Clinical Monthly

200th Edition

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The Clinical Monthly Team

Sam Barr News of the Month

Qualified: BSc (Hons) Physiotherapy

Clinical Interests: Back pain, health and wellbeing

Josh Featherstone Clinical differential of the Month

Qualified: BSc (Hons) Physiotherapy

Clinical Interests: I love rehab

Abi Peck Editor

Qualified: BSc (Hons) Physiotherapy

Clinical Interests: Hands and spinal pathology, netball rehab

Scott Rowbotham Podcast of the Month

Qualified: BSc (Hons) Physiotherapy

Clinical Interests: climbing and improving physical activity for children and adults with long term disabilities

Lee Platt Journal of the Month

Qualified: MSc (Hons) Physiotherapy

Clinical Interests: all areas in MSK

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News of the Month

Including the Nordic hamstring exercise in injury prevention pro-grammes halves the rate of hamstring injuries: a systematic review

and meta-analysis of 8459 athletes (van Dyk et al, 2019).

Do Nordic hamstring exercises prevent hamstring injuries when included as part of an injury prevention

intervention?

The Nordic hamstring exercise (NHE) is thought to be an effective injury prevention tool that may

reduce the number of hamstring injuries if implemented successfully. The results of this study indi-

cate a statistically significant and clinically meaningful reduction of 51% in hamstring injuries.

This study used research from a wide population range in terms of age, gender, and type of sport –

the reduction in injury rates were the same for all athletes competing at different levels of competi-

tion and across multiple sports.

Systematic reviews should inform clinical practice where possible, and clinicians can be confident

that the inclusion of the NHE programme is supported when hamstring injury reduction is a goal.

There is a large amount of variability in the training protocols used to introduce eccentric training

through the NHE. To improve adaptation and implementation of the NHE, the focus should be di-

rected towards dose response relationships, as well as compliance and adherence with the pre-

scribed exercise to improve prevention programme efficacy.

The mechanism by which the NHE provides a protective effect is not yet fully understood. The NHE

may increase fascicle length, leading to morphological changes that may protect the hamstring mus-

cle from injury. Alternatively, increasing eccentric strength may reduce the risk associated with a

hamstring injury.

#NewsOfTheMonth by Sam Barr

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News of the Month

Plantar flexor strength and endurance deficits associated with mid-portion Achilles tendinopathy: The role of soleus (O’Neill et al, 2019).

Which plantar flexor is most affected in patients with an Achilles tendinopathy and how does this impact our rehabilitation? Evidence suggests plantar flexor weakness predates the onset of Achilles tendon pain

suggesting a cause and effect relationship between plantar flexor weakness and tendi-nopathy.

Muscle weakness has been identified as an important factor in mid-portion Achilles tendinopathy (AT) with experts suggesting this is the primary modifiable risk factor for athletic tendinopathy. However, no consideration has been given to which muscle is most affected – gastrocnemius or soleus.

This study suggests that Achilles tendinopathy is associated with large deficits in plan-tar flexor force and endurance.

- There are large statistically and clinically meaningful differences in plantar flexor strength and endurance between subjects with and without Achilles tendinopathy. - The deficits are bilateral in nature and appear to be explained by a greater loss of the so-leus force generating capacity rather than the gastrocnemius. Rehabilitation should take into account the specific strength and endurance deficits

associated with Achilles tendinopathy. However, the lack of difference in force between limbs of subjects with AT suggests

that clinicians should not aim to rehabilitate peak force to that of the uninjured/asymptomatic limb as this limb does not appear to have normal power. Clinicians should instead use normative data from relevant populations as rehabilitation targets for plantar flexor force.

It is important that rehabilitation also targets the bilateral weakness identified as this may explain the high rates of the asymptomatic limb becoming symptomatic in the future.

It would appear likely that rehabilitating force capacity to levels of around twice body-weight would allow the plantar flexors to function within normal physiologic levels during locomotion and that this may account for improvements in the clinical mani-festation of AT.

#NewsOfTheMonth by Sam Barr

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News of the Month

This framework is adapted from a recent BJSM podcast by Seth O’Neill (‘Talking tendinopathy and

solving the soleus conundrum with Dr Seth O’Neill’ – April 2019) and is based on treating Achilles

tendinopathies but can be used as a guideline for treating all lower limb tendinopathies.

#NewsOfTheMonth by Sam Barr

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Differentials of the Month

Shoulder Differentials by Josh Featherstone

Last months

Clinical case

Subjective: 22 year old female rugby player sustained a heavy tackle onto her shoulder at the weekend

Objective: specific pain localised to her acromioclavicular joint (ACJ) and a step deformity

of her ACJ.

The working diagnosis of last issues ‘differential diagnosis’ case study is ACJ strain. Pathology: The acromio-clavicular joint (ACJ) is a common site for injury either from a fall directly onto the shoulder or through contact (A. Cools 2017). A 6 stage classification system is used to classify injuries sustained to the ACJ. Type 1 = sprain to the joint capsule and localised tenderness to the ACJ accompanies with pain on movement especially on horizontal adduction Type 2 = complete tear of the acromio-clavicular ligaments and sprain of the coraco-clavicular ligaments. Type 3 = complete tear of the coraco-clavicular, conoid and trapezoid ligaments with an ob-served step deformity Type 4 = complete tear of the coraco-clavicular, conoid and trapezoid ligaments with an ob-served step deformity Type 5 = Differential between type 5 and 3 depends on clavicular distance from acromion radi-ographically. Type 5 injuries have between a 3-5 x increase in corococlavicular space than a normal shoulder. Also have complete tears of the coraco-clavicular, conoid and trapezoid liga-ments with an observed step deformity Type 6 = complete tear of the coraco-clavicular, conoid and trapezoid ligaments and n inferi-orly displaced clavicle into sub-acromial or subcoracoid positions. (Cools 2017).

Management: Refer through to peripheral ESP as per traumatic shoulder guidelines within east Suffolk Initially ice and offload Sling for 2-3 days for type 1 sprains and 6/52 for type 2-3

injuries. Exercises and taping the ACJ are advocated initially as

pain allows and a return to functional activities/ rugby once tenderness has settled and patient has full pain free active ROM

More severe injuries to the ACJ consisting of type 3-6 may result in a reduction in shoulder stability and might be considered for surgical intervention (Cools, 2017)

References Cools, A. (2017) Shoulder pain ‘in’ Brukner and Khan’s Clinical sports medicine: 5th edition McGraw- Hill Educa-tion: Sydney

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Differentials of the Month

Elbow Differentials by Josh Featherstone

Clinical case

Subjective A 52 year old female who is dependent on mobilising with 2 x elbow crutches present-ed to physiotherapy with a 1 year history of right posterior elbow pain located at her olecranon. Objective: On assessment there is no apparent swell-ing and she has full active and passive ROM of her elbow. She has relatively good strength through elbow extension but reports pain on resist-ed extension at inner range elbow flexion. She denies any other further resisted pos-terior elbow pain through range

Differential diagnosis

1) Olecranon bursitis

2) Posterior elbow impingement

3) Insertional triceps tendinopathy

Last months differential diagnosis has been revealed as a ACJ Sprain. This months differential diagnosis is detailed below, lets see how well you can do!

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Podcast of the Month

BJSM Podcast - Physical activity in pregnancy—what, when, how and why to be active: Prof Greg Whyte, OBE. #367

1) What is the current consensus on exercise during pregnancy?

Research is limited and guidelines are given on limited research compared to other areas.

The concept of physical activity being beneficial for longevity and health holds true for both mother and baby during pregnancy (and post).

Physical activity should be encouraged due to the benefit of coping with stress and the psychological aspects of pregnancy

Useful in dealing with changing hormones during pregnancy and postpartum.

If pregnancy services are poor in a particular area then exercise and classes can be a useful social construct to meet pregnant women for a better support network and reduce isolation

Importantly what a person does pre-pregnancy will indicate what they should do during pregnancy.

Focus should be spent on maintaining fitness levels.

Modified versions of exercise such as pregnancy yoga and pilates are useful due to physical and psychological benefits of this form of exercise

Overheating needs to be considered particularly in first trimester therefore all ex-ercise should be no harder than moderate intensity and appropriate clothing to prevent overheating. The “talk test” i.e. ability to talk during exercise or rate of perceived exertion is a useful tool for in-tensity.

High risk and medium risk should have input from consultant or midwifery. Ex-ercise is still very important in these groups.

Maintaining levels of fitness will allow a faster return to sport or chosen activity that they were previously accustomed to.

# Podcasts by Scott

Last months podcast revealed

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Podcast of the Month

2) What are the common misconceptions and top tips?

Oxygen and nutrient delivery to the foetus is favoured over the mother therefore concern about poor oxygen delivery to the foetus is unwarranted.

Pelvic floor exercises should be encouraged throughout and post pregnancy.

Monitoring of weight is important – over and underweight during each milestone of pregnancy can be detrimental to foetal development.

WHO recommend 150 minutes of moderate intensity exercise per week.

Resistance bands are an excellent method to achieve moderate intensity exercise

90% of people are reported to experience some form of pelvic girdle pain

3) What are the common barriers for during pregnancy and post pregnancy?

Perinetal tears and c-sections will require specific advice regarding exercise. As soon as is appropriate encourage swimming as is excellent bonding exercise be-tween mother and baby

The physiological trauma to a mother during and post childbirth is not to be under-estimated. They should be reassured that they need to rest, recover and bond. Gradual return to normal activities as able is excellent form of rehabilitation in the early stages

“Baby blues” and fear as first time mother should not be ignored. Social and well-being benefits of organised meet ups and exercises need to be encouraged.

# Podcasts by Scott

Next months podcast:

Physio Edge 084 Running Injury treatment – tendinopathy, MTSS, total hip

replacement & high BMI patients

1) What are the differential diagnosis of running injuries?

2) What are the top tips to manage and treat these injuries?

3) What are the current evidence bases for treatment in runners?

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Journal of the Month

#Journal club by Lee Platt

The Adductor Strengthening Programme prevents groin problems among male football players: A cluster-randomised controlled trial

Harøy et al (2019)

Section A: Are the results of the trial valid? 1) Did the trial address a clearly focused issue? Yes - whether the Copenhagen Adductor Strengthening programme (CA) reduced the self-reported prevalence and risk of groin problems in male football players. 2) Were all of the patients who entered the trial properly accounted for at its conclusion? Yes - Players with <75% response rate were removed from the data. Players who complet-ed <67% of the programme during pre-season and <50% during the competitive season were removed from the data. One team withdrew following randomisation. 3) Were patients, health workers and study personnel ‘blind’ to treatment? Patients were cluster-randomised by team. Players, coaches and the principal investigator were not blinded to group allocation. A research assistant who managed all of the date was blind-ed. 4) Were the groups similar at the start of the trial? All teams involved were from the sec-ond and third levels (semi-professional) of the Norway football league. 5) Aside from the experimental intervention, were the groups treated equally? The inter-vention group were given specific guidance on the frequency and level of exercise to be completed. The control group were instructed to train as normal, however this was not monitored or data collected. Section B: What are the results? 6) What was the outcome of the study? The prevalence of groin problems during the competitive season was 13.5% in the inter-vention group and 21.3% in the control group. The authors report a 41% lower risk of groin problems in the intervention group compared to the control group based on self-reported outcomes. 7) How large was the treatment effect? To assess the effect of the intervention they used a generalised estimating equation (GEE) analysis for groin problems. There was a narrow confidence in-terval for the effect. The per-protocol analysis has a P level of 0.001

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#Journal club by Lee Platt

Journal of the Month

#Journal club by Lee Platt

Questions: Section A: Are the results of the review valid? 1. Did the review address a clearly focused question? 2. Did the authors use an appropriate method to answer their question? 3. Were the cases recruited in an acceptable way? 4. Were the controls selected in an acceptable way? 5. Was the exposure accurately measured to minimise bias? 6. (a) Aside from the experimental intervention, were the groups treated equally? (b) Have the authors taken account of the potential confounding factors in the design and/or in their analysis? Section B: What are the results? 7. How large was the treatment effect? 8. How precise was the estimate of the treatment effect? 9. Do you believe the results? Section C: Will the results help locally? 10. Can the results be applied to the local population? 11. Do the results of this study fit with other available evidence?

Section C: Will the results help locally 8) Can the results be applied to the local population, or in your context? Young male patients with football related groin injuries can be common, however the in-tervention could also be considered for female patients and injuries that have occurred in other sports. The intervention is a single exercise approach with differing levels of difficul-ty which could be given in an MSK setting. That said, the patients in this study already had a good level of fitness being semi-professional football players. This study included some players with existing groin problems as well as players with no current problems. This ex-ercise approach could potentially be provided during rehabilitation or in promoting self management and re-injury prevention. 9) Were all clinically important outcomes considered? There was no differentiation for pa-tient with or without current groin problems. Compliance was based on self reported measures. The optimal dosage was not considered. Players with <75% response removed, yet these had more severe symptoms at baseline and therefore we do not know how it would have helped recovery of these patients. 10) Are the benefits worth the harms and costs? There were no significant harms or costs and no reported adverse effects.

Next article: Investigating the prevalence of anxiety and depression in peo-ple living with patellofemoral pain in the UK: the Dep-Pf Study. James Wride* and Katrina Bannigan (2019)

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