery with associated criteria may help in the RTS decision making process. Conclusion Patients who did not meet the discharge criteria before returning to professional sport had a four times greater risk of sustaining an ACL graft rupture than those who passed the RTS criteria. So what are the relevant clinical findings from this study? •
Meeting 6 specific objective discharge criteria before RTS after ACL reconstruction rehabilitation was associated with ¼ the risk of ACL graft rupture.
•
For every 10% decrease in the hamstring to quadriceps strength ratio there was a 10.6 times higher risk of sustain an ACL graft rupture.
How could this impact clinical practice? •
Meeting specific objective discharge criteria can reduce the relative risk of sustaining an ACL graft rupture by four times.
•
Appropriate hamstring to quadriceps strength ratio should be achieved before discharge after ACL reconstruction to help reduce the likelihood of graft rupture
A full set of references are available on request By Pip Sail Physiotherapist
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Post-Grad Research Best Current Practice in Reducing Injury Risk in Runners By Gait Retraining MITCHELL VAN SCHAIK Introduction Running is a rapidly evolving sport that is very popular in the world, which can be partially reflected by the number of participants in distance running events worldwide (Chan et al., 2017). In 2015, there were 17.1 million finishers that participated in over 30,000 races in the United States, this can be attributed to the positive impact of running on the cardiovascular system, mental health, and weight loss (Chan et al., 2017). However, with these significant health benefits, the repetitive nature of running results with more musculoskeletal related injuries, 37-39% of runners sustaining an injury in each year (Chan et al., 2017). Novices are more vulnerable to injury due to being less physically prepared for distance running (Chan et al., 2017). The most common injuries amongst runners are medial tibial stress syndrome (MTSS), patellofemoral pain (PFPS), stress fractures, ilio-tibial band friction syndrome (ITBFS), plantar fasciitis (PF) and achilles tendinopathy (AT) (Chan et al., 2017). These are all overuse injuries that slowly build up, purportedly due to increased loading/impact forces to certain areas of the body by poor running biomechanics. Vertical ground reaction force (VGRF) is a key biomechanical force that can influence injury (Chan et al., 2017; van der Worp et al., 2016). High VGRF often is related to lower extremity stress fractures (van der Worp et al., 2016; Zadpoor and Nikooyan., 2011). Increased vertical impact peaks, load rates and tibial shock in those who have had tibial stress fractures, plantar fasciitis and PFPS have been found two of the most common injuries in runners (van der Worp et al., 2016; Altman and Davies., 2012). Gait can be modified by changing a runner’s stride length, cadence, and conversion of rearfoot strike (RFS) to forefoot strike (FFS). Gait retraining may be effective for runners who are not injured, have poor running biomechanics, had previous injury and runners who are injured with persistent symptoms and can be taught through verbal and auditory cues (Chan et al., 2017; Willy et al., 2016). This is an important topic because of the growing popularity in the sport that is being burdened by
increasing overuse injuries. However, the research is limited to mainly small, anecdotal and retrospective studies with methodological weaknesses (Hall et al., 2013). The aim of the critical review is to discover whether gait retraining can be helpful in reducing injury risk in runners. Foot Strike Pattern The earliest example of footwear was discovered 10,000 years ago and were shoes constructed on a flat surface of woven sage bush (Altman and Davies., 2012). Modern shoes have evolved after the running boom of the 1970’s, and now have a significant amount of cushioning and stabilisation incorporated into them, marketed for comfort, injury protection and correcting movement patterns (Altman and Davies., 2012). Theoretically this makes perfect sense, but why do we get injured? It’s been suggested that these additional extras may take the job away from the adaptive foot causing the foot to decondition, resulting in changes to the kinetic chain (Altman and Davies., 2012). Seventy-five percent of distance runners land on their heel which is referred to as a rear foot strike (RFS), thought to be due to the elevated cushioned heel on the modern day running shoe (Altman and Davies., 2012). Twenty-four percent land with a flat foot, or a mid-foot strike (MFS) and 1% land on the ball of their foot (FFS) (Altman and Davies., 2012). As we fatigue, RFS becomes more common. At the 10 km point of a half-marathon 88.9% were RFS, 3.4% MFS and 1.8% FFS (Altman and Davies., 2012). A retrospective study determined that mild and moderate running related injuries occur 2.5 times more frequently in RFS to FFS (Daoud et al., 2012). They also determined that hip, knee and lower back pain, tibial stress injuries, plantar fasciitis and stress fractures (excluding metatarsal fractures) were 2.7 times more likely to occur in RFS (Daoud et al., 2012). During a FFS, the impact forces are dispersed throughout two points on the foot; the first as the forefoot comes into initial contact with the ground, followed by an eccentric contraction of the plantar CONTINUED ON NEXT PAGE
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Post-Grad Research Best Current Practice in Reducing Injury Risk in Runners By Gait Retraining MITCHELL VAN SCHAIK fascia and achilles tendon as the heel lowers and comes into contact with the ground as the second point of contact (Altman and Davies., 2012). This spreads the large impact force over two contact points which reduces the VGRF through the foot and kinetic chain (Altman and Davies., 2012). Our body naturally adopts a shorter stride length with the foot landing under the bodies centre of mass (COM) which reduces the VGRF to the hip and knee joint (Altman and Davies., 2012). Eccentric loading of the achilles and posterior calf muscle during the FFS results in a significant reduction in VGRF and acts as a shock absorber for the lower limb (Altman and Davies., 2012). The increased loads to the posterior calf muscles with the increased eccentric work of the plantar flexors can result in greater strain rate to the achilles tendon and calf muscle and landing on the ball of the foot, will likely increase the stress to the metatarsal heads (Altman and Davies., 2012). High calf muscle, achilles and metatarsal injury rates have been reported in FFS runners (Chan et al., 2017). One of the biggest risk factors for a transition from RFS to FFS is load management. The body must have time to adapt to the new loading that it is experiencing. During a RFS, the foot is required to actively dorsiflex through the swing phase and with the direct contact of the heel with the ground, the impact goes straight into the heel, to the shin and up the kinetic chain (Altman and Davies., 2012). Landing with a RFS consequently results in a large, defined impact peak in the VGRF, which is directly related to stress fractures (Altman and Davies., 2012). The active dorsiflexion required to clear the toes of the ground during the swing phase is also responsible for eccentrically contracting to lower the forefoot to the ground once the heel has landed (Altman and Davies, 2012). This is associated with an increased load to the muscles of the anterior compartment of the lower limb, potentially resulting in hypertrophy of these muscles and increased pressures in the anterior compartment (Altman and Davies., 2012). This can lead to chronic exertional compartment syndrome (CECS), which is often treated by surgical
intervention by relieving the compartment pressure. Ten RFS military cadets with CECS, who were waiting for a fasciotomy, underwent a 6-week transitioning programme from RFS to shod FFS pattern (Diebal et al., 2012). Following the six weeks, pain reduced to 10/100 on the visual analogue scale, anterior compartment pressures were reduced to normal and participants could safely increase their running distance (Diebal et al., 2012). In another study, a 10-week running intervention allowed nine runners with PFPS, to change from being habitually RFS to FFS (Sinclair., 2016). They found reductions in peak patellofemoral forces and reduced pain symptoms at the knee by altering their foot strike pattern, although this was at the expense of increased pain and forces at the achilles tendon (Sinclair., 2016). While these two studies are limited by the small sample sizes, they provide initial evidence that a conservative management programme, specifically transitioning from RFS to FFS patterns, may be effective for runners with CECS or PFPS. Decreasing stride length Small reductions in stride length have been shown to reduce the VGRF (Altman and Davies., 2012). An effective way to reduce the stride length is to land with a FFS, enabling the foot to land closer to the COM of the body (Altman and Davies., 2012). This reduces the impact loading to the hip and knee joints, reducing the joint moments that are generated (Altman and Davies., 2012). Just a 10% decrease in stride length, while still rearfoot striking, results in a significant reduction in hip and knee energy absorption, thereby decreasing the loading to these joints (Heiderscheit et al., 2011; Edwards et al., 2009). Edwards et al. (2009) reported that reducing stride length by 10% (while maintaining speed) reduces the probability of developing a tibial stress fracture. In contrast, a 10% increase in stride length increased the risk of a stress fracture (Edwards et al., 2009). However, this study only included 10 participants and was determined using modelling techniques.
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Post-Grad Research Best Current Practice in Reducing Injury Risk in Runners By Gait Retraining MITCHELL VAN SCHAIK Cadence A further variable of the running gait that can be modified is the cadence. When increasing step rate but maintaining running speed, step length decreases. The reduction in step length and increased the step rate are associated with decreased energy absorption at the knee and hip (Heiderscheit et al., 2011). The shortened step length locates the heel more under the COM at initial contact, decreasing the breaking impulse, peak knee flexion during stance and COM vertical excursion, suggesting a greater lower extremity stiffness (Altman and Davies et al., 2012; Heiderscheit et al., 2011). With a step rate increase of 5% the knee displays the most significant change with a 20% decrease in loading rates, and 34% reduction with a 10% increase in step rate. This indicates less stress on the knee and a decrease in mechanical work performed at the knee with increasing step rates (Heiderscheit et al., 2011). Similar effects were seen at the hip while the stress on the ankle joint increased (Heiderscheit et al., 2011). The energy that was generated by the hip, knee and ankle decreased significantly as the step rate increased (Heiderscheit et al., 2011). Furthermore, a recent study verified that 10% step rate increase can reduce the patella-femoral joint stress by 14% and reduce PFPS symptoms by 22% (Lenhart et al., 2014). Running with a higher cadence thus appears to place the body into a more biomechanically advantageous position, reducing energy demands. However, when step length and rate were changed independent of each other, energy absorption difference was only observed if the step length decreased (Heiderscheit et al., 2011). This study measured kinetics and kinematics, included 44 participants and had a short term follow up of 30 days, therefore can conclude that increasing the cadence may be beneficial for the treatment and prevention of stress fractures, knee and hip injuries (Heiderscheit et al, 2011). Excessive hip adduction and internal rotation is associated with anterior knee pain and ITBFS (Sinclair., 2016). A 5-10% increase in step rate can significantly reduce peak adduction while running by reducing the
biomechanical demands placed on the hip in the frontal and transverse planes of motion, and may be useful in the clinical management of running injuries involving the hip and knee (Heiderscheit et al., 2011; Sinclair., 2016). Despite the benefits of increasing the step rate and shortening the stride length, the cumulative load may increase due to a greater number of loading cycles (Heiderscheit et al., 2011). Feedback Tools A randomised clinical trial (RCT) with 320 participants explored the effects of eight sessions of gait modification over two weeks (Chan et al., 2017). The training involved participants running at a selected speed on an instrumented treadmill that had a visual feedback of VGRF signal on a monitor in front of them. The participants were instructed to â&#x20AC;&#x153;run softerâ&#x20AC;? so that the amplitude of the VGRF was reduced. The running time increased from 15 to 30 minutes over the eight sessions and the visual feedback was progressively decreased in the last four sessions (Chan et al., 2017). The control group received no gait retraining, but had eight running sessions over the two weeks, running the same times as the retrained group (Chan et al., 2017). At 12 months follow up, 16% of the gait retraining and 38% of the control group runners reported that they had a running related injury (Chan et al., 2017). More Achilles (18%) and calf injures (18%) were observed in the re-trained group, as opposed to none in the control group (Chan et al., 2017). On the contrary, the control group had plantar fasciitis (38%) and PFPS (29%), while only 7% and 14% in the gait retrained group had these injuries (Chan et al., 2017). Overall, the laboratory based gait retraining programme reduced the impact loading and the running related injuries in novice runners by 62% during the 12 months follow up (Chan et al., 2017). Lower VGRF was achieved through a reduction in the vertical body stiffness during impact (Chan et al., 2017). The running retraining group did have increased calf strains and Achilles tendinopathy, likely due to greater strains on the ankle plantar flexors when the participated attempted to soften the footfalls by a FFS switch (Chan et al., 2017). These findings CONTINUED ON NEXT PAGE
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Post-Grad Research Best Current Practice in Reducing Injury Risk in Runners By Gait Retraining MITCHELL VAN SCHAIK support the use of visual biofeedback in reducing the impact loading and is an effective way in injury prevention (Chan et al., 2017). However, based on the increased injury rates of the Achilles tendon and calf muscles, a carefully progressed programme remains important. Although this was an RCT, the main limitations to this study was that they didn’t measure running biomechanics outside of the laboratory, they used a patient controlled online platform to monitor the injury patterns and they didn’t remeasure after the 10 weeks to ensure they still ran with a low VGRF (Chan et al., 2017). Another study included 30 healthy ‘at-risk’ runners, randomized into a gait retraining and control group (Willy et al., 2016). An accelerometer was used to increase step rate to above 7.5% of their usual cadence over 8 sessions and education sessions were delivered with a 3D gait analysis (Willy et al., 2016). The gait-retrained group increased their step rates by an average of 8.6%. Average vertical loading rate was reduced by 19%, and eccentric knee joint work was reduced by 27% per stance phase and 21% per kilometre of running (Willy et al., 2016). The increased step rates were maintained over the 30 days suggesting the potential for long-term gait alterations being evident with retraining supported with the use of an accelerometer (Willy et al., 2016). This study indicates that increasing step rates is likely to be associated with decreased impact forces and eccentric knee joint work which, in turn, may decrease risk of injury, particularly of the knee.
Conclusion Increasing cadence, decreasing stride length and changing the way the foot strikes the ground from RFS to FFS individually significantly reduce VGRF and energy absorption at the hip and knee. This is important as 50% of running injuries occur at the knee (Altman and Davies., 2012). The body becomes more energy efficient, reducing stress to the areas where we commonly experience overuse injuries and one study
reported reducing injuries by 62% over a one-year period (Chan et al., 2017). Increasing cadence and decreasing the stride length can be achieved through a transition from RFS to FFS, although a slow transition from a qualified professional is recommended because while adapting, injuries have been reported. Emerging evidence suggests these running modifications may be beneficial for the treatment and prevention of CECS, PFPS and ITBFS. These modifications have shown to be maintained at one month follow-up using biofeedback and an accelerometer. Biomechanical evidence suggests gait retraining reduces the magnitude of key biomechanical factors associated with running injuries, there is currently limited evidence that supports gait retraining to lower injury risk. The main limitations in the research in this topic are the challenges with investigator blinding, infrequent intervention randomisation, small sample sizes and lack of evaluation following habituation. Well controlled, larger prospective studies are needed to confidently conclude that gait retraining can reduce injury risk.
Acknowledgement This review was completed towards partial fulfilment of the PHTY542 Sports Physiotherapy paper towards the Post-graduate Diploma in Sports and Exercise Medicine at the University of Otago. Mitch currently works as a physiotherapist at Proactive in Auckland.
References available on request
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Research Publications British Journal of Sports Medicine www.bjsm.bjm.com
Volume 52, Number 4, February 2018 WARM UP Where sports medicine and physical activity for health intersect – occasion for opportunity or improbable idealism? Jane S Thornton REVIEWS Determination and regulation of body composition in elite athletes Peter Sonksen Exercise prescription for overhead athletes with shoulder pathology: a systematic review with best evidence synthesis Alexis A Wright, Eric J Hegedus, Daniel T Tarara, Samantha C Ray, Steven L Dischiavi The effects of shoe-worn insoles on gait biomechanics in people with knee osteoarthritis: a systematic review and meta-analysis Kathryn E Shaw, Jesse M Charlton, Christina K L Perry, Courtney M de Vries, Matthew J Redekopp, Jordan A White, Michael A Hunt ORIGINAL RESEARCH Injuries sustained in National Collegiate Athletic Association men's and women's basketball, 2009/2010–2014/2015 Scott L Zuckerman, Adam M Wegner, Karen G Roos, Aristarque Djoko, Thomas P Dompier, Zachary Y Kerr Psychological factors are associated with the outcome of physiotherapy for people with shoulder pain: a multicentre longitudinal cohort study Rachel Chester, Christina Jerosch-Herold, Jeremy Lewis, Lee Shepstone International variability in 20 m shuttle run performance in children and youth: who are the fittest from a 50-country comparison? A systematic literature review with pooling of aggregate results Justin J Lang, Mark S Tremblay, Luc Léger, Tim Olds, Grant R Tomkinson Comparison of four alternative national universal anterior cruciate ligament injury prevention programme implementation strategies to reduce secondary future medical costs Dion A Lewis, Brent Kirkbride, Christopher J Vertullo, Louisa Gordon, Tracy A Comans
http://bjsm.bmj.com/content/
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Continuing Education
and PNZ Northland Branch presents:
Concussion Management Dr. Deb Robinson (ex All Blacks & Crusaders Doctor)
Sideline assessment through to return to play
Dr Deb Robinson will be presenting the latest research in acute management of concussion, including sideline management and practical skills.
Saturday March 3rd Whangarei Toll Stadium 1.00â&#x20AC;&#x201C; 5.00pm LIMITED 30 places Registrations: contact Kim Northland Branch Secretary at kimberly.pow@hotmail.com
PNZ Member: $130
Non PNZ Member: $150
Concussion symposium & workshop discounted combined rate: PNZ Member: $170 Non PNZ Member: $200 (Lunch provided)
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Classifieds
Full or Part Time Physiotherapist required â&#x20AC;&#x201C; Auckland, North Shore Forrest Hill Physiotherapy A full or part time position will be available with Forrest Hill Physiotherapy from early April 2018. Our musculoskeletal practice is a certified community based clinic, with representative team and High Performance sport links amongst the six post-graduate qualified physiotherapists. Established over 25 years ago, the clinic has a loyal patient and GP referral base and an excellent reputation within the community. Our clinic has a strong manual therapy and exercise rehabilitation focus, facilitated by a fully equipped Clinical Pilates studio, rehab gym and Real Time Ultrasound Imaging service. In addition to fortnightly in-service education, the successful applicant will work alongside Clinical Pilates instructors, a continence physiotherapist and massage therapists. All staff are supported by a skilled and experienced administration team and practice manager. A competitive financial package is offered including support of on-going education, conferences, courses and work in special interest areas, e.g. sports teams. Post-graduate qualifications are desirable but PGD students with private practice experience will be considered. If you fit these criteria and are motivated to learn and work in a dynamic post-graduate environment, then please e-mail CV to Chris McCullough at chris.mccullough@xtra.co.nz. All replies received in the strictest confidence.
Position: Part time physiotherapist (Full time job share position may be available in conjunction with another clinic) Location: WSAFC, Seddon Fields, 108 Meola Rd, Western Springs, Auckland Start date: Feb March 2018 Back To Your Feet Physiotherapy are a central Auckland ACC accredited physiotherapy and sports clinic based onsite at the best footballing facility in the country. We focus on prevention, treatment and performance and provide services to national and regional teams for a variety of sports (football, ice hockey, roller derby). We are looking for an enthusiastic and reliable part time physiotherapist to join our friendly team. Part of the role will be to provide physiotherapy services to the WSAFC Premier Womenâ&#x20AC;&#x2122;s Football Team. The successful applicant will benefit from a significant mentoring and a comprehensive CPD programme. Please direct any questions or email your CV to Justin at info@backtoyourfeet.co.nz