SPNZ October 2015 Bulletin by Sports & Exercise Physiotherapy NZ

SPNZ BULLETIN PAGE

Issue 5 October 2015

Feature Heartland Rugby Physiotherapist ASICS Grant Recipient Impressions of the APA Connect 2015Conference Case Study NZ Sevens Gradual Onset Shoulder Paraesthesia

FEATURE TOPIC: Rugby

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Contents FEATURE TOPIC: Education SPNZ MEMBERS PAGE

See our page for committee members, links & member information EDITORIAL

By SPNZ President Hamish Ashton MEMBERS’ BENEFITS

Free Stuff FEATURE

Joel Van Doorn - Heartland Rugby Physiotherapist PLANET OF THE APPS

Get Set CASE STUDY

In this issue:

NZ Sevens – Gradual Onset Shoulder Paraesthesia SPRINZ

Adding Science to the Rehabilitation of Running Injuries ASICS GRANT

Impressions of the APA Connect 2015 Conference CLINICAL SECTION- ARTICLE REVIEW

The Impact of Physical Therapy Residency or Fellowship Education on Clinical Outcomes for Patients with Musculoskeletal Conditions CLINICAL SECTION - ARTICLE REVIEW

More Than 50% of Players Sustained a Time Loss Injury (>1 Day of Lost Training or Playing Time) During the 2012 Super Rugby Union Tournament: a Prospective Cohort Study of 17340 Player Hours RESEARCH PUBLICATIONS JOSPT Volume 45, Number 10, October 2015

BJSM Volume 49, Number 20, October 2015

CONTINUING EDUCATION Local course and APA CPD Event Finder

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SPNZ Members’ Page Welcome to Sports Physiotherapy New Zealand SPNZ EXECUTIVE COMMITTEE President

Hamish Ashton

Secretary

Michael Borich

Treasurer

Timofei Dovbysh

Website

Blair Jarratt

Sponsorship

Bharat Sukha Kara Thomas

Social Media

Timofei Dovbysh

Committee

Monique Baigent Justin Lopes

Visit our website www.spnz.org.nz CHECK OUT THESE LINKS

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List of Open Access Journals Asics Apparel and order form

Emma Mark EDUCATION SUB-COMMITTEE Hamish Ashton - chair

Sports Physiotherapy NZ

McGraw-Hill Books and order form Asics Education Fund information

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Monique Baigent Dr Angela Cadogan Justin Lopes Emma Mark Dr Grant Mawston Dr Chris Whatman BULLETIN EDITOR Aveny Moore SPECIAL PROJECTS Karen Carmichael Kate Polson Amanda O’Reilly Pip Sail Louise Turner

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ASICS EDUCATION FUND A reminder to graduate members that this $1000 fund is available twice a year with application deadlines being 31 March 2016. Through this fund, SPNZ remains committed to assisting physiotherapists in their endeavours to fulfil ongoing education in the fields of sports and orthopaedic physiotherapy. An application form can be downloaded on the SPNZ website

sportsphysiotherapy.org.nz.

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Editorial Hamish Ashton, SPNZ President I am starting to understand the value of guest editorials. Even though I only have to sit down and write something six times a year, thinking of something to write then getting it down on paper is quite a task. The last few times the bulletin has gone out there has been something a bit on the controversial side happening in the sports social media. Not this time. My wife jokingly said she could write it for me but didn’t think the connection between needlecraft and sports physiotherapy was that strong.

still had to play. First place was now out of our reach. We knew what we had to do – win everything and we would come second and be promoted.

A couple of weeks ago the winter football season finished for me. Those who know me realise that I don’t play and haven’t for some time now. I sit on the sideline and enjoy (most of the time) watching the game, and occasionally run out onto the field to do some work. I also make it my ambition each week to make the coach’s job as hard as possible by providing him with a full squad to choose from.

Faith is a funny thing. While mathematically we could get there, we were aiming for second. We beat the second placed team 4-1, won the next game then had our two catch up games against lowly placed teams. This left us needing two wins and a 10 point goal difference. The first we won 6-0, the second 4-0. And that was our season over – a promotion to the top division for next year. And true to my aims the coach had a completely full squad of players to choose from.

This season has been a bit up and down for us. We were in the middle division of three, having been promoted last season. Early in the season we were near the top of the points table with the top two teams going up to the top division next year. In the first round our first few games were against tough opponents and we had played well. However, when we played some of the lower teams in the league we started dropping points, and positions on the points table. The management staff put it to the team as to why this was happening. What came back led to some reflection on how we may sometimes work. The players said their effort was lacking because we expected to win whereas with the tougher teams they knew they had to pull out their A game. I think we can sometimes get into stages like this at work. A difficult patient comes in and we really have to think about what is going on and what we are going to do, but a straight forward ankle that would probably get better anyway may not receive as much thought. But why shouldn’t it? Anyway back to the season. We had a good cup run, almost beating the team that eventually won. This meant that we had a few catch up games at the end. With only a few weeks to go we were sitting in fifth place but had two games in hand on the second place team, which we

Knowing this, what did the team do? They lost to a midtable team. This is probably what makes sport exciting to watch but it also can be very frustrating – just ask any Warriors fans out there. The best we could now do was come level with the second place team. However our goal difference was 15 points worse off.

Most of the time I don’t get too caught up in the emotion of the sport when I am on the sideline. Though I am considered a vital part of the team by the coach and players I have my job to do. However before that last game I was nervous. Needing four goals was achievable but always going to be hard. Not letting one in for us this season was going to be even harder. When the final whistle went it reminded me why we do this job. In the clinic after 25 years working I still enjoy sending someone home better, and back to their work, sport or normal activity. Our work can be very rewarding and extremely satisfying. However, the excitement of being involved with a team at any level when they achieve their goals, be it promotion, or winning, is quite contagious. It creates a high not only for those directly involved with the team but also the supporters, being those few at a local club level or many more for higher level competition. As I am writing this the All Blacks are due to play France in the quarter finals this weekend. Let’s hope that they can provide us, the nation, some excitement (without too many nerves), this weekend, and the next two, and bring the rugby world cup back to New Zealand.

To quote Nelson Mandela “Sports have the power to change the world. It has the power to inspire, the power to unite people in a way that little else does. It speaks to youth in a language they understand. Sports can create hope, where there was once only despair. It is more powerful than governments in breaking down racial barriers. It laughs in the face of all types of discrimination. Sports is the game of lovers.” And that is why we love being a sports physiotherapist. Hamish

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Members’ Benefits

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

FREE STUFF ISSUU Magazines Our newsletters are available as a flip book online on ISSUUE http://issuu.com/sportsphysiotherapynz There are also heaps of other resources ion 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/free-podcasts

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/

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Feature Joel van Doorn - Heartland Rugby Physiotherapist BHSc (physio), PGCert Traditional Chinese Acupuncture, PGCert special topic - Women’s Health Acupuncture

I did my physiotherapy undergraduate study at AUT and graduated in 2003, then completed a post-graduate certificate at AUT in traditional Chinese acupuncture and women’s health acupuncture in 2008. This included spending five weeks in China observing and learning from their doctors in mainstream hospitals as they used acupuncture to treat various medical disorders. It gave me a new perspective on combining traditional techniques with western medicine. I have since attended various courses on manipulation and sports orientated physiotherapy. I have been involved with sports teams as a physiotherapist/strapper since my second year of physiotherapy study when I volunteered to look after North Harbour Marist premiers under the tutorage of Dene Coleman. Whilst still training I worked with age grade Harbour representative rugby teams and the Glenfield premier rugby team. My first fulltime physiotherapy job was with Roland Jeffery (All Whites physiotherapist) who gave excellent training in dealing with sports teams which opened the door for me to work with the Glenfield Rovers and Albany premier soccer teams. Working in Roland’s busy clinic exposed me to sports physiotherapy clients in multiple age grades and skill levels. I moved to Tairua in the beautiful Coromandel in 2006, set up my own clinic in 2008, and proceeded to get involved with local club rugby as the Tairua physiotherapist. Through this I managed to secure my current role as the Thames Valley Heartland rugby team physiotherapist in 2010 which enabled exposure to the Chiefs training camps and occasional physiotherapist involvement with their development team. A highlight was being invited to be the travelling physiotherapist for the Waihou club team when they toured Argentina and Brazil in 2014. Heartland rugby Heartland rugby is at a provincial level just below ITM cup, and involves travelling to all the hotspots of New Zealand from Oamaru to Paeroa. It is an interesting and challenging level of competition as it is a breeding ground for future ITM cup players, some of whom train very seriously and some who just enjoy a higher level of rugby. It is mostly amateur with heavy travel commitments and a wide catchment area for players. It means I can only see and treat the bulk of players at training or away trips because they all live in far off lands. This makes managing their injuries more complex as I am usually liaising with their own local medical personnel, whilst still trying to run my own business in Tairua. Through this I have learnt to be very efficient and succinct in the advice and treatment I give. Injury prevention and my role Due to the limited time I have available with players, I see my biggest role as being an educator to management staff and players about injury prevention, management and recovery. I find coaches at this level always want to increase the level of fitness of the players on the back end of a long club season (with some players having just finished arduous finals campaigns). This usually

means an increase in intensity, duration and loadings at trainings which has often led to multiple shin and Achilles complaints, and an increase in illness. Through me educating the coaches on safer loading schedules, and being aware of the state of our training field, we have begun to reduce the precedence of some of these. A big focus in the last two seasons has been educating the players on the importance of recovery after training and games. Simple advice around hydration, nutrition, sleep and rest has been very beneficial. The information that Yann Le Meur has on his Facebook page has been incredibly helpful for this. At the beginning of the season I do a quick screen of each player looking at their injury history, current management they’re receiving, and then prescribe some simple strengthening and proprioceptive exercises depending on their position. This is usually:  forwards – isometric neck holds  locks- ankle strength and proprioception  backs- eccentric hamstring strengthening. Common injuries I’ve seen in the last five seasons have been knee and ankle ligament strains, ACL ruptures, AC

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Feature Joel van Doorn - Heartland Rugby Physiotherapist continued...

joint strains, thigh contusions and concussions. I have found the SCAT3 testing tool excellent in managing and educating players around concussion, and it is harder to cheat on compared to previous psychometric speed tests that I used to use. Return to play It is seldom that I need to get a player back to 100% before they can safely return to the field (with the exception of concussion). I will get each player to complete a fitness test of position specific activities at increasing intensities to assess their ability to tolerate load. These usually involve tackling, fending, getting off the ground quickly, passing, kicking, sprinting, cutting and wrestling. Some players we have to manage through each week with reduced loads in order that they can play in the weekend. Key attributes for a team sports physiotherapist I believe we need a strong knowledge of the sport we are in so as to know all the different physical demands of each position. We need to be able to make an accurate diagnosis early as there is no luxury of time in a short season. This often means referring on early and knowing the limitations of our scope of expertise. We need to be clear communicators and be honest with players and coaches around timeframes and expectations. It also helps to have a strong disposition to deal with changing room antics, and to be calm in the face of sometimes horrific injuries. Challenges for sports physiotherapy A big challenge is liaising between the player and coach

around injury, as we have an obligation to do whatâ&#x20AC;&#x2122;s best for the player knowing that it can impact the ability of the team to perform. I explain to players and get them to sign a contract saying that I need to be able to explain to management what is going on, but that they can choose for me to withhold information that they wish to remain confidential. At this level of rugby, I am the sole medical practitioner within the team and this presents challenges around support. I find it important to have strong inter-discipline relationships with another physiotherapist and sports doctor to discuss cases. For me a big challenge is juggling my work and family around the large time commitments of Heartland rugby. It takes me 50 minutes to get to each training twice per week and every second weekend we are away travelling from Friday to Sunday. It is essential to have an understanding partner! Final Thoughts Despite the long hours and pressures of a team environment, I have found my experience at this level to be incredibly rewarding. I enjoy the challenge to get and keep players on the field, and value the skills this has enabled me to transfer into my private practice. It has caused me to have strong community ties around my region which has helped in the growth of my clinics. Above all though, I enjoy the people I get to work and spend time with. Nothing else compares to the banter and laughs of a tight knit team, and being able to share in the highs and lows of competitive sport.

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Planet of the Apps Your monthly App review by Justin Lopes - Back To Your Feet Physiotherapy, SPNZ executive member. Hi team, Rugby? In the Olympics? That should help our medal count! This month I am reviewing the IOC’s injury prevention app GET SET. This app has injury prevention programmes for over 30 Olympic summer sports, and you can search by body area if you would prefer to just target a certain region. The app is not too large, but does take up more data space when you download the videos. Where possible it is based on research, for instance the football section is the FIFA 11+. This is a great app that you can give to patients that has pictures and links to videos for clients to follow.

App: Get Set Category: Updated: Version: Size: Language: Seller:

Health & Fitness Aug 12, 2014 1.1.0 22.2 MB English, French, Spanish, Russian, and Chinese International Olympic Committee © 2014 International Olympic Committee & Oslo Sports Trauma Research Center https://itunes.apple.com/us/app/get-set-train-smarter/id894609112?mt=8 FREE IOS 5.0 or later. Compatible with iPhone, iPad, and iPod touch. This app is optimized for iPhone 5

Website: Cost: Requires: What it is used for:

Injury prevention, education

Where to find it:

Download from Apple store,

Android or Apple:

Apple

Pros:  All exercise programmes can be downloaded as PDF’s and shared with clients  All exercises have links to videos, supported by short descriptions on how to perform the exercise correctly.  There are three levels of progressions, so you can progress programmes  The exercises are mostly bodyweight so clients don’t need a lot of equipment.  You can email a link for a generic injury prevention programme for either a body site or a sport to your client that they can download as a pdf Cons:  Can end up taking up a lot of space if you download all the videos (it’s a good idea to do that over a WIFI connection unless you have unlimited data too)  Sometimes there are a lot of exercises in each level (for instance 20 exercises in level 1 of rugby) so if the client was to do all of them it would take too long. How I use the app: I educate the clients on which exercises I think they can target, and then email them the PDF. Clients can choose different exercises to do too. You could also print off the PDF and write on it if you need to add more detail. Overall Rating: 3.8/5 As always if you have a great app you would like to share, or one that you would like reviewed please contact me at info@backtoyourfeet.health.nz Cheers, Justin For further discussion on this App check the SPNZ LinkedIn forum page Click here

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Planet of the Apps App: Get Set continued...

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Case Study NZ Sevens – Gradual Onset Shoulder Paraesthesia By Jacinta Horan - NZ Women’s Sevens Physiotherapist Introduction Shoulder pain is among the most common musculoskeletal complaints in the general population and is a very common complaint amongst rugby players. In the female NZ 7’s squad it has largely been the injury suffered by “converts” to the game of 7’s particularly young, hypermobile females with no history of playing contact sport along with those players who are later in the playing careers. Often, it is due to rotator cuff pathologies such as tendonopathies and/or tears, instability and dislocation episodes often also resulting in labral pathologies. On rare occasions when patients present with shoulder symptoms, suprascapular nerve compression may be the cause of such shoulder pain or weakness. Because of its rarity, this condition is unfortunately often not diagnosed until a magnetic resonance imaging (MRI) scan is performed on the patient who fails to respond to therapy. Supraglenoid Ganglions can occur without cause or secondary to labral pathology. Supraglenoid ganglions compress the suprascapular nerve at one of two sites – at the Transverse Scapular Ligament where the nerve branches to both supra and infraspinatus are affected. The other site where compression occurs is at the Spinoglenoid Ligament where only the branch to Infraspinatus is affected. The most signficant symptoms suffered from Supraglenoid ganglions are muscle atrophy and weakness. Early on pain may be the only symptom but it doesn’t necessarily have to be present. In order to diagnose this condition you need to ensure the ganglion is not just an incidental finding. Nerve conduction studies are often performed to confirm this if required but are not always required for the diagnosis of this condition. This shoulder condition is often diagnosed as a RC tear due to the significant weakness that occurs. If diagnosed on MRI and clinically research suggests the best treatment approach is decompression of the suprascapular nerve asap to reverse denervation before the muscle atrophy continues. An U/S guided aspiration of ganglion achieves this and is a simple procedure with minimal complications and a quick recovery period although in cases where labral pathology is significant arthroscopic repair of this may also be required. The next essential element is an intensive rehab programme (scapular stability, proprioception, activation and endurance programme) and a strength/power and sports specific programme targeted at the denervated muscles and surrounding musculature that has often compensated for this dysfunction over a prolonged period of time prior to symptoms becoming noticeable.

Patient Presentation Player X was a NZ Sevens Player and had been playing International Rugby for the previous 5 years. She is a forward in 7s and had no prior history of any shoulder injury, pain or weakness. She presented in camp with what was initially a “mild” complaint that was increasing in freqency and severity. She had a 4 week history of shoulder and upper arm paraesthesia along with a loss of strength and power in overhead activities. This was most noticeable to her in the gym when doing an upper body strength session. If certain exercises were avoided ie Military press she was unaware of the weakness and was able to compensate and complete her normal gym programme without any limitations. She was also aware of this weakness during primers and band warmups prior to trainings and games particularly during the press exercises and had to reduce the thickness of the band she used in order to be able to complete this. CONTINUED ON NEXT PAGE

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Case Study NZ Sevens – Gradual Onset Shoulder Paraesthesia continued... The other time that her symptoms were noticeable were when she ran. In normal speed and interval type training sessions she suffered no symptoms but when running continuously for > 15 minutes her shoulder paraesthesia came on and remained until post session. In everyday life the only other time Player X was aware of her symptoms were her inability to sleep on either side at night due to the aggravation of her shoulder paraesthesia. She was unaware of her symptoms during any other ADLs or during any other training and was able to play initially without any limitations. Player X had no history of shoulder injuries or any significant cervical or thoracic spine issues. As time progressed while awaiting confirmation of diagnosis and treatment of her condition the weakness did begin to impact more obviously on her playing ability particularly her passing width and speed and her ability to bind in a scrum due to the strength required in a position of shoulder elevation. On clinical examination there was nothing of note in her cervical or thoracic spine. Patient X had a normal upper limb neural examination. She had no positive stability tests. She had significant “scalloping” of infra fossa. On further objective testing she had nil pain on all tests, 50% loss of external rotation and abduction strength and an inability to maintain an isometric hold against resistance ie band with arm above 90 deg. It was suspected after the clinical examination that she had a Supraglenoid ganglion and she was referred for imaging. She was not referred for an xray or U/S due to the suspected diagnosis although this would commonly be referred for first in the non-elite sporting population. She was referred for an MRI asap which confirmed the presence of the Supraglenoid ganglion along with a mild labral tear which was suspected to be degenerative and therefore no surgery was appropriate which made for a much shorter return to play which was predicted at 4 weeks post decompression. Goals and Key Treatment Elements Player X had her ganglion aspirated within 3 weeks of her initial clinical examination. The procedure was straight forward and there were no complications in her rehabilitation phase. Her symptoms resolved as soon as the aspiration was complete. The most important aspect was then her combined “physio rehab” and S and C programme in order to ensure that she regained full control, strength and power in her right shoulder. She was cleared for return to play once she could achieve appropriate sport specific measures including a return to her previous “normal” passing width, symmetry in her “one arm hop test”, a return to full upper body strength programme without any limitations and >90% symmetry in upper limb strength testing particularly above head exercises. Player X was back playing 7’s within 7 weeks of diagnosis although her full rehab programme took significantly longer than this.

Image of scalloped infraspinous fossa

Key Case Point The symptoms Patient X was suffering from along with the lack of pain, lack of initiating incident, and the very obvious scalloping of the infraspinous fossa were all points that directed us towards this diagnosis. In over 15 years of Sports Physiotherapy this is the first case of a Supraglenoid Ganglion I have seen and I think it is an important condition for us to be aware of for those shoulders that don’t quite fit with our more common dysfunctions and diagnoses as delayed diagnosis can have a significant effect on prognosis.

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Case Study NZ Sevens – Gradual Onset Shoulder Paraesthesia continued...

Discussion The suprascapular nerve may be injured in a number of ways including trauma, repetitive overuse, a spaceoccupying lesion, or iatrogenic causes. Whilst this is the case the most common space occupying lesions are ganglion cysts which arise from the glenohumeral joint (1). The most common presenting symptom is pain, typically located in the posterior aspect of the shoulder, characterised as a dull ache, and exacerbated by overhead activities. What is important to note as in our case is that a substantial number of patients may present with weakness as the chief symptom, and with little or no pain. Certain patients are completely asymptomatic – in these cases, atrophy may be detected as an incidental finding (2). There exists a very strong association between ganglion cysts and labral tears. There is discussion in the literature with regards to reoccurrence rates and it is thought that there is a lower reoccurrence rate in those who undergo labral repair in comparison to those who have solely needle decompression where reoccurrence rates have been stated to be as high as 48% over 2 years (4). In summary, suprascapular nerve compression secondary to a Supraglenoid ganglion, although uncommon, should form part of the differential diagnosis in a patient who complains of posterior shoulder pain, even in the absence of significant trauma. Conclusion and Reflective Statement Patient X had suffered no return of any issues in the year following her decompression until an instability episode during competition 12 months post. This presented differently from her Supraglenoid ganglion but she was imaged to assess if the ganglion had returned. This was not the case and it was more likely a more typical instability episode as a result of her degenerated labrum and the tackle scenario it occurred during. 18 months post diagnosis she remains asymptomatic with normal strength and power of her right shoulder and has no restrictions in her training or playing ability. We all know about “horses, zebras and unicorns” and whilst we don’t often see “unicorns” I think it is important we are aware that they are out there and if on clinical examination things aren’t clear as you would expect them to be or alternatively symptoms aren’t improving as they should be (in this case treatment wouldn’t have resulted in any reduction in symptoms and they would most likely have continued to worsen) that further assessment or imaging is warranted in order to get the appropriate diagnosis. References 1. Fritz RC, Helms CA, Steinbach LS, Genant HK. Suprascapular nerve entrapment: evaluation with MR imaging. Radiology. 1992;182:437–444. [PubMed] 2. Cummins CA, Messer TM, Nuber GW. Suprascapular nerve entrapment. J Bone Joint Surg Am. 2000;82:415– 424. [PubMed] 3. Tirman PF, Feller JF, Janzen DL, Peterfy G, Bergman AG. Association of glenoid labral cysts with labral tears and glenohumeral instability: radiologic findings and clinical significance. Radiology. 1994;190:653–658. [PubMed] 4. Tan BY. SLAP Lesion with Supraglenoid Labral Cyst causing Suprascapular Nerve Compression: A case report. Malaysian Orthopaedic Journal, 2012 June, 46-48. 5. Falsone SA1, Gross MT, Guskiewicz KM, Schneider RA. One-arm hop test: reliability and effects of arm dominance. J Orthop Sports Phys Ther. 2002 Mar;32(3):98-103.

What was your original impression of what was going on? What was the process to final diagnosis? In hind sight is there anything you would do differently? Do you have any clinical tips on this injury? For answers to these and further discussion check the SPNZ LinkedIn forum page Click here

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SPRINZ

Adding Science to the Rehabilitation of Running Injuries By Kelly Sheerin Running is a hugely popular recreational and competitive pursuit for many New Zealanders, with new running events popping up on an almost monthly basis. However, despite the many potential positive benefits, running has a dark side, with research indicating that anywhere between 30 and 70% of runners suffering at least one overuse injury each year. Ultimately this means that runners make up a large proportion of physiotherapistsâ&#x20AC;&#x2122; clients! While New Zealand physiotherapists are well renowned for their manual skills, the multi-factorial nature of running injuries demand that therapists have an understanding of the interrelationships between injuries and running gait biomechanics, and an insight into how biomechanics is impacting on the current injury. Without this we are often sending patients away on a path destined for re-injury. While stress fractures are not the highest incidence injury seen in runners, they are one of the most serious in terms of time spent out of running. They are also one of the most poorly managed in terms of addressing the underlying faulty biomechanics. CASE STUDY This case is a female recreationally competitive triathlete who was referred via a sports physician and physiotherapist with a healing stress fracture of the left inferior pubic ramus, with accompanying partial thickness tears of the left gluteus medius and minimis tendons at the femoral insertions, and left adductor tendon at the origin. The initial injury was likely linked with an increase in speed-work running training, in addition to high volume swim and bike training. She was under the care of a Physiotherapist in her hometown, who questioned faulty biomechanics based on a simple clinic based running assessment. At the time of assessment this runner was very frustrated and desperately keen to get back into running, while the Physiotherapist was keen to ensure any return to full running was ultimately successful. Previous management The Sports Physician had provided clearance for the initiation of a walk-run progression beginning with a 1520 min walking every second day. Physiotherapy treatment to date had been limited to soft-tissue massage of the surrounding gluteal and adductor musculature, and unstructured hip and core strengthening. Supplementary treatments Given the multi-factorial nature of stress fractures, and several flags for potential hormonal and/or nutritional contributing factors, this patient was also referred for DEXA densitometry to rule out any systemic issues with bone density, as well as nutritional and hormonal specialist input.

Assessment A full clinical examination, as well as a 3D and force running assessment were carried out with this runner. She was found to have weak hip abductor and flexor muscle strength (L>R), reduced flexibility in her left hip internal rotators, and right hip flexors, as well as excessive soleus flexibility bilaterally. Analysis of the 3D biomechanical running data showed that this runner exhibited increased peak hip adduction angles bilaterally, as well as increased peak hip rotation and pelvic drop on the left side at mid-stance. She also demonstrated prolonged pronation bilaterally. Further analysis of force data demonstrated marked impact peaks (L>R) in her vertical ground reaction force traces, which were reinforced by an obvious tendency to over-stride. It was concluded that this runner exhibited specific faulty gait biomechanics, teamed with a lack of proximal hip control that was highly likely linked to the development of her original fracture. Treatment During the initial 6-week phase, a conservative walk-torun programme was instigated that progressed from 30 sec to 5 min intervals of running. Alongside this, several hip strengthening exercises emphasizing progressive overload, as well as plyometric calf strengthening were programmed. After six weeks the runner was re-assessed and deemed to have sufficient proximal strength and control to initiate a gait re-education programme. Initially the focus was on increasing cadence and reducing the over-stride position at initial contact. Over the course of the following 4-weeks emphasis shifted, as the runner CONTINUED ON NEXT PAGE

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SPRINZ

Adding Science to the Rehabilitation of Running Injuries continued... improved, to improving hip extension leg drive, and reducing ground contact time. Outcome Three months after beginning her biomechanical rehabilitation programme this runner underwent a full reassessment, and was now within the normal range for all key biomechanical variables. Six months on from the initial assessment, this runner is able to maintain her improved running biomechanics with a minimum of effort. She has just completed her first 10 km event, and is training for a half marathon. A return to short-distance triathlon is high on the agenda for this summer. This case provides a prime example of the advantages that can be gained from athletes undergoing a specific biomechanical assessment as part of their rehabilitation from serious or long-standing injuries. A quantitative biomechanical running assessment can allow a tailored combination of interventions to be established that can

take undue pressure off this runners injured pelvis and hip, and redistribute these forces across other areas. Only through taking specific measures are we able to properly tailor interventions, and adequately measure their success. The Running & Cycling Clinic forms part of the Sports Performance Clinics at AUT Millennium. The Clinic is the only publically available facility in New Zealand to be equipped with 3D motion analysis and force treadmill technology. The services of the Clinics are grounded in research, and underpinned by the principles of AUTâ&#x20AC;&#x2122;s Sports Performance Research Institute NZ. Visit the website to find out more about the services on offer at the Clinic: http://www.autmillennium.org.nz/ health-and-fitness/clinics Alternatively, e-mail us at rcc@autmillennium.org.nz to find out how you can work with us to optimise the rehabilitation of your patients.

Kelly Sheerin Kelly is a registered physiotherapist and biomechanist who has a Masters degree in 3D gait mechanics, and is currently working towards his PhD. He is the Manager of the Running & Cycling Clinic, and is also a lecturer within AUTâ&#x20AC;&#x2122;s School of Sport and Recreation, where he teaches courses in human anatomy, human movement and body composition analysis. He has a unique mix of injury and biomechanics knowledge that enables him to take proven research and put it into practice to enhance the prevention and rehabilitation of running related injuries.

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ASICS Grant Impressions of the APA Connect 2015 Conference By Dr Gisela Sole It was a real privilege to attend the APA Connect 2015 conference in Gold Coast, 3rd to 6th October 2015. Partly due to the raucous birds, but also remaining in the NZ time zone meant that I was up before six in the morning, could enjoy runs along the beachfront, return to the apartment to have tropical fruits for breakfast before heading off in time for the conference programme. I found the conference inspiring with much to think about in terms of clinical practice, teaching and research, and will cover selected highlights in this report.

“ordinary” brains. Our brain is inherently lazy (Law of Least Effort), but can be stimulated by Forced Adaptation (such as learning a language, musical instrument or brushing teeth with the non-dominant hand), Visualisation (describing how he learnt to accurately memorise 52 cards in 15 minutes), Attention Control (we should be able to focus on something for at least 20 minutes without interruption), and Emotional Control (fear is OK, it never goes away but we can learn to control it, for example, with meditation) – all things that I would like to teach my children!

I attended a full-day pre-conference workshop on the role of physiotherapy in Emergency Departments. While we don’t have the opportunity yet to work in those departments, the skills that were included relate directly to sports physiotherapy, such as abdominal palpation (relevant following sports-related lumbar/abdominal injuries or with “non-mechanical” back pain), hand and finger injuries and immediate management of shoulder dislocations, including various (gentle) methods of relocation. A session on clinical reasoning emphasised the “fast and slow thinking”, using pattern recognition and/or gut feel to make fast decisions, while also constantly thinking “slowly” to ensure that less common presentations are not missed. The workshop had a robust evidence base integrated with skills demonstration and practice, and was presented by physiotherapists and ED medical doctors.

A plenary panel discussion on Pain and Neuroplasticity included Prof Phil Siddall (pain physician), Dr Blake Blair (psychologist), and Associate Prof Jo Nijs (Belgian physiotherapy researcher). It was evident that all three were considering the central nervous system as the basis for their treatment of persistent pain conditions. Challenges for clinicians include the following:

The conference started off and ended with the theme of physical activity and health, applicable to all speciality fields of physiotherapy. Prof Steven Blair highlighted that the independent relative risks for death for low fitness is comparable to that of cardiovascular disease. We need to consider societal, environmental and individual factors to physical activity of our patients. My “take home message” from his talk is that we should screen each of our patients for their level of physical activity, and if these are low should be included in our treatment goals and plan.

Dr Blake Blair presented the use of an online pain education course for patients, provided over a number of weeks, with direct telephonic or e-mail contact with him. The presentation by Jo Nijs, “Thinking Beyond Anatomy and Physiology” highlighted that therapists’ and patients’ attitudes and beliefs regrading chronic pain are key to applying effective treatment. Our beliefs affect choice of treatment as much as the patients’ beliefs affect outcomes. The discussion following their presentations highlighted that many of our physical assessment procedures lacked sensitivity and specificity, thus may be “wasting time”. The approach by the psychologist, Dr Blair, was to increase the patient’s understanding of pain rather than focussing on the “diagnosis”; sharing with the patient what we “do know” and what we “don’t know”. Prof Siddall suggested that we should consider phrases such as: ”Your pain seems to be coming from L4/L5, but, BY THE WAY, the pain does not indicate that there is damage”. He also indicated that he wants his patients to understand that “The way you feel and the way you think directly controls how much pain you feel”. In summary, we need to be aware of limitations of our clinical tests (particularly in terms of specificity and sensitivity), the influence of the central nervous system on pain experience, and what messages we give our patients.

A highlight of the conference was the presentation by Todd Sampson. I had not known about him (pardon my ignorance!), but apparently most Australians do. The main auditorium was packed with the 2,000 delegates, most likely the biggest physiotherapy conference ever in the Southern Hemisphere. Todd is co-creator of Earth Hour, has won the Australian CEO of the Year price twice, besides also having been a guinea pig in a Discovery Channel “Redesign (Hack) my Brain” amongst many other exiting and daring achievements (such as climbing up Mt Everest unguided). His talk “Brain Power” was in line with a neuroscience theme that I found present across the conference. His charismatic presentation suggested that by training the brain, we can all achieve “extraordinary” things despite our

 The challenge of mixed messages: is pain a problem of the periphery or the brain? Is plasticity fixed or modifiable?  Challenge of diagnosis: when can we ignore the periphery? How do we assess central changes?  Challenge of treatment: neuroplasticity – chicken or egg? Do we treat, manage or focus on function?

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ASICS Grant Impressions of the APA Connect 2015 Conference continued... It may be argued that the above presentations focussed on management of chronic pain, however, break-out sessions for sports physiotherapist followed up with that theme. Entertaining as ever, an excellent presentation by Prof Lorimer Moseley on “The Cortical Body Matrix in Sports and Performance” illustrated that what we think, what we do, and what we feel influence each other - three primary neurotags to produce action, cognition and perception. Dr Leanne Bisset followed his talk with pain in tendinopathies, providing strategies to assess evidence for central sensitisation for patients with that diagnosis, and how the findings would influence treatment decisions. Specialist sports physiotherapist JP Caneiro from Perth presented two cases using Cognitive Behavioural Therapy for athletes with back pain, including a long jumper and a rower. In another stream, Dr Mary Magarey, with dual speciality in sports and in musculoskeletal physiotherapy, presented her approach to shoulder injuries, entitled “Connecting the Brain, the Hand and the Foot”, illustrating the neuroscience approach to treatment to management of shoulder injuries in athletes. Similarly, the next presentation, also on shoulder injuries, by Dr Tania Pizzari, integrated strategies that influence cortical changes into the physical management of these patients.

and thereby outcomes for our patients and communities.

The above presentations do not negate making an accurate clinical diagnosis, however, debate is clearly evident with regards to how accurate these can be, particularly with persistent or recurring pain and injuries. Furthermore, it is known that many imaging findings also appear in asymptomatic individuals and may indicate “normal” ageing. We thus need to continuously interpret clinical and imaging findings carefully and critically, and include reasoning regarding mechanisms of symptoms (eg. peripheral and/or central sensitisation) into our decision making processes when informing the patient of our assessment findings, and when setting goals and treatment plans with them.

As indicated above, this report could not cover all aspects of the sports physiotherapy programme, rather highlighting some of those that I could attend. I found it challenging to choose which session to go to: there were up to four sports physiotherapy and three or four musculoskeletal physiotherapy break-out sessions, often at the same time as international and national (Australian) key note and invited speakers. This meant missing really good presentations, such as on the athletic hip, load management in athletes, the ‘How to…’ sessions presented by physiotherapists undergoing the Fellowship Specialists programmes, and so on. The conference showed how clinicians and researchers can work in teams, listening to each other and building on each other’s strengths, knowledge and experience. Overall, I returned from the conference, motivated and enthusiastic about our potential as physiotherapists, whether in the clinical, teaching or research role. It is this synergistic, collaborative approach that we should continuously promote and support within and across our Special Interest Groups. A special “thank you” to SPNZ for supporting my attendance with the Education Fund.

Prof. May Arna Risberg from Norway focussed on the current level of evidence for management of knee injuries, in particular ACL ruptures. She presented a knowledge continuum from “bench to bedside” in physiotherapy, providing an improved understanding the processes needed to implement knowledge to clinic settings. More defined screening tests are needed to predict outcomes of individuals with ACL ruptures, and current evidence indicates that non -operative interventions should be implemented prior to undergoing surgery. She suggested that while many clinical trials for ACL and knee OA have been conducted, these normally are limited by including heterogeneous groups of patients. More information is needed to understand the mechanisms of our interventions, namely WHY and for WHOM they are (or aren’t) effective. She thus highlighted the need for basic science, laboratory-based studies to complement the clinically-based approaches. She emphasised the importance of clinicians and researchers to work collaboratively to advance knowledge,

I presented the results of Arlene von Aesch’s BPhty Honours research (2014) in a break-out session on lower limb sports injuries. Arlene had interviewed 15 physiotherapists on their perceptions of ACL injuries as part of a larger study determining outcomes of these injuries. Findings of physiotherapists focussing on the psychological responses of their patients during rehabilitation, but not being formally trained for this, was also highlighted in other presentations throughout the conference. There is a need to include management of psychosocial factors by physiotherapists in our under- and post-graduate programmes, to complement the physical considerations. Prof Paul Hodges exemplified the commonalities across the specialities of physiotherapy, including how we can learn from each other across musculoskeletal, neurological and cardiopulmonary physiotherapy, and men’s/women’s health. He provided an excellent overview of the pathway that research has taken to expand understanding of impairments of motor control of the trunk, literally from the pelvic floor to the brain. I definitely look forward to his workshop and presentation at the Southern Physiotherapy Symposium in Queenstown in November.

Dr Gisela Sole Physiotherapist, Senior Lecturer School of Physiotherapy University of Otago Gisela.sole@otago.ac.nz

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Clinical Section - Article Review More Than 50% of Players Sustained a Time Loss Injury (>1 Day of Lost Training or Playing Time) During the 2012 Super Rugby Union Tournament: a Prospective Cohort Study of 17340 Player Hours Martin P Schwellnus, Alan Thomson, Wayne Derman, Esme Jordaan, Clint Readhead, Rob Collins, Ian Morris, Org Strauss, Ewoudt Van der Linde, Arthur Williams British Journal of Sports Medicine, 2014; 48:1306-1315. Rugby Union is a contact sport with one of the highest reported incidence of injuries in professional sport, however there have been few studies on epidemiology of injuries conducted regarding the super rugby competition. In the three previous studies have found that there is a higher rate of match injuries vs training injuries and minimal difference in injury rates between forwards and backs. It is not possible to compare these studies as the definition of injuries were different and there has since been changes to rules and the competition format. This study was a prospective cohort study of 152 players from 5 South African teams. The team physician collected injury data regarding squad size, type of day, player position, training or match injury, hours of play, time of match injury, location and anatomical structure of injury as well as type and severity of injury. The authors proposed that the super rugby competition may be associated with a higher risk of injury given the long duration of the competition, the weekly nature of games, the more open style of play leading to higher tackle count and the large amount of international travel. Injuries were defined according to the consensus statement of injury definition in rugby union. A time loss injury was defined as an injury that prevented training for > 1day. The severity of injury was divided into categories according to training days lost with minimal being 2-3 days, mild 4-7 days, moderate 8-28 days and severe being > 28 days lost to injury. Daily player hours were calculated as the number of team training hours x the number of players in the team on that day. They assumed all players participated in the entire session. Match player hours for 1 team was calculated at 1.33 (1.33= 80min) x 15 players (20 match player hours). It was not mentioned if the warmup time pre game was calculated at all or as training hours. Results 160 time loss injuries were recorded in 83 players with the proportion of players sustaining a time loss injury (IPP) being 55%, with 25% of players sustaining more than one injury. 19.7% of injuries occurred during matches compared to 21% in training. The overall incidence of time loss injuries were 9.2/1000 player hours with the incidence in matches (8.3/1000 hours) being significantly higher compared to training injuries (2.1/1000 hours). The study found there were 95 injuries to forwards and 65 to backs but there was no significant difference in injury incidence between forwards and backs. The majority of injuries to players occurred in the lower limb (48.1%), upper limb (25.6%) and less commonly to the trunk (13.1%) and head and neck (13.1%). There was no significant difference between forwards and backs. The forwards sustained the majority of injuries to the lower limb (46.3%) and upper limb (27.4%). Backs also sustained most injuries to the lower limb (50.8%) and upper limb (23.1%). Similar results were also found with regards to match injuries with the majority occurring in the lower limb (41.3%) and upper limb (30.2%) followed by the head and neck (15.1%) and trunk (13.5%). The specific anatomical structure with the highest overall incidence of injury per 1000 player hours was the shoulder/ clavicle (1.6) followed by the knee (1.4), thigh (1.1) and head/face (1.0). In matches the highest incidence of injuries occurred in the shoulder/clavicle (16.5), knee (14.6) followed by the face (11.2) compared to the thigh in training (0.6). The majority of all injuries (>90%) occurred in the soft tissues (muscle, tendon, ligament, skin and CNS) with the soft tissues and muscle/tendon injuries accounting for the majority of all injuries (50%), match injuries (46.2%) and training injuries (64.5%). This was followed by joint/ligament injuries (all injuries = 32.7%, match injuries = 33.6%, training injuries = 29%). With regards to the severity of injury there was only data available for 142/160 injuries. This may affect the assumptions that can be made regarding injury severity. The authors found that the overall incidence of training injuries was low however in contrast to match injuries the they were of a more moderate or severe nature (> 59.2%). Moderate and severe

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Clinical Section - Article Review More Than 50% of Players Sustained a Time Loss Injury (>1 Day of Lost Training or Playing Time) During the 2012 Super Rugby Union Tournament: a Prospective Cohort Study of 17340 Player Hours continued... injuries accounted for 40.7% and 18.5% respectively of training injuries. The majority of injuries to the head/neck, upper limb and trunk were minimal to mild severity (>57%), however, 51% of lower limb injuries were graded as moderate (42.3%) or severe (12.7%). Frequency of injury at different periods in the match was also analysed with the majority (>50%) of injuries occurring in the 3rd and 4th quarters. Very few injuries occurred in the cool down phase (<2%). There is no mention of whether injuries the warm up phase of a match was recorded. The most common mechanism of injury was tackling (all =23.1%, match 28.6%) or being tackled (all= 20%, match = 24.6%). Other was a subgrouping but the mechanisms were not detailed and associated with the majority of training injuries (47.1%) and a significant portion of match injuries (20.6%). Despite the long periods of travel (>6 hours) in the super rugby competition the authors found no significant difference in the incidence of all injuries, match or training injuries when play took place in home country compared to a foreign location. Discussion The proportion of injured players in this study (55%) was twice the reported proportion of injury in a rugby world cup competition. The authors suggested that this is largely due to the longer duration of competition and greater player fatigue. The findings were also consistent with a recent meta-analysis of overall injuries in professional rugby union who reported injuries occurring at a rate of 81/1000 player hours. The rate of injury in the meta- analysis and this study is higher than that reported in 2 of the 3 previous studies on the super rugby competition. Perhaps a reason for this is in part due to the increase in the number of teams hence extending the duration of the competition and the rule changes that occurred since the studies were undertaken. The current study has a low rate of training injuries but when they occurred they were more severe with 59.2% resulting in >8 days lost to training. Whilst the rate of training injuries is similar to that of other studies, the severity has not been previously recorded. In contrast the meta-analysis found minimal difference in severity of training and match injuries. Further study into strategies to reduce the incidence and severity of injury is required with particular focus on common areas of injury (upper and lower limb). It is important to note that the injury severity was not recorded in 18/160 injuries which may have altered the results of this study. This study was consistent with the other studies and the meta-analysis regarding timing and mechanisms of injuries with most match injuries occurring in the 3rd and 4th quarters through either tackling or being tackled. They reported that there were minimal injuries in the cool down phase however injuries that occurred in the warmup were not mentioned or recorded. This is a significant flaw in the study. The authors of this study used a non-specific category of â&#x20AC;&#x2DC;otherâ&#x20AC;&#x2122; to describe other mechanisms of injury outside tackling or being tackled. This category was noted to have the highest cause of training injuries (presumably as most training is noncontact). A lack of information regarding mechanisms is of limits the clinical usefulness as it is difficult to reduce risk without understanding the mechanisms that were at fault. Future studies need to have further details regarding injury mechanisms so clinicians and coaches can develop injury prevention strategies and management plans. There has been detailed information regarding the injury rates, however, a flaw in this study is the lack of detailed exploration of injury subgroupings making potential prevention strategies largely non-specific. Further limitations relate to the relatively small sample size and with one team of the five involved only having 53% consenting to the study which may significantly affect the injury rates. Given that the teams participating were from the same country it would be interesting to note if there would be similar rates if the study was repeated including different countries. A further limitation of the study is the recording period only began a few days prior to the first game and did not include pre -season training or games. It is not known if there were further injuries in this time frame that would have then impacted on the overall incidence. Clinical Implications Knowledge of injury rates in Super rugby can allow the medical team to anticipate the injury risk, nature and type of injuries they are likely to encounter which will help to plan medical care and develop prevention strategies. The prevention strategies should be targeted towards certain areas such as lower limb muscle injuries. Team management and coaches are also better able to anticipate the effect of injuries on the squad composition and can hence carry a wider squad of players to compensate for this. Further studies detailing more detailed information about injury mechanisms and the specific anatomical location and type of injury would be of assistance in developing more complex prevention strategies. By Louise Turner B App Science (Physiotherapy), Masters of Health Practice (Musculoskeletal Physiotherapy)

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Continuing Education Upcoming courses and conferences in New Zealand in 2015 and 2016 For a full list of local courses visit the PNZ Events Calendar For a list of international courses visit http://ifspt.org/education/conferences/

LOCAL COURSES & CONFERENCES When?

What?

Where?

31 October 1 November 2015

Kinesio Taping Course - KT 1 & 2

Auckland

7 November 2015

RockTape (Kinesiology) Taping 1 day Seminar

Whakatane

14 November 2015

RockTape (Kinesiology) Taping 1 day Seminar

Auckland

14-15 November 2015

Kinesio Taping Course - KT 3

Hamilton

19-21 November 2015

Sports Medicine New Zealand Conference 2015

Christchurch

23 November 2015

Concussion Workshop The Latest Developments

Auckland

26 November 3 December 2015

PNZ Wellington Branch and Clinical Edge Webinar Series

Nationwide

21 May 2016

Acupuncture - Tendinopathy

A.U.T, North Shore Campus, Northcote, Auckland

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Research Publications JOSPT JOSPT ACCESS

www.jospt.org

All SPNZ members would have been sent advice directly from JOSPT with regards to accessing the new JOSPT website. You will have needed to have followed the information within that email in order to create your own password. If you did not follow this advice, have lost the email, have any further questions or require more information then please email JOSPT directly at jospt@jospt.org in order to resolve any access problems that you may have. If you have just forgotten your password then first please click on the â&#x20AC;&#x153;Forgotten your passwordâ&#x20AC;? link found on the JOSPT sign on page in order to either retrieve or reset your own password. Only current financial SPNZ members will have JOSPT online access.

Volume 45, Number 10, October 2015

EDITORIAL Anterior Cruciate Ligament Injury Prevention and Rehabilitation: Let's Get It Right RESEARCH REPORT Excursion of the Sciatic Nerve During Nerve Mobilization Exercises: An In Vivo Cross-sectional Study Using Dynamic Ultrasound Imaging Biomechanical Differences of Foot-Strike Patterns During Running: A Systematic Review With Meta-analysis Knee Confidence as It Relates to Self-reported and Objective Correlates of Knee Osteoarthritis: A Cross-sectional Study of 220 Patients Star Excursion Balance Test Performance Varies by Sport in Healthy Division I Collegiate Athletes The Immediate Effects on Inter-rectus Distance of Abdominal Crunch and Drawing-in Exercises During Pregnancy and the Postpartum Period Predicting Dynamic Foot Function From Static Foot Posture: Comparison Between Visual Assessment, Motion Analysis, and a Commercially Available Depth Camera Kinematic and Kinetic Analysis of the Single-Leg Triple Hop Test in Women With and Without Patellofemoral Pain CASE REPORT The Consequence of a Medial Ankle Sprain on Physical and Self-reported Functional Limitations: A Case Study Over a 5-Month Period BRIEF REPORT Validity of Inter-rectus Distance Measurement in Postpartum Women Using Extended Field-of-View Ultrasound Imaging Techniques

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

Volume 49, Number 20, October 2015

EDITORIAL Return to play and physical performance tests: evidence-based, rough guess or charade? Eric J Hegedus, Chad E Cook http://bjsm.bmj.com/content/ REVIEWS After revision anterior cruciate ligament reconstruction, who returns to sport? A systematic review and meta-analysis Alberto Grassi, Stefano Zaffagnini, Giulio Maria Marcheggiani Muccioli, Maria Pia Neri, Stefano Della Villa, Maurilio Marcacci http://bjsm.bmj.com/content/ Strategic Assessment of Risk and Risk Tolerance (StARRT) framework for return-to-play decision-making Ian Shrier http://bjsm.bmj.com/content/ Early functional rehabilitation or cast immobilisation for the postoperative management of acute Achilles tendon rupture? A systematic review and meta-analysis of randomised controlled trials R McCormack, J Bovard http://bjsm.bmj.com/content/ REPUBLISHED RESEARCH FROM THE BMJ The effect of fall prevention exercise programmes on fall induced injuries in community dwelling older adults Fabienne El-Khoury, Bernard Cassou, Marie-Aline Charles, Patricia Dargent-Molina http://bjsm.bmj.com/content/ MOBILE APP USER GUIDES Coach's eye Rod Whiteley http://bjsm.bmj.com/content/ PEDRO SYSTEMATIC REVIEW UPDATE Therapeutic exercise for chronic non-specific neck pain: PEDro systematic review update TiĂŞ Parma Yamato, Bruno Tirotti Saragiotto, Chris Maher http://bjsm.bmj.com/content/