SEPNZ Bulletin June 2019

PAGE

SEPNZ BULLETIN

ISSUE 9. JUNE 2019

Lacrosse Injury & Prevention p12

p15 Knowledge, Attitudes and Behaviours of New Zealand Physiotherapists to Sports Related Concussion

p19 Wrist Injuries in Tennis Players: A Narrative Review

p21 UPCOMING SEPNZ COURSES

www.sepnz.org.nz

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SEPNZ EXECUTIVE COMMITTEE

Members Page

President - Blair Jarratt Vice-President - Timofei Dovbysh Secretary - Michael Borich Treasurer - Timofei Dovbysh Website - Hamish Ashton Sponsorship - Bharat Sukha Committee Emma Clabburn Rebecca Longhurst Justin Lopes Emma Lattey

EDUCATION SUB-COMMITTEE Dr Angela Cadogan Emma Clabburn Rebecca Longhurst Justin Lopes Dr Grant Mawston Dr Chris Whatman

Visit www.sepnz.org.nz

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CONTACT US Michael Borich (Secretary) 26 Vine St, St Marys Bay, Auckland secretary@sepnz.co.nz

PAGE 3

CONTENTS

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

2

EDITORIAL: By SEPNZ President Blair Jarratt

4

GET TO KNOW THE TEAM: 2 MINUTES WITH…Rebecca Longhurst

5

APP REVIEW: Insight Timer

6

MEMBER BENEFITS: Discounts

10

FEATURE ARTICLE: Lacrosse - Injury & Prevention

12

SPRINZ: Knowledge, Attitudes and Behaviours of New Zealand Physiotherapists to Sports Related Concussion

15

CLINICAL REVIEW: Wrist Injuries in Tennis Players: A Narrative Review

19

UPCOMING SEPNZ COURSES

21

RESEARCH PUBLICATIONS: BJSM Volume 53, Number 11, 12 June 2019

22

CLASSIFIEDS

23

PAGE 4

EDITORIAL

Welcome,

to another jam-packed SEPNZ

bulletin delivered straight to your inbox. It's a bumper bulletin this time tapping out at 23 pages. Perfect for this time of year when Game of Thrones has finished, and you can't seem to find your next evening fix.

As a feature in this bulletin, we look at Lacrosse. It's a little known sport in NZ, but its popularity is on the increase. In 2000 the senior men's league was started in Auckland, and a year later NZ Women's Lacrosse Association was formed and a Women's league established. It's estimated that over 900 school children are playing or learning the skills at Lacrosse, and the number is growing. As a sports physiotherapist you need to know your sports and the skills and demands it places on players. SEPNZ member Andrew Muir gives us an insight into common Lacrosse injuries and prevention. If you want to know more, including a full History of the sport and a video of the NZ U18 v Victoria game then check out the NZ Lacrosse website https://www.nzlacrosse.com Our bulletin also is a chance to get to know your SEPNZ executive better. Rebecca Longhurst talks about her position on your SIG committee and her experiences as a sports physiotherapist. She is currently on maternity leave from her HPSNZ position but is still actively putting together the SEPNZ education program - which recently delivered three concussion workshops across NZ. The SEPNZ upcoming courses are on page 21 of this bulletin so please save the dates for those that interest you.

While I am on the subject of concussion, earlier this year we sent out a concussion survey from AUT. The results of this survey are in this bulletin and the excellent work Duncan Reid and the team are presenting to ACC. There is a real push going on in the background to get

Physiotherapists recognised as appropriate providers for concussion, and again we ask you to have a look at the survey link by Dr Ewan Kennedy from Otago University. I encourage you to head to this survey and fill this in as this data may help physiotherapists be able to make decisions around return to play along-side medical practitioners as is currently possible in other countries. I will include the link to the survey at the bottom of my editorial.

Also in this bulletin, there is another superb APP review suggested by SEPNZ member Andrea Marchand on insight timer with an excellent rundown on its clinical uses, pros and cons, plus a clinical review on wrist injuries in tennis players.

Ok so that's a roundup of the bulletin - on an executive front we held a meeting in Wellington with PNZ in regards to the up and coming unity plan. As your executive we will be discussing the outcome of this meeting at our Face to Face and letting you know our next steps and how we can and always want to deliver a SIG that you find of great value. Any suggestions for our executive, please send to Michael Borich so we can discuss this at our upcoming Face to Face meeting in July.

Until then it's business as usual for SEPNZ. We have passed the longest day, so summer is on the way......

Kind Regards Blair Jarratt SEPNZ President

Concussion survey here: https://otago.au1.qualtrics.com/jfe/form/ SV_2lzkGFQVTBLZOOV

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GET TO KNOW THE TEAM - 2 MINUTES WITH...

Rebecca Longhurst SEPNZ Committee Member

What role do you play on the exec?

Favourite tune on a road trip?

I am on the Executive Committee and am the Chairperson of the Education Committee. I have been on the Exec since 2016.

Currently all I get to hear is The Wiggles on repeat, but to be fair it is better than crying.

Favourite sporting physiotherapy moment Life outside of SEPNZ? I am a mum of two young girls and am currently on maternity leave from my role at High Performance Sport New Zealand. Like most Kiwi physios I started off in club rugby.

Seeing someone perform at their chosen sport after either coming through an intense training block or injury, especially ones that have had them out for long periods of time, is the part of my job I enjoy the best.

I then got some pretty cool opportunities with Netball travelling to the Commonwealth Games and World Cup.

Favourite / Best or Worst destination as touring Physio and why?

I moved to Canada prior to the 2010 Vancouver Winter Olympics and ended up working with the Canadian Paralympic Ski Team from 2009-2014 attending World Cup, World Champ and both the Vancouver and Sochi Paralympic Games.

Upon returning home to New Zealand I starting working with HPSNZ with Yachting, Netball, Winter Sports and Para-Swimming. I was lucky enough to attend the Glasgow Commonwealth Games and PyeongChang Winter Olympics as a New Zealand Olympic Committee (NZOC) physio.

I skied growing up and nothing beats a day on the mountain! I also love mountain biking and hiking and have enjoyed introducing my eldest daughter to the great outdoors.

Sochi a year out before the Games was an eye opener, skiing past soldiers sitting in the trees with assault rifles took some getting used to. Going from working at -30 with a snow gun pointed at me with Winter Sports to sitting on a beach in Spain with Yachting was quite the contrast and love being able to have done both.

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APP REVIEW

Back to the App...

Your App Review Insight Timer Thank you to SEPNZ member Andrea Marchand for the recommendation and help with the analysis of the “Insight Timer” app. Andrea has had extensive use of the app and provided invaluable information for this review.

What is it?

“Insight Timer" is an app for mediation and mindfulness practice and is promoted as a comprehensive and award-wining app for helping people de-stress, reduce anxiety, improve their sleep and generally deal with the stresses and strains of everyday living! It has several categories and lengths of meditations, adding new ones every day with over 20,000 free ones to choose from.

Who is it for?

The categories most relevant to patients and athletes are for sleep, mindfulness, healing imagery, breathing, performance and pain. Examples of patients who may benefit are those with chronic pain, poor breathers, poor sleepers, the generally stressed out, those with known depression or anxiety, or athletes who are trying to optimise performance. The vastness of this app allows anyone to find what type of meditation or mindfulness practice suits them.

Seller:

Insight Network Inc

Size:

87.4 MB

Category:

Health & Fitness

Compatibility:

Available for iOS 11.0 or later and Android .

Languages:

English and 10 more

Age rating:

4+

Copyright:

Ó 2019 ONYX Apps

Price:

Free or $99 for a year – with extra courses.

CONTINUED ON NEXT PAGE >>

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APP REVIEW Are there special categories for athletes?

For athletes - find the "Performance in Sport" and "Sport Science" sections - under Meditations > Motivation > Sport - along with several topics relevant to sport psychology, i.e. breathing, imagery, visualization, and selfconfidence. Andrea recommends guided meditations by teacher Josh Crist who provides interviews relevant for sport and athletes.

For injuries - under Meditation > Pain, there are specific ones for physical healing and pain release.

CONTINUED ON NEXT PAGE >>

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APP REVIEW What are Mindfulness and Meditation?

Mindfulness has its roots in Eastern meditational practice and this practice helps to direct attention to the present experience on a moment-to-moment basis. Meditation exercises encourage individuals to engage in nonjudging awareness of their internal experience occurring at each moment, such as bodily sensations, cognitions, emotions and to environmental stimuli, such as sights and sounds.

Latest research and our role regarding the mental health of our athletes Meditative approaches have been shown to reduce anxiety, stress and neurobiological markers such as cortisol, epinephrine and norepinephrine (Noetel, Ciarrochi, Van Zanden, & Lonsdale, 2017), and despite requiring further investigation mindfulness training appears to be a promising strategy for athletes. Recent studies have reported significant improvements to athletes’ mental state with 4–6 weeks of mindfulness training and in wheelchair basketball players, 8 weeks of mindful mediation utilizing a smart phone app attenuated the rise in cortisol associated with a competition period (Keaney, Kilding, Merien, & Dulson, 2019).

Reviewing this app has felt like perfect “timing” as our scope of practice as physiotherapists continues to extend as primary contact health professionals. This includes improved mental health awareness and appropriate referral of our patients as we provide a holistic, multi-disciplinary approach to the care of each individual. This approach is especially important with elite athletes as a recent BJSM systematic review has shown that the prevalence of mental health symptoms and disorders ranged from 34% for anxiety/depression in current athletes and 26% for anxiety/depression for former elite athletes (Gouttebarge et al., 2019). Our incredibly privileged role amongst athletes, sports teams and patients puts us in the perfect position to utilise and recommend apps like “Insight Timer” and also allows us to never miss a moment to ask, “Are you OK?” to any of the people we care for.

Pro’s •

Con’s User friendly interface is easy to understand and • Cost $99/year for full access to all aspects of the makes meditation accessible. app.

•

App lets the user choose from MANY free • options to trial and find the right fit for each individual.

•

Meditation and mindfulness are more mainstream these days with good evidence to support benefits to health and mental health, as discussed above, so people shouldn’t feel embarrassed about using it.

•

There is a huge variety in the app and courses are divided into different topics, lengths of time.

People can explore around the sections and see what is relevant and save favourites to "Bookmarks".

•

You can personalise your own meditation timer and review each course – reviews online are overwhelmingly positive.

Some of the voices are quite irritating so my advice would be to explore the app to find the most appropriate instructor for you!

OVERALL RATING = 4.9 / 5 CONTINUED ON NEXT PAGE >>

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APP REVIEW References Gouttebarge, V., Castaldelli-Maia, J. M., Gorczynski, P., Hainline, B., Hitchcock, M. E., Kerkhoffs, G. M., . . .

Reardon, C. L. (2019). Occurrence of mental health symptoms and disorders in current and former elite athletes: a systematic review and meta-analysis. Br J Sports Med, 53(11), 700-706. doi:10.1136/bjsports -2019-100671 Keaney, L. C., Kilding, A. E., Merien, F., & Dulson, D. K. (2019). Keeping Athletes Healthy at the 2020 Tokyo Summer Games: Considerations and Illness Prevention Strategies. Front Physiol, 10, 426. doi:10.3389/ fphys.2019.00426 Noetel, M., Ciarrochi, J., Van Zanden, B., & Lonsdale, C. (2017). Mindfulness and acceptance approaches to sporting performance enhancement: a systematic review. International Review of Sport and Exercise Psychology, 1-37. doi:10.1080/1750984X.2017.1387803

MEMBER BENEFITS

PAGE 10

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.

issuu Our newsletters are available as a flip book online on ISSUU http://issuu.com/sportsphysiotherapynz There are also heaps of other resources on the site and a number of them have been grouped for your benefit. Click the “Stacks” button to find copies of sports related magazines for free. These include: Football Medic, Journal of Physiotherapy and Sports Medicine, Sports Performance and Technology and more.

Podcasts

Podcasts are recorded interviews or talks that are made available for access anytime.

A number of sports medicine related podcasts are available which have been linked to our website. http://sportsphysiotherapy.org.nz/members/resources/freepodcasts

Journals

Not studying at present and miss the library at physio school?

There are a number of journals that are available online for free.

This list is increasing as more companies are developing free access journals, but please let Hamish know if you are aware of ones not on the list.

We currently have a list of sports medicine, orthopaedic related and sports science. http://sportsphysiotherapy.org.nz/members/resources/journal/

PAGE 11

PAGE 12

FEATURE ARTICLE

Andrew Muir (BHSc, PGDip), Physiotherapist, New Zealand Lacrosse Lacrosse has a long history having originated with the native populations of North America, particularly a group of tribes called the Iriquois, now an area that encompasses parts of the northern US and Canada. Although first documented by a Jesuit missionary (thus the French name) some form of lacrosse is thought to have been around for thousands of years and still holds very deep cultural and spiritual significance for certain groups in these areas. Previously played between tribes, the more modern game as it is seen now can be traced back to the late 1800’s and remains strongest in both Canada and the US. New Zealand was one of a few countries that had an active lacrosse community in the late 19th and early 20th century. However, as with many other sports, World War 1 decimated the game and it was absent from the country until 2001 at which point the game was restarted in Auckland. With numbers growing steadily, the growth of the game in New Zealand has mirrored the progress of the sport internationally, evidenced by the number of countries competing at the World Championships growing from 8 in 2002 to nearly 50 in 2018.

Lacrosse Today With only 400 men’s players in NZ Lacrosse is still an obscure sport so an overview may be of value. The game is played over 4 x 20 minute quarters and involves 10 players on each team- 3 attackmen, 3 midfielders, 3 in defence and a goalie. Required gear includes gloves, arm pads, and a full helmet (similar to Ice Hockey) with few restrictions on how long or where to carry, pass and, or shoot the ball. Each restart begins with a contested faceoff, there are few stoppages and no restrictions on substitutions allowing for a rapid, fluid game with consistent changes of personnel throughout. Defence and attack have to stay in their respective half of the field, usually creating a 6v6 situation when attacking the goal except when players incur a penalty during which time the penalised player is sent from the field for up to a minute. Contact is allowed in 2 primary ways. The first is using your stick to check the ball carrier’s stick or gloves in an attempt to dislodge the ball, the second is using your body and hands in contact with the opposition player’s body (from the side or front) to impede their progress or knock them away from the ball when not in possession. The combination of speed and physical contact makes lacrosse an extremely taxing game when played well.

It’s fast pace and end to end nature makes a balance

of speed, agility, and size a necessity. However, it also leaves ample opportunity for injury.

The challenges as a developing sport are, I suspect, not unique to lacrosse. As the sport has grown domestically and internationally the level of physical capability and skill level has risen accordingly. Within the National team the expectation on players and support staff has increased significantly with the level of fitness, skill, game knowledge, and time commitment rising pointedly to simply keep pace with international competition. Finding a way to balance this while acknowledging that lacrosse is still an amateur sport can be difficult with the need to work around the other commitments for player’s and support staff alike including study, work, and family.

CONTINUED ON NEXT PAGE >>

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FEATURE ARTICLE Lacrosse Injury and Prevention During my time looking after the NZ lacrosse squad most significant injuries other than bruising and contusions have been largely unrelated to the contact nature of the sport. Most commonly seen are joint related injuries to the hip, knee and ankle along with muscle injuries to hamstrings and gastrocnemius and were sustained during the rotational loading and rapid changes of direction during play, particularly while passing or shooting on the run. Although shoulder issues and lower back tightness has been noted, it has been less frequent than anticipated. As a result of these observations, the 6-month conditioning program for the national team intially focussed around building strong foundational strength of key muscle groups including glute med, hamstrings, quads and the core along with generalised upper body work and was then

progressed into sports specific functional movement and interval training. Although difficult to quantify, this approach appears to have been effective at helping minimise game restricting injuries.

High quality, basic physiotherapy advice and intervention pre and post injury is vital in helping developing sports such as lacrosse continue to progress. As the sport grows, I’m hoping that you start to encounter more players looking for assistance in both injury prevention and rehabilitation to help keep performing at a top level and help to raise the quality and performance at all levels of the sport.

Andrew Muir (BHSc, PGDip), Physiotherapist, New Zealand Lacrosse Past Sports/Orthopaedic Physiotherapy commitments/involvement?

Graduated from AUT in 2005 before moving to Taranaki where I worked with the Mountain Airs NBL team then Wanaka where I worked with a range of winter athletes, mostly on injury rehabilitation. In 2008 I moved back to Auckland to work and complete post graduate studies during which time I focused on coaching both hockey and lacrosse and playing in the national team.

CONTINUED ON NEXT PAGE >>

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FEATURE ARTCLE Andrew Muir (BHSc, PGDip), Physiotherapist, New Zealand Lacrosse‌.

Please describe your current role and how you ended up there.

After completing my time playing lacrosse for NZ I subsequently transitioned into a support role as physiotherapist.

What are your specific areas of interest/research?

My clinical work has two aspects with sports and personal injury intervention along chronic pain assessment and treatment using the Biopsychosocial Model of care What are the types of injuries you commonly see?

In the lacrosse setting its primarily contusions and injuries typically associated with fast, agility based running sports. Lower limb muscle and joint injuries are the main concern What do you think are the key elements in successfully preventing injury? (Please provide any specific information regarding screening tools/injury prevention strategies that would be useful for our members and links to documents if possible).

Basic, fundamentally sound advice and intervention is often the most effective. Sports specific strengthening in particular during the conditioning phase along with accurate assessment and staged return to activity plans avoid ongoing complications.

Who else is involved in the “support� team that you communicate with and how do you integrate with them to optimise injury prevention and rehabilitation?

Communicating with coaches as well as athletes and their health providers located around the country and internationally is challenging, but important in ensuring complete, effective injury management Are you involved in performance aspects for your clients?

I also set the conditioning programs which helps to ensure appropriate injury prevention elements are included.

What are the key attributes you feel are required to work with elite level athletes?

An understanding of the pressures the athletes feel, often self inflicted, to continue performing. The desire to return to sporting activity needs to be managed well to ensure squad members have the best possibility if performing when it matters What do you see as the major challenges for Sports Physiotherapy?

Effectively understanding and addressing the pyschosocial contributors to ongoing injury. Fear of movement, anxiety around return to sporting activity, low mood, and frustration are often left to physiotherapists, particularly in developing sports where a sports psychologist is unavailable. This is nan area in which we have a great effect, often unknowingly, and a greater knowledge in these aspects may help us gain better, more consistent outcomes.

PAGE 15

SPRINZ

Knowledge, Attitudes and Behaviours of New Zealand Physiotherapists to Sports Related Concussion The following article is a summary of the key outcomes of the recent survey completed by physiotherapists, some of whom are members of SEPNZ. Citation for full report: Reid, D., Hume, P. A., Theadom, A., Whatman, C., Walters, S. R & Fulcher, M. (2019). Knowledge attitudes and behaviours (KAB) surveys on concussion in sport: Physiotherapists December 2018 Survey. Report # 6 to Accident Compensation Corporation. SPRINZ, Auckland University of Technology. 16 pages.

Duncan Reid (Professor, Physiotherapy) Chris Whatman (Associate Professor, Sport and Exercise Science) Sports Performance Research Institute NZ, Auckland University of Technology Introduction Sport related concussion (SRC) is a significant problem

in

New

Zealand

sporting

populations

(Theadom et al., 2014) and related claims represent a significant cost to ACC. It has been estimated that 21% of all traumatic brain injuries (TBI) are sustained in the sports arena. Rugby, cycling and equestrian activities have been identified as the most common cause of mild-TBI/concussion in sports (Theadom et al., 2014).

The management of SRC was outlined in the most recent consensus statement released in 2017 by the Concussion

in

Sport

Group

(Echemendia,

Meeuwisse, McCrory, 2017). The purpose of the consensus

statement

was

to

assist

health

professionals who are involved with assessment and management of SRC.

The guideline recommends

the use of the Sport Concussion Assessment Tool (SCAT) fifth edition and the 11 R’s (Recognise; Remove; Re-evaluate; Rest; Rehabilitation; Refer; Recover; Return to sport; Reconsider; Residual effects and sequelae; Risk reduction) (McCrory et al., 2017).

play (RTP) be signed off by that medical doctor.

However, a recent survey of NZ General Practitioners (GP) and Emergency Care Doctors (ECD), (Reid et al 2018) indicates several key issues with this guideline recommendation. Firstly, few are using the Side-line Concussion Assessment Tool (SCAT) as part of the assessment, secondly, the number of patients being assessed is low and thirdly GP and ECD are not confident with making RTP decisions.

Physiotherapists are a key part of the health management of people that suffer SRC. They are often the only health professional available at the sports field to potentially assess and manage acute concussion episodes and the sequelae. There is no previous research into the knowledge, attitudes and behaviours of New Zealand physiotherapists to SRC. American research (Yorke et al., 2016) found that Physical Therapists had very good knowledge and attitudes to SRC but were less confident in their knowledge of return to play decisions. Therefore, the purpose of this research was to survey physiotherapists in relation to their knowledge, attitudes and behaviours to SRC in a NZ setting.

One of the key aspects in these guidelines is the ability of the concussed sports person to be assessed by a medical doctor and that clearance to return to CONTINUED ON NEXT PAGE >>

PAGE 16

SPRINZ Methods A survey (35-item multi-choice questionnaire) of SRC knowledge, attitudes and behaviours (KAB) was completed between December 2018 and February 2019 via a Survey Monkey Platform. It was sent to

awareness of the need for cognitive rest and the need to avoid blue screen devices whilst recovering (Facebook 81%, texting 79%).

members of two physiotherapy special interest

Attitude towards SRC Overall the participants had very good attitudes to

groups;

concussion management.

the

NZ

Manipulative

Physiotherapists

Participants tended to

Association and Sport and Exercise Physiotherapy

“strongly agree” and “agree” (98%) that guidelines

New Zealand. The survey was also sent to a small

should be followed in sports and that concussion is

group of physiotherapists with a special interest in

often not reported (71%). Ninety one percent agreed

concussion

designated

or strongly agreed physical activity should be avoided

concussion clinics and in total 122 responses were

while symptoms are still present. Ninety nine percent

received.

of participants felt strongly that it was important to

who

mostly

work

in

report signs and symptoms to a medical professional.

Findings Knowledge of SRC Ninety eight percent of participants recognised concussion as an injury to the brain. With respect to symptoms the participants identified all the key symptoms to a very high level of consistency. These were blurred vision (99%), confusion (99%), dizziness (98%), headache (99%), insomnia (80%), nausea (94%) and loss of consciousness (97%). They also recognised

who

concussion

in

would the

possibly

short

present

scenarios

that

with were

presented in the questionnaire (99-100%). The responses to the question regarding who the best person is to make the return to play decision were varied. Whilst 58% agreed this should be a doctor, 33% stated ‘other’. In reading the free text answers, the ‘other’ was determined as a multidisciplinary team.

Behaviour towards SRC With respect to the question “Have you seen players playing on with a suspected concussion when you thought they should not have”, most participants (65%) stated this “sometimes” or “often” happened.

Nearly 60% had also “sometimes” or “often” seen coaches encouraging players to play on with suspected concussion and 65% stated they had “often” or “sometimes” seen players putting pressure on other players to play on with concussion. There was a high percentage of participants who felt as physiotherapists they were being asked to make decisions

about

RTP

“very often”

(14%)

and

“often” (34%) and that they were the key medical person to manage concussion “often” (33%) and “very often”

(16%).

A

large

percentage

were

“always” (60%) or “often” (29%) referring patients for a medical review before players returned to sport.

Participants also correctly identified that head gear was only useful in preventing cuts and grazes (85%).

Ninety percent recognised head gear does not prevent concussion. Most participants stated that

Participants felt they should be involved in several stages of concussion management; in particular, side -line recognition and removal (98%) and return to play decisions (91%).

someone who has been concussed should return to play when symptoms had resolved (81%) or following medical

clearance

(85%).

There

was

good CONTINUED ON NEXT PAGE >>

PAGE 17

SPRINZ Discussion

it is safe to RTP. One of the most varied responses

The main findings of this survey indicate that this

was to the question ‘who was the best person to

group of health professionals are very knowledgeable

decide if a player was ready to return to sport’? Whilst

regarding SRC and have very positive attitudes and

58% stated a doctor, a further 33% stated ‘other’. In

behaviours towards correct management of the

reviewing the free text associated with this response,

injury.

the participants stated that RTP should be a multidisciplinary decision, not just that of the doctor.

Participants demonstrated the ability to identify all common signs and symptoms of SRC to a very high

This is currently outside the recommendations of the

level. In comparison to respondents to other KAB

ACC Guidelines (2014) but is in keeping with the

surveys, they were able to identify the more

results of the Yorke et al. (2016) study that found

challenging

(96%),

physical therapists felt they should be part of a

“insomnia” (80%) and “nausea” (94%). These results

multidisciplinary team process related to RTP. This is

compare well with the study by Yorke et al. (2016)

a key area of further research given the limited

with

capacity of medical doctors in the current clinics in

more

symptoms

than

94%

of

of

“amnesia”

participants

correctly

identifying the main symptoms of concussion.

New Zealand with waiting times for appointments for SRC assessments. This is also important given that

There

were

good

levels

of

awareness

when

previous research into NZ secondary school rugby

participants were asked about which activities should

players has demonstrated limited knowledge of RTP

be avoided following a concussion with regards to

time frames and under-reporting of concussion (Sye

physical exertion, and the impact of using technology

et al., 2006). There is also research that states that

which can over-stimulate a recovering brain, such as

when college athletes have greater contact with

texting and Facebook. Participants were able to apply

athletic trainers (who have a mix of strength and

their concussion knowledge of signs and symptoms

conditioning and physical therapy training), they are

practically and identified players with concussion from

more likely to report concussion than those without

the scenarios presented to a good level. The

access to athletic trainers (Wallace et al., 2017). This

concussion symptoms exhibited in the scenarios

is a useful area of further investigation given that

were impaired decision-making, headache, blurred

physiotherapists are often at the forefront of side-line

vision, loss of consciousness and nausea, and were

concussion management. Investigation of the KAB of

correctly identified by 95-100% of participants in each

New Zealand strength and conditioning practitioners

hypothetical situation. This most likely reflects the day

should also be investigated in future given these

to day contact these participants have with those

practitioners may also be useful in helping monitor

suffering SRC.

RTP progress and be able to provide referral to physiotherapists

The

RTP

decision

questions

provided

varied

and

medical

doctors

for

RTP

decisions.

responses. Most participants indicated a player should RTP once the symptoms had fully resolved

In conclusion, physiotherapists in this survey are very

(81%) or when cleared by a medical professional

knowledgeable regarding concussion and show

(85%). The participants did not seem to select the

positive attitudes towards correct management of the

time frames set by sports as a good indicator of when

injury. They are very good at recognising the key CONTINUED ON NEXT PAGE >>

PAGE 18

SPRINZ signs and symptoms and have good referral patterns to medical practitioners. They share a strong desire

recognition and management of SRC. •

That there are discussions with the variety of

to be more involved in side-line management and

practitioners

testing and would like to see a more multidisciplinary

management to improve strategies to manage

approach to RTP decision making. Further work

RTP in a more multidisciplinary environment.

should look at this area as well as the potential for

•

involved

with

concussion

That there should be discussions around the

physiotherapists to be able to make decisions around

scope of physiotherapy practice with respect to

RTP along-side medical practitioners as is currently

decision making around management and RTP

possible in other countries.

decision.

•

That there should be a KAB survey of strength

Implications

and conditioning practitioners as they too are

•

That physiotherapists take a greater role in the

often involved in RTP decisions in a sports

education of players to improve symptom

team environment.

Duncan Reid Duncan is a Professor of Physiotherapy within the Faculty of Health & Environmental; Science, Auckland University of Technology. Duncan has had 38yrs of clinical experience in Musculoskeletal & Sports Physiotherapy. His main areas of interest are Sports Injury Incidence, Prevention & Movement Screening He is a Fellow of the NZ College of Physiotherapy and a life member of NZMPA and Physiotherapy NZ. He has been a member of the Olympic and Commonwealth Games Medical team from 1988 until the Sydney Olympics in 2000 and was Chief Physiotherapist for the 1992, 1994 and 1996 Games. Duncan is the Physiotherapy Advisor for High Performance Sport NZ. He has over 300 peer review journal and book publications and is on the editorial panel of the journals Musculoskeletal Science and Practice, Manual and Manipulative Therapy and the Journal of Orthopaedic and Sports Physical Therapy.

Chris Whatman Chris Whatman is an Associate Professor, Sport and Exercise Science at AUT. Chris originally qualified as a physiotherapist and worked in private practice and with various sports teams for over 10 years prior to becoming an academic. The current focus of his research is prevention of sports injuries in youth with a focus on neuromuscular warm-up, player development pathways (e.g. early specialisation) and knowledge/attitudes to injury. He has current research collaborations with NZ Rugby, Netball NZ and NZ Football.

References Accident Compensation Corporation. (2016). Sport concussion in New Zealand: ACC national guidelines. Retrieved from https://accsportsmart.co.nz/ assets/assets-final/resources-final/ACC7555-ACCSportSmart-concussion-national-guidelines.pdf Echemendia, R. J., Meeuwisse, W., McCrory, P., Davis, G. A., Putukian, M., Leddy, J., ... & Schneider, K. (2017). The sport concussion assessment tool 5th edition (SCAT5). British Journal of Sports Medicine, 51(11), 848850. doi: 10.1136/bjsports-2017-097506 McCrory, P., Meeuwisse, W., Dvorak, J., Aubry, M., Bailes, J., Broglio, S., ... & Davis, G. A. (2017). Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016. British Journal of Sports Medicine, 51(11), 838–847. doi: 10.1136/bjsports2017-097699 Reid, D.; Stuart, C.; Fulcher, M.; Hume, P.; Theadom, A.; Whatman, C.; & Walters, S. (2018). Knowledge and Attitudes (KA) surveys on concussion in sports: Doctors September 2017 survey. Report to Accident Compensation Corporation. SPRINZ, Auckland University of Technology.

Sye, G., O’Sullivan, J., & McCrory, P. (2006). High school rugby players’ understanding of concussion and return to play guidelines. British Journal of Sports Medicine, 40, 1003-1005.

Theadom, A., Starkey, N., Dowell, T. et al. (2014). Sports-related brain injury in the general population: An epidemiological study. Journal of Science and Medicine in Sport, 17(1), 591–596. doi:10.1016/j.jsams.2014.02.001 Wallace, J., Covassin, T., Nogle, S., Gould, D., & Kovan, J. Knowledge of Concussion and Reporting Behaviours in High School Athletes with or without Access to an Athletic Trainer Journal of Athletic Training 2017;52(3):228–235 doi: 10.4085/1062-6050-52.1.07 Yorke, A.M., Littleton, S., & Alsalaheen, B.A. Concussion attitudes and beliefs, knowledge, and clinical practice: survey of physical therapists. Phys Ther.

2016;96: 1018–1028.]

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CLINICAL REVIEW

Max Stuelcken; Daniel Mellifint; Adam Gorman; Mark Sayers School of Health and Sport Sciences University of the Sunshine Coast QLD, Australia Sports Med (2017) 47:857-868

By Pip Sale ABSTRACT The wrist/hand complex forms the crucial final link in the kinetic chain between the body and the racquet.

The internal and external loads that are created at the wrist during all tennis strokes have potential to contribute to pain and injury.

Epidemiological data suggests that wrist pain/injury accounts for a higher percentage of all injuries in more recent studies (2014-2015) than in earlier studies (1986-1995) and that the relative frequency of wrist pain/injury compared with other regions in tennis players is noticeably higher in recent studies, particularly in females. This collective data would suggest that wrist pain/injury has increased in the modern game and appears to be related specifically to the use of the semi-western or western forehand grip and the double handed backhand. Cumulative loading with inadequate time to complete normal processes of repair and adaptation would appear to also contribute to the cause of the increase.

The complex interaction between load, repetition and training practices in tennis, particularly among young developing players who choose a path of early specialisation needs further investigation.

The wrist/hand complex has a number of important roles in the production of tennis strokes because it forms the crucial final link between the body and the racquet [1]. When players are performing tennis strokes the loads applied to the wrist, both internally (muscle force/torque) and externally (ball/racquet interaction at contact) have the potential to contribute to pain and injury [6]. Internal torques may be influenced by grip tightness [9-11], the type of grip adopted by the player [12], the alignment of the trunk

when performing the stroke [6] , the type of spin imparted on the ball [13] and the relative size of the grip of the racquet [14]. External torques occur as a function of the racquet size and mass, string tension, and the relative location of the ball contact on the strings [5,9,10,15-19].

Although the relative magnitude of these torques is likely to be below levels at which permanent structural damage to tissues occurs, tennis players can hit in excess of 1100 ground strokes in a match [21] so the cumulative loads are considerable. Thus it would appear that wrist injuries in tennis players are primarily a result of overuse [22,23]. Overuse injuries will generally present when there is a combination of load and repetition that exceeds the tolerance level of bony and soft tissue structures when there is inadequate time allowed to complete normal processes or repair and adaptation.

Tennis injuries are described in all regions of the wrist. The literature describing the various injuries mirrors clinical practice by grouping conditions according to their location. Genuinely traumatic mechanisms of wrist injury are rarely noted in the tennis literature other than an occasional fall on an outstretched hand. Most wrist and upper limb injuries in tennis are associated with overuse and a chronic time course [23], with repeated loading during the tennis stroke [22, 40-42]. Even acute presentations may be the manifestation of chronic maladaptation of local tissue [43] and the kinetic chain [44].

Three quarters of tennis players [Tagliafico et al 12] most commonly report ulnar wrist pain [38] that is associated with stroke technique [22,35,41] and of those, two-thirds involved the extensor carpi ulnaris (ECU) tendon and furthermore 90% of the players CONTINUED ON NEXT PAGE >>

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CLINICAL REVIEW with ECU injuries used a western or semi-western grip. This relationship has been attributed to increased loading on the ulnar wrist structures, particularly through wrist extension, ulnar deviation and supination [12]. Evidence also supports an association between ulnar-sided wrist pain in the non -dominant wrist and the use of a double-handed backhand [22] as it loads the ECU tendon with excessive supination. The wrist experiences opposing torques that may result in relative supination of the hand and carpals on the pronating forearm [49]. Another group of ulnar wrist injuries has been directly attributed to grip error [39,51,52,53] and a small amount to ulnar variance [38].

Radial wrist injuries account for the majority of other (non-ulnar) injuries and appear to be significantly associated with an eastern forehand grip [Tagliafico et al. 12].

should ascertain the type of grips and stroke production used by their patients. For example, use of a double-handed backhand demands that the clinician should assess the non-dominant wrist and use of the western and semi-western forehand grip may be primarily associated with ulnar-sided wrist injuries.

Further literature should report data for the dominant and non-dominant wrist separately , the grip used for each stroke and explore the complex interaction between load, repetition and training practices in tennis, particularly among young developing players who have chosen early specialisation.

A full set of references is available on request

Other factors contributing to tennis injuries may be poor technique as this can effect the magnitude of loads transferred to the wrist [20,56] and early specialisation where and individual starts participating in one main sport at an early age and is exposed to early competition and engagement in high intensity training [60]. When a player is physically immature, the combination of load, repetition and inadequate recovery increases the susceptibility to injury [22,61,63,64]. The use of inappropriate or unnecessary repetitive blocked-type training drills involving the same stroke [68] may lead to physical maladaptations and overuse injury [22,65,66,69].

CONCLUSION Clinicians treating tennis players should have a greater index of suspicion for a range of wrist injuries, including several diagnoses that should not be missed, that is those that are associated with a poor outcome if not identified and managed in a timely manner.

Wrist pain/injury is a relatively common problem for tennis players in the modern game, where the use of the western and semi-western forehand grip and double-handed backhand predominate.

Clinicians CONTINUED ON NEXT PAGE >>

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UPCOMING SEPNZ COURSES - Save the Dates A concussion Workshop in Auckland on Sunday the 30th of June. – Only several spaces left!

Presented by Dr Stephen Kara (Sports Doctor - Axis Sports Concussion Clinic ) In this workshop you will learn the Basic physiology and current understanding of concussion. Pitch side management of the concussed athlete, Initial Assessment and referral guidelines, Follow up assessment, graduated return to play protocols including use of SCAT, SAC and neurocognitive tests (just description of the latter) and this course is a Combination of lectures, case studies and practical workshops.

Lower Limb The Lower Limb in Sport (SEPNZ LEVEL 2 COURSE) Auckland October/November Date TBC Presenters: Dr Peter McNair Professor of Physiotherapy Geoff Potts Sports Physiotherapist, Clinical Educator & DHSc Student Justin Lopes Sports Physiotherapist This course is for registered physiotherapists who work with individual athletes or teams in which lower limb injury is common. The focus of the course is on pathomechanics and kinetic chain deficits as they relate to injury prevention and performance, diagnosis and advanced rehabilitation of lower limb conditions.

By the end of the course you will understand the pathoaetiology of common lower limb injuries, be able to perform key clinical and functional tests, rehabilitate lower limb injury in a number of sporting contexts including football, running and contact sports, and develop individualised return-to-sport programmes.

Promotion and Prescription of Physical Activity and Exercise (SEPNZ Level 1 Course) Dunedin October Date TBC Presenters – TBC This course is suitable for physiotherapists wanting to improve their knowledge and skills in assessment and prescription of physical activity and exercise to use with patients on a daily basis. This course provides a bridge to Level 2 SPNZ courses and important background information for those considering university postgraduate study.

The course will provide a combination of lectures, practical demonstrations, practical assessments and case studies and will cover the following topics: Principles of exercise prescription, Promotion and assessment of physical activity, Assessment of neuromuscular performance, Aerobic and functional capacity testing ,Strategies to enhance exercise adherence, Screening for return to sport, Exercise risk screening and goal setting, Physiological effects of disuse and ageing Injury Prevention & Performance Enhancement.(SEPNZ LEVEL 2 COURSE) Auckland November/December Date TBC This course will provide you with the key skills used in the enhancement of sporting performance and prevention of injury. It covers the analysis of physical, biomechanical and technical needs of sport, identifying key factors affecting performance and injury prevention.

You will learn how to assess athletes and implement an individualised programme designed to optimise movement efficiency, performance and minimise injury risk. You will learn how to develop a sport–‐specific screening assessment, how to monitor injury rates and target injury prevention strategies within different sporting contexts.

Registrations will be open soon via www.pnz.co.nz Dates are subject to change. Limited spots available

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RESEARCH PUBLICATIONS

British Journal of Sports Medicine June 2019; Vol. 53, No. 11, 12 EDITORIAL Breaking a taboo: why the International Olympic Committee convened experts to develop a consensus statement on mental health in elite athletes (16 May, 2019) Brian Hainline, Claudia L Reardon CONSENSUS STATEMENT Mental health in elite athletes: International Olympic Committee consensus statement (2019) (16 May, 2019) FREE Claudia L Reardon, Brian Hainline, Cindy Miller Aron, David Baron, Antonia L Baum, Abhinav Bindra, Richard Budgett, Niccolo Campriani, João Mauricio Castaldelli-Maia, Alan Currie, Jeffrey Lee Derevensky, Ira D Glick, Paul Gorczynski, Vincent Gouttebarge, Michael A Grandner, Doug Hyun Han, David McDuff, Margo Mountjoy, Aslihan Polat, Rosemary Purcell, Margot Putukian, Simon Rice, Allen Sills, Todd Stull, Leslie Swartz, Li Jing Zhu, Lars Engebretsen SYSTEMATIC REVIEWS Occurrence of mental health symptoms and disorders in current and former elite athletes: a systematic review and meta-analysis (16 May, 2019) Vincent Gouttebarge, João Mauricio Castaldelli-Maia, Paul Gorczynski, Brian Hainline, Mary E Hitchcock, Gino M Kerkhoffs, Simon M Rice, Claudia L Reardon Mental health symptoms and disorders in elite athletes: a systematic review on cultural influencers and barriers to athletes seeking treatment (15 May, 2019) João Mauricio Castaldelli-Maia, João Guilherme de Mello e Gallinaro, Rodrigo Scialfa Falcão, Vincent Gouttebarge, Mary E Hitchcock, Brian Hainline, Claudia L Reardon, Todd Stull Determinants of anxiety in elite athletes: a systematic review and meta-analysis (16 May, 2019) Simon M Rice, Kate Gwyther, Olga SantestebanEcharri, David Baron, Paul Gorczynski, Vincent Gouttebarge, Claudia L Reardon, Mary E Hitchcock, Brian Hainline, Rosemary Purcell

NARRATIVE REVIEWS Mental health symptoms and disorders in Paralympic athletes: a narrative review (16 May, 2019) Leslie Swartz, Xanthe Hunt, Jason Bantjes, Brian Hainline, Claudia L Reardon Attention-deficit/hyperactivity disorder in elite athletes: a narrative review (16 May, 2019) Free Doug Hyun Han, David McDuff, Donald Thompson, Mary E Hitchcock, Claudia L Reardon, Brian Hainline Recreational and ergogenic substance use and substance use disorders in elite athletes: a narrative review (16 May, 2019) David McDuff, Todd Stull, João Mauricio CastaldelliMaia, Mary E Hitchcock, Brian Hainline, Claudia L Reardon Psychotherapy for mental health symptoms and disorders in elite athletes: a narrative review (3 April, 2019) Mark A Stillman, Ira D Glick, David McDuff, Claudia L Reardon, Mary E Hitchcock, Vincent M Fitch, Brian Hainline Management of mental health emergencies in elite athletes: a narrative review (16 May, 2019) Alan Currie, David McDuff, Allan Johnston, Phil Hopley, Mary E Hitchcock, Claudia L Reardon, Brian Hainline Post-traumatic stress disorder (PTSD) and other trauma-related mental disorders in elite athletes: a narrative review (25 April, 2019) Cindy Miller Aron, Sydney Harvey, Brian Hainline, Mary E Hitchcock, Claudia L Reardon

http://bjsm.bmj.com/content/52/15 All articles are accessible via our website https://sportsphysiotherapy.org.nz/members/bjsm/

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CLASSIFIEDS CONCUSSION SURVEY Greetings New Zealand Physiotherapists!

We are conducting research to improve our understanding of how NZ Physiotherapists are involved in the recognition, assessment and management of concussion.

If you are a NZ Registered Physiotherapist involved in concussion care (also known as mild traumatic brain injury) we invite you to participate in an online survey that will take approx. 10min.

Please click here to go to the survey or for more information. https://otago.au1.qualtrics.com/jfe/form/ SV_2lzkGFQVTBLZOOV This project has been reviewed and approved by the School of Physiotherapy Ethics Committee, University of Otago.

If you have any questions please don’t hesitate to contact us: Dr Ewan Kennedy e. ewan.kennedy@otago.ac.nz p: +64 3 479 7473 Sophie Maxtone(Honours student) e: maxso890@student.otago.ac.nz

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