We actually published this blog post earlier this month (Apr 13), obviously before the tragic events of the Boston Marathon this past Sunday. With the London Marathon looming this Sunday, have the events of the Boston Marathon affected your views on volunteering? Please read on and give us your thoughts.
We know that physical therapy is – in and of itself – good for people. What is perhaps sometimes overlooked, though, is where this care is put to use in a voluntary capacity – doubling the goodness factor. There are several types of this sort of activity.
Firstly, there’s the voluntary support at sporting events. Hundreds of therapists volunteer at the London Marathon every year, and 1,500 volunteer physical therapists and medics from across the globe volunteered at London 2012 (some of them making many additional sacrifices!). This commitment runs through all levels of sporting event across the world, all year round.
Beyond that, the physical therapy and sports medicine sector often displays a deep commitment to community fundraising. From collecting shoes for charity to donating money to local food banks for each patient who completes a cycle of care to organising charity fundraising sporting events, physical therapists are nothing if not inventive about how they can broaden their support for the communities in which they live and work. Some take it even further – leading some physical therapy institutions to establish volunteering programmes to partner with charities working in local communities facing disadvantage.
While many humanitarian or disaster projects focus on food and basic medical supplies, we all know that lack of physiotherapy or injury recovery support can have a massively debilitating impact on individuals in need. So physical therapists volunteer many thousands of hours a year through recognised programmes to meet this need.
The lack of specialist skills in some areas is outlined here in an article by a Médecins Sans Frontières trainer, but it’s important to note that disaster relief efforts can be extremely complicated, and the same is true for physiotherapy support.
This research paper highlighted many of the issues faced with the delivery of physical rehabilitation services (much of it involving international actors and some of it voluntary) in the aftermath of the Haiti earthquake in 2010. Lack of shared standards, disruption of local markets and lack of capacity for longer-term follow-up were all highlighted as being area where progress is needed, to get the very best out of the efforts made and the skills made available.
Disaster areas are obviously chaotic environments, so you can see how having some sort of shared standards as reference points would be invaluable, and it will be interesting to see how this progresses in the coming years.
However, despite these areas for potential improvement, nobody is questioning the huge impact of voluntary physio services in these troubled areas. As this video report from an MSF physio working in Haiti illustrates, the value of their work is undoubted. This personal account of a volunteering placement in Africa also underlines the huge benefits to be gained by the local population – and the pain at not being able to give more when the need is so great.
So, immense kudos to all physical therapists across the globe who extend their caring responsibilities beyond the workplace. If you’re keen to know more, Voluntary Service Overseas have a specialist physiotherapist recruitment strand, and MSF (who themselves send over 3,000 medical volunteers on international placements each year) also provide a longer list of international volunteering placement agencies.
Do you have experience of volunteering as a physical therapist? At home or abroad? Were you thanked for your work? And what did you take away from the experience? If not, what would encourage you? Please share your thoughts in our short survey which can be found at the following link http://spxj.nl/YGsWf3 and we’ll be publishing the results on this blog.
I have been asked on numerous occasions what my thoughts are on volunteer work within our profession. Now, don’t get me wrong I have no issues what so ever when it comes to volunteering your time and training to boost your experience, I have done plenty of that myself. I am a firm believer that in order to reach the heights you may want to reach, it is worth investing a little of your own time. But I think there are lots of people out there that take advantage of that very fact.
When does this time end and when does it become a liberty, which seems to only be afforded to the sports massage and soft tissue therapy professions? Is it because we are seen as the ‘low man on the totem pole’ and therefore we must need the ‘practice’ or is it because we are not seen as a primary service by ‘some’?
In elite sport there is another addition to this quandary, after all we are privileged to work with athletes, surely that’s enough recompense, surely we need no more (just a little sarcasm). However, this seems to be, unless you are really established, the only way to enter this very exclusive world.
Back in the day when I first was coming onto the scene and even later on, I volunteered my time because I wanted to be the best, so variety of experience was the key. I wasn’t fussy about who, how long or how difficult. I wanted every scenario thrown at me so that I would be able to handle anything and not be afraid. Nothing has changed, I still love a challenge and I am regularly sent ‘difficult’ cases because of that. I thrive on this stuff and the bonus is, these days I get paid for it.
Would I change what I did? No, but there definitely comes a time when enough is enough and companies/sports/NGB’s/clubs you name it, need to be clear about what they are looking for out of a practitioner. If their primary aim is to get something for nothing, unless they are a charity, or you are a student looking for bodies, I would be steering clear. If however, there is an opportunity to really shine and the possibility of future paid work, grab it with both hands; you just never know where this might lead. I volunteered to work on the cast of Cats in Birmingham many moons ago when I was fully qualified and established and ended up volunteering with another therapist on that same job to work with Birmingham City. From here I became employed, then ended up with West Bromwich Albion for four years. Who knew?
If you are currently volunteering somewhere and have been there for some time, take the plunge, speak to someone in charge and broach the subject of either contracted or employed work. What’s the worst that can happen, they say no and you have a decision to make. They may just acknowledge how valuable you are and take you up on your offer. What have you got to lose?
There are always exceptions and I believe we had one jumping up and down and blowing trumpets in our ears last year. The London Olympics, why didnt you? I was lucky enough to have been picked once again to be part of the medical team for GB athletics; my third Olympics. But if I didn’t go as a paid member of staff, I sure as hell would have volunteered. What an experience, not just the work, not just the sheer fact that it was THE Olympic Games, it was at home …
Many of you will have lost money or ended up paying out a considerable amount to volunteer. Why was that ok? Was it because all the professions had to volunteer this time, so for once it was an even playing field? Or was it because it was just simply ‘the Olympics?’ I have a feeling it was the latter … did I say it was at home (sighs). The experience of being in an Olympic Village is incomparable to any other major championships. If you were there I hope you soaked it up. You will never forget it. I know I wont.
We would really like to hear your thoughts on this? Would you/Do you? Never? Good experience? Bad experience? Fill in our quick survey at the following link and we’ll publish the results on the blog http://spxj.nl/YGsWf3
I run regular courses, for more information email me: firstname.lastname@example.org or contact me through fb www.bit.ly/stt4performance
Articles featured in this April’s sportEX medicine journal – the international sports injury and rehabilitation journal
Articles featured in this April’s sportEX dynamics journal – an international sports massage and manual therapy journal
- Facilitated Stretching: an overview by Bob McAtee RMT,CSCS,C-PT
- Medial Tibial Stress Syndrome: a case study of a national tennis player by Ron Alexander, STT (MSK)
- Effective Patient Communication by Lewis Wood, MSc,BSc
- An Alternative Approach to Exercise Prescription: Part 2 by Matthew Palfrey, BSc,CSCS
- Assisted Soft Tissue Manipulation: An introduction to using the ‘spoon’ by Dave Orton, MSc,MCSP,HPC
- Journal Watch: This quarter’s best research from key international manual therapy research journals
These articles are now live online and available in full through a subscription to sportEX medicine, the internationally read sports injury journal and leading manual therapy journal, sportEX dynamics. The articles are all written by practitioners from around the world. The publication is available in print and online as well as on the Apple, Android and Kindle Fire platforms.
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Despite advances in training methods and equipment, injuries sustained during sport are common. These may be seen either in competitive sport or among amateur athletes. Of these approximately 50% are due to overuse. The common overuse injuries include tendinopathies, ligamentopathies and stress fractures. More acute sports injuries include muscle, ligament and tendon tears as well as fractures (1).
There are strong theoretical arguments and laboratory evidence to show that PRP can significantly improve healing in tissues
Rehabilitation with rest of the area and site-specific interventions are necessary in both acute and chronic injuries. In addition to conservative measures such as rest, elevation, non-steroidal anti-inflammatory drugs (NSAIDs) and physiotherapy, chronic injuries have traditionally also been treated with long-acting steroid injections or even surgery. Both NSAIDs and injectable steroids have potentially deleterious effects if used regularly or in high doses (2,11).
Although there is strong lab evidence and many clinical studies showing the efficacy of PRP, very few Level 1 studies have been performed
In the last 10 years there has been growing interest in the use of platelet-rich plasma (PRP), a substance obtained by centrifuging human blood. It has been trialled in various acute and chronic musculoskeletal injuries. It was initially identified and clinically used in cardiothoracic and maxillofacial surgery in the 1990s. The use has now spread to the fields of plastic surgery and orthopaedics. The applications in musculoskeletal soft tissue injuries are expanding with new research showing a number of applications in both acute and chronic settings. The present article aims to review the pathophysiology of tissue healing and actions of platelets and associated substances in the healing cascade.
The article goes on to review the method of preparation, technique of injection and practical applications of PRP in musculoskeletal injuries with a review of the evidence for each indication. Finally, the article looks at some controversies in its indications in sports. Although this article is primarily directed towards the uses of PRP in sports injuries, it has applications in occupational and age-related musculoskeletal disorders.
The Future of PRP
PRP therapies are an exciting new development in the treatment of musculoskeletal injuries in sport. There are theoretical arguments and laboratory evidence to show that it can significantly improve healing in tissues. Clinically, this has lead to a boom in PRP treatments of various sports injuries with variable but generally good outcomes. Unfortunately, there is little level 1 evidence of its efficacy in the world literature. This has led the IOC, other sports medicine stakeholders and governments to call for better designed studies to look at its efficacy in various sports injuries. With the removal of PRP from the Prohibited Substances list by WADA in 2011, level 1 studies in elite athletes may become more common.
The author: Dr Amit Lakkaraju, musculoskeletal radiologist
Dr Amit Lakkaraju is a musculoskeleltal radiologist with a subspecialist interest in sports radiology. After training in his junior years in orthopaedics, he did his specialist training in radiology at Leeds. Amit went on to do a fellowship year in musculoskeletal radiology at Liverpool where he honed his skills in sports imaging and image guided musculoskeletal intervention. He is currently working as a consultant radiologist at the Goulburn Valley Imaging Group, Shepparton, New South Wales, Australia.
This article “Platelet-Rich Plasma (PRP): A review of actions and applications in sports injuries” is now live online and available in full through a subscription to leading international physical therapy journal, sportEX medicine. The articles are written by leading physical therapists and sports medicine specialists from around the world. The publication is available in print and online as well as on the Apple, Android and Kindle Fire platforms.
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Upon a patient’s initial visit to a Physical Therapist, a static postural assessment is routinely performed. Many therapists assess for “abnormalities” such as a forward head, rounded shoulders, decreased or increased spinal kyphotic/lordotic curves, abnormal pelvic positioning, etc. They often associate any abnormal findings to their patient’s condition and attempt to treat by altering the found positional faults. But in doing this, is there existing evidence that associates abnormalities found in static postures with pain? In this article, I want to challenge this widely-accepted association by presenting a review of the current understanding of pain in addition to research which has assessed the relationship between posture and pain.
Quick Review of our Knowledge of Pain
In a post that I wrote for SportEX last year, I discussed the topic of pain. I stated that one of the most essential things we must understand about pain is that nociception (which is input from nociceptors—unmylenated, danger receptors) is not necessary or sufficient for the experience of pain. Pain is always an output from the brain based upon many different variables, and simply the brain’s suspicion that a tissue has the potential for damage, will cause it to react. The brain’s reaction can be based off a conglomerate of information including but not limited to: sensory input from the body, previous experiences of injury, social and/or environmental influences, expectations of consequences of the threat, beliefs/logic, etc. Mechanical tissue deformation, which may occur with prolonged static posturing, may result in nociception, but according to the current models of pain, it will not always result in pain. Other variables are likely necessary.
The first association made between posture and pain was likely based upon an older, Cartesian model of pain. Pain was originally thought to be a bottom-up response, in which excessive stress on a tissue causes this negative sensation. This concept first originated in 1664 by Rene Descartes. In the Treatise of Man Descartes theorized that pain was carried from nerve fibers to the brain and was the result of physical and mechanical deformation. This theory (with slight modifications) was followed for centuries until the current models of pain, the Gate Control Theory and the Neuromatrix, were developed by Dr. Ronald Melzack. Melzack proposed that pain was an output of the brain and is caused by much more than simply tissue damage. His model challenged the belief that posture and pain are simply associated. Its much more complex.
What does the research show?
A 2010 systematic review assessing the relationship between awkward occupational postures and low back pain found that there is strong evidence to support there is no relationship between the two. This article included the review of eight high-quality studies that assessed individuals who worked in professions that forced them to assume prolonged, static postures. These professions included scaffolding, nursing, retail sales, podiatry, firefighting, etc. It would be expected that individuals with these professions would have higher incidences of low back pain but statistically , they did not.
A 2007 article published in Manual Therapy assessed the relationship between sustained static posturing and postural neck pain. Similar to the systematic review, the authors found that neck pain was not associated with the individuals habitual postures or kinesthetic sensibility. The study came to this conclusion after assessing the habitual sitting posture, perception of good posture and postural repositioning error in symptomatic and asymptomatic individuals.
Another article published in 2000, challenged the concept of lumbopelvic imbalances and pain. Many Physical Therapists believe that excessive lumbar lordosis is due to weak abdominal muscles in combination with shortened lumbar extensor and hip flexors muscles, which in turn leads to pain. This positional fault leads to an anterior pelvic tilt which should be addressed through abdominal stabilization (often utilizing the infamous posterior pelvic tilt). The article assessed 30 men and women who had chronic low back pain (CLBP). It assessed the location of pelvic inclination and magnitude of lordosis and found that in individuals with CLBP, there was no more standing lumbar lordosis or pelvic inclination than their counterparts with healthy backs. In patients with CLBP, the magnitude of the lumbar lordosis and pelvic inclination in standing was not associated with the force production of the abdominal muscles. The authors go as far as concluding,
“Abdominal muscle strengthening exercises are routinely recommended by physical therapists to correct faulty standing posture in patients with CLBP. These recommendations are often based on assessment of standing posture. We urge physical therapists to avoid prescribing therapeutic exercise programs of muscle strengthening of abdominal muscles in patients with CLBP based solely on assessment of relaxed standing posture.”
So what does this mean?
I would argue that we spend too much time focusing on holding static postures and less time on movement. It appears that there is little evidence to support the notion that poor posture leads to pain. I recommend to my patients to find positions of comfort. When those positions get uncomfortable, move and find another position of comfort. We were built to move.
The author: Joe Brence, physical therapist
Joseph Brence is a doctor of physical therapy from Pennsylvania, USA. He is currently a director of two facilities in Pittsburgh and takes a manual approach to patient care. He is also a contributor to www.physiotherapyinfo.com and www. theptproject.com and is currently working on multiple research projects which he will present to the sportEX community as they are published. To read Joseph’s monthly contributions, click the following link http://eepurl.com/bRGmj
- Merskey H, Bogduk N. Classification of Chronic Pain. 2nd ed. Seattle: IASP; 1994.
- Melzack R, Katz J. The Gate Control Theory: Reaching for the Brain. In: Craig KD, Hadjistavropoulos T. Pain: psychological perspectives. Mahwah, N.J: Lawrence Erlbaum Associates, Publishers; 2004.
- Iannetti GD, Mouraux A. From the neuromatrix to the pain matrix (and back). Exp Brain Res 2010; 205; 1-12.
- Moseley GL. A pain neuromatrix approach to patients with chronic pain. Manual Therapy 2003;8:130-140.
- Roffey DM, Wai EK, Bishop P. Causal assessment of awkward occupational postures and low back pain: results of a systematic review. The Spine Journal 2010: 10; 89-99.
- Edmondston SJ, Chan HY, Ngai GC, et al. Postural neck pain: An investigation of habitual sitting posture, perception of ‘good’ posture, and cervicothoracic kinaesthesia. Manual Therapy 2007: 12; 363-371.
- Youdas JW, Garrett TR, Egan KS, et al. Lumbar Lordosis and Pelvic Inclination in Adults With Chronic Low Back Pain. Physical Therapy2000: 80; 261-275.
This article “Is static posture related to pain? Probably not.” is now live online and available in full through a subscription to leading international physical therapy journal ,sportEX medicine. The articles are written by leading physical therapists and sports medicine specialists from around the world. The publication is available in print and online as well as on the Apple, Android and Kindle Fire platforms.
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This article has been adapted from a handbook, Groin & Hips: the latest international evidence, 2012, written by the author of this article, primarily for premier league football medical personnel, but also for those involved in other elite sports, in response to the controversy and lack of consensus among clinicians working in this area. On reviewing the literature, it became clear that the best answer to these problems is prevention/pre-habilitation. An in-depth knowledge of the basic and functional anatomy of this area is critical and this encompasses the entire kinetic chain above and below the groin. In particular, the adductor muscles are mostly neglected and are invaluable in the prevention strategy. Thus the most pertinent point is that many of the groin/hip pathologies can be averted by thorough and specific pre- habilitation. That is … treat the cause, not the symptom!
There are 82 differential diagnoses relating to the groin + another 41 related to the hip
The literature review that was undertaken for the handbook, Groin & Hips: the latest international evidence (1) was based on 240 studies and confirmed that the groin, an anatomical region where diagnosis and symptoms are often confusing, and may also represent a Bermuda Triangle for clinicians to disappear into in vortices of suppositions and assumptions. The Fédération Internationale de Football Association (FIFA) sports physiotherapist, Dr Mario Bizzini (2) called groin pain “The Bermuda Triangle” of sports medicine, and with good reason. There is little international consensus on diagnosis, pathophysiology, investigation or management. The diagnosis is multifactorial and there are 82 differential diagnoses relating to the groin, plus another 41 related to the hip. It is not simple. Also, in elite sports, it is often very difficult for a doctor to diagnose accurately and thus be able to send the player to the relevant specialist who deals only with his specific area. One of the key points is to understand the entire anatomy and likely generator of pain (3). The importance of the two joints in the pelvis should be emphasised – the hip joint and the pubic symphysis (PS). If one bases one’s diagnosis on this anatomy and, in particular, the functional anatomy, the whole diagnostic reasoning becomes easier.
The author: Helen Millson, physiotherapist
Helen has worked for IRPS Ltd for Elite Sports since 2006. As medical director, her expertise has been taken to all premier league (PL) football clubs to collate and interpret medical information for Insurers. This has included advising lawyers during complicated high financial claims. She organised a bespoke database specifically for PL and therefore has an excellent overview of all injuries/illnesses sustained by PL footballers. She has comprehensive knowledge of PL football medical conditions and has been acclaimed by the industry as a top-class expert. The medical advice to Insurers includes England cricket, international rugby, professional golf, international cyclists, UAE footballers, and other professional sportspeople at the pinnacle of their careers. As sport physiotherapist for Elite National Sport she worked in pre-habilitation, treatment, rehabilitation, and return-to-play criteria. Her professionalism, expert advice and outstanding interpersonal skills have been sought and appreciated by all medical and management teams at elite sports level, with insurers and their medical teams. She has a unique ability to confer and collaborate with other high-level experts in her field. She is the evidence based clinician for the company and the medical legal advisor within and outside the company, Previously Helen gained high acclaim in her field as physiotherapist for national rugby, hockey, cricket and surf lifesaving in South Africa. She also provided physiotherapy cover for two All Africa games, for football (Maccabi Games) and two Commonwealth Games (1992 to 2006).
This article “Groin and Hip Quandaries: The “Bermuda Triangle” of Sports Medicine” is now live online and available in full through a subscription to leading international physical therapy journal, sportEX medicine. The articles are written by leading physical therapists and sports medicine specialists from around the world. The publication is available in print and online as well as on the Apple, Android and Kindle Fire platforms.
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Chronic pain in sport is a problem. It is a problem for professionals and amateurs alike although the stakes are different. The professional athlete will consider the consequences of persisting pain and injury in terms of his or her career and income. The amateur sports person will not be concerned about income but will certainly be frustrated and disappointed. Both will struggle if they cannot resume their chosen sport within their expected time span. The professional is supported by a medical team who will ensure that every test and investigation is performed to reveal the nature of the pain whereas the amateur must often fund his or her own treatment. Both must develop an effective therapeutic relationship with the therapists and medical staff based upon trust to move forwards.
The injury moment: nothing happens in isolation
Around every injury is a circumstance that led to the injurious event, a point in time that I call the ‘injury moment’. They include the stage of the game, the fitness of the player, the environment, previous experiences of pain, and prior successful and failed attempts to deal with injury. Nothing happens in isolation. The great Muslim philosopher Ibn Khaldun talked about the importance of placing an event in context when referring to history. We can learn from this and apply the same thinking to understanding an individual’s injury experience. The player is a complex, moving and thinking instrument playing a tune that seeks to follow the rhythm of the game. Dependent upon what he is thinking, doing, planning, and anticipating within the game, the injury moment will unfold.
The “meaning” of pain has a significant influence on the route of management
This article discusses the science of pain in relation to the sports injury and how it can evolve into a persisting problem. No injury happens in isolation, and the early responses and management have an influence upon the journey – hence the need for effective pain control, diagnosis and a plan. Understanding that a persisting problem is underpinned by an ongoing protective and vigilant state allows for wise action in terms of treatment.
About the author
Richmond Stace MCSP, MSc (Pain), BSc (Hons), is a chartered physiotherapist who specialises in the treatment of persisting pain and injury. In addition to being a qualified physiotherapist, Richmond has a Masters degree in Pain Science from Kings College London. The Specialist Pain Physio clinics in London were set up by Richmond in 2008 to deliver comprehensive neuroscience-based programmes for ongoing pain. Outside of the clinic Richmond writes and talks about pain with the aim of advancing the general understanding of pain.
This article “Chronic Pain in Sport” is now live online and available in full through a subscription to leading international physical therapy journal, sportEX medicine. The articles are written by leading physical therapists and sports medicine specialists from around the world. The publication is available in print and online as well as on the Apple, Android and Kindle Fire platforms.
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