SPNZ Bulletin Oct 2012 by Sports & Exercise Physiotherapy NZ

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BULLETIN

ISSUE 5 l October 2012

View the SPNZ Bulletin online in flip-format http://issuu.com/sportsphysiotherapynz SPNZ EXECUTIVE COMMITTEE President

Dr Angela Cadogan

Secretary

Michael Borich

Treasurer

Dr Gisela Sole

Website

Hamish Ashton

Committee

Dr Tony Schneiders

Welcome to the October 2012 SPNZ Bulletin.

EDUCATION SUB-COMMITTEE

Welcome to the October 2012 Edition of the SPNZ Bulletin. Firstly, a big congratulations to all our Olympic and Paralympic athletes who participated in the London 2012 Games. Special congratulations to both Valerie Adams and Sophie Pascoe for their gold medal success, and also to their physiotherapists Louise Johnson and Chelsea Lane for their contribution to the success of these two outstanding athletes. Both Louise and Chelsea were featured in the June and August editions of SPNZ Bulletin available on the website (Members Section/Newsletters). SPNZ can pick the winners!!

Dr Gisela Sole

David Rice

Chelsea Lane

Dr Grant Mawston

What is Sports Physiotherapy?

Bharat Sukha Jim Webb David Rice

Jim Webb

EDITORIAL ASSISTANT Aveny Moore

SPECIAL PROJECTS Monique Baigent Deborah Nelson Kate Polson

Karen Carmichael Amanda O’Reilly Charlotte Raynor

Nathan Wharerimu

ADVERTISING

The October edition presents an editorial titled “What is Sports Physiotherapy”. Historically this area of physiotherapy has lacked identity despite its high public profile. Sports physiotherapy competencies, particularly at the advanced level, have been poorly defined and understood both by the physiotherapy profession, and consumers of sports physiotherapy services. This editorial aims to clearly define sports physiotherapy, its place within the physiotherapy profession both nationally and internationally, and highlights the knowledge and competencies that make this a unique area of physiotherapy. This may serve as a useful resource for those of you involved in sports physiotherapy as a clinic ‘waiting room’ pamphlet, or as a guide when putting together your CV.

Advertising terms & conditions click here.

Feature: Total Knee Arthroplasty, by Bronwyn Harman.

LINKS

In this edition we also feature Total Knee Arthroplasty, and Bronwyn Harman (lecturer at AUT University) talks about the operative criteria, operative techniques, factors influencing outcomes and rehabilitation following TKA surgery. The SPNZ Research Review team complement this with reviews of several articles focussing on rehabilitation. Continued on next page…..

Sports Physiotherapy NZ List of Open-Access Journals SPNZ Research Reviews Asics Apparel and order form McGraw-Hill Books and order form Asics Education Fund information

INSIDE THIS EDITION:  Editorial: What is Sports Physiotherapy?  Feature: Bronwyn Harman - Total Knee Arthroplasty in New Zealand, patient selection, surgical options, clinical management options.  Clinical Feature: Current Opinion on Total Knee Arthroplasty Rehabilitation  Research Section: Total Knee Arthroplasty Rehabilitation Perspectives  Outcome Measure: KOOS and MORE…….

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New Website! Check out our new website. Thanks to Hamish for all his hard work on this! This site now includes a new section for “Health Advice” including information for patients about “Immediate Care” and Injury Advice and we will shortly be adding a “Physical Activity” section where patients and therapists will be able to access resources that aid in assessing levels of physical activity, as well as providing guidelines for physical activity in various age groups to aid combating the epidemic of ‘inactivity’-related diseases. “Find a Physio” link on Website We are also adding “Find a Physio” links to our website so the public can easily locate sports physiotherapists with expertise in various sports, or in different locations around the country. A link will shortly be sent to all SPNZ members. If you want to be listed, make sure you fill in the form online. Thanks to Aveny Moore, Stephanie Ashton and all the contributors to this edition for their outstanding work and continuing efforts – we hope you enjoy the read. As always we welcome any feedback or suggestions you may have, or if you are interested in joining the Special Projects Team to help with the Research Reviews please get in touch!

Dr Angela Cadogan SPNZ President

2014 Symposium Update We are starting to plan our next Sports Physiotherapy Symposium. If anyone has any speakers or topics that they would like to hear please contact Hamish at help@spnz.org.nz .

ADVERTISING Deadlines: December bulletin: February bulletin: April bulletin:

Advertising terms & conditions click here. 30th November 30th January 30th March

IN THIS EDITION

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To locate a page quickly, click on the ’pages’ symbol at the top of the pdf reading panel at left of screen and select the required page.

EDITORIAL

What is Sports Physiotherapy?

LATEST NEWS

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SPNZ Website Upgrade and Public Resources Find a Physio Shortly we will be adding a link to our webpage for you as a Member to list your name, interests and services you provide. This information will be available for the public to access. The information will be tabulated by regions. An example of how this will look is currently available at http://sportsphysiotherapy.org.nz/find-a-physio/. A link will be sent out to you soon. If you wish for your details to be added follow the link and fill out the form.

Resources A new section has been added in the SPNZ Resources section. There are links to Podcasts (audio files) that can be listened to online or down loaded via iTunes to your iPod. There are some good topics available including interviews with some high profile international physiotherapists. A good way to get some CPD done at home.

International Journal of Sports Physical Therapy - Individual Subscriptions Available The IJSPT journal is available to purchase for individual members. SPNZ members interested in subscribing to this journal can purchase an individual subscription through the journal directly. To purchase a subscription go to the IJSPT website, and click on “subscriptions”. Subscription rate for 2012: 

Individual

$60 (USD)



Student

$35 (USD)

October 2012 edition includes:

(To view contents of the current issue click here.)



Trunk endurance muscle testing



Static, dynamic and ballistic stretching



Shoulder ROM, pitch count and injuries in softball pitchers

And more…

SPNZ Member Benefits Remember to take advantage of the full range of SPNZ member benefits: 

FREE online access to JOSPT (value approx USD$275)



FREE Editions of the Quarterly APA “Sports Physio” Magazine



25% Discount on all McGraw-Hill book publications



Funding Support for continuing education and research (Asics Education Fund).



Substantial discount, Advanced Notice and preferential placing on SPNZ Educational Courses.



Access to website with clinical and relevant articles.



Sports Physiotherapy Forum to discuss ideas and ask questions



Bi-monthly SPNZ Bulletin featuring Activity, Course and information updates.



FREE classified advertising in the SPNZ Bulletin

Education Awards for 2012 Please note that the deadline for all applicants is as follows: Student Research Prize (Auckland and Otago Schools of Physiotherapy):

20 November 2012

All applicants should visit the SPNZ website for further information and eligibility.

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FEATURE TOTAL KNEE ARTHROPLASTY PHYSIOTHERAPIST - BRONWYN HARMAN

In this edition we feature Bronwyn Harman talking about her experience working in orthopaedic practice, with specific focus on Total Knee Arthroplasty, the different types of surgery, surgical criteria, factors affecting patient outcomes and post-operative rehabilitation.

Background Bronwyn graduated as a physiotherapist from Otago in 1985 and has over 20 years clinical experience as a musculoskeletal physiotherapist. She is currently a lecturer at AUT University and has been teaching on the undergraduate curriculum for the past 5 years. Her work experience has mostly been in private practice, sports medicine and orthopaedics but has also covered intensive care, paediatrics, psychiatry, oncology, haematology and neurology. In 1990 she completed the Advanced Diploma of Physiotherapy in 1990 and was the physiotherapist for the cyclists at the Commonwealth Games. She moved to England was sole charge of a physio practice owned by the physio for the Royal family and when she returned to New Zealand she worked with David Abercrombie, the All Black physiotherapist. Following this she worked in private practice in Nelson and was physio for the Nelson Giants and then ran a physiotherapy practice in Wellington before returning to Auckland in 2001. She completed a certificate in Tertiary Teaching in 2009 and the Post graduate Diploma of Health Science (Musculoskeletal) in 2010 and is currently undertaking a Masters in Health Science. How did you become involved in your current role? Having worked as a clinician in private practice within the area of musculoskeletal physio for many years when I returned to Auckland I wanted to work in orthopaedics to find out the latest advances in orthopaedics. I ended up working in orthopaedics at Ascot Hospital and five years ago was invited to join the teaching team at AUT. What are your specific tasks/responsibilities? I am a Lecturer on the undergraduate BHSc (physio) programme at AUT University. I teach across years 2 to 4. My main area of teaching is musculoskeletal physiotherapy, plus I am the Year 3 Programme leader which entails certain administration duties and pastoral care of students. Can you describe some of the different types of knee joint replacement surgery? Ok where do I start? There are many different types of knee joint replacement surgeries; they can be unicondylar where one compartment is replaced which is undertaken when there is osteoarthritis (OA) of only one compartment, usually the medial compartment. The more common type of surgery is the unilateral total knee arthroplasty with both medial and lateral compartments being replaced (New Zealand National Joint Registry, 2010). The unilateral prostheses can be mobile bearing or fixed bearing (see figure 1 below). The mobile bearing prosthesis (see Figure 2) allows for some rotation to occur of the polyethylene spacer in the tibial tray which is thought to cause less wear of the polyethylene and replicate the normal kinematics of the knee joint. The patella may also be resurfaced if there is patello-femoral arthritis. The posterior cruciate ligament may be retained or it can be substituted and the surgery itself may or may not be computer navigated. The prostheses can either be cemented in place or uncemented where the bone grows into the prosthesis or they can be hybrid which is a mixture of both, usually with a cemented tibia and an uncemented femur.

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FEATURE PHYSIOTHERAPIST - BRONWYN HARMAN

Fig. 1 Diagramatic representation of a mobile versus a fixed bearing total knee prosthesis. Reproduced with permission.

Fig 2. Mobile bearing knee joint prosthesis. Reproduced with permission.

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FEATURE PHYSIOTHERAPIST - BRONWYN HARMAN What are the current criteria for proceeding to knee joint replacement? The American College of Rheumatology criteria developed by Altman (1991) is used to define knee OA and the Kellgren Lawrence scale (Kellgren & Lawrence, 1957) identifies the degree of radiographic changes on xray. The guidelines produced by the New Zealand Orthopaedic Association (New Zealand Orthopaedic Association, 2010) state that severe pain and disability accompanied by radiographic changes which are not responsive to conservative management are indications for knee joint replacement surgery. New Zealand was one of the first countries to develop a comprehensive prioritisation scheme for surgical procedures such as hip and knee replacement surgery (Hadorn & Holmes, 1997). A prioritisation tool is currently used for knee arthroplasty surgery in New Zealand which is important given our increasing ageing population which will create further demand for this surgery (Derrett, Devlin, Hansen, & Herbison, 2003; Hadorn & Holmes, 1997). This priority tool has 5 criteria, pain, function, social limitation, potential to benefit and consequences of delay to surgery. Can you describe some of the pre-replacement techniques and any important points relating to the post-operative rehabilitation? A high tibial osteotomy is an alternative surgery that can be performed for medial compartment OA, which is where the tibia has a wedge shaped section either taken out of (closing wedge) or inserted into (opening the wedge) the proximal tibia to help to correct the varus deformity. This may extend the length of time prior to needing a total knee arthroplasty. Lateral compartment OA needs to be ruled out prior to this procedure being performed and the rehabilitation following this surgery usually involves some degree of restriction on weight bearing. From a rehab perspective this is an area where there is quite a bit of new research. At the Physiotherapy New Zealand conference this year I presented a literature review which looked at quadriceps strength, activation and function pre and post-operatively in knee arthroplasty surgery. Pre-operatively there are already strength and activation deficits of the quadriceps with OA. In the first month after surgery the quadriceps strength losses compared to the non-operative leg are large with losses of up to 65% (Mizner, Petterson, & Snyder-Mackler, 2005; Mizner, Stevens, & Snyder-Mackler, 2003; Stevens, Mizner, & Snyder-Mackler, 2003). Quadriceps activation also decreases dramatically with deficits of up 31% by one month compared to the non-operative limb (Mizner, Petterson, Stevens, Vandenborne, & Snyder-Mackler,

2005; Stevens et al., 2003). Currently in the literature there is a focus on early intensive rehabilitation following surgery and different methods of improving strength, activation and function such as progressive strengthening and neuromuscular electrical stimulation. Michael Bade and Jennifer Stevens-Lapsley last year published a trial that looked at a high intensity versus a low intensity rehabilitation programme in patients undergoing knee arthroplasty and found the high intensity group had better functional outcomes and strength with the results lasting up to one year after knee arthroplasty (Bade & StevensLapsley, 2011). Other studies have looked at progressive strengthening versus progressive strengthening and neuromuscular electrical stimulation and found a statistically significant effect on strength and activation from both interventions but no greater effect from one over the other (Petterson et al., 2009). Quadriceps strength and activation improves by one year after surgery but tends to plateau after that, however even with rehabilitation it doesnâ&#x20AC;&#x2122;t really return to the same level as healthy controls. One of the key areas of research that needs to be looked at is an understanding of the neural mechanisms underpinning the quadriceps activation deficits as once these mechanisms are understood this will potentially enhance the ability to reduce activation deficits and improve quadriceps strength. What seem to be the factors influencing outcomes? There have been numerous factors that have been identified as being associated with outcome post TKA, in fact Paul Dieppe has written about this and has listed 34 factors (Dieppe, Lim, & Lohmander, 2011). These can be categorised into pre-operative factors, surgical factors and post-operative factors. The pre-operative factors include factors such as age, gender body mass index, mood (anxiety, depression, catastrophizing), muscle strength, level of pain and function, deformity, stability and comorbidities (Sullivan et al., 2009; Vissers et al., 2012). The New Zealand Joint Registry has identified a higher revision rate for younger patients as well as for male patients (New Zealand National Joint Registry, 2010). The surgical factors can vary from the surgical expertise to the amount of blood loss, the type of anaesthesia and the type of prosthesis. Mark Clatworthy, orthopaedic surgeon has just presented at a conference in Australia and some of the surgical factors that he identified were; that patella resurfaced, cruciate retained knee arthroplasties have a better outcome and survival and that computer navigated surgery has a better outcome but no difference in survival. The fixed prosthesis has been shown to have a better survival rate in New Zealand (New Zealand National Joint Registry, 2010) whereas a recent meta-analysis has

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FEATURE PHYSIOTHERAPIST - BRONWYN HARMAN shown no difference in clinical outcomes between the mobile and fixed bearing prostheses (Smith, Jan, Mahomed, Davey, & Gandhi, 2011). If we look at surgical expertise affecting outcome and survival the results, the New Zealand Joint Registry indicate that surgeons performing higher volumes of knee arthroplasties have better results (New Zealand National Joint Registry, 2010). Post-operative factors include the type of rehabilitation, pain control, post-operative complications, mood and social support (Lopez-Olivo et al., 2011). How essential is physiotherapy involvement with prehab/immediate post op/after discharge? Are there any guidelines around rehab and return to activity/ sport? Potentially there are benefits to a strengthening programme pre-operatively however at present there are few studies that have looked at this area of research. Two studies have found an improvement in quadriceps strength pre-operatively from a prehabilitation programme

(McKay, Prapavessis, & Doherty, 2012; Swank et al., 2011). One of these studies found no difference in the strength at 12 weeks post op however this study was underpowered and needs to be replicated with a larger sample size. There is also limited evidence as to what advice patients should be given regarding the return to sporting activities although high impact or contact sports are not recommended. In New Zealand walking and swimming are the most common activities undertaken by patients following knee arthroplasty (Chatterji, Ashworth, Lewis, & Dobson, 2005). Other research has shown that approximately 50% of knee arthroplasty patients don’t undertake the health enhancing physical activity levels recommended by guidelines such as the American College of Sports Medicine (Kersten, Stevens, van Raay, Bulstra, & van den Akker-Scheek, 2012). The trick is to get the patient back into regular activities that are not going to wear out the prosthesis or cause peri-prosthetic fractures.

For more information about Bronwyn’s profile click here.

References Altman, R. (1991). Criteria for the classification of clinical osteoarthritis. Journal of Rheumatology, 18(Supplement 27), 10-12. Retrieved from www.jrheum.org Bade, M. J., & Stevens-Lapsley, J. E. (2011). Early high-intensity rehabilitation following total knee arthroplasty improves outcomes. The Journal Of Orthopaedic And Sports Physical Therapy, 41(12), 932-941. doi:10.2519/ jospt.2011.3734. Chatterji, U., Ashworth, M. J., Lewis, P. L., & Dobson, P. J. (2005). Effect of total knee arthroplasty on recreational and sporting activity. ANZ Journal of Surgery, 75(6), 405-408. doi:10.1111/j.1445-2197.2005.03400.x Derrett, S., Devlin, N., Hansen, P., & Herbison, P. (2003). Prioritizing patients for elective surgery. International Journal of Technology Assessment in Health Care, 19(1), 91-105. doi:10.1017/S0266462303000096 Dieppe, P., Lim, K., & Lohmander, S. (2011). Who should have knee joint replacement surgery for osteoarthritis? International Journal of Rheumatic Diseases, 14(2), 175-180. doi:10.1111/j.1756-185X.2011.01611.x Hadorn, D. C., & Holmes, A. C. (1997). The New Zealand priority criteria project. Part 1: Overview. British Medical Journal, 314(7074), 131-141. Retrieved from www.bmj.com Kellgren, J. H., & Lawrence, J. S. (1957). Radiological assessment of osteo-arthrosis. Annals of the Rheumatic Diseases, 16(4), 494-502. Kersten, R. F. M. R., Stevens, M., van Raay, J. J. A. M., Bulstra, S. K., & van den Akker-Scheek, I. (2012). Habitual physical activity after total knee replacement. Physical Therapy, 92(9), 1109-1116. doi:10.2522/ptj.20110273 Lopez-Olivo, M. A., Landon, G. C., Siff, S. J., Edelstein, D., Pak, C., Kallen, M. A., ... Suarez-Almazor, M. A. (2011). Psychosocial determinants of outcomes in knee replacement. Annals of the Rheumatic Diseases. doi:10.1136/ ard.2010.146423 CONTINUED ON NEXT PAGE…

FEATURE

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PHYSIOTHERAPIST - BRONWYN HARMAN References contâ&#x20AC;&#x2122;d McKay, C., Prapavessis, H., & Doherty, T. (2012). The effect of a prehabilitation exercise program on quadriceps strength for patients undergoing total knee arthroplasty: A randomized controlled pilot study. PM and R. doi:10.1016/j.pmrj.2012.04.012 Mizner, R. L., Petterson, S. C., & Snyder-Mackler, L. (2005). Quadriceps strength and the time course of functional recovery after total knee arthroplasty. The Journal of Orthopaedic And Sports Physical Therapy, 35(7), 424-436. Mizner, R. L., Petterson, S. C., Stevens, J. E., Vandenborne, K., & Snyder-Mackler, L. (2005). Early quadriceps strength loss after total knee arthroplasty. Journal of Bone and Joint Surgery, 87-A(5), 1047-1053. Mizner, R. L., Stevens, J. E., & Snyder-Mackler, L. (2003). Voluntary activation and decreased force production of the quadriceps femoris muscle after total knee arthroplasty. Physical Therapy, 83(4), 359-365. Retrieved from www.ptjournal.org New Zealand National Joint Registry. (2010). New Zealand Joint Register Latest Figures. Retrieved 19 May, 2012, from www.cdhb.govt.nz New Zealand Orthopaedic Association. (2010). Total knee replacement: A guide to good practice. Retrieved 20 September, 2012, from http://www.nzoa.org.nz/Publications%20Guidelines%20and%20Reports.php Petterson, S. C., Mizner, R. L., Stevens, J. E., Raisis, L., Bodenstab, A., Newcomb, W., & Snyder-Mackler, L. (2009). Improved function from progressive strengthening interventions after total knee arthroplasty: A randomized clinical trial with an imbedded prospective cohort. Arthritis and Rheumatism, 61(2), 174-183. doi:10.1002/ art.24167 Smith, H., Jan, M., Mahomed, N. N., Davey, J. R., & Gandhi, R. (2011). Meta-analysis and systematic review of clinical outcomes comparing mobile bearing and fixed bearing total knee arthroplasty. Journal of Arthroplasty, 26(8), 1205-1213. doi:10.1016/j.arth.2010.12.017 Stevens, J. E., Mizner, R. L., & Snyder-Mackler, L. (2003). Quadriceps strength and volitional activation before and after total knee arthroplasty for osteoarthritis. Journal of Orthopaedic Research, 21(5), 775-779. doi:10.1016/S07360266(03)00052-4 Sullivan, M. J. L., Tanzer, M., Stanish, W., Fallaha, M., Keefe, F., Simmonds, M., & Dunbar, M. (2009). Psychological determinants of problematic outcomes following total knee arthroplasty. Pain, 143(1-2), 123-129. doi:10.1016/ j.pain.2009.02.011 Swank, A. M., Joseph, B. K., Wendy, B., Quesada, P. M., Nyland, J., Arthur, M., & Topp, R. V. (2011). Prehabilitation before total knee arthroplasty increases strength and function in older adults with severe osteoarthritis. Journal of Strength and Conditioning Research, 25(2), 318-325. doi:10.1519/JSC.0b013e318202e431 Vissers, M. M., Bussmann, J. B., Verhaar, J. A. N., Busschbach, J. J. V., Bierma-Zeinstra, S. M. A., & Reijman, M. (2012). Psychological factors affecting the outcome of total hip and knee arthroplasty: A systematic review. Seminars in Arthritis and Rheumatism, 41(4), 576-588. doi:10.1016/j.semarthrit.2011.07.003

CLINICAL SECTION

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ARTICLE REVIEW Restoration of Physical Function in Patients Following Total Knee Arthroplasty: An Update on Rehabilitation Practices. Bade, M. J., & Stevens-Lapsley, J. E. (2012). Restoration of physical function in patients following total knee arthroplasty: An update on rehabilitation practices. Current Opinion in Rheumatology, 24(2), 208â&#x20AC;&#x201C;214. doi:10.1097/ BOR.0b013e32834ff26d Article Summary This is a narrative review that looks at rehabilitation approaches post total knee joint replacement (TKJR). TKJRs are very commonly performed surgical procedures, with more than 687 000 undertaken yearly in America. Many candidates for this surgery are osteoarthritic patients (approximately 70%), who already have significant and long standing weakness and functional deficits leading up to surgery. Studies show that these patients within the first month following surgery lose a further 60% quadriceps strength compared with preoperative levels. Function also decreases significantly in this time. Performance tests such as the stair climbing test (SCT) and the 6 minute walk test (6MWT) have been shown to decline as much as 90% and 40% respectively. Six months post-surgery, compared to healthy subjects, TKJR patients have 40% less quadriceps strength, 30% less distance on the 6MWT and are 110% slower on the SCT. The majority of TKJR candidates are older adults, these functional and strength deficits combined with the natural declines of age predispose individuals to increasing disability, risk of falls and a loss of independence. This emphasises the need for a comprehensive and thorough rehabilitation programme starting very early in the recovery process. Neuromuscular electrical stimulation (NMES) has been used effectively to speed up the recovery process from TKJR. If applied to the quadriceps muscle in the first six weeks post-surgery it can lead to long-term strength and functional performance increases. The recommendation is for twice daily application to the quadriceps muscles commencing day two following surgery. Across three studies the application of NMES was between 40-50Hz, the pulse duration between 250-400Îźs and the on/off phases varied widely. In two of the three studies the application of NMES showed significant improvements over the control group. Rehabilitation programs should include high intensity, progressive resistance exercises. All major lower limb muscle groups should be targeted to restore correct movement patterns. Evidence by Piva et al. (2011) shows that hip abductor strength has a strong correlation with functional performance following TKJR. Other literature shows that strength loss following TKA occurs not only in the knee extensors but also in the hamstrings and calf muscles. Good outcomes are shown from strengthening not only the quadriceps muscles but hip abductors and adductors, hip flexors and extensors, knee flexors and plantar flexors. As well as comprehensive lower limb strengthening, training intensity is an important variable. There is evidence that a higher intensity progressive resistance program is well tolerated and successful following TKJR, with weights based on the patientâ&#x20AC;&#x2122;s 10-repetition maximum. It is also important not to forget to address balance, agility, endurance, and functional exercises in the rehabilitation process. Finally if patients are presenting more than 4 months post-surgery, and have significant strength loss and disability, the recommendation in this review is to trial an eccentric rehabilitation programme or a progressive aquatic based programme. The article that endorsed eccentric training however used a machine called an Eccentron which may not produce the same results as conventional eccentric training. The aquatic programme study compared their results to a passive control group, so there is no evidence this is superior to standard resistance training. Clinical Relevance Following TKJR the use of NMES is recommended to facilitate muscle activation and strengthening. The most significant losses in strength and function are seen immediately following surgery. Therefore it is important to target patients early in the postoperative period to avoid having to reverse losses months after surgery. The rehabilitation programme should include the whole lower limb kinetic chain as well as the contralateral side. High intensity resistance training can be well tolerated and a focus on not just strength but agility, endurance, power, proprioception and power is important. Perhaps there is also need for the public health system to evaluate funding and the current treatment of these patients post-surgery in the interests of falls prevention and functional independence. More reliable and extensive research however would need to be implemented here. Review by Monique Baigent BHsc (Physiotherapy)

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CLINICAL SECTION ASICS INJURY CORNER Tarsal Navicular Stress Fracture The navicular is often called in the “keystone” of the foot, since its response for linking the rearfoot to the midfoot via the talar navicular articulation and, from an engineering perspective, it is situated at the apex of the medial longitudinal arch and is important in maintaining the structural integrity of the arch. Traumatic fractures of the navicular are rare in sport, since they require high energy and the navicular itself is anatomically protected. Stress fractures of the tarsal navicular however are common in athletes and represent one of the most important and challenging injuries in sports medicine. Once thought to be a relatively uncommon stress fracture, it is now recognised as a major cause of midfoot pain, as diagnosis has improved vastly with improved imaging techniques. In past years morbidity from a navicular stress fracture was high, secondary to long delays in diagnosis due to their occult nature with plain radiographic investigation. Modern sports medicine practice however assumes a high index of suspicion for any persistent midfoot pain, with the diagnosis confirmed on isotopic bone scan, CT or MRI. Track and field athletes are thought to be particularly susceptible to navicular stress fracture however high incidence has also been reported in jumping sports including football, basketball, cricket, field hockey, gymnastics and racquet sports, as well as high energy pursuits like ballet. Aetiology Historically, navicular stress fractures have been attributed many causes, including; 

Repetitive lower limb loading.

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Increased activity of repetitive work, a new or altered training regime, a change in training equipment or a rest period followed by normal return to activity.

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As a result of muscular action on bone, where muscles react faster than bone resulting in dynamic imbalance and pathology.

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Anatomical and mechanical abnormalities including foot structure, limited joint range of motion of the feet and ankles, excessive pronation and varus alignment of the lower limbs.

Much of this literature is speculative and indeed the exact cause of navicular stress fractures remains unknown. It is clear however, that in common with most stress fractures, navicular stress fracture aetiology is linked to a combination of underuse and training errors in the presence of a biomechanical abnormality. Presentation Symptom onset in tarsal navicular stress fracture is often

insidious, with pain reported after activity, especially sprinting and jumping. Navicular stress fractures are often overlooked because symptoms may be vague, particularly in the early stages of the injury and pain tends to settle with rest, but recur when the patient recommences. Diagnosis is further clouded by the often radiating nature of pain into the arch of the foot, dorsally along the 1st or 2nd ray, or even laterally towards the cuboid. In 1992, Khan and co-workers described the “N-spot” which remains the definitive clinical hallmark for identifying navicular stress fracture. The “N-spot” is located over the proximaldorsal portion of the navicular, and palpation of this zone elicits tenderness or pain. Further investigation to exclude navicular stress fracture is required in the presence of a tender “N-spot”. Investigation Isotopic bone scanning plays an important role in the early identification of navicular stress fracture, to which it is highly sensitive. CT examination will follow a positive isotopic bone scan and will allow accurate lesion characterisation Treatment The key to management of navicular stress fracture is early and accurate diagnosis. History is littered with athletes who suffer a delayed or non-union of this fracture because they are committed to continue activities in the presence of a navicular stress fracture. Initially treatment may be as simple as weight bearing rest. However, the literature reports a high failure rate with this management. It’s thought to be secondary to an inability of osteoblastic activity to fill the breach of the fracture site. Immobilisation with a non-weight bearing cast for a period from two weeks to three months is the primary option of choice and demonstrates excellent outcomes in navicular stress fracture. If non-union occurs after conservative management, or fragments are separated, surgery is a successful treatment option. This may include internal fixation or curettage and bone grafting with a six weeks post-surgical immobilisation in non-weight bearing. Return to Sport A tarsal navicular stress fracture is clinically healed when no tenderness can be palpated at the “N-spot”. A six week rehabilitation programme administered by a sports physiotherapist is recommended. This programme should include gentle stretching, joint mobilisation and muscular strengthening, with a graduated return to sport. This is especially important given the recognised morbidity associated with long term cast immobilisation.

RESEARCH SECTION

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SPNZ PHYSIOTHERAPY RESEARCH REVIEWS Total Knee Arthroplasty: Rehabilitation Perspectives www.sportsphysiotherapy.org.nz/resources

An Eccentrically Biased Rehabilitation Program Early after TKA Surgery LaStayo P.C, Marcus R.L, Meier W, Peters C, Yoshida Y (2011). Clinical Study. An eccentrically biased rehabilitation program early after TKA surgery. Arthritis 2011:1-10 Article Summary Studies have shown that more than one third of Total Knee Arthroplasty (TKA) recipients have suboptimal function. Walking speeds, the time to negotiate stairs and distance walked in six minutes were all slower than control subjects. This study looked at the use of an eccentrically-biased postoperative rehabilitation intervention following TKA. The programme involved twelve, sixty minute sessions over a six week period. A resistance exercise via negative, eccentrically-induced work (RENEW) of both lower extremities was performed on a recumbent ergometer that appears like a normal stepper ergometer. The RENEW was designed to progressively increase in intensity while avoiding muscle damage. All participants significantly improved on all physical function outcomes; Lower Extremity Functional Scale increased 55%, Stair Climbing Test improved 47% and Gait Speed improved 30%. Clinical Applications A limitation of this study was the low participant number of thirteen. The programme involved recumbent ergometer that induced negative eccentric work. Not all clinics will have access to machines that allow this programme. There were no control or comparison group for this study. Even though the study showed significant improvements in physical function via the eccentric programme, it is not possible to determine if the outcomes are clinically relevant. Reviewed by Amanda O'Reilly BPhty (Otago)

Early High-Intensity Rehabilitation Following Total Knee Arthroplasty Improves Outcome Bade M., Stevens-Lapsley J., (2011) Journal of Orthopaedic & Sports Physical Therapy: 41(12):932-941 doi:10.2519/ jospt.2011.3734 Article Summary This research specifically targeted the finding that persistent lower limb impairment (quadriceps strength deficit) and loss of functional ability occurred post total knee arthroplasty (TKA) surgery and that this deficit is evident from as early as one month post surgery. Previous studies have revealed a mixed outcome for physiotherapy intervention following TKA, but no studies had examined a lower limb high-intensity (HI) training as a post operative rehabilitation approach. Compared to age and sex matched controls (who underwent a low intensity rehabilitation programme) this study applied a HI rehabilitation programme to 8 participants for 12 weeks. This commenced following discharge where patients were treated at home for 3 visits in the first week after which patients were treated at outpatient physiotherapy clinic 2-3 times a week until the completion of the rehabilitation supervision programme at 12 weeks (see programme below). Patients were assessed preoperatively, at 3.5, 6.5, 12, 26, and 52 weeks postoperatively. Outcomes measured were pain rates, ROM, functional performance (stair climbing, timed up and go, 6 minute walk) and quadriceps strength and activation. The results revealed no differences in ROM and pain between groups at any post operative time point however the HI group had significantly better function of stair climbing, timed up and go and walking efficiency plus improved quadriceps strength and activation which was evident as early as 3.5 weeks, 12 weeks. The improved levels of function were still evident at 52 weeks post operatively. It is notable that no self reported outcome measures were used so it is unclear if the patients felt they had also improved. Limitations of this study include no randomisation occurred, lack of blinding and

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SPNZ PHYSIOTHERAPY RESEARCH REVIEWS CONTINUED….. there was only a small sample size. Of note however there were little side effects of the HI programme other than transient increase in symptoms of pain and swelling that were well managed with local modalities and not progressing the programme till these were controlled.

High-Intensity Rehabilitation Program Phase 1 (Weeks 0-2) • Supine knee flexion (heel slides) • Short-arc knee extensions • Standing bilateral squats • Sidelying hip external rotation, with hips flexed to 45° and knees flexed to 90° (clams) • Sidelying hip adduction • Supine ankle plantar flexion and dorsiflexion (ankle pumps) Progression: • When able to complete 2 × 8 repetitions without fatigue; NPRS at rest, <5/10; ROM, >15°-80° Phase 2 (Weeks 0-4) • Seated single-leg knee extension* • Straight leg raise* • Standing hamstring curls* • Sidelying hip adduction* • Sidelying hip abduction* • Standing bilateral calf raises • Repeated sit-to-stand transfers • Marching or single-limb stance • Multidirectional stepping Progression: • When able to complete 2 × 8 reps without fatigue; NPRS at rest, <5/10; ROM, >15°-90° Phase 3 (Weeks 2-12) • Seated single-leg knee extension* • Seated single-leg knee flexion* • Single-leg press* • Single-leg calf press* • Standing hip extension, flexion, abduction, and adduction* • Step-ups, side step-ups, step-downs • Forward lunging • Single-limb stance progression (shoe to sock to foam, with eyes open, then with eyes closed) • Tilt board squats • Wall slides to 90° of knee flexion • Stability ball supine hip extension Progression: • When able to complete 2 × 8 repetitions without fatigue; NPRS at rest, <3/10; ROM, >10°-100° Phase 4 (Weeks 6-12) • Seated single-leg knee extension (eccentric)* • Seated single-leg knee flexion (eccentric)* • Single-leg press (eccentric)* • Single-leg calf press (eccentric)* • Standing hip extension, flexion, abduction, and adduction* • Step-ups, side step-ups, step-downs • Multidirectional lunging • Star excursion balance reaching • Wall slides with 5- to 10-second endurance holds at 90° • Stability ball supine combined hip extension with knee flexion • Agility exercises: side-shuffle, backward walking, and braiding • Single-limb stance progression Abbreviations: ROM, total active arc of knee range of motion; NPRS, numeric pain rating scale. *Resistive exercise utilizing ankle weight, resistive band, cable column or machine.

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SPNZ PHYSIOTHERAPY RESEARCH REVIEWS CONTINUED….. Clinical Applications The findings of this small research (which may be considered a pilot study), are very optimistic that a HI programme may benefit TKA patients. The key clinical applications drawn from this study are that firstly; the programme was supervised, had a greater number of treatment sessions and extended over a 12 week period. With patients who have had invasive and painful surgery that need to recover from the actual surgery and who would have had functional deficits pre-surgery, it is unrealistic to expect them to overcome these deficits with a brief and low intensity intervention. Secondly, the programme had single leg exercises, machine resistance and a progressive component to the exercise prescription. This also suggests that supervision is warranted to assist with the progression which needs to be individualised. Thirdly, there has been an empirical assumption that HI exercises would produce pain, decreased ROM and swelling; however the patients on the HI programme did not seem to suffer these detrimental effects and had an improved and longer lasting functional gain. It would be interesting to see if physiotherapists in New Zealand are already providing a version of HI exercise programmes to their TKA patients, or if some motivated patients are self prescribing their own exercise programme and coming up with similar outcomes. Reviewed by Kate Polson MHSc(Hons); Dip Phty, Dip MT, MNZCP; MNZSP

Improved function from progressive strengthening interventions after total knee arthroplasty: a randomized clinical trial with an imbedded prospective cohort Petterson S, Mizner R, Stevens J, Raisis L, Bodenstab A, Newcomb W, Snyder-Mackler L (2009). Improved function from progressive strengthening interventions after total knee arthroplasty: a randomized clinical trial with an imbedded prospective cohort. Arthritis and Rheumatism (Arthritis Care and Research) 61(2):174-183. doi:10.1002/art.24167. Article Summary This study looked at the effectiveness of progressive quadriceps strengthening with or without neuromuscular electrical stimulation (NMES) on quadriceps strength, activation and functional recovery after total knee arthroplasty. A randomised clinical trial was conducted and the subjects allocated six weeks of outpatient physical therapy to; 1) a volitional strength training exercise group or 2) a volitional strength training exercise group plus NMES; and were compared to a conventional standard of care group. Both groups (N=100) were given exercises based on knee ROM, patella mobility, quad strength, pain control, gait, lower leg and hip strength; but were not described in detail. The NMES protocol was thoroughly documented. The standard of care group had therapy in various clinics and their exercises were also not described in detail but were based on ROM, stationary cycling and various straight leg raise exercises without weights. The Medical Outcomes Study Short Form 36, Knee Outcome Survey, knee ROM, Timed Up and Go, Stair-Climbing Test and 6-minute Walk were the outcome measures used. Petterson et al hypothesised that NMES, as an adjunct to volitional strength training, would result in greater quadriceps strength, however, the results showed no significant or clinically meaningful difference between the two intervention groups. Subjects in both groups showed similar improvements in quads strength, activation and function at 3 and 12 months post surgery. The conventional standard of care group had weaker quads and exhibited worse function at 12 months. This group was the prospective cohort as it was not randomised and contained patients from one surgeon only, they were therefore only compared to his patients in the RCT groups. Clinical Applications The addition of NMES did not make a clinically significant difference and as it was ‘uncomfortable’ it accounted for a higher dropout rate in this group (11/16 participants). The lack of information on the exercise protocols used in the study makes the reproducibility of the interventions difficult. However, the article has demonstrated that quadriceps strength is strongly correlated with functional performance and that post-operative TKA exercise programmes should incorporate this component. Reviewed by Charlotte Raynor PGDipPhty, BSc(Hons), NZRP, MNZSP

OUTCOME MEASURES

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KNEE INJURY AND OSTEOARTHRITIS OUTCOME SCORE (KOOS) There are many knee instruments and rating scales available to measure outcomes from the perspective of the patient. Some of these have been evaluated for reliability, validity and responsiveness. Choosing an outcome measure will depend on the population you are considering and no one tool is seen as being universally applicable across all knee disorders or patient groups. We have included the Knee Injury and Osteoarthritis Outcome Score (KOOS) as an instrument you may like to use to assess the patientâ&#x20AC;&#x2122;s opinion about their knee and associated problems. It is intended to be used for knee injury that can subsequently result in post traumatic Osteoarthritis (OA); ie ACL injury, meniscus injury, chondral injury, etc. It is also used in knee OA. The KOOS tool can be used over short and long-term intervals and includes two different subscales of function relating to daily life, and sport and recreation. To find out more follow the link http://www.koos.nu and see the pdf attachment on this bulletin - click on the at the left of your screen.

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www.spts.org/ijspt Volume Seven, Number Three, October 2012 The Research Issue TABLE OF CONTENTS Invited Clinical Commentary: Research Handbook Publishing your work in a journal: understanding the peer review process. Authors: Voight M, Hoogenboom B Evidence-based medicine/practice in sports physical therapy. Authors: Manske R, Lehecka B Levels of evidence in medicine. Authors: McNair P, Lewis G Research designs in sports physical therapy. Authors: Page P Systematic review and meta-analysis: a primer. Authors: Impellizzeri F, Bizzini M Statistical principles for prospective study protocols: design, analysis and reporting. Authors: Christensen R, Langberg H How to write a scientific article. Authors: Hoogenboom B, Manske R Avoiding manuscript mistakes. Authors: Grindstaff T, Saliba S

Original Research Changes in lower extremity movement and power absorption during forefoot striking and barefoot running. Authors: Williams B, Green DH, Wurzinger B Comparison of different trunk endurance testing methods in college-aged individuals. Authors: Reiman MP, Krier AD, Nelson JA, Rogers MA, Stuke ZO, Smith BS The acute effects of various types of stretching: static, dynamic, ballistic, and no stretching of the iliopsoas on 40-yard sprint times in recreational runners. Authors: Wallmann HW, Christensen SD, Perry C, Hoover DL Shoulder range of motion, pitch count, and injuries among interscholastic female softball pitchers: a descriptive study. Authors: Shanley E, Michener L, Ellenbecker T, Rauh M

Clinical Commentary: Diagnostics Corner Acute management concepts of the acromioclavicular joint.

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RESEARCH SECTION RESEARCH REVIEWS Register (FREE) and download the latest “NZ Research Reviews”

http://researchreview.co.nz

Studies in this issue:        

Intervention thresholds for fracture risk Antiresorptive treatment and nonvertebral fractures Reduced risk of fracture after cataract surgery Antifracture efficacy of zoledronate Self-reported vs DXAdefined osteoporosis Vitamin D receptor not found in muscle Worldwide incidences of hip fracture Oral calcitonin for postmenopausal osteoporosis

Studies in this issue:  Comparing the Māori and NZ Caucasian foot  Chronic plantar fasciitis: botulinum toxin vs corticosteroids  Ankle-foot orthoses in Charcot–Marie–Tooth disease  Intrinsic functional deficits predicit ankle injury  Custom orthoses/shoes reduce diabetic ulcer risk  Multiple sclerosis: gait effects of textured insoles  Plantar fasciitis: US-guided dexamethasone effective short-term  Metatarsal pads and the forefoot during gait  RA: foot symptoms and quality of life  Reliability of Inlow’s 60-Second Diabetic Foot Screen

Studies in this issue:          

System factors affect functional recovery Yoga may improve balance post-stroke Optimising custom-made diabetic footwear When can sick-listed employees resume work? Pain coping strategies used by workers Frustrations experienced with chronic pain Health literacy in rehabilitation AEs under-reported with chiropractic treatments Chiropractic in acute musculoskeletal chest pain Deconstructing the (un)motivated client

Studies in this issue:  ACT for older patients with chronic pain  Intensive CBT programme for chronic low back pain  Gabapentin and pregabalin prevent chronic postsurgical pain  Exercise training attenuates neuropathic pain in rats  Continuous femoral nerve analgesia after knee surgery  Perioperative systemic alpha 2-agonists  Opioid switching to methadone  Subcostal transversus abdominis plane block  A new ‘platform’ concept for pain management  A shortened, restructured TOPS instrument

Studies in this issue:          

Cognitive decline and aging Altitude training and elite athletes’ performance Knee laxity after complete ACL tear Doping and supplementation: attitudes of athletes Imaging in patellofemoral instability OC pill for the female athlete triad Interpreting ECG in competitive athletes ‘23½h’ video goes viral Hamstring eccentrics are essentials Asymptomatic status following sports concussion

http://www.researchreview.co.nz

Studies in this issue:          

Squeaking 10 years post THA THA: are recovery room radiographs necessary? Infection risk from surgeons’ eyeglasses Hip resurfacing: greater revision risk in sporty patients High failure rates with metal-on-metal THR Excellent outcomes with paediatric ACL reconstruction TKA blood loss: tranexamic acid useful Cemented TKR: 10-year survival Computer-assisted surgery in TKA Predictive value of ASA score post TKA and THA

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RESEARCH SECTION JOURNAL OF ORTHOPAEDIC & SPORTS PHYSICAL THERAPY

October 2012; Volume 42, Issue 10

www.jospt.org

Click on the article title for a direct link to the abstract

Hip Posterolateral Musculature Strengthening in Sedentary Women With Patellofemoral Pain Syndrome: A Randomized Controlled Clinical Trial With 1-Year Follow-up Thiago Yukio Fukuda, William Pagotti Melo, Bruno Marcos Zaffalon, Flavio Marcondes Rossetto, Eduardo Magalhães, Flavio Fernandes Bryk, RobRoy L. Martin

A Web-Based Intervention to Improve and Prevent Low Back Pain Among Office Workers: A Randomized Controlled Trial Borja del Pozo-Cruz, Jose C. Adsuar, Jose Parraca, Jesús del Pozo-Cruz, Antonio Moreno, Narcis Gusi

Clinical and Radiological Investigation of Thoracic Spine Extension Motion During Bilateral Arm Elevation Stephen J. Edmondston, Andrij Ferguson, Patrick Ippersiel, Lars Ronningen, Stig Sodeland, Luke Barclay

The Effect of Training the Deep Cervical Flexors on Neck Pain, Neck Mobility, and Dizziness in a Patient With Chronic Nonspecific Neck Pain After Prolonged Bed Rest: A Case Report Marloes Thoomes-de Graaf, Maarten S. Schmitt

IFOMPT 2012: A Rendez-Vous of Hands and Minds Rob Werstine, Bert M. Chesworth

Measurement of Segmental Lumbar Spine Flexion and Extension Using Ultrasound Imaging Gary S. Chleboun, Matthew J. Amway, Jesse G. Hill, Kara J. Root, Hugh C. Murray, Alexander V. Sergeev

Integration of Critically Appraised Topics Into Evidence-Based Physical Therapist Practice Michael S. Crowell, Bradley S. Tragord, Alden L. Taylor, Gail D. Deyle

Osteochondritis Dissecans of the Humeral Head Jason B. Lunden, Alexander B. LeGrand

Distal Fibula Fracture Diagnosed With Ultrasound Imaging Joseph R. Kardouni

Differential Diagnosis and Management of Ankylosing Spondylitis Masked as Adhesive Capsulitis: A Resident's Case Problem Chelsea L. Jordan, Daniel I. Rhon

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CONTINUING EDUCATION Upcoming courses and conferences in New Zealand and overseas in 2012. www.sportsphysiotherapy.org.nz/calendar LOCAL COURSES & CONFERENCES When?

What?

Where?

More information

27 October

Kinesio Taping Course KT3

Hamilton

linley@handsongroup.co.nz

27 October

Solving Lower Limb Injuries

Te Aroha

See PNZ Website

02 Nov

NZMPA - Dynamic Stability of the Hip & Pelvis

Auckland

admin@nzmpa.org.nz

03 Nov

Motor Control and Sensorimotor Training for Wellington Stubborn Hip, Knee and Ankle Injuries

03 Nov

NZMPA - Foot and Ankle, Review Lower Quartile

Christchurch www.nzmpa.org.nz

04 Nov

NZMPA - Dynamic Stability of the Hip & Pelvis

Dunedin

09 Nov

DMA Clinical Pilates - Matwork/Theraband Level 1 Wellington

2012

david@thephysioshed.com

admin@nzmpa.org.nz www.clinicalpilates.com courses@clinicalpilates.com

11 Nov

DMA Clinical Pilates - Matwork/Theraband Level 2 Wellington

www.clinicalpilates.com courses@clinicalpilates.com

17 Nov

Mulligan Concept - Part C - Advanced Techniques Nelson & Credentialing Exam

jillianmcdowell@xtra.co.nz

17 Nov

Stability Plus Pilates - Reformer 3

Click Here

17 Nov

Sensory Processing Training & Primitive Reflex Tauranga Inhibition for Movement and Stubborn Pain Problems

cath.mcfadyen@physio.co.nz

15-17 Nov

New Zealand Sports Medicine Conference

Auckland

Click Here

What?

Where?

More information

31 Oct - 2 Nov

Be Active 2012 (Sports Medicine Australia)

Sydney

beactive2012

16 November

10th Sport Symposium

Bern

http://www.sportfisio.ch/ index.php/main/getNews

17 Nov â&#x20AC;&#x201C; 18 Nov

Active Health Solutions TMJ Course

Melbourne

ahsde@bigpond.net.au

29 Nov- 1 Dec

Team Concept Conference

Las Vegas

http://www.spts.org/education/ team-concept-conference

Auckland

INTERNATIONAL COURSES & CONFERENCES When?

2012

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SPNZ Member Login Login: Your login is your email address that you supplied to Physiotherapy NZ. Change Your Password: Your initial password will be “spnz2012”. For security, please change this immediately to a password of your choice. In the top right hand corner hover your mouse over your name / email address. Go to “Edit My Profile”. At the bottom of the page there is a new password box. Type in your new password. Retype it. Click the “Update Profile” box. Lost Passwords: Click on “Lost Passwords” in the login box.

MEMBERS SECTION: Copies of all clinical article reviews and SPNZ Research Reviews that appear in the SPNZ Bulletin editions will be placed in the new “Resources” section, as well as an updated list of Open Access Journals. These will be available for all members to access at any time.

SPNZ’s Research Reviews

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Osteoarthritis

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Barefoot running and the minimalist shoe debate

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Injuries in Cricket

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Bench pressers’ shoulder—overuse tendinosis of pectoralis minor

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Medical Exercise

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Blood clots and plane flights

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Sport and Athlete.

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Heat acclimatization guidelines for high school athletes

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Management of hamstring injuries—issues in diagnosis

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Sideline evaluation of bone and joint injury

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Occular injuries in basketball and baseball

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Clinical and MRI features of a cricket bowlers side strain

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Quick Links to Members Section Resources Copies of SPNZ’s Research Reviews, a list of open-access journals (full-text available), clinical article summaries and other sports physiotherapy related articles. Vacancies Sports Team Positions and Clinic Positions available. Asics Education Grant Information Application form, guidelines and instructions.

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