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ESSA-accredited Knee Rehabilitation Course 10/09/2016

Elite Rehab is hosting a highly practical 1-day course on clinical management and high level rehabilitation of knee conditions for ESSA-accredited exercise physiologists and rehabilitation coaches on 10th September 2016. The course boasts some of the most experienced clinicians in the fields of Sports Physiotherapy, Rehabilitation, and Strength Coaching to give a well rounded cutting approach to the management of these patients.

Presenters:

  • Tim McGrath (PhD Candidate and Head Physiotherapist Port Adelaide Football Club)

  • Billy Giampaolo (Strength / Power Coach and Former World Record Holder)

Venue Details:

Elite Rehab & Sports Physiotherapy
17Q / 2 King Street Deakin ACT 2600
reception@ersportsphysio.com.au
(02) 6282 6889

Booking Information:

Click and download the following form and return to reception@ersportsphysio.com.au or fax: (02) 6285 3886 with payment by 3rd September 2016

Advanced Knee Rehabilitation Course Booking Form – Click to Download

APA Accredited Advanced Knee Course For Physiotherapists

Elite Rehab is hosting a highly practical 2-day course on knee diagnoses, imaging and management of knee conditions for physiotherapists on 30th-31st January 2016. The course boasts some of the most experienced clinicians in the fields of Orthopaedics, Sports and Exercise Medicine, Rehabilitation, Strength & Conditioning and Speed to give a well rounded cutting approach to the management of these patients.

Presenters:

  • Tim McGrath (PhD Candidate and Head Physiotherapist Port Adelaide Football Club)

  • Dr. Rob Creer (Orthopaedic Surgeon)

  • Billy Giampaolo (Strength / Power Coach and Former World Record Holder)

  • Dr. Kylie Shaw (Sport and Exercise Medicine Physician)

  • Marcus Kain (Head of Strength and Conditioning Wests Tigers NRL Team)

Venue Details:

Elite Rehab & Sports Physiotherapy
17Q / 2 King Street Deakin ACT 2600
reception@ersportsphysio.com.au
(02) 6282 6889

Booking Information:

Click and download the following form and return to reception@ersportsphysio.com.au or fax: (02) 6285 3886 with payment by 15th January 2016

Advanced Knee Course Booking Form

Elite Women’s Rugby Program Information

Good Afternoon Ladies,

We are pleased to announce the 12-week Elite Women’s Rugby Program schedule has been finalised and the details are as follows:

Start Date: Tuesday 22nd September 2015 End Date: Thursday 10th December 2015

Session Times:

  • Tuesday (strength) 5:30pm – 6:30pm

  • Thursday (speed/power) 5:30pm – 6:30pm

The total cost: $480 ($40 per week/$20 per session) due by Tuesday 22nd September to Elite Rehab and Sports Physiotherapy either by cash, card or over the phone payment. Private Health Fund rebates will be available after the final session (10th December) with a collated invoice to take to your health fund provider.

The program will be coordinated by David Slater (Royals Head S&C) and assisted by Kristian Waller (Physiotherapist). The initial training session and final week of the program will test strength, power, control and speed performance.

Please contact the practice for the Health Pre-screening Form, which needs to be filled out and either emailed to reception@ersportsphysio.com.au or brought to your initial session on Tuesday 22nd September.

Please notify reception by Friday 28th September via email or phone if you wish to participate.

If you have any concerns or queries, please do not hesitate to contact us.

Kind Regards,

Tash Hart

Elite High Performance

 

Train Like The Pro’s Do

By David Slater Accredited Exercise Physiologist

The object of any competitive sport is to win! But how do you develop a winner physically?

There are varying levels/grades of competition that get more competitive the closer you are to the elite pinnacle. With greater competition comes a great requirement for superior skill and physical dominance. At the elite level of most sports, players gain access to professional coaching that targets both skill and physical development. However, a club level athlete often only has access to skills-based training sessions during their designated season and is often left to complete their own physical development

So without any professional guidance where is a club level athlete supposed to start? How do they develop a plan and how do they overcome barriers and complacency?

If you fail to prepare, you’ve prepared to fail

The off-season should initially be a time to recover and reflect on the season past. However, after a few weeks of rest & recovery if you are serious about your sport the attention should quickly turn to -how can I improve myself to be better next season?. For most field-based sports physicality and athletic prowess can often be the critical difference between athletes. Therefore, it is essential to improve the various physical attributes specific to the sport (strength, speed, power, etc).

When looking to prepare an offseason program, each individual athlete needs to identify what his/her physical shortcomings are (too heavy, lean, weak, slow, injury prone, etc). These shortcomings should then be prioritized to ensure the program is designed accordingly to sufficiently accommodate these goals. Once these first two components have been clarified, the program length and frequency can then be mapped out.

A common question surrounding gym-based training is “how often should I train?” The simple fact of the matter is that there is no black or white answer as each individual is different. However, there are guidelines to help steer you into the right direction because training frequency depends on the training goals and available time. Muscle hypertrophy is defined by time under tension and thus requires increased volume to ensure the muscles are stimulated enough to adapt and grow. Strength is defined as the maximal force you can apply against a load. Power is defined as the ability to exert a maximal force in as short a time as possible. Therefore, if the training goals include hypertrophy for example, then the training program will require more training time due to increased volume, as where power and strength require a greater intensity (working hard at the time) but likely greater break between sessions. Volume can be implemented in various ways, such as more repetitions (8-12), more sets (4+), more exercises or more training days (3+).

At the completion of this process, the training plan should have identified the following key features:

Table

Variety is the spice of life

All too often athletes and weekend warriors complain about ‘hitting a wall’ with their training. However, most people don’t understand that because the body is the ultimate adaption tool, it gets comfortable with training regimes and needs to be challenged out of its comfort zone. For example, flat bench press with a barbell may be the testing modality but it can?t be the only chest focused training exercise. Varying lifting apparatus, lifting speed ratio, volume and intensity will ensure the muscles do not get comfortable.

Another important element of a training program for a functional athlete is their injury prevention training. This should be a key feature of every athletes training program because without the ability of the joints to stabilize and control force, there is increased risk of injury. Injury prevention training should be included at the beginning of each training session as part of the warm-up. It?s during this time when the body is fresh that the various muscle groups can be warmed-up using highly neuromuscular focused exercises (jungle gym push-ups, Turkish get-ups, mini-tramp hops, etc). Pre-existing injuries should always be prioritized, otherwise a general combination of upper and lower body exercises.

The final element to consider with the training program is postural/abdominal/core strength and capacity. This is best done at the end of a training session because pre-fatigue of these important muscles can severely impair the body’s ability to maintain technique during compound lifts such as squats.

When mapping out exercise variety, various modalities should be used to ensure muscle groups are continuously challenged and stimulated in line with the training goals. Continuing on from the above training plan, lower limb exercise variation may include:

Program 1
Day 1 – Squat & Single leg bridge
Day 2 – Split squat & Nordics
Day 3 – Diamond deadlift
Program 2
Day 1 – Box squat with power band & Glute-ham raise
Day 2 – Deadlift & Glute-ham hold
Day 3 – Bulgarian squat & Leg press

Program 3
Day 1 – Lateral box lunge & Romanian deadlifts
Day 2 – Squat from rails & Single leg glute-ham holds
Day 3 – Front squat & Step-up with gluteal endurance

With strategies and a plan any goal can be strived for, the final step is implementation. For further information or guidance with any of the above information please contact the practice.

How to prevent lower limb injuries

By Tim McGrath, APA Sports and Musculoskeletal Physiotherapist, PhD Candidate

The health benefits of sport and exercise are unquestionable, but staying injury-free is the ‘holy grail’ of both active people and sports medicine professionals alike. No one likes spending time on the sideline. It is beyond the scope of this article to give a ‘one size fits all’ approach to prevention of EVERY lower body injury related to work or sport. The reality is that the more you know about the subject, the more this becomes apparent. However, it is our experience that many people participate in sport without proper physical preparation, and thereby expose themselves to injury. A high percentage of injuries (particularly in social sports groups and work-related activity) could perceivably be prevented by better preparation prior to the chosen activity. The focus of this article then is to give practical examples backed by research to help you reduce your risk of injury.

How ready are you for sport?

Broadly speaking, good physical preparation can be broken down into 2 main categories:

1. Strength, plyometric and balance
2. General aerobic fitness / running conditioning

Strength, balance and plyometric activity

In simple terms, one of the main jobs of our muscular system is to dynamically control how the body moves. The better one is at this, the less the body is dictated to by external forces (e.g. landing from a jump) during sport. Without this system, the body is increasingly forced to use passive tissue structures (e.g.: tendon, ligament, cartilage and bone) to absorb force, which can cause damage to these tissues through trauma or progressive overload over a period of time.

A key component in prevention of lower limb injuries is to have sufficient strength and dynamic balance to optimise movement during sport. Resistance training in general increases both athletic performance and contributes to injury prevention by increasing joint stability. Balance and plyometric activity relate to HOW these different structures coordinate movement in a safe and effective manner. They rely on both efferent (impulses coming from the brain to the tissues) and afferent signals (feedback from the tissues back to the brain about how movement is coordinated).

We know from research that many movements (i.e. running, jumping etc.) are pre-planned activities within the brain. Poor movement habits are associated in research with increased injury risk. A review by Hubscher et al (2010) pooled the results of seven well-constructed studies which looked at the effectiveness of balance training in reducing the incidence of injuries (including acute knee injuries and ankle sprains) and found significant risk reductions in both.

General aerobic fitness / running conditioning

An important part of injury prevention is the ability to participate in a given activity without excessive fatigue. Fatigue is associated with an increased risk of injury as it is proposed to promote extreme (sub-optimal) lower limb biomechanics. This includes:

1. A more extended hip and knee posture
2. Increased hip rotations
3. Increased movements and loads at the knee joint (McLean, 2009)

The important effect of this is that apart from poor performances, the worse our conditioning is, the more likely we will move in a ‘lazy’ fashion to try to conserve energy but expose ourselves to increased risk of injury. The ‘double-whammy’ is that should an injury occur in such individuals, the harder it is to optimise recovery due to starting from a ‘poor base’.

So What Can I do to reduce my risk of Injury?

The simple answer is to better prepare yourself for the activity you aim to participate in. For example, don?t expect to turn up and play social netball after 12 months without any activity and expect to remain injury free. Some people can indeed get away with this, but many can?t.

In attempt to promote this form of injury prevention, some organisations have attempted to develop specific programs to help combat this. The best programs attempt to combine the elements described above, as none of these appear to be individually worthy on their own right alone. An excellent example is the FIFA 11+ (http://www.f-marc.com/downloads/cards/11pluscards_e.pdf) program. The program is aimed at soccer players, though could be applied broadly across a range of team sports. Daneshjoo et al (2012) reported that the FIFA 11+ program was successful in improving dynamic balance and joint control in professional male soccer players.

Although programs such as the FIFA 11+ are designed to be conducted as part of the pre-session warm-up, it is my own humble opinion that these training elements should ideally also be addressed in greater detail during an average training week to avoid both under stimulation (and therefore a reduced effect), or excessive fatigue prior to actually participating in the session (and thereby increase injury risk). However, it is generally accepted that an active warm-up that utilises many of the elements found in the FIFA 11+ program are the best way to immediately prepare the body for activity.

If you would like any further information, please feel free to contact the practice.

Pregnancy: It can be a pain in the a#$

Pain during pregnancy – the pelvis

Whilst the agony of pregnancy should only be about choosing a name and assembling the Ikea cot, for almost half of pregnant women there is the added burden of disabling pelvic pain which typically presents through the second trimester.

Pregnancy related pelvic pain is a familiar issue to Physiotherapists and can be difficult to treat. This is due to the complex nature of the problem, the close proximity of the pelvis to the hip joints and low back. Also, because the pregnant body continually changes – posture, fluid and hormone levels progress, the problem you were dealing with one week is completely different to the next.

The majority of pelvic pain during pregnancy occurs around the buttocks and the pubic symphysis (where the pelvis meets at the front). Typically, the onset of pain occurs around the 18th week and reaches peak intensity between the 24th and 36th week of pregnancy. This pain can radiate to other parts of the pelvis and to the upper and lower legs but can have a similar referral pattern to herniated discs, facet joint syndrome and spinal stenosis which complicates diagnosis. It is aggravated by transferring load to a single leg, such as walking, stair climbing or getting in and out of a car.

Where does the problem occur?

The sacroiliac joint (SIJ) is a primary source of dysfunction effected by a complex system of structures, which attempt to stabilise and control movement at the pelvis. The events which prepare the pelvis for delivery (namely the release of a hormone called Relaxin), also affect the function of the pelvis to transfer load (whilst walking) and compromise stability. This can lead to disabling pain and impaired function during pregnancy which requires astute assessment, differential diagnosis and applied intervention by a Physiotherapist.

Pelvis

The sacrum sits between two large pelvic bones called ilia. The attachment of the sacrum to the ilia is the sacroiliac joint. The joint surfaces are flat (to allow forward bending) and are therefore vulnerable to shearing forces. Normally held strongly together by a system of ligaments and muscles acting over the joint, when pregnant the ligaments and muscles are unable to sufficiently support the pelvis and it is the asymmetric shearing of the joint that causes pain. The laxity of ligaments, ineffective timing and activation of surrounding muscles occurs during pregnancy for various reasons:

1. Relaxin is a hormone which peaks at the 12th gestational week, with a gradual reduction until the 17th week. Relaxin decreases the intrinsic strength of connective tissue to allow it to stretch (prepares the pelvis to enable it to separate when giving birth).
2. Due to pregnancy related changes in posture, the deep (core) muscle system which controls the stability of the pelvis is stretched and is unable to work at the optimum tension. The global (bigger muscles designed to move rather than stabilise) muscle system is also affected with the splitting (diastasis) of the abdominals.
3. Increased ligament laxity also allows separation of the pubic symphysis in preparation for birth. A 10mm diastasis of the pubic symphysis is not uncommon in pregnancy.

The effect of pregnancy on the body

Pregnancy

Pregnancy table

Getting the right diagnosis!

The pelvis is a complex area and pain can be often confused with low back or hip pain. Therefore a good Physiotherapist will develop a diagnosis by clinically assessing the lumbar spine, hip and pelvis to differentiate between the areas and localise a source of pain. This is important as the path of treatment will change based on the diagnosis.

Magnetic resonance imaging (MRI), computed tomography (CT) and bone scans of the SIJ cannot reliably determine whether the joint is the source of pain. The use of ultrasound diagnostically can determine the effectiveness of the stabilising muscles.

Treating pregnancy related pelvic pain

The modalities listed here are those which have been shown to be most appropriate and helpful.

1. Supervised exercise: There is no doubt in the literature that a supervised exercise program is the best form of Physiotherapy for this issue (either on land or in the pool). Treatment should begin with the retraining of the local muscle system (core muscles including pelvic floor); Because there is room to make the pain worse with the wrong exercises or by performing the right exercises incorrectly, any prescribed program should be supervised initially and individualised.
2. Mobilisation/ Manual treatment including massage: Mobilisation techniques and soft-tissue release are appropriate for treatment. It must be recognised that ligaments of the pelvis remain stretched for as long as 6-12 months following delivery and joints are more mobile as a result. This should therefore be considered before undergoing aggressive manual therapy techniques such as manipulation of the pelvic joints.
3. The pelvic belt: The prescription of a pelvic belt is common practice as it has been shown to produce relief. The basis for the use of the pelvic belt is that the joint surfaces are placed in a position of maximum stability. The pelvic belt – whilst not the next thing to hit the fashion runways, allows decreased pain following activity and increases tolerance for daily activities.
4. Education: Understanding the issue and how to retrain muscles, alleviate pain and to avoid aggravating factors is a helpful adjunct to treatment.
5. Hydrotherapy: Hydrotherapy has been shown to be effective for reducing pain and improving movement in women with pelvic pain. The benefit of water exercise is it is low impact, the whole body can be exercised with the training of core and global muscles systems, integrated.
6. Acupuncture: Whist acupuncture alone has not been shown in the scientific literature to be helpful in reducing pregnancy related pelvic pain, one quality study found acupuncture and stabilising exercises decreased pain greater than stabilising exercises alone (Elden et al. 2005).

It is always best to prevent pelvic instability and exercise programs can start prior to pregnancy. However, if pain develops during pregnancy, outcomes are better if treated it in the initial stages.

A Hands On Approach

Helen Mussett joined Elite Rehab & Sports Physiotherapy in 2013 after working in Canberra since 2001. Her main interest continues to be found on post-operative shoulder rehabilitation. She also works with patients following hip and knee joint replacement surgery. Helen is an APA titled Musculoskeletal Physiotherapist, which recognises her high level of expertise. This month we asked Helen to reflect on her vast experiences and share some of her ‘pearls of wisdom’. Enjoy!

 

I have been a Physiotherapist for nearly 38 years, longer than half the world?s population has been alive.

I have enjoyed my career for many reasons. It has been enriching in that it has enabled me to travel and work overseas. It has allowed me to do some teaching, to work in a variety of settings and to meet people from all walks of life.

I have had the privilege, as do many physiotherapists of working very closely with people. Patients can be surprisingly candid and honest in that face to face situation.

Being a physiotherapist means that apart from all the practical skills you learn, you need to be empathetic enough to communicate well with your patients. Having them onside, having their compliance is essential to the successful outcome of treatment. I believe that there is ?art and science? in the practice of physiotherapy.

The practice of physiotherapy has changed dramatically since I first graduated. The most important change being that we are now first contact practitioners. This places much greater responsibility on us for patient care and has led to major changes in the education of physiotherapists. Research and evidence based practice i.e. ‘the science’, are core requirements of best physiotherapy practice today.

Despite all this, for me one of the most important aspects of my practice, apart from communicating well has to do with the ‘art’ side of the art and science equation. It is the ‘hands on’ aspect of my work ¬†feeling what the tissues can tell me about their condition and how pain behaviour relates to what I feel when I move the joints and tissues.

I sometimes feel that this skill of palpation is not used to advantage for it plays a large part in forming our treatment choices.

I work in musculo-skeletal physiotherapy and in recent years, mostly in the area of post-operative orthopaedics. Treatment after most surgeries follows a prescribed course where progression is associated with the degree of healing in the tissues and the amount of load the structures can take. Failure to move smoothly from one stage to the next can be a barrier to progress overall.

It is here that what we feel when moving or testing the tissues can tell us how to overcome the barrier. When treating the shoulder for example, the joint can be painful to move actively and passively. But feeling the quality of the passive movement tells us how the pain is related to movement. Failure to recognise pain caused by stiffness, as opposed to pain caused by impingement or inflammation, and dealing with the stiffness using adequate ‘hands on’ passive stretching and mobilisation, will slow progression even if the patient continues range of motion exercises. A joint that can’t move fully, can’t strengthen fully nor function fully.

My point here, and it is only an opinion, is that we need to have enough time with our patients to avoid so called ?recipe? treatments. We need to have adequate time to assess, using clinical reasoning and ?hands on? skills to provide optimal treatment for our patients, so they can progress to a more active programme and complete their rehabilitation.

I believe our manual ?hands on? skills in assessment and treatment, along with well honed clinical reasoning skills, are what provide us with a unique point of separation from other practitioners. They are an essential part of the ‘art’ in the art and science of physiotherapy practice.

 

What you sow you shall reap

Like most life events the more work, effort and dedication you put into an activity the greater your chance of achievement and reward. Rehabilitation post injury is no different. It doesn?t matter if you are a ?weekend warrior? with a sprained ankle, a high-level athlete post surgery or an employee with chronic back pain. The more work, effort and dedication you put into your rehabilitation program the greater your chance of maximizing your post-injury function within the shortest possible timeframe.


The Devil is ALWAYS in the detail

Your body is the ultimate adaption tool and for better or worse it will adapt to whatever stimulus (or lack thereof) you expose it to. Typically optimal recovery post-injury follows a characteristic pattern:

Phase 1: Early Post-Injury or Post-Operative Phase
Phase 2: Early Functional Strengthening Phase
Phase 3: Rehab Running and Resumption of Functional Activities Phase
Phase 4: Running Intensity / Integrated Activity Phase
Phase 5: Return to Sport Phase

It is the responsibility of your exercise physiologist or sports physiotherapist to prescribe the specific exercises within these phases at the right intensity & volume. However, it is your responsibility to complete the program with diligence and accuracy. Unfortunately, patients who don?t put in the required hard work, effort and dedication get sub-par results and are usually the ones complaining that their ?physical function was never the same?.

Likewise the content of the program needs to be quality, and the devil is always in the detail. Arguably, many rehabilitation protocols in use today focus too heavily on low-loading functional sport-specific exercises at the expense of weight training. Another reason could be that the weight training intensity is indeed too low during rehabilitation in order to produce improvements in muscle size and strength (Thomee, 2012).

How should I structure a rehab program to make sure I get the best result?

During the ?functional strengthening phase? of a rehabilitation program, it is important to expose the targeted muscles to a stimulus that will promote positive adaption (improved strength, control, etc). One of the reasons elite level athletes are able to return back to their chosen sports ASAP following an injury is their access to professional supervision. Professional supervision is important because it ENSURES that all assigned exercises are completed properly and progressed as functionally able without delay. Unless you have exceptional body awareness, understanding of exercises and motivation then strictly home-based programs will not work. More commonly, a combination of supervised rehabilitation sessions and home-based exercises are ideal to ensure accuracy, diligence and understanding.

The length of a rehabilitation program will largely depend on the type of injury (acute / chronic), location & an individual?s pre-injury physical condition. The vast majority of injuries (if detected early and diagnosed correctly) can be mapped out to the week /day back to a full return to pre-injury activities. However, the reality is that age, pre-injury fitness levels, how chronic the injury is, and the location (tendon in particular) can vary and increase the time and effort needed to get the best possible result.

No one ever plans to fail but many have failed to plan. Thus, every rehabilitation program should have a clear plan that outlines the goals, timeframe and staged progressions. The staged progressions should detail how you will progress to your goal within the desired timeframe. Below is an example of a rehabilitation plan for a rugby player recovering from a grade 1 rectus femoris tear.

3 week optimal return to play timeframe

Stage 1 (day 1-4)
– Return ROM and manage symptoms (RICE)

Stage 2 (day 5+) – Criteria to start this stage is NO local tenderness
– Bodyweight quadriceps loading
– Introduction to exercise bike

Stage 3 (day 7-13) Criteria to start this stage is NO pain on bodyweight lunge
– Rehabilitation running (volume)

Stage 4 (day 14+) Criteria to start this stage is NO pain with 2km running volume
– Rehabilitation running (intensity)

Stage 5 (day 18+) Criteria to start this stage is NO pain accelerating to or holding 90%+ speed
– Team training

Play (day 21+) Criteria to play is completion of team training with nil issues

Supervised ?practice makes perfect?

Having an accurate plan is essential but the success of a rehabilitation program lies in the specificity of the exercises, attention to detail and practice. Detail is achieved through accurate feedback, which is the missing key separating home based and supervised rehabilitation programs. In the early stages of a new rehabilitation program it is easy to loose form and develop / reinforce bad habits. However, accurate feedback ensures the cementing of a strong foundation that you can build and progress exercises from. Only once you have demonstrated the ability to recognize incorrect technique and correct it yourself, should you begin transitioning towards self-supervision.

Arden et al (2011) found 3-27% of Autograft hamstring ACL reconstructions have hamstring strength deficits up to 3 years post op. However, current isokinetic strength data collected since February 2011 on patients who have had an ACL knee reconstruction and completed supervised rehabilitation at Elite Rehab & Sports Physiotherapy demonstrate an average return to equal strength between limbs at 16 weeks (dominant leg injured) and 24 weeks (non-dominant leg injury). These results support the impact of supervised rehabilitation and the ideology what you sow you shall reap.