Articles featured in the January 2015 issue of sportEX dynamics journal – an international sports massage and manual therapy journal:
* PROFESSIONAL STANDARDS: HAVE WE LOST THE OPPORTUNITY TO CREATE A REPUTABLE BRAND?
The following letter from one of our regular Australian contributors provides an interesting insight into some of the difficulties facing the Australian massage therapy industry. This introduction describes how the Australian healthcare and education systems have contributed to creating this situation and how we in the UK can perhaps avoid ending up
in a similar position.
* WHY MASSAGE RESEARCH IS FLAWED
Massage is used extensively in sport but a huge number of experimental studies reach the conclusion that it has little or no actual benefit. This is because virtually every study is methodologically flawed – not for the usually stated reasons of a lack of randomisation or blinding but because of a lack of consensus about what massage actually is, a lack of understanding about what is being tested and on whom, and above all a total disregard for the dose of application.
* AN UPDATE ON THE RESEARCH EVIDENCE BASE FOR KINESIO TAPE
This article discusses recent studies on the effectiveness of kinesio tape used to treat medial tibial stress syndrome, osteoarthritis of the knee, calf pain and low back pain in order to assess the evidence base for this therapy.
* YOGA AS THERAPY
Yoga is an ideal form of exercise for stretching tight muscles and improving flexibility, gaining strength and also providing psychological benefits. This article describes how yoga can be used in a rehabilitation setting.
* FASCIA AND BIOTENSEGRITY
This second article about the concept of biotensegrity, considers the fascia, or tensional network of the living body. Many traditional concepts of biomechanics and musculoskeletal anatomy are evolving rapidly. There are challenges in naming the fascia and relating this ubiquitous fabric of human form to structure and natural function in living movement. Some key questions arising are explored here, before more detailed discussion of biotensegrity is elaborated on in later articles. The question is, is biotensegrity the missing link?
* JOURNAL WATCH
Quarterly roundup of key research published in the last three months.
* SOCIAL WATCH
Quarterly roundup of key resources from some of the main social media sites.
These articles are available in full through a subscription to 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.
Highlights of Jan 15 sportEX medicine
Articles featured in the January 2015 issue of sportEX medicine journal – the international sports injury and rehabilitation journal:
* VITAMIN D IN SPORT AND EXERCISE MEDICINE: A PRACTICAL REVIEW
Suboptimal levels of vitamin D are now recognised as a worldwide public health problem (1), having a range of effects through many mechanisms. A wide range of individuals – even the supremely fit – can have suboptimal vitamin D levels. This article provides an overview of the current understanding of vitamin D, its effects, mechanisms, measurement and approaches to supplementation.
* THE CHALLENGES OF YOUTH: PSYCHOSOCIAL RESPONSE TO INJURY AND REHABILITATION IN YOUNG ATHLETES
Understanding the psychosocial challenges faced by youth athletes can be key to a successful return to competition following sports injury. This article extends other recent articles that have examined the salient role of psychology within sports injury risk, rehabilitation and return to competition (1) by providing an overview of some of the challenges of working with youth athletes as well as presenting some strategies that can be used to enhance the quality of rehabilitation outcomes. It is hoped that this will stimulate reflective practice and increase practitioner confidence in working with some of the psychosocial challenges presented by youth athletes. This article includes a continuing education quiz.
* A PRACTICAL MODEL FOR MANAGING TENNIS ELBOW (INCLUDING CLIENT ADVICE LEAFLET)
Tennis elbow (lateral epicondylitis) is a common injury that is notoriously difficult to rehabilitate. This article provides a practical and progressive model for athletes to manage the condition and rehabilitate back to full function.
* PROXIMAL INTERVENTION FOR THE MANAGEMENT OF PATELLOFEMORAL PAIN
This article offers the reader an evidence-informed and clinically reasoned review of the current literature with respect to proximal interventions in the management of patellofemoral pain. The evidence clearly backs up this approach, but it is not possible to establish the mechanism of the effect or to identify patient subgroups within which
favourable outcomes are more likely. From reading this article you will gain a broader understanding of how hip strengthening can be implemented, targeted to specific individuals and consequently results in more favourable outcomes for your patients.
* SHOULD SPORTS CONSIDER NEUROIMAGING IN THE ASSESSMENT OF CONCUSSION?
This article discusses the current evidence for the short- and long-term effects of concussion in sport and how occurrences of concussion should be managed. The article also considers the potential role of medical imaging in terms of assessing both acute and chronic head injuries. Greater awareness of when medical imaging could be used will aid practitioner’s understanding of its potential contribution while still maintaining the fundamental importance of clinical judgement. This article includes a continuing education quiz.
* RESEARCH REVIEWS
Our regular research reviewer, physical therapist Joseph Brence, reviews research looking into (i) better diagnosis of subacromial impingement and rotator cuff pathology with clustered tests, and (ii) to what extent pain is an indication of severity of injury.
* JOURNAL WATCH
Quarterly roundup from the musculoskeletal research journals.
* SOCIAL WATCH
Quarterly roundup of resources from key social media sites.
These articles are available in full through a subscription to sportEX medicine. 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.
This is one not to miss purely because you get some excellent speakers for an extremely low delegate fee (just £35 for both days of the event or £20 for a single day).
Day 1 – The State of the Art: CRAIG RANSON Advances in managing tendon injury, IAN HORSLEY Advances in managing shoulder injury, IAN HORSLEY Olympic Sport Injury Management Update, BOB DONATELLI The role of foot mechanics in gradual onset lower limb sports injury, JOHN HOUGHTON The latest topics in injection therapy, JON GRAHAM Integrating neurological concepts into MSK rehab, JOHN HOUGHTON Modern medical management of MSK injury
Day 2 – Adolescent Sport Injury and Performance: STEVE MCCAIG Profiling and Prehabilitation for Injury Prevention, ABBIE NAJJARINE Modern day role of the Podiatrist in the rehabilitative process, RHODRI LLOYD Principles of injury prevention and performance optimisation when training young athletes, STEVE MCCAIG Throwing related shoulder pain in young athletes, RHODRI LLOYD Strength training in young athletes, CRAIG RANSON Workload Management in Youth Sports.
Click here for more info and booking >
Falls have a large impact on the overall health and quality of life in older adults. It has been estimated that 30-60% of older, community-dwelling adults experience a fall each year and that approximately half of these individuals experience multiple falls. This number appears to be the highest in those who are 80 years of age and older, and increases as high as 75% in individuals who live in a nursing home.1 Multiple variables have been determined to predict the risk for falling and this article is to provide a comprehensive review of these factors as well as what we can do in an attempt to prevent them.
Fall Risk Factors:
A 2010 systematic review by Deandrea et al.2 set out to analyze the results of 74 prospective studies conducted to assess fall risk factors in older adults. Out of these studies, the authors found 31 risk factors to be considered. They concluded that the variables demonstrating the strongest association for fall risk include: history of falls, gait problems, use of walking aids, vertigo, Parkinson’s disease and antiepileptic drug use. The researchers suspected that additional risk factors may be present but are underreported, especially if the associated fall did not result in injury.
One of the variables found in this study, “gait problems”, is a factor which we often analyze and treat as Physical Therapists. But despite this notion, there is currently a lack of uniformity in the diagnosis of gait abnormalities. So in 2009, Verghese et al3 set out to quantify gait markers of falls in older adults, with the ultimate goal of improving diagnostic, gait assessments by the practicing clinician. Their study included 597 older adults (>70 yo) and baseline measurements of gait speed, cadence, stride length, swing, double support, stride length variability, and swing time variability were taken. The participants were followed over a long period and within 20 months, 226 of the 597 (38%) adults experienced a fall. When analyzing the baseline measurements in those who fell, it was found that slower gait speed at baseline (< 100 cm/s or 2.2 mph) was associated. Additional fall predictors included: worse performance on swing, double-support phase, swing time variability and stride length variability, even after accounting for cognitive status and disability.
In a third study, researchers set out to determine whether a disease-specific diagnosis resulting in cognitive loss (such as dementia) is predictive as a fall-risk factor, and compared it to measures of global cognition as well as other impairments in specific cognitive domains (i.e. executive function).4 This systematic review included 27 studies and using an inverse-variance method of data analysis found: executive function impairment, even subtle deficits in community-dwelling older adults, was associated with an increased risk for fall as well as falls resulting in serious injury. A diagnosis of dementia, without specification of dementia subtype or disease severity, was also associated with risk for fall but did not appear to be associated with falls resulting in serious injury.
Treating Fall Risk:
So with the above known as risk-factors for falling, what can we do about it? Well, the current consensus varies within the research community.
According to a 2008 systematic review published in the British Medical Journal5, the researchers conclude that our current knowledge and ability to prevent falling is limited. This study assessed research performed on multifactorial fall prevention programs in primary care, community and emergency care settings, and found the quality of studies in this area not to be high and most trials performed are ridden with methodological flaws.
A Cochrane review (159 trials and 79,193 participants)6 which assessed the effects of interventions designed to reduce the incidence of falls, found more encouraging results. The researchers concluded that multiple-component group and home exercise programs significantly reduced the rate of falls and risk of falling. In addition, home safety assessment and modifications demonstrated similar results. Additional variables which showed some effectiveness included: pacemakers (in those with carotid sinus hypersensitivity), the first cataract surgery (additional surgeries did not reduce incidence or risk), gradual withdrawl of psychotropic medications, etc.
In conclusion, we currently have some good guidelines in determining who is at-risk for falling but need additional, quality research to determine how to reduce the risk, as well incidence rates.
- Rubenstein LZ, Josephson KR. The epidemiology of falls and syncope. Clin Geriatr Med. 2002;18:141–158.
- Deandrea S, Lucenteforte E, Bravi F, et al. Risk factors for falls in community-dwelling older people: a systematic review and meta-analysis. Epidemiology. 2010; 21: 658-668.
- Verghese J, Holtzer R, Lipton RB, et al. Quantitative gait makers and incident fall risk in older adults. J Gerontol A Biol Sci Med. 2009; 64: 896-901.
- Muir SW, Gopaul K, Odasso MMM. The role of cognitive impairment in fall risk among older adults: a systematic review and meta-analysis. Age and Ageing 2012; 0: 0-10.
- Gates S, Fisher JD, Cooke MW, et al. Multifactorial assessment and targeted intervention for preventing falls and injuries among older people in community and emergency care settings: systematic review and meta-analysis. 2008 BMJ; 336: 130.
- Gillespie LD, Robertson MC, Gillepsie WJ, et al. Interventions for preventing falls in older people living in the community. The Cochrane Collaboration. DOI: 10.1002/14651858.CD007146.pub3.
Recently, many in the manual therapy community have been questioning the mechanisms of how spinal manipulation works. While some hold onto the belief that spinal manipulation has more of a biomechanical and structural influence, others believe the effects to be neurophysiological. In a 2011 study published in the journal Spine, Fritz et al concluded that the mechanisms are likely multi-factorial. These researchers reported measuring a decrease in global and terminal stiffness and improved recruitment of the lumbar multifidus following a lumbar manipulation.1 A more recent randomized controlled trial published in Physical Therapy assessed and compared the immediate effects of regional and non-regional spinal manipulation in patients with chronic low back pain.2 This study was necessary to determine if we need to segmentally target vertebrae to get the positive effects, that others have found. Let’s take a closer look at what they did and what they discovered:
This study included 148 individuals who had at least a 12-week history of low back pain. They were divided into one of two groups to receive either a: lumbar manipulation (to the painful segments) or upper thoracic manipulation (non-regional). Pain, pain pressure thresholds and level of perceived disability (via Roland-Morris Disability Questionnaire) were measured by a blinded researcher at baseline and following the intervention.
The researchers found that there were “immediate” effects in pain and pain pressure thresholds following both manipulations. Furthermore, they found that the degree of reduction did not differ between the two groups. Each appeared to have an immediate 30% reduction in pain intensity.
What this means:
This study refutes the concept that a biomechanical approach needs to be taken when manipulation is performed to those with chronic low back pain (it further supports the notion that manipulation likely elicits a neurophysiologic response). It also makes one speculate the idea that the dramatization of manipulation may elicit non-specific effects (expectations and psychosocial factors) and that environment or interaction may have some effect on outcomes.
The cohort tested in this study had chronic symptoms. From our understanding of pain neurophysiology (as I have written about in the past), when a tissue is damaged, an output of pain will likely occur to protect it (this leads to an adaptation within the pain pathways). The longer (more chronic) the nervous system reacts to protect the tissue, the more efficient it becomes. This creates a nervous system that is more “sensitive” and eventually, the simple suspicion that a tissue is in danger will cause it to react. A prolonged output of pain can result in a process called central sensitization which is due to an augmentation of responsiveness of central neurons to input from unimodel and polymodal nociceptors.. This results in a central process of an increased responsiveness to peripheral stimuli, even if they are non-threatening.
This study demonstrated that manipulation (even outside of the region of suspected damage), can alter this sensitivity. It appears to make the brain less reactive, demonstrated by the “reduced pain”.
- The researchers used “Mitchell’s Test” to verify vertebral position and mobility for the regional manipulation. In a search of the literature, I was unable to find any literature which has validated or found this method reliable.
- The researchers only assessed “immediate” effects and did not track long-term outcomes. Between-session changes were not even accounted for.
- This study only involved one therapist who applied the interventions. The interactions with this one individual may limit clinical variability and applicability of results.
- This study did not assess a combination of manipulation and therapeutic exercise, which is more likely to occur in clinical practice.
We must be cautious when interpreting the results from this study. With the manual techniques being performed in isolation, and only immediate effects measured, the applicability to clinical practice is limited. This study does have importance for our understanding of “how manipulation works” but I would be interested to see if its reproducible. We shall wait and see.
- Fritz JM, Koppenhaver SL, Kawchuk GN, et al. Preliminary investigations of the mechanisms underlying the effects of manipulation: exploration of a multivariate model including spinal stiffness, multifidus recruitment, and clinical findings. Spine 2011; 36: 1772-1781.
- de Oliveira RF, Liebano RE, Costa LCM, et al. Immediate effects of region-specific and non-region specific spinal manipulative therapy in patients with chronic low back pain: a randomized controlled trial. Physical Therapy 2013 Published online February 21, 2013 doi: 10.2522/ptj.20120256.
There are now 38 elearning quizzes available to you (subscription dependent) through the elearning section of our website and as from this month, all the quizzes are now mobile-friendly (as in you can do them on most smart phones and tablet devices such as iPad, Nexus etc.). There’s a help post here with screenshots if needed. We prioritised this because we know many of you are regularly traveling with teams and often only have tablets or mobile devices with you during your trips. (There’s a list of the quizzes below and links to some examples).
There is one caveat however – you do need to be logged into our website to do them. It doesn’t matter what kind of device you’re logged in on ie. it could be a mobile device or it could be your normal laptop/desktop, the important thing is that you’re logged in through a normal web browser.
Why? Because we’ve actually ended up building our own custom mini-elearning system on our website. There were several reasons for doing this which I won’t bore you with (feel free to ask if you’re interested), but essentially we wanted to be able to provide you with time-stamped customised certificates displaying your specific results and quiz details. In order to do this, we have to store this data against your account on our website – hence the reason you needed to be logged in so we can identify you.
Why can’t you access the quizzes from the mobile app that you download from the various app stores? Because the mobile app is a totally technology different platform that’s been developed by someone completely different and is used by lots of publishers, including us, so it’s not possible to have our elearning system built into it. It might seem like the website and the mobile app are closely integrated because we’ve “glued” them together so you can use the same login and passwords but they are two totally different platforms (there’s a lot more to this publishing lark than first meets the eye!), but this is why you need log in to our website from whatever your chosen device, to do our quizzes.
By the way, all our elearning material is developed to be SCORM compliant (an elearning technology standard) so that we have plenty of flexibility in the future. In the meantime make sure to use them as part of your CPD portfolios (when you pass a certificate is stored under the CPD certificates section of the My Account area) and I hope you find the added flexibility of being able to do your continuing education, on the go.
Quizzes at time of writing this post:
Clinical Reasoning in Exercise & Performance Rehabilitation
20th & 21st September 2014 – Part 1 – Bisham Abbey, near Marlow
8th & 9th November 2014 – Part 2 – Bisham Abbey, near Marlow
Current Soft Tissue Techniques for Sport
26th & 27th April 2014: Part 1 – Colchester
7th & 8th June 2014: Part 2 – Colchester
Current Taping Techniques for Sport
7th & 8th June 2014 – London
The ACPSEM Autumn Study Day “All About the Knee” in Manchester (4th October 2014) comprises of talks focusing on the knee as well as practical demonstrations. There will also be an opportunity to ask the panel questions.
- Lee Herrington – Relationship of Running, Landing and Squatting Performance to Patellofemoral Pain and Potential Treatment by Modifying Movement with Verbal and Visual Feedback
- Paul Comfort – Development of Force and Rate of Force Development: Implications for Prevention and Rehabilitation of ACL Injuries
- Karen Hambly – Articular Cartilage – Implications for Rehabilitation
- Duncan French – Low Load Blood-Flow Restricted Resistance Exercise (BFRRE) and its Application to Strength and Conditioning
- James Moore – The High Hamstring Tendonopathy, Management Strategies
Anyone can attend these courses with discounts for ACPSEM members. Full details available at www.physiosinsport.org/courses or contact Lisa Kerry on firstname.lastname@example.org
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