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  • Blog: Using strength and conditioning in Physiotherapy by Emily Drakes

    My interest in strength and conditioning started after watching an evening lecture from Raphael Brandon. I was intrigued by the theory behind exercise prescription. Also, physiotherapy seems to be moving more and more towards exercise as the mainstay of treatment, as seen in the recent NICE guidelines for low back pain1, so this seemed like the right path to follow.

    For those of you lucky enough to work with S&C coaches you will have them on hand to guide exercise prescription. However for most of us working in physiotherapy teams, having more of an S&C background can offer valuable insight into the best way to strengthen and prepare a patient for their activities whether that is a seasoned marathon runner or a stay at home parent with children to carry.

    It has been refreshing in learning about S&C to put injuries to one side and focus on the most effective way to plan an exercise programme. Many physiotherapist’s are preoccupied with making an exercise look like the movement or sport they are trying to rehabilitate their patient to i.e. giving a patient who plays football a ball to use in an exercise. However when if you break down the amount of time a footballer spends with a ball over 90mins it amounts to 90s2! The rest of the time is spent running, changing direction and jostling for the ball. Obviously a lot of the time a footballer is training involves a ball but unless you break it down in to the components of a skill you have no overload. This is what S&C essentially comes down to, ensuring specific adaptations to imposed demands. We need to understand the way a force is developed in the sport/activity we are interested in and in the exercise we are choosing to prescribe to get the desired outcome.

    There are some general principles that I now use daily that are key to exercise prescription. Firstly a needs analysis, which is something we all do to some extent but it formalises the process of deciding where a person is dysfunctional for the activity they are struggling with. The diagram below outlines this:

    Once you’ve specified the activity and what one would need to perform that successfully/pain free then you would look at the gap between the person in front of you vs. the ideal attributes they need. Once you know this, targeting their exercise should be much easier.

    The needs analysis and the selection of exercises both incorporate the principle of dynamic correspondence described by Siff and Verkoshansky3. This is a guide on the different aspects of the activity to consider and how the exercise you are choosing will correlate to it.

    Unless you are doing the exercise itself i.e. kicking a ball you are not going to be 100% specific, however as discussed above in order to overload the components you need to break it down into parts. We will use the example of squatting and sprint ability in football:

     

     

     

     

    There are 5 key aspects to consider:

    Amplitude and direction of movement

    This is the most familiar principle in that we are looking at the direction of force relative to the performed movement.

    The squat does not look like a sprint however the lower limb movement of the hip, knee and ankle triple extension on the ascent on the squat is similar.

    The transmission of force from a flexed position to full extension in the squat is similar to the explosive action a footballer will need to perform when starting to sprint.

    Rate and time of peak force production

    The peak rate of force production of a footballer sprinting is within 100 – 200 ms4 and for a squat is 300ms5 therefore it may not be as fast as it needs to be, however you may choose to use a lighter load at performed at maximum speed to improve this. It has been seen that 40-50% of 1RM achieves peak velocity and power in a squat.

    Dynamics of effort (whether a concentric max effort or eccentric slow effort is desired for each lift)

    The training stimulus and effort needs to be greater than the sporting skill or activity we are training for, which in a heavy weighted squat certainly would be for sprinting over 30m. Peak power for the concentric phase of a squat is 4000W5 and for sprinting it’s 1200W4 in the propulsion phase.

    Accentuated region of force development (Joint angle specificity)

    The squat will yield a greater range of movement than the sprinting motion. This means that you are overloading the skill by creating greater strength in a larger range of movement. Based on research football players accelerating the knee angle averages at 89 degrees6, correlates well with a parallel squat (90 degrees).

    Regime of muscular work (Type of muscle action)

    For a squat the initial phase is eccentric action of the quadriceps and glutes then concentric extension on the ascent of the glutes, quadriceps and hamstrings. In a sprint the initial movement to overcome inertia is concentric which corresponds with the ascent phase of the squat. The top speed running of a footballer will involve the glutes, hamstrings and quadriceps moving from concentric to eccentric muscle action, as does the squat7.

    The greater power needed through the triple extension phase of the squat achieves greater motor recruitment which is thought to be one of the reasons a squat correlates so well with sprint speed in soccer players as the athlete is able to use more of the motor units to generate max speed8.

    This was a brief illustration of how strength and conditioning principles can be used to look deeper into the activity or sport you are looking to achieve with a patient. It has certainly highlighted to me over my degree so far that there is a lot more to train than what a movement looks like which can help you prepare your patient or athlete in a more well rounded way for their sport.

    References

    1. https://www.nice.org.uk/guidance/NG59
    1. Bradley, Sheldon, Wooster, Olsen, Boanas & Krustrup (2009) High-intensity running in English FA Premier League soccer matches, Journal of Sports Sciences, 27:2, 159-168
    2. Siff,MC. (2003) Supertraining(6thEd).Denver,CO:Supertraining Institute
    3. Plisk,SS.Speed,agility,andspeed-endurancedevelopment. In: Baechle, TR, and Earle, RW (Eds.), Essentials of Strength Training and Conditioning (3rd Edition). Champaign IL: Human Kinetics; 457-485, 2008.
    4. Nummela, Rusko and Mero (1994). EMG activities and ground reaction forces during fatigued and non fatigued sprinting. Medicine and science in sports and exercise 22(2) 605-609
    5. Zink, Perry, Robertson, Roach and Signorile (2006). Peak power, Ground Reaction Forces and Velocity During the Squat Exercise Performed at Different Loads. Journal of Strength and Conditioning Research, 20(3), 658–664
    6. Spinks, Murphy, Spinks and Lockie (2007) The Effects of Resisted Sprint Training and Acceleration Performance and Kinematics in Soccer, Rugby Union and Australian Football Players Journal of Strength and Conditioning Research 21(1), 77-85
    7. Wisloff,U,Castagna,C,Helgerud,J,Jones,R,andHoff, J. Strong correlation of maximal squat strength with sprint performance and vertical jump height in elite soccer players. British Journal of Sports Medicine 38(3): 285-288, 2004.
    8. Markovic, Jukic, Milanovic and Metikos (2007) Effects of Sprint and Plyometric Trianing on Muscle Function and Athletic Performance Journal of Strength and Conditioning Research 21(2), 543-549.

    **************

    Emily Drakes, ACPSEM Physio

  • Blog - Using Strength and Conditioning in Physiotherapy by Emily Drakes

    Using strength and conditioning in Physiotherapy

    My interest in strength and conditioning started after watching an evening lecture from Raphael Brandon. I was intrigued by the theory behind exercise prescription and as physiotherapy seemed to be moving more and more towards exercise as the mainstay of treatment, as seen in the recent NICE guidelines for low back pain1, this seemed like the right path to follow.

    For those of you lucky enough to work with S&C coaches you will have them on hand to guide exercise prescription. However for most of us working in physiotherapy teams, having more of an S&C background can offer valuable insight into the best way to strengthen and prepare a patient for their activities whether that is a seasoned marathon runner or a stay at home parent with children to carry.

    It has been refreshing in learning about S&C to put injuries to one side and focus on the most effective way to plan an exercise programme. Many physiotherapist’s are preoccupied with making an exercise look like the movement or sport they are trying to rehabilitate their patient to i.e. giving a patient who plays football a ball to use in an exercise. However when if you break down the amount of time a footballer spends with a ball over 90mins it amounts to 90s2! The rest of the time is spent running, changing direction and jostling for the ball. Obviously a lot of the time a footballer is training involves a ball but unless you break it down in to the components of a skill you have no overload. This is what S&C essentially comes down to, ensuring specific adaptations to imposed demands. We need to understand the way a force is developed in the sport/activity we are interested in and in the exercise we are choosing to prescribe to get the desired outcome.

    There are some general principles that I now use daily that are key to exercise prescription. Firstly a needs analysis, which is something we all do to some extent but it formalises the process of deciding where a person is dysfunctional for the activity they are struggling with. This is outlined in the diagram below:

    Once you’ve specified the activity and what one would need to perform that successfully/pain free then you would look at the gap between the person in front of you vs. the ideal attributes they need. Once you know this targeting their exercise should be much easier.

    The needs analysis and the selection of exercises both incorporate the principle of dynamic correspondence described by Siff and Verkoshansky3. This is a guide on the different aspects of the activity to consider and how the exercise you are choosing will correlate to it.

    Unless you are doing the exercise itself i.e. kicking a ball you are not going to be 100% specific, however as discussed above in order to overload the components you need to break it down into parts. We will use the example of squatting and sprint ability in football:

    There are 5 key aspects to consider:

    Amplitude and direction of movement

    This is the most familiar principle in that we are looking at the direction of force relative to the performed movement.

    The squat does not look like a sprint however the lower limb movement of the hip, knee and ankle triple extension on the ascent on the squat is similar.

    The transmission of force from a flexed position to full extension in the squat is similar to the explosive action a footballer will need to perform when starting to sprint.

    Rate and time of peak force production

    The peak rate of force production of a footballer sprinting is within 100 – 200 ms4 and for a squat is 300ms5 therefore it may not be as fast as it needs to be, however you may choose to use a lighter load at performed at maximum speed to improve this. It has been seen that 40-50% of 1RM achieves peak velocity and power in a squat.

    Dynamics of effort (whether a concentric max effort or eccentric slow effort is desired for each lift)

    The training stimulus and effort needs to be greater than the sporting skill or activity we are training for, which in a heavy weighted squat certainly would be for sprinting over 30m. Peak power for the concentric phase of a squat is 4000W5 and for sprinting it’s 1200W4 in the propulsion phase.

    Accentuated region of force development (Joint angle specificity)

    The squat will yield a greater range of movement than the sprinting motion meaning that you are overloading the skill by creating greater strength in a larger range of movement. It has been seen that in football players accelerating the knee angle averages at 89 degrees6, which correlates well with a parallel squat (90 degrees).

    Regime of muscular work (Type of muscle action)

    For a squat the initial phase is eccentric action of the quadriceps and glutes then concentric extension on the ascent of the glutes, quadriceps and hamstrings. In a sprint the initial movement to overcome inertia is concentric which corresponds with the ascent phase of the squat. The top speed running of a footballer will involve the glutes, hamstrings and quadriceps moving from concentric to eccentric muscle action, as does the squat7.

    The greater power needed through the triple extension phase of the squat achieves greater motor recruitment which is thought to be one of the reasons a squat correlates so well with sprint speed in soccer players as the athlete is able to use more of the motor units to generate max speed8.

    This was a brief illustration of how strength and conditioning principles can be used to look deeper into the activity or sport you are looking to achieve with a patient. It has certainly highlighted to me over my degree so far that there is a lot more to train than what a movement looks like which can help you prepare your patient or athlete in a more well rounded way for their sport.

    References

    1. https://www.nice.org.uk/guidance/NG59
    1. Bradley, Sheldon, Wooster, Olsen, Boanas & Krustrup (2009) High-intensity running in English FA Premier League soccer matches, Journal of Sports Sciences, 27:2, 159-168
    2. Siff,MC. (2003) Supertraining(6thEd).Denver,CO:Supertraining Institute
    3. Plisk,SS.Speed,agility,andspeed-endurancedevelopment. In: Baechle, TR, and Earle, RW (Eds.), Essentials of Strength Training and Conditioning (3rd Edition). Champaign IL: Human Kinetics; 457-485, 2008.
    4. Nummela, Rusko and Mero (1994). EMG activities and ground reaction forces during fatigued and non fatigued sprinting. Medicine and science in sports and exercise 22(2) 605-609
    5. Zink, Perry, Robertson, Roach and Signorile (2006). Peak power, Ground Reaction Forces and Velocity During the Squat Exercise Performed at Different Loads. Journal of Strength and Conditioning Research, 20(3), 658–664
    6. Spinks, Murphy, Spinks and Lockie (2007) The Effects of Resisted Sprint Training and Acceleration Performance and Kinematics in Soccer, Rugby Union and Australian Football Players Journal of Strength and Conditioning Research 21(1), 77-85
    7. Wisloff,U,Castagna,C,Helgerud,J,Jones,R,andHoff, J. Strong correlation of maximal squat strength with sprint performance and vertical jump height in elite soccer players. British Journal of Sports Medicine 38(3): 285-288, 2004.
    8. Markovic, Jukic, Milanovic and Metikos (2007) Effects of Sprint and Plyometric Trianing on Muscle Function and Athletic Performance Journal of Strength and Conditioning Research 21(2), 543-549.
  • Alliance Medical Confirmed as Gold Exhibitor for The 2nd World Conference on Sports Physical Therapy - Optimal Loading in Sport.

    "Alliance Medical Diagnostic Imaging are delighted to be a gold exhibitor for The 2nd World Conference on Sports Physical Therapy- Optimal Loading in Sport, taking place at the iconic Titanic venue in Belfast 6th – 7th October 2017. We specialize in MRI, CT, PET CT, DXA, X-ray & Ultrasound scans. At Alliance Medical we are committed to delivering fast access to medical scans with high quality diagnostic care at affordable prices."

    Alliance Medical is Europe’s leading provider of outsourced Diagnostic Imaging across Europe. In Ireland, we are headquartered in Limerick and have 20 clinical locations throughout the country, including Dublin, Cork, Galway and Belfast.

    We invest heavily in our technology and our people to ensure we recruit, train and retain a highly qualified and competent team. Our radiographers are among the best specialists in Europe. Our radiologists are accredited by the Royal College of Surgeons in Ireland.

    Alliance Medical is committed to providing patients with high quality, efficient, affordable diagnostic imaging which is reported by local Consultant Radiologists. We partner with all of the leading Private Health insurance companies to deliver our services to your patients seamlessly.

    For more information on Alliance Medical visit http://www.alliancemedical.ie/

    For further information on ‘The 2nd World Conference on Sports Physical Therapy’ please click here

  • CSP Membership Review. URGENT Response needed

    Dear Members

    Please read the following documents Membership Review QA for Council FINAL - March 17,  MAR17 Paper 03 Membership Review with the highest priority and we strongly recommend you reply to Phil Hulse  hulsep@csp.org.uk  and Rob Yeldham via the CSP enquiries team with your comments regarding the proposed changes to CSP membership.

    In particular please note page 17 (Affliliated member regulations – 1.2 c ) and  Section 8.4 Affliiates and appendix E

    A few points to note:

    Confusion for the public e.g. Sports therapists documenting they are a member of the CSP

    Why only name massage therapists and sports therapist and not any other healthcare professional?

    Physiotherapy managers who are not physios being able to join

    Page 7 diluting of profession, confusing the public, allowing an affiliate category

    Confusion within the members for voting rights

    Cost implication and money generation

    Thank you

    ACPSEM Committee

  • ACPSEM Victims of Fraud

    Dear Colleagues,

    We are writing to you to bring your attention to fraudulent activity with regard to the Association of Chartered Physiotherapist in Sport and Exercise Medicine (ACPSEM) / Physios in Sport association. It has been brought to our attention that someone calling himself Michael Darlington has been contacting sports persons and football club through social media in order to conduct research. The request is to provide pictures of the athlete’s legs and feet and completing a short online survey. A letter endorsed by the Physios in sport or ACPSEM and allegedly sent from our Events and Partnerships Officer Liz Olsen accompanies the request. There are also promises financial remuneration if the survey is completed.
    This individual is not in any way associated and their activity is in no way endorsed or supported by the ACPSEM. In addition, this action goes against the morals and ethics that the research community uphold potentially damaging the relationship between Sport persons and Researchers.

    We are unsure of the motives behind this activity but request that you report any contact from this individual or similar request for research information to ourselves by emailing Liz Olsen at info@physiosinsport.org This fraudulent activity has also been reported to the National Fraud Intelligence Bureau via Action Fraud.

    We would be very grateful if you could circulate this information to any contacts you have with any sports teams or athletes that may be contacted so that we limit this activity.

    Thank for your co-operation
    Tim Sharp
    Education and Research Chair for ACPSEM

  • ACPSEM Research Grants

    The ACPSEM will shortly be releasing funds for small research grants to support research in the area of Sport and Rehabilitation.

    Main aim of the grant

    The main purpose of the grant is to provide specific CPD opportunities, such as post-graduation courses or to contribute to an MSc or to provide support for specific activities such as providing conference and travel expenses to present research. The grant is to support the CPD development plan of the individual. The grant is not to provide any form of required training such as First Aid / Sports Trauma courses.

    Who is the grant aimed at?

    Applications are open to qualified Chartered Physiotherapist and a member of the ACPSEM. It is not necessary that the individual works in sport however the grant application should demonstrate how this would develop their career in sport.

    Level of funding.

    The level of funding is up to a maximum of £1000. Applications are required to justify the level of funding by detailing the expected expenditure.

    Expectations of the ACPSEM.

    The ACPSEM would request acknowledgement of support for any research undertaken or presented that comes as a result of this grant. Individuals may also be asked to provide feedback to Committee in order to either promote the ACPSEM activity or to advertise further grants.

    More details for this grant will be made through the website shortly

  • Interested in joining the ACPSEM Education and Research Committee?

    The ACPSEM would like to invite expressions of interest in joining the education and research committee of the ACPSEM. The role would involve working with the current Education and Research chair in continuing to support the current short courses run by the ACPSEM, developing appropriate short courses, supporting the organisation of conferences and study days within the remit of the organisation. It is also expected that there will be a role in supporting and developing the current ACPSEM CPD pathway.

    Applications should be made in writing and should contain the following a CV and a short supporting letter (no more than 1 page of A4).

    The supporting letter should highlight your education and research experience especially toward Sports Physio including contribution to ACPSEM. Outline what you think that you can bring to the role in relation to your experience and what you believe is the priority or development need for the ACPSEM Education Committee.

    Applications should be emailed to Liz Olsen info@physiosinsport.org by Jan 30th 2017.

  • Stephen Mutch Appointed as New ACPSEM Chair

    Stephen Mutch has been appointed as the new ACPSEM Chair taking over from Colin Patterson.

    We'd like to take this opportunity to thank Colin and welcome Stephen.

    Stephen Mutch Biography

    Stephen graduated with a Physiotherapy BSc from Queens College, Glasgow and MSc (Sports Physiotherapy) from University College London. His first physio positions were in the North West of England (NHS) and in Auckland(NZ) before signing up to full-time professional sport with Scottish Rugby from 1998 to 2007 RWC, working as 7s physio from 1999-2006 in addition to consultancy work with the Scottish Institute of Sport from its inception.

    Stephen will be Head of Physiotherapy for Scotland at the Commonwealth Games in 2018 in Gold Coast. He has worked as HQ/Lead Physiotherapist to a number of sports at multi-event Games, such as Team Scotland at Commonwealth Games in 2002, 2006, 2010, 2014 (also Deputy Head of Team) and the Youth Games of 2000, 2008 (co-Physio Head), World University Games (GB) 2009, 2015, 2017 (Head Physio) plus the gold medal-winning Australian Womens’ Water Polo Commonwealth team of 2002. He was amongst the physical therapies staff at the polyclinic within the Athletes’ Village in the Summer Olympics in London 2012.

    As well as being Clinical Director at a private practice in Edinburgh, Stephen continues to work as a clinician in various elite-level sports, in addition to working with the Scotland National Rugby Team during competitions such as 6 Nations Championships and World Cups (2007, 2011 & 2015).

    Stephen is actively involved in PhD research into Return to Sport, and as co-author of papers & texts into Return to Play plus sport and movement. He enjoys speaking engagements across the world, including various coach education experiences with sportscotland, Glasgow City Council and Pro Performance Rugby.

  • Blog - AchillesAl part 3 pyschosocial considerations in achilles pain by Tom Goom

    Blog - AchillesAl part 3 pyschosocial considerations in achilles pain - by Tom Goom

    http://blogs.bmj.com/bjsm/2016/12/07/achillesal-part-3-pyschosocial-considerations-achilles-pain 

    After a short hiatus we're back with #AchillesAl part 3. We've touched upon training error and how to modify training to find the right level in parts 1 and 2. Next we have a couple of tricky questions from Al and have to consider the psychosocial factors in tendon pain...

    “Will continuing to run damage my tendon?”

    “Is it likely to lead to a rupture?”

    We had some great discussion of this on social media, check out the hashtag #AchillesAl and once again we invite you to tweet along and share you thoughts on this blog with @BJSM_BMJ and @Physiosinsport. @SportsTherapy56 was on fine form again sharing some great recent tendon research, follow his thread here.

    I think it's fair to say the focus in tendinopathy research to date has mainly been on building load capacity and on the tendon itself. The role of psychosocial factors such as thoughts, feelings and beliefs around pain are discussed less often despite evidence of their importance in sports injury (Forsdyke et al. 2016). This is beginning to change though with a new systematic review just published in BJSM from Adrian Mallows and colleagues - Mallows et al. (2016). In addition, this excellent review of patellar tendinopathy from Malliaras et al. (2015) covers both psychosocial factors and central sensitisation.

    Adrian has kindly shared some insights from his recent research;

    "The findings of the review suggest that taken as a whole, there is conflicting evidence as to the significance of psychological variables in tendinopathy. However, specific psychological variables may be associated with tendinopathy and suboptimal outcomes from treatment. Conflicting evidence exists surrounding the significance of the association of anxiety, depression and lateral epicondylalgia. However, strong evidence suggests lateral epicondylalgia is not associated with kinesiophobia. Moderate evidence links catastrophisation and distress with lateral epicondylalgia, with distress being associated with a less than 50% reduction in pain at twelve months. Conflictingly, moderate evidence suggests distress is not associated with rotator cuff tendinopathy, but kinesiophobia and catastrophisation are. However, this may not lead to a suboptimal outcome. Limited evidence exists linking psychological variables and Achilles tendinopathy and patella tendinopathy, but current evidence suggests patella tendinopathy is not associated with anxiety or depression and kinesiophobia may be linked with suboptimal outcomes in Achilles tendinopathy.

    Being aware that psychological variables may be associated with tendinopathy could assist the clinician in optimising management by utilising strategies to help overcome or reduce their influence. This may be particularly important when considering more invasive procedures such as surgery, as they are associated with negatively influencing outcomes (Brand and Nyland 2009, Cobo Soriano et al. 2010, Judge et al. 2012). As such, when a person is suspected to have tendinopathy, clinicians should firstly consider using validated screening tools for the presence of psychological variables. Secondly, although future testing by research is required, adopting an individualised management approach which aims to influence hope and positive beliefs (Benedetti et al. 2013) places emphasis on neuroscience education (Louw et al. 2011) or addresses individual cognitive behavioural barriers (Vibe Fersum et al. 2013) whilst maximising working alliance (Ferreira et al. 2012, Fuentes et al. 2014, Hall et al. 2010) are all plausible strategies to adopt in conjunction with a graded loaded programme (Littlewood et al. 2015, Malliaras et al. 2013)"

    Follow Adrian on Twitter via @ajmallows1

    In a clinical setting concern about damaging or rupturing the tendon appears quite common and emerging research suggests it may be a barrier to rehab. We've developed TendonQ, a questionnaire to help screen for factors that might influence tendon health and response to rehab. Many patients, especially with longstanding symptoms, reveal regular concerns about tendon damage, so Al is not alone in this!

    Before we try to answer Al's questions it might help to find out a little more about Al's beliefs about his pain...

    PT, "What do you think is happening within your tendon to make it painful?"

    Al, "I've read that the tendon develops micro-ruptures that build up over time and these cause pain. If you keep running eventually this can lead to the tendon rupturing altogether."

    Beliefs like Al's above aren't that unusual. Sometimes we can even add to them! In insertional tendinopathy clinicians often recommend that people avoid activity that compresses the tendon. This may be sensible initially but can lead to long term patterns of avoidance if patients see these activities as damaging to the tendon. Choose your words carefully!

    A positive perception of return to sport is associated with a greater likelihood of returning to your pre-injury level (Ardern et al. 2013) and confidence in the injured area can be an important part of that. It's hard to have confidence and a positive perception if you see exercise as damaging. It may also increase perceived threat which could influence symptoms.

    Perhaps a more positive message would be something like this,

    PT, "Tendons are amazing, adaptive tissue. They get stronger with exercise a little bit like muscle does so regular exercise can reduce the risk of rupture rather than increase it. They tend to hurt not because of micro-ruptures or damage as such but simply because they've been overworked. Looking back at your training we can see that the achilles load has increased quite quickly. The tendon reacts to this with swelling and discomfort but this settles once the excess load is reduced."

    Al, "So running won't damage the tendon, providing I don't do too much?"

    PT, "That's right. We've modified your training to a level which should help encourage your tendon to adapt. We can then build up gradually towards your marathon. The tendon thrives with consistent exercise, it struggles if we fluctuate too much, both with big increases AND decreases in activity."

    There's a good example of this final point from the NFL in 2011. An enforced 'lockout' prevented the usual 14 week pre-season training and instead resulted in a period of relative inactivity followed by an intensive training camp to prepare for the season in just 17 days! The results are startling - pre-season achilles tendon ruptures increased 4 fold! Approximately 8 achilles tendon ruptures might be expected in an entire season, in 2011 there were 10 within the first 12 days of training!

    Putting this into a simple, positive message for Al, "It's better for the tendon to keep running at a manageable level and loading the tendon than to stop altogether and start again."

    Every patient will require a different approach to discussing pain and re-framing the injury in a more positive light. Some may become fear-avoidant or concerned about long term implications. It isn't unusual for some patients to have tried multiple treatment approaches without success. Understandably they can become despondent and deserve our support and empathy. The Pain Catastrophising Scale (PCS) can be a useful assessment tool in those with prolonged or severe symptoms. It helps to appraise a patient's view of their symptoms and the impact they're having on their life. Higher PCS scores (typically >30) may indicate a clinically relevant level of catastrophising and suggest treatment focuses more on pain education and self-management at least until this improves.

    A pain monitoring approach is favoured in management of tendinopathy (as discussed in part 2) using a pain score out of 10 during activity and assessing symptom response over the following 24 - 48 hours. Such an approach can be very helpful in guiding a gradual progression of tendon loading, however, psychosocial factors may influence pain scores and symptom response. Recent work in DOMS (Delayed Onset Muscle Soreness) suggest that an athlete’s fear avoidance beliefs and trait anxiety before injury may influence reports of their pain intensity after exercise. Might we see a similar impact in tendinopathy? If so what would be the implications for how we use the pain monitoring system in those with evidence of fear avoidance and negative beliefs about pain? Share your thoughts on #AchillesAl.

    Patient's expectations and our own can be important part of tendon rehab. In particular understanding the timescales involved is key. For the patient, so they can expect 3 to 6 months of rehab, and for us so we don't abandon a loading programme when we don't seen changes in a couple of sessions.

    Stress and lifestyle

    Stress can delay healing (Alford 2006) and impair response to resistance training (Bartholomew et al. 2008). When building strength and load capacity is such a central part to tendon rehab stress could represent a significant barrier.

    Chatting to Al about his general health we ask, "How are your stress levels?"

    "Not good!" He replies, and explains that he works long hours, gets very little 'downtime' to recover, and isn't sleeping well. He runs his own IT business and says it feels like he's 'constantly working' (sound familiar?!). He uses coffee and sugary snacks to keep him awake during the day only to find he's then wide awake at night! The dreaded, 'caffeine cycle' (courtesy of @Twisteddoodles)...

    Al's has been coping like this for quite some time and the upshot is he now has hypertension and raised cholesterol alongside more stress as he struggles to get by on 5 or 6 hours sleep a night. He uses the running to help manage this stress (and lower his cholesterol) which adds a further level of complexity to his desire to continue running. A purely practical consideration too with such a lifestyle is how will Al fit any rehab in? This may well have an impact on our exercise selection, when we come to it.

    These lifestyle factors may have a very direct link on Al's tendon health. Hypertension has been associated with tendon pain (Abate et al. 2009) and raised cholesterol is thought to impair type I collagen production and reduce tendon strength and energy storage capacity (Scott et al. 2014). Less is known about diet although a diet rich in saturated fat causes significant tendon metabolic and structural alterations in mice (Scott and Nordic 2016).

    Stress and lifestyle may well then influence pain, rehab and response to treatment. This highlights how a very tendon focussed approach may miss the important bigger picture in tendinopathy.

    What we don't know yet is how much of an impact these factors have on symptoms and function in tendinopathy. Equally though it isn't always clear from the research what role biomechanics, muscle strength, flexibility and movement control have in pain. The challenge is to identify which factors are key for each individual patient.

    A fascinating study in the Israeli Army reported that sleep can have a significant role in injury prevention (Finestone and Milgrom 2008). Combining a minimal sleep duration of 6 hours per night with a modified training regime helped reduce stress fracture incidence from 31% to less than 10%. This mirrors what we might aim to do in tendinopathy - identify relevant psychosocial factors and address them alongside addressing tissue load and load capacity. Further research is required however to determine the effects of sleep, lifestyle and psychosocial factors on symptoms and outcomes in painful tendinopathy.

    These issues raises some interesting questions too and we'd love to hear your thoughts on this;

    What is our role in addressing lifestyle factors including mental health? Are we equipped to do this?

    Share your views on #AchillesAl.

    Hopefully our discussion with Al with have reassured him that exercise has a positive effect on tendon health but we want to ensure this message is understood. Asking open questions like, "how might you describe what's happened to your tendon to a friend?" Or "what key points have you taken from today's session?" Might help clarify if we've helped change Al's beliefs.

    It may not be within our role to advise on mental health and diet in detail but we can act as a signpost towards the right services and resources such as suggesting Al speaks to his GP or counsellor about his stress or contacts a dietician regarding diet. Free online resources such as the mental health foundation website can be a great help, they also produce a free download to improve sleep.

    Sometimes suggesting a subtle attitude change can help, one that moves away from self admonishment and criticism towards self care for both physical and mental wellbeing;

    We have to recognise our limitations here though and, ideally, work together for the patient within an integrated multi-disciplinary team wherever indicated.

    In part 4 we'll be discussing exercise selection for Al's achilles. Until then we'd love to hear your thoughts on some of the questions and issues raised in this piece. Join the discussion on #AchillesAl all views welcome!

  • PHYSIOLAB® announced as Gold Partner for ACPSEM Optimal Loading in Sport Conference

    physiolab-technologies-logo-whitebackground

    PHYSIOLAB® announced as Gold Partner for ACPSEM Conference

    PHYSIOLAB® has been announced as the Gold Partner at ACPSEM’s World Conference of Sports Physical Therapy, which takes place in Belfast from 6th to 7th October 2017.

    Simon Withey, CEO at PHYSIOLAB®, commented: “At PHYSIOLAB® our mission is to make the intangible tangible by developing innovative technology for use during performance, recovery and repair. By working with physiotherapists and medical professionals we have developed a toolkit for delivering thermal energy and compression to the body with maximum efficiency. The application of pressure, warming and cooling is commonly used but never with any real precision.  It is vital to change this ‘no control’ approach. By continuing our relationship with key organisations such as ACPSEM, and maintaining conversations with its members, we can further develop knowledge and skills creating products and programmes which exceed their expectations.”

    PHYSIOLAB® specialises in human performance equipment.  Its machines deliver clinically effective compression and contrast therapies including cryotherapy (cooling) and thermotherapy (warming).

    By using cooling, heating and compression combined or separately, PHYSIOLAB® delivers a precise, targeted, repeatable and clinically effective treatment which genuinely maximises the body’s ability to recover.  This level of precision and repeatability has simply never been possible before.

    As experts in human performance equipment PHYSIOLAB’s ® innovative design overcomes the limitations of existing technologies, driving clinical practice forward to create clarity.

    For further information visit www.physiolab.com

    ENDS.

    Editor’s notes:

    PHYSIOLAB® is the world’s leading developer of products that deliver clinically effective compression and contrast therapies including cryotherapy (cooling) and thermotherapy (warming).  Its intelligent thermal compression unit maximises the body’s performance, supporting injury recovery using precise and targeted treatments.  As experts in human performance equipment PHYSIOLAB’s ® innovative design overcomes the limitations of existing technologies, driving clinical practice forward to create clarity.

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