News

  • ACPSEM Soft Tissue Techniques - Blog by @vikki_mills80 and @physiofaith

    The ACPSEM hosted a 2 part soft tissue techniques course aimed at practicing clinicians in sports medicine to equip them with the hands on skills necessary for soft tissue management.  The course was held over 2 weekends, 6 weeks apart with completion of all 4 days which included the submission of a case study.

    There are many schools of thought emerging in sports and exercise medicine which question the use of what is often termed ‘hands on’ physiotherapy, specifically massage or soft tissue mobilisation. As physiotherapists working in elite sports settings, the thought of completing a day with-out utilising ‘hands on’ techniques in some capacity is for us, impossible to imagine, let alone our athletes. However, despite being an integral part of our day to day routines, could either of us recall ever having any formal training on ‘massage’? The answer was no!

    We highlight several examples of how this has changed our practice and thought processes to justify the use of massage as part of our clinical tool kit.

    Evidence base

    During the course we explored the evidence base behind sports massage, and discussed the justifications we articulated to our clients. It became quickly apparent that we were missing several fundamental reasons for using massage, with most attendees noting blood flow improvement as the main justification. We were exposed to many other reasons, including the positive impact of wellbeing, biomechanical, physiological, neurological and psychological effects (Moraska 2007).

    Practical skills

    The content of this course was highly practical, allowing us to develop our techniques and gain feedback from both tutors and peers. Evidence has suggested that differences in practitioners’ proficiency affect the effectiveness of massage (Donozama et al 2010). Therefore, handling and optimising patient position was fundamental to the effectiveness of not only the treatment but the wellbeing and comfort of the therapist.

    Technical skills gained included a detailed breakdown of individual massage technique in part 1, with further study and practice of more advanced skills involving tool assisted soft tissue release techniques, cupping and myofascial release in part 2. Development of massage techniques and application over the entire 4 days addressed specific soft tissue dysfunction, which included muscular imbalances, trigger point development and altered motor patterns.

    Lecturers

    To host a course for 4 days to teach fundamental skills to clinicians already practicing in the sporting environment is no easy feat, yet Colin Paterson and Ros Cooke managed to pull this off. Their knowledge, skills and experience in addition to their enthusiasm made for an engaging and enjoyable learning experience.

    For any clinician embarking on the ACPSEM CPD pathway it is compulsory that they undertake and evidence post graduate training in massage. This course provides an opportunity for any practicing clinician to challenge their current knowledge and practice. The theory and content challenged thoughts, beliefs and existing skills. We now feel better equipped to justify, articulate and carry out soft tissue techniques as a treatment modality.

    Vikki Mills BSc (HONS) MCSP HCPC ACPSEM AACP

    Vikki has been a charted physiotherapist for 15 years working in both the private and elite sport setting. Vikki divides her clinical practice between Leeds United Academy and community MSK services. Her clinical interests include paediatric lower limb biomechanics and growth related pathology.

    @vikki_mills80

    Faith Fisher-Atack BSc (HONS) MCSP HCPC ACPSEM ACPAT

    Faith is a chartered Human and Veterinary Physiotherapist and clinical director of Equine Physio Services, a physiotherapy practice specialising in equine and rider biomechanics and performance. Former Head of Sports Science and Medicine at Leeds United Academy.

    @physiofaith

    References:

    Donozama N, Shibasaki M (2010) Differences in practitioners' proficiency affect the effectiveness of massage therapy on physical and psychological states.
    Journal of bodywork and movement therapists. Volume 14 issue 3 July 2010 pages 238-245

    Moraska A (2007) Therapist education impacts the massage effect on post-race muscle recovery. Medicine and science in sport and exercise

  • 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.
  • 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!

  • Blog - Bike Fitting – An Introduction for Physiotherapists by Bianca Broadbent

    by Bianca Broadbent, @Thecyclingphys is a @physiokinetic and Bikefitter@fityourbikeuk

    bike-fit-002

    Bike Fitting – An Introduction for Physiotherapists

    A proper bicycle fit is essential for comfort, injury prevention, and performance. It optimises power output, aerobic efficiency, aerodynamics, sustainability for the target event duration and helps to avoid injury (Silberman et al. 2005).   Cyclists average between 80-100 pedal revolutions per minute, which equates to around 5400 revolutions per hour.  With cyclists riding anything from a few hours per week as a leisure ride, through to competitive age group cyclists doing 15-20 hours or professional riders doing 30-40hours per week, over the course of a season any asymmetries or mal-alignments can easily result in injuries and discomfort.

    A combination of high training volume and mal-alignment is indicated as an anatomic risk factor for overuse injury (Ahonen 2008, Fousekis et al. 2010, Krivickas 1997).  However, quantification of the contribution of asymmetric intrinsic and extrinsic factors to a dose response relationship within musculo-skeletal loading is problematic, as norm values do not allude to the epidemiology of asymmetry.  The introduction of technology to the bike fitting process through 3D kinematics is starting to produce this database of knowledge.

    Use of technology to drive the decision making within bike fitting is a relatively new phenomenon within the cycling world, and has become more popular recently with bike mechanics, coaches, physios, and other health care professionals getting on board. However there is the risk of commercial bias, where companies will use the fitting tools to push their latest products, but does not always identify the most appropriate product for the consumer and their specific injury or complaint.

    So what actually is a bike fit?  Bicycle fitting methods can broadly be categorised into static (measurements taken at rest) and dynamic (measurements taken while riding).  Looking at several sources it can be defined as a “harmonisation between the rider and the bicycle, based on their goals, injuries and physical capabilities”.

    Market leading companies are Specialized, Retül (which now comes under specialized), with alternative approaches including Bikefit.com, Apex, Torke, and Gebiomized which also offer pressure assessment for saddles, feet and handlebars.

    Like all tools and techniques it is the operator rather than the software who needs to make the fit decisions and the clinical reasoning skills of an experienced clinician are essential when dealing with a multifactorial presentation.

    As the whole experience of a bike fit is highly complex, it would be beneficial for us to speak about some current trends and how you might utilise these with your current clients.

    There are three contact points a rider has with the bicycle; shoe-cleat-pedal interface, pelvis-saddle interface, and hands-handlebar interface.

    image1-004A new theoretical model of factors associated with functional asymmetry in cycling sports

    NB: Trialing should be trialling and convensitional should be conventional

    The cleats

    There are many cleat systems available, Speedplay, Look, Shimano and others, which all offer varying degrees of adjustment, rotation, shimming and wedging. Certainly research seems to suggest allowing cleat float can reduce the incidence of knee pain (Gregor and Wheeler 1994).

    There are also many studies linking a poor cleat set up with iliotibial band syndrome (Farrell, Reisinger and Tillman 2003), anterior knee pain (Asplund and St Pierre 2004), and foot disorders e.g. paraesthesia and “hot foot”.

    Historically the cleat was positioned so that the first metatarsal head lies directly over the pedal axle, however more recently this idea has changed to suggest that positioning the pedal axle beneath the third metatarsal head allows a more efficient transfer of power.

    If the rider has a leg length discrepancy then the shoe-pedal interface can be adjusted by inserting a shim between the shoe and the cleat or by having a custom orthotic insole manufactured.   It has been suggested that anything greater than 6mm is considered significant and needs correcting (Silberman et al. 2005) although some athletes may not be able to tolerate a difference of 3mm (Baker 2000).   If a rider has a leg length discrepancy then up to half the difference should be corrected.  Any excessive malalignment of the lower extremity, such as forefoot varus or overpronation, can be corrected with the use of canted shims or wedges (Sanderson 1990).

    The saddle

    specialized-women-s-oura-pro-saddle-ev180911-9999-1-002

    A common and under reported phenomenon amongst cyclists is numbness (Leibovitch and Mor 2005). This can present complexly, or be resolved by means of simply correcting the bike fit – evidence suggests looking at saddle height (too high and forwards), saddle shape (cut out and removing the long nose) and maintaining an upright position (Lowe et al 2004) beneficial for reducing pressure on the perineum.

    ISM, Cobb, Rido and Specialized are all leaders in providing ergonomic and carefully thought out saddles, but products can also be limited by many fit systems which place clients into “neutral fits”. As a result the saddle may be the “perfect” height for pedalling, but not for other complaints which they may have.

    The cranks

    A great deal of research has been conducted to discuss the physiological effects of crank length, but there has been less investigation of outcomes relating to running shorter crank on cyclists with hip, knee and ankle pathologies. Reducing crank length in these clients, does, however, seem logical. Anecdotally I can report great success from switching those struggling with a closed hip angle to shorter cranks e.g. labral pathology, FAI, arthritic hips, but commercially you will struggle to obtain anything shorter than 165mm. Research does not appear to show shortening the cranks adversely affects power (Tomas, Ross & Martin 2010) and it may help with rapid acceleration in some situations (Macdermid and Edwards 2009).

    Bianca Broadbent MCSP ACPSEM

    Physiotherapist at Physiokinetic, Spire & Fit Your Bike

    bianca@fityourbike.co.uk

    www.physiokinetic.co.uk

    www.spirehealthcare.com/littleaston/physiotherapy-at-spire-little-aston-hospital

    www.fityourbike.co.uk

    With extra special thanks to:

    Tim Pigott MCSP ACPSEM

    Physiotherapist – Athlete Matters / Preston Physiotherapy & Sports Injuries Clinic

    Academic lead – Clinical Biomechanics Salford University

    www.hp-3.co.uk

    info@hp-3.co.uk

    Useful Links

    Specialized BG http://www.specializedconceptstore.co.uk/body-geometry-fit/

    Trek http://www.trekmk.com/bike-fitting/

    Apex http://www.apexbikeperformance.com/

    Torke https://torkecycling.com/

    Bikefit.com http://bikefit.com/

    Cyclefit http://cyclefit.co.uk/

    Retul www.retul.com

    Medicine of Cycling Research Library - http://www.medicineofcycling.com/research/

    References

    GREGOR, R. & WHEELER, JB. (1994) Biomechanical Factors Associated with Shoe/Pedal Interfaces. Sports Medicine, Volume 17, Issue 2, pg 117–131

    FARREL, K. REISINGER, K. & TILMAN, M. (2003) Force and Repetition in Cycling: Possible Implications for Iliotibial Band Friction Syndrome. The Knee, Volume 10, Issue 1, pg 103-109

    ASPLUND, C & ST. PIERRE, P. (2004) Knee Pain and Bicycling – Fitting Concepts for Clinicians. The Physician and Sports Medicine, Volume 32, Issue 4

    LEIBOVITCH, I. & MOR, Y. (2005) The Vicious Cycling: Bicycling Related Urogenital Disorders. Eur Urol, Volume 47, Issue 3, Pg 277-286

    LOWE, B. SCHRADER, S. & BREITENSTEIN, M. (2004) Effect of Bicycle Saddle Designs on the Pressure to the Perineum of the Bicyclist. American College of Sports Medidine, Pg 1055-1062

    TOMAS, A. ROSS, E. & MARTIN, J. (2010) Fatigue During Maximal Sprint Cycling: Unique Role of Cumulative Contraction Cycles. Medicine and Science in Sports and Exercise, Volume 42, Issue 7, pg 1364-1369

    MACDERMID, P. & EDWARDS, A. (2009) Influence of Crank Length on Cycle Ergonometry Performance of Well Trained Female Cross Country Mountain Bike Athletes. European Journal of Applied Physiology, Volume 108

    AHONEN, J. (2008) Biomechanics of the foot in dance. Journal of Dance Medicine & Science 12:3 99-109

    FOUSEKIS, J. TSEPSIS, K. & VAGENAS, G. (2010) Multivariate Isokinetic Strength Asymmetries of the Knee and Ankle in Professional Soccer Players.  Sports Medicine and Physical Fitness. Volume 50, Issue 4, Pg 465-474

    KRIVICKAS, L. (1997) Anatomical Factors Associated With Overuse Sports Injuries. Sports Medicine Volume 24, Issue 2, Pg 132-146

    SILBERMAN, M. WEBNER, D, COLLINA, S. & SHIPLE, B. (2005) Road Bicycle Fit.  Clinical Journal of Sports Medicine. Volume 15, Issue 4, Pg 271-276

    BAKER, A.  (2000) Medical problems in road cycling.  In Gregor RJ, Conconi F, eds. Road Cycling, Oxford, UK. Blackwell Sciences Ltd, Pg 68-120

    SANDERSON, D. (1990) The Biomechanics of Cycling Shoes. Cycling science. Pg 17-30.

     

  • Blog - The International Sports Physical Therapy Specialist: reflections on the UK situation (what we may take for granted) by Colin Patterson

    The International Sports Physical Therapy Specialist: reflections on the UK situation (what we may take for granted)

    16 Sep, 16 | by BJSM

    Association of Chartered Physiotherapists in Sport and Exercise Medicine blog series @PhysiosinSport

    By Colin Paterson ,MSc PGCert (Ed) MCSP SFHEA RISPT

    I recently presented at the Japanese Physical Therapy Congress in Saporro on the development of the International Federation of Sports Physical Therapy (IFSPT) competencies. Specifically, how we use them in the UK in relation to our Continuous Professional Development (CPD) pathway. I met with a variety of sports physical therapists in Japan, national committee members, the Lead Physical Therapist for TOCOG/Tokyo 2020 games to share knowledge and learn more about the professional context in Japan. These experiences spurred me to reflect on the specialty in the UK. Notably, the status and skill level of the profession and opportunities that exist in the UK- that others may take for granted.

    Selfie at the top of the ski jump used for the Winter Olympics in Saporro 1972.

    At the top of the ski jump used for the Winter Olympics in Saporro 1972.

    Broad and enriching scope of practice

    In the UK, physiotherapists are autonomous, first contact health care professionals able to work in a number of environments: hospitals, private clinics, the community and the sports field. With extending skills and scope of practice, physiotherapists with appropriate training adopt skills and roles previously only undertaken by doctors. In sport these skills and experiences continually grow and develop. Sports physiotherapists work at all levels from aiding the patient with a chronic long term condition to exercise, to recreational weekend warrior athletes, to high level elite athletes. In the UK they are the ‘go to’ practitioner for sports injury management advice, rehabilitation and advice to optimise sporting performance unlike other countries where athletic trainers have a greater presence.

    This scope of practice isn’t the case in other countries where physical therapists are not always licensed to be a first contact practitioner, or work pitch side. They may not be able to use advanced skills or perform the trauma management role. UK sports (and exercise medicine) physiotherapists must not take this for granted. They must maintain the high reputation of the profession. Experienced physiotherapists also need to ensure a legacy by supporting new physiotherapists to work within the specialty to maintain its strong presence and reputation.

    Organizational support networks

    The UK sports Physiotherapy group, the Association of Chartered Physiotherapists in Sports and Exercise Medicine (ACPSEM), has always maintained strong UK links with other sporting bodies and also internationally with IFSPT and WFATT (athletic training group). This facilitates UK physios involvement in discussions, debates and information exchange – positioning us well to influence and implement best practice. The ACPSEM/UK was one of the first countries worldwide to have a sports physiotherapy CPD pathway based on the IFSPT competencies (IFSPT 2016. See Figure 1) when they were developed in 2004 (Bulley et al 2004). Only 8 countries now have an approved pathway for members to call themselves a Registered International Sports Physical Therapists, again something we shouldn’t take for granted in the UK.

    ifst-graph

    Figure 1. IFSPT Competencies.

    Part of my trip to Japan was to provide support and advice on their preliminary discussions about developing their own specialty pathway. The build up to the 2020 Olympic Games are motivation and an opportunity to negotiate change. The IFSPT sees mentoring and support, on an individual or wider scale as an important element of developing the specialty worldwide. The IFSPT competencies underscore the skills and knowledge required to be a sports physical therapist. They also promote what the profession can offer (by and for individuals, educators, and employers) and guide development. The journey from being a novice to expert requires more than years of experience. Research highlights the need for the development of critical reflection skills, deliberate action/practice, organised and varied knowledge, and having a patient centred focus (Paterson and Chapman 2013. Higgs et al 2008. Jensen et al 2006. Edwards and Jones 2007). When did you last look at the competency document and reflect on your skills and development?!

    Standing on the shoulders of giants

    Personally I would like to thank all those sports physiotherapists who have impacted me, mentored me and provided me with opportunities to develop and learn. I am not sure I have thanked them enough. Have you thanked your mentors? UK sports physiotherapists must thank the work of the current ACPSEM committee and also all those members of previous executive and regional committees who have put in the hours to develop and provide the opportunities that currently exist for sports physiotherapists. The status we have as a profession and Physiotherapy specialty is taken for granted by some, but it has been earned.

    Still, there is always more to be done and developed.

    Reflecting back and aspiring forward

    I will finish by asking you to take a moment to reflect on your career to date; how have you got to where you are? What/who are your influencers? Are you providing opportunities for others? Can you call yourself a registered international sports physical therapist?

    We all have a role to play in maintaining the strong reputation and skill level of sports physiotherapists in the UK and globally. This involves promoting what we can offer and looking to make developments where appropriate. What capacity do you have to contribute? I will leave you with one last question to reflect on: do you take the sports physiotherapy specialism for granted?

    References

    Bulley, C., Donaghy, M., Coppoolse, R., et al (2004) Sports Physiotherapy Competencies and Standards. Sports Physiotherapy for All Project.(online) available at http://ifspt.org/wp-content/uploads/2012/04/SPTCompetenciesStandards-final-draft.pdf (accessed 07.07.16)

    Edwards, I and Jones MA 2007 Clinical reasoning and expert practice. In: Jensen GM, Gwyer J, Hack LM, Shepard KF 2007 Expertise in PhysicalTherapy Practice,2nd edition.

    Higgs, J., Jones, M.A., Loftus, S and Christensen, N 2008. Clinical Reasoning in the Health Professions. 3rd Edition. London. Butterworth Heinemann

    IFSPT 2016 www.ifspt.org (accessed 27.7.16)

    Jensen, G.M., Gwyer, J., and Hack, J 2006. Expertise in Physical Therapy Practice. 2ndEd. Elsevier, St Louis

    Paterson, C and Chapman, J 2013. Enhancing skills of critical reflection to evidence learning in professional practice. Physical Therapy in Sport. 14(3); 133-138

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

    By Colin Paterson MSc PGCert(Ed) MCSP SFHEA RISPT, Senior Lecturer (Physiotherapy) Brighton University. UK, Member of the IFSPT Registration Board. Chair of the ACPSEM UK

  • IJSPT log in changes

    Feb 2016

    IJSPT has moved to a new platform and the way in which ACPSEM members log in has changed.

    Use UKPT_ followed by your membership number for both the username and password

    eg UKPT_1111

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