BASRaT Conference

Staff and students travelled up to the Etihad Stadium in Manchester for the British Association of Sport Rehabilitators and Trainers (BASRaT) conference on Friday 17^th November 2017 with the theme of Rehabilitation and Fitness for Life.

This was an interesting conference that included information on exercise prescription, exercise and cognitive function, exercise and cardiovascular health, how to get your patients moving, the role of the brain in osteoarthritic pain and the implementation of weightlifting derivatives during rehabilitation.

The keynote speaker, Professor Karim Khan opened the conference with the reasons to exercises and how we can translate the message to patients. There were some interesting facts that came out of this talk, such as if an individual does not complete the required physical activity on any one day of the week, it is equivalent to the body smoking 3 cigarettes, the role of insulin in physical activity and how its effectiveness decreases as we get older and its link with the ‘middle-age spread’. There is evidence of cardiovascular and resistance training benefits the brain; long term structural changes and the volume of brain mass increases, which has implications for preventing/reducing the risk of developing Alzheimers and Dementia.

John Buckley also presented some interesting facts relating to the cardiovascular system and physical activity. For every 10% increase in aerobic fitness, there is an 8% reduction in the risk of cardiovascular disease (CVD).

The risk of CVD is also higher in those who complete their recommended physical activity. This was due to their sedentary habits the rest of the time. It was suggested that even if an individual completes the recommended level of activity, if they are sat for greater than 8 hours a day then they are at risk of developing CVD by 5% (Ekelund et al., 2016).

The final speaker of the day was Tasha Stanton and this talk was the most interesting one. We know our brains are capable of some incredible processes, but when dealing with pain there can be a difference in actual structural damage and the pain that an individual is in. So as rehabilitators we have to find a way to help reduce or manage the pain an individual is in. Our communication is a key factor in this, if we are positive with our words and management then the outcome could be greater than if we are negative.  Another key factor is the visual input, if patients are able to see themselves performing a movement, it can also reduce their levels of pain.

Overall the conference gave a few insights into new topic areas that as a rehabilitator is it worth considering for the longevity of patient care.

“Being a 1st year rehab student, I booked the BASRaT conference with a fairly open mind as I didn't really know what to expect nor did I know any of the speakers. I was simply hoping to network with other students and understand a little more about the accrediting body of my course. Transport was arranged by Vicki and Sarah, which was great as without this I'm not sure I would've attended. The speakers were clearly experts in their fields and very credible. The topics covered were really relevant and presented in a way that were easy to follow, even for a 1st year. Outside of Uni I work as a personal trainer, so some topics were very familiar and served as reassurance and reinforcement of my existing knowledge. Other topics were less familiar but really relevant to my course; tendinopathy and neuro network efficiencies with pain and their link to OA. These topics were pitched a fairly high level but not so high I couldn't take away a few gems and get a little ahead of the game. I would definitely go again.”

Paul Johnson. First year Rehabilitation in Sport and Exercise Student

 

“I found the Karim Khan lecture on Tendon rehab very beneficial, especially the interesting link between Scoliosis and inflamed tendonitis. Also the pain lecture, a talk on the brains function with regards Pain in OA, was very informative”

Karl Parish. Third year Rehabilitation in Sport and Exercise Student

 

“As far as conferences go, the BASRaT Conference far exceeded our already high expectations. Being able to network with big names such as Karim Kahn (BJSM editor and autor or clinical sports medicine) and Steve Aspinall is a fantastic opportunity for any Sports rehab student. The BASRaT conference was beneficial for all year groups as the key note speakers delivered relevant and thought provoking research with charisma and enthusiasm.”

Helena Radcliffe. Second year Rehabilitation in Sport and Exercise Student

 

“The conference was another great experience, which I feel I have learnt great deal in relation to my course, from how to get the public active to how pain can be perceived. Great day out, especially as it was at the Etihad stadium!”

Laura Woodbridge. Second year Rehabilitation in Sport and Exercise Student

Muscle Injuries at FISIC 2017

On the 27th & 28th September 2017, staff and students from Plymouth Marjon University went up to the Fortius International Sports Injury Conference in London.

Over the 2 days there were some fantastic, inspirational break out sessions. Here, Sarah Martin (Lecturer in Sports Therapy & Rehabilitation, & Programme Leader for the MSc Sport Rehabilitation) shares her notes on the Muscle Injuries breakout session.

An excellent presentation by Justin Lee demonstrated  British Athletics have encouraging use of their Muscle Injury Classification System – Grade 0, 1, 2, 3 & 4 (Pollock et al., 2014). This has since been observed for its reliability (Patel et al., 2015).

The classification is made depending on the severity and site of the injury. Grade 0 have normal MRI results and clinically present as generalised muscle soreness. Grade 1 injuries are minor tears where the athlete usually presents with pain during or after activity. Their ROM will be normal after 24 hours but there may be pain on contraction, although strength and initiation of contraction will appear normal on examination. Grade 2 injuries are moderate tears to the muscle which usually present with pain during activity where the athlete needs to stop activity. The ROM is usually limited after 24 hours, with pain on initiation of contraction, usually with an apparent weakness on strength assessment. Grade 3 injuries are extensive tears to the muscle. The athlete usually presents with sudden onset pain and may fall to the ground. ROM after 24 hours is significantly reduced and the athlete has pain on walking with obvious weakness in contraction. Grade 4 injuries are complete tears to the muscle or the tendon (grade 4c). Sudden traumatic onset of pain, a palpable gap is felt but less pain on contraction than a grade 3 presents with.

The site of injury is determined as illustrated below:

Muscle Injury Classication (Pollock et al., 2014)

Some examples:

Grade 2A – myofascial; CC length 5-15cm, CSA 10-50%, Normal Tendon

Grade 2C – MTJ; CC length 5-15cm, Oedema CSA 10-50%, Abnormal tendon = <50% CSA, <5cm length, no loss of tension

Grade 3C – MTJ; CC length >15cm, Oedema CSA >50%, Abnormal tendon = >50% CSA, >5cm length, loss of tension

Grade 4C – rupture of muscle or tendon, loss of tension with retraction

Note – muscle oedema not reliably assessed on ultrasound; 50% of grade 1 injuries have normal ultrasound examination.

However, tendon involvement can be reliably assessed on ultrasound. %CSA involvement & length is easily observed but loss of tension may be difficult to identify. Full thickness tendon tear ends may be obscured by Haematoma so MRI may be more beneficial (Connell et al., 2004).

Peetron (2002) devised a useful Grading System on Hamstring Injuries which has since been modified.

Key considerations when ultrasounding acute muscle injury:

·         Can’t reliably assess oedema

·         Can’t reliably assess loss of tension

·         Can assess percentage CSA involvement of tendon

·         Can assess length of tendon involvement

·         May not be able to identify retracted tendon ends if complex haematoma present

Rob Chakravety highlighted the key factors which hold an athlete back during rehabilitation:

·         Tissue healing

·         Pain

·         Strength

·         Intolerance to load

·         Suboptimal movement patterns

There is a need to promote and focus on:

·         Regeneration – PRP?

·         Inflammation control – PRP or Traumeel

·         Nociception – afferent signals, muscle inhibition -  Trp’s injected with Traumeel or Local Anaesthetic

·         Peripheral inhibition - afferent signals, muscle inhibition -  Trp’s injected with Traumeel or Local Anaesthetic

·         Central inhibition – spinal inflammation of longitudinal ligaments leads to pressure on dura; inject with kenalog, an anti-inflammatory with saline to wash away inflammatory mediators

·         Ligamentous instability – inject with dextrose or P2G

·         Musculoskeletal dysfunction – e.g. lack of DF, muscle overload or TrP’s – inject with Traumeel or Osteril

Key point – the evidence base for injection is SPARCE!

Noel Pollock from British Athletics then discussed the assessment and management of recurrent ‘Calf Strains’. 5 key points for consideration are:

·         Accurate diagnosis –

o   Structural Diagnosis

§  Clinical assessment, imaging & imaging videos (mechanism of injury).

§  Don’t miss a plantaris rupture for calf pain. Also consider sural nerve & lumbar referral, popliteal artery entrapment syndrome (especially those with a large head of gastroc). The new muscle classification system works well for soleus injury (Pezzotta et al., 2017).

o   Functional Diagnosis

§  Technical errors

§  Neural

§  Articular

§  Muscular imbalances and dysfunction

·         Medical Intervention

·         Rehabilitation

o   Consider the functional demands of the athlete (Lieber and Ward (2011) have an excellent paper which discusses muscle fibre length to meet functional demands). E.g soleus – fatigue resistance must be built in due to isometric nature of mm

·         Monitoring/Milestones

o   Consider Gabbett’s (2016) Injury Prevention Paradox to monitor risk

·         Return to Play

o   Role of the athlete, HCP and coach – essential reading by Dijkstra et al. (2017) in the British Journal of Sports Medicine on the decision making process for RTP

Dijkstra et al. (2017) - Decision-making process for RTP

British Athletics Muscle Injury for the calf:

a) Myofascial

                        Very low reinjury

Sore but functional, quick recovery

b) Muscle-Tendon Junction

                        Small injuries prone to reinjury

                        Gradual ‘traditional’ progression

c) Intratendinous

                        High reinjury rate

                  Manage tendon

Nick van der Horst presented his PhD research on hamstring injuries and return to play. HSI’s are the number 1 muscle injury in football (match incidence 22/1000 hours; training incidence 3.5/1000 hours). Recurrence rate is 12-33% and there is a frequent link to decrease performance following HSI (Hagglund et al., 2013). Despite an increase in research, there is still an upward trend for Hamstring Injuries (by 4% annually for the last 13 years (Ekstrand et al., 2016)). 50% of all recurrences occur within 1 month after RTP (Brooks et al., 2006; Wangensteen et al., 2016) which may be due to inadequate rehabilitation or premature RTP.

The decision to return to play should be multidisplinary (Athlete, team coach, physical therapy, sports physician and fitness trainer should all have an input). The Return to Play Criteria is suggested below:

The widely publicised Strategic Assessment of Risk and Risk Tolerance (StARRT) Framework is imperative in the return to play process (Shrier, 2015).

Craig Ranson discussed the role of prehabilitation and rehabilitation in muscle injuries. He highlighted a recent debate in the press with Arsene Wenger describing cryotherapy as ‘smoke and mirrors’ as he questioned its’ effectiveness, the lack of evidence base for many of our treatment modalities and why muscle problems are still taking 21 days for return to play, the same timescale as 30 years ago. He also highlighted the shortly available MRI scan of Usain Bolts hamstring strain in the infamous incident of Bolt’s last race.

Workload patterns are directly related to injury, but it is difficult to calculate workload (Bourdon et al., 2017; Williams et al.,2017). Strength should be measured through isokinetics, Nordbord, Single Leg Bridge Test (Freckleton et al., 2014).

Factors attributing to muscle injury include:

·         Sleep

·         Previous injury

·         Inadequate preparation

Rehabilitation must exceed pre-injury state to address probable pre-existing weakness. Context-specific exercises are imperative including OKC functional activities. In the early stage, stair running in the first 7-10 days as there is very little hamstring and calf activation. Askling Test for RTP should be used (Erickson and Sherry, 2017). Acute-Chronic Workload models must also be monitored and considered (Bowen et al., 2016; Hulin et al., 2016; Murray et al., 2016).

James Moore concluded the session by discussing factors which may speed up the RTP process. Key decisions include:

·         Effective differential diagnosis and classification

·         1^st 48 hours is critical – do not be afraid to offload with crutches

·         Athlete profile

·         Sport profile

·         Athlete specific clinical outcome measures

·         Define the end point early

·         Need to pass clinical measures at each stage (stretch, force, palpation)

·         Capacity Assessment within the rehab

The injury continuum includes mechanism, type, location and size and should be considered in all cases.

E.g Injury profile/classification for a Quad Injury – consider how these variables interact with each other:

·         Mechanism

o   Under striding vs bwd lean vs Hip Extension vs backswing vs VGRF

·         Sports Mechanism

o   Sprinting vs kicking (high vs low velocity of limb movement)

·         Location

o   Proximal vs Mid vs Distal/Tendon vs Muscle vs Fascia

·         Size / Grade

o   0, 1, 2, 3, 4 (a, b, c)

·         Functionality

o   Of the region (architecture) vs the individual (kinetics) vs sport specific

Typical vs Atypical Hamstring Injury?

Typical:

·         Proximal BF in terminal swing phase at speed

·         Distal medial hamstring on stance phase (sprinting)

·         Proximal SM in stance on rapid stretch

Atypical:

·         Distal BF on stance phase (running)

·         BF muscle belly alone

·         Proximal Medial hamstring (SM) in swing phase (sprinting)

Muscle Architecture should be relevant to the rehabilitation, and how the muscles work synergistically:

Muscle	Fibre Length (cm)	Pennation	PCSA (cm2)	Peak Force (N)	Tendon Slack
Gastroc – medial	5.1	9.9	21.4	1308.0	40.1
Gastroc – lateral	5.9	12.0	9.9	606.4	38.2
Soleus	4.4	28.3	58.8	3585.9	28.2
Tibialis Anterior	6.8	9.6	11.0	673.7	24.1
Peroneus Longus	5.1	14.1	10.7	653.3	33.3
Peroneus Brevis	4.5	11.5	5.0	305.9	14.8
Tibialis Posterior	3.8	13.7	14.8	905.6	28.2
FHL	5.3	16.9	7.2	436.8	35.6
FDL	4.5	13.6	4.5	274.4	37.8

In sports which require a change of direction, consider developing ankle power, PF moment and minimal ground contact time (Marshall et al., 2014).

In the first 48 hours:

·         Inflammation – friend or foe?

·         Avoid use of NSAID’s

·         Ice and compression critical

·         Early movement useful, but avoid stretching

·         Avoid direct soft tissue work

·         Avoid excessive travel

Muscle Stiffness regulated by:

·         Muscle activation frequency (temporal summation)

·         Muscle fibre recruitment (spatial summation)

·         Sarcomere length-tension relationship

·         Sarcomere force-velocity relationship

·         Passive sarcomere length-tension relationships

·         Intrafusal and extrafusal (muscle spindle) fibres feedback mechanism

·         Muscle force and moment regulation by skeletal muscle architecture

Early rehab activity:

·         Short period of immobilisation

·         Early resumption of activities during the repair and remodelling (Orchard & Best, 2002)

·         Initial loading within a protected MT length (Sherry & Best, 2004)

Agility & Stability

·         Progressive agility and trunk stabilisation > isolated stretching & strengthening (Sherry & Best, 2004)

·         Relative flexibility vs relative stiffness (Hamilton, 1996)

·         Direction of movement allows early loading of injured tissue and resumption of NM co-ordination (Sherry & Best, 2004)

·         Later stages plyometric activities NM co-ordination and prepare for rapid high load movements (Chmielewski et al., 2006)

Specific Loading

·         Atrophy greatest risk of re-injury after tissue healing (Orchard & Best, 2002)

·         Lower incidence of hamstring injury has been reported in athletes who undergo high load eccentric hamstring training (Askling, 2003)

·         Running – max peak torque coincides with eccentric activity occurring at late swing phase (Heiderscheit, 2005)

·         Following injury it shifts to shorter muscle lengths (Brockett, 2004)

·         HamSprint drills may reduce the risk of recurrence (Cameron, 2009)

·         High load eccentric training may shift the peak torque to longer lengths (Brockett, 2004)

McAllister et al.’s (2014) paper ‘Muscle activation during various hamstring exercises’ is an essential read.

Return to Running following Quad & Hams Injury (Freckleton, 2013)

·         Repeated bike sprint efforts

o   (>140rpm) 30s duration – Growth Hormone production (Stokes, 2010)

·         Single leg strength endurance challenge

o   1 leg Hack Squat vs Step Ups

·         Speed frequency loading in Quadriceps

o   Velocity & Volume

·         Drop Jump Capacity

Tendinopathy at FISIC 2017

On the 27th & 28th September 2017, staff and students from Plymouth Marjon University went up to the Fortius International Sports Injury Conference in London.

Over the 2 days there were some fantastic, inspirational break out sessions. Here, Sarah Martin (Lecturer in Sports Therapy & Rehabilitation, & Programme Leader for the MSc Sport Rehabilitation) shares her notes on the Tendinopathy breakout session.

London Marathon 2017 - Rocktape role for Sport Rehabilitation student Maisie Squibb

The London Marathon. One of the most sought after events of the marathon calendar.

On Saturday 22nd April, BSc Rehabilitation in Sport and Exercise second year student Maisie Squibb volunteered to support RockTape at the London Marathon expo, providing free RockTape applications to runners.

The atmosphere in the expo was electric with everyone pumped to be running the following day. Both the RockTape stands were rushed off their feet all day so a massive well done to everyone involved!

It was a great way to practice and learn new taping techniques from the other 'Rock Docs'. Most of the taping was for knees, ITB, Achilles, plantar fascia, lower back and shin splints. I couldn't even fathom a guess to how many people we taped on the Saturday, all I know is it was a huge amount. I'm sure if you watched the marathon on TV, you would've seen the tape (some of it is pretty bright!).

Maisie's Uniform and Pass for the London Marathon Expo 2017

For anyone wondering if they should volunteer, I would 100% say YES! I didn't know anyone before helping out, but they were all incredibly friendly and very knowledgeable. It is a great place to soak up the atmosphere for all the amazing people running for great causes, you may even get to see some famous faces - I got to see Paula Radcliffe on one of the stands! 

Volunteers at the London Marathon Expo (Credit: Rocktape UK)

To find out more about our BSc Rehabilitation in Sport and Exercise or our BSc Sports Therapy courses at Plymouth Marjon University, visit our website. Our courses have lots of built in and heavily subsidised CPD courses and qualifications which provide students with additional contacts for work placements such as Maisie's experiences working with RockTape. 

This blog post was edited by Sarah Martin, lecturer in Sports Therapy & Rehabilitation and course leader for the MSc Sport Rehabilitation at Plymouth Marjon University (smartin@marjon.ac.uk).

BASES Student Conference 2017

As first year Sport Rehabilitation students, we were excited to attend the BASES Student Conference for the first time. As the theme was clinical sport and exercise science, we were expecting to be out of our depth with the content. However, we found that the topics discussed were extremely relevant to our degree which gave us potential to pick up some top tips along the way.

BSc Rehabilitation in Sport and Exercise students Amy Day, Becky Jacob-Harris, Heli Radcliffe & Laura Woodbridge.