BJSM Podcast

Physiotherapist Dr Michael Skovdal Rathleff from the Research Unit for General Practice in Aalborg chats with Dr Dylan Morrissey from Queen Mary University of London and Barts Health NHS trust and Dr. Christian Barton from the new sport and exercise medicine research centre at Latrobe University in Australia. Both Dylan and Christian are clinically active physiotherapists working on moving research from journal papers into the hands of people who can put it to practical use. They discuss the challenges of clinicians being aware of the latest research and the researchers asking relevant questions. They propose to marry quantitative (eg. Systematic review) and qualitative (interviews, patient experience, clinician experience) approaches and they share examples of having already done this. Drs Rathleff, Morrissey & Barton will run a session on this topic at the Danish Sports Medicine and Physiotherapy Conference in Kolding, Denmark on 4-6th February. www.sportskongres.dk They’ll also speak on other topics (including running injuries) in an excellent programme packed with starts. Each speaker has many great papers and you can find two of those discussed in the podcast at these links: The 'Best Practice Guide to Conservative Management of Patellofemoral Pain': incorporating level 1 evidence with expert clinical reasoning. Barton CJ, Lack S, Hemmings S, Tufail S, Morrissey D. http://bjsm.bmj.com/content/49/14/923.full Conservative management of midportion Achilles tendinopathy: a mixed methods study, integrating systematic review and clinical reasoning Rowe V, Hemmings S, Barton C, Malliaras P, Maffulli N, Morrissey D http://www.ncbi.nlm.nih.gov/pubmed/23006143

All clinicians aim to classify muscle injury classifications to guide treatment and predict return – it’s a hot topic. The British Athletics Muscle Injury Classification is one helpful classification system and Dr Noel Pollock explains to Dr Markus Laupheimer (BJSM) how and why the Classification developed, as well as why the (older) Munich classification was not ideal. Listen for tips on how this classification adds something special and is of practical value for treating your athletes with muscle injuries. Timeline: 01:01m – Why a new muscle injury classification? 03:50m – Limitations of the Munich consensus Open access Munich Paper: http://bjsm.bmj.com/content/47/6/342.full.pdf+html 05:18m – British Athletics classification explained Open access British athletics paper: http://bjsm.bmj.com/content/48/18/1347.full 09:15m – Clinical application, follow up papers 12:00m – Discussion: MRI or not? http://bjsm.bmj.com/content/49/24/1579.full 14:05m – Future Development of muscle injury classification Links: British athletics muscle injury classification: a new grading system http://bjsm.bmj.com/content/48/18/1347.long (Open Access) Time to return to full training is delayed and recurrence rate is higher in intratendinous (‘c’) acute hamstring injury in elite track and field athletes: clinical application of the British Athletics Muscle Injury Classification http://bmj.co/1lWvDdy Previous podcast: The Munich muscle classification: Using it for more accurate diagnosis and treatment https://soundcloud.com/bmjpodcasts/the-munich-muscle-classification-using-it-for-more-accurate-diagnosis-and-treatment?in=bmjpodcasts/sets/bjsm-1 Range of BJSM podcast: http://bjsm.bmj.com/site/podcasts/ You can readily access BJSM podcasts via our Mobile App (BJSM). Latest sports medicine updates are posted via Twitter (@BJSM_BMJ)

AMSSM has a series of podcasts (https://www.amssm.org/E-Learning.php) and here experts highlight the management of shoulder, elbow and knee pain with a focus on the declining role of corticosteroid injections. The sports physicians discuss other injection treatment options – PRP, prolotherapy and viscosupplementation where relevant. Keep the AMSSM’s 2016 Annual Meeting in mind – Registration opens on January 8th. It will be in Dallas, Texas, April 15-20, 2016. And the special AMSSM issue of BJSM appears online first on January 18th, 2016.(Mental health theme). The experienced and popular hosts are Dr Blair Becker and Dr Scott Young, with special guest AMSSM Vice-President, Dr Matt Gammons. Timeline: 2:00 m Shoulder pain and subacromial corticosteroid injection – what is the level 1 evidence? 4:05 m What about corticosteroid for frozen shoulder? Does distention add benefits? 5:30 m Dr Gammons in his experience with adhesive capsulitis and shared decision making. 6:30 m The severity of symptoms may influence the decision. What would make it worth it for the patient to have an injection? 7:30 m PRP – platelet rich plasma. Again, as usually the case with PRP, no therapeutic benefit. What about prolotherapy? 8:30 m The AMSSM position statement on ultrasound guidance for shoulder injection. 12:30 m The elbow – an area where corticosteroids are becoming less popular. 15:30 m Is there support for long-term benefit of PRP? Nothing in the short term but a benefit at 2 years? 16:00 m Dr Gammons provides an overview. “Tools to add to the toolbox”, “Reasonable discussions to have with the patient”. Remember that the natural history is toward resolution. 17:00 m Shared decision making is key 17:30 m Moving on to the knee. Osteoarthritis and corticosteroid – short term benefit. Dealing with the acute flare-up. 18:40 m Viscosupplementation. See also the AMSSM scientific statement – (http://ow.ly/VKUxC ) and its recommendation for use in patients aged >60 years with grade 2 or 3 Kellgren-Lawrence. 20:00 m Dextrose prolotherapy for knee osteoarthritis (University of Wisconsin). 21:00 m Intra-articular PRP for knee osteoarthritis 23:30 m Other targets around the knee. Iliotibial band, pes anserinus as well as the patellar tendon. 25:30 m Summary of clinical practice – putting it all into perspective. Other links Clinical Journal of Sport Medicine blog and link to AMSSM Viscosupplementation position statement http://ow.ly/VKUxC Evidence against elbow PRP via Dr Robert-Jan de Vos: http://bjsm.bmj.com/content/48/12/952.long

The American Medical Society for Sports Medicine (AMSSM) is strongly committed to embedding Exercise is Medicine in the health of Americans. A member of the AMSSM’s leadership group is Associate Professor Irfan Asif, the Director of the Sports Medicine Fellowship within the Department of Family Medicine at the University of South Carolina Greenville. Our chat focuses on the practical aspects of Lifestyle Medicine – which is more than exercise medicine alone. You’ll hear about: (i) the patient’s journey through a 6-week clinical service, (ii) exercise being embedded in all 4 years of the medical curriculum, (iii) how medical students are engaging with high school students in very practical ways and with some surprising outcomes. We discuss the challenges of rolling out a lifestyle medicine programme in rural areas with minimal resources and the devil’s advocate asks the hard question: ‘Are doctors really the right persons in health care teams to prescribe exercise?’. Timeline: 00:47m - What is the Lifestyle Medicine clinic? Who is involved, what are the goals? 02:00m - The diet part – modifying the DASH diet with a Southern Flavour (Dietary Approaches to Stop Hypertension (http://ow.ly/VtPSR)) 04:00m - An example: walking through the patient’s journey – such as a patient with COPD. The role of partners such at the YMCA 05:30m - What the patient finds important – health or weight loss? 06:00m - How the curriculum embraces Lifestyle Medicine. See the link to Dr Jennifer Trilk’s work below (BJSM paper) 08:00m - Practical experiences of medical students within their communities. From given practical cooking advice to engaging high school students who are at risk of gang-related behaviour. Leadership concepts and team dynamic training – beyond the traditional medical model 10:00m - Physicians encouraging 7th & 8th grade children to ‘get your 30’ (minutes). Teaching CPR to children at this level. Encouraging young students to be open about concussion symptoms. Practical stuff 11:00m - Exercise Vital Sign: how many minutes do you exercise and how often do you exercise? Integrated into the Electronic Medical Record of the 13th largest health system in the US (with credit to Kaiser-Permanent as well). Flipping the health care system upside down from its focus on fee-for-service to prioritising prevention. 13:00m - Rural roll out: how to make this happen outside of major centres: ‘Think big but start small – practical first steps that will bring partners on board’ 14:45m - Taking a broader view – 'If we rely only on medical professionals to provide care our system is bound to sink'. 'There is plenty of pathology to go around'. The role of various health professionals in a team that provides excellence: 'Everyone plays a vital role' 15:30m - Dr Asif answers the hard question: 'What if an exercise professional feels he or she knows more about exercise prescription than the doctor?' Links: Incorporating ‘Exercise is Medicine’ into the University of South Carolina School of Medicine and Greenville Health System (Editorial, BJSM, 2014) - http://ow.ly/VtWv4 Check out the 2015 Physical Activity Issue of BJSM - http://bjsm.bmj.com/content/49/4.toc 2014 Physical Activity Issue of BJSM - http://bjsm.bmj.com/content/48/3.toc

In this 2nd of 2 podcasts for 2015 (link to previous one here http://ow.ly/V8h97) Professor Jill Cook from the La Trobe University Centre for Sports and Exercise Medicine Research (Australia) introduces the term ‘capacity’ for physical therapy / physiotherapy. ‘Capacity’ is a very practical concept that underpins successful tendon rehabilitation. Prof. Cook discusses how to use the figure from the linked paper to list exercises a patient should do. Practical stuff. 13 minutes of gold! Timeline: 1:00m - Why do we need the term ‘capacity’ in clinical practice? 1:30m - Definition – What is tissue ‘capacity’? 2:15m - The difference between ‘capacity’ and ‘function’ – capacity is tissue-specific 3:15m - Practical example: Hamstring muscle strain 5:30m - How to use this in the clinical setting – sitting with a patient and explaining the rehab programme 7:00m - The ‘Capacity’ figure – how to use it with patients to get buy-in to their rehabilitation 8:30m - ‘Building a bridge’ from what patients can do now to what they want to return to 9:00m - Practical tips including examples of (i) strength, (ii) energy storage, (iii) energy storage & release exercises 12:00m - Summary (30 seconds!) Previous podcast: How tendons fail, how to treat in season/out of season http://ow.ly/V8h97 Related papers: The Continuum model of tendinopathy http://ow.ly/V8hLr The challenge of managing tendinopathy during the season http://ow.ly/V8oTl Capacity – the paper (with Figure!) that underpins this podcast! http://bmj.co/1MIaBrx

Dr. Mark Hutchinson is professor of orthopaedics and head of the sports medicine services at the University of Illinois College of Medicine. He has been a team physician for the WNBA Chicago Sky, USA gymnastics, USA Field Hockey, USA Basketball and Team USA at two World University Games and the Paralympics Games. In this second of a two-part set, he discusses management of the patient who presents with recent onset of acute knee pain. You might be surprised by some of what this orthopaedic surgeon says! Timeline: 1:30m - Does everybody who ruptures an ACL need a knee reconstruction? 2:00m - How do you advise the person who wants to play soccer? 3:00m - How can you tell whether someone will make a good recovery or not with exercise therapy (not surgery)? 4:00m - OK for patients to go through a trial of physio to see if they are going to be stable or not 5:30m - Management of children who rupture their ACL. It’s a hot topic. On the one hand kids may be less compliant with ACL-risky behaviours than adults; on the other hand, operating and crossing growth plates can cause significant problems 7:30m - The key study by Håvard Moksnes and Lars Engebretsen – ACL injuries in kids (http://www.ncbi.nlm.nih.gov/pubmed/26025937) (not open access) 7:45m - How to discuss ACL management options with patients directly – ‘Tell us what you say to the patient Hutch’ (An introduction to shared decision-making) 9:15m - Non-operative, quality physiotherapy for ACL deficient patients 10:15m - Does ACL reconstruction prevent osteoarthritis? 11:15m - The elephant in the room – what about management of the patient whose ACL reconstruction has reruptured? 12:45m - Injuring the other knee – a disaster that occurs all too often! 13:30m - Psychological factors: a neglected part of the equation? http://bjsm.bmj.com/content/48/21/1543.abstract 14:30m - Return to play after reconstruction: the mind matters too! What is the optimal time for collagen healing? Coordination training, functional tests. 16:45m - Return to play with an unoperated knee: with a focus on neuromuscular training exercises Links: Previous BJSM podcasts: Pearls on knee examination: http://ow.ly/UBy3v Pearls on treating shoulder conditions and one wrist bonus: http://ow.ly/UBym YouTube videos on Physical Examination have been viewed more than 5 million times! https://www.youtube.com/user/BJSMVideos YouTube video: 39-minute lecture by Associate Editor Dr Clare Ardern on similar issues – return to play after ACL injury https://youtu.be/P_JJf0h6rhU Want a replay from last week? (1st podcast in this set) A 40-year old patient presents with an acute exacerbation of knee pain – Professor Hutchinson discusses whether arthroscopy is helpful in the arthritic knee. Which ones need orthopaedic referral? https://soundcloud.com/bmjpodcasts/mark-hutchinson?in=bmjpodcasts/sets/bjsm-1 Return to Play conference 2016: April 9-11, London (UK). The immensely successful annual Football Medicine Strategies conference focuses on Return to Play for all football injuries – not just ACL. Give this one serious consideration – top programme with over 100 invited speakers, terrific international audience (you will feel at home), friendly atmosphere and convenient venue. All the benefits of London without the need to own an expensive home there! http://www.footballmedicinestrategies.com/en/

Guest Prof Mark Hutchinson, an international leader in Orthopaedics and Sports Medicine, discusses the management of patients with degenerative meniscal tears. He emphasizes the importance of a broad clinical workup and highlights that arthroscopy does not improve outcomes in arthritic knees. Mechanical symptoms may warrant a surgical referral, but most orthopaedic surgeons recommend conservative management. Surgery should be considered as a second-line treatment.

In her first podcast since being recruited to the La Trobe University Centre for Sports and Exercise Medicine Research (Australia), Professor Jill Cook explains: (i) how tendons break down, (ii) how to assess painful tendons, (iii) how to manage tendon pain DURING a season, and (iv) how to rehabilitate a tendon properly after a season has finished. She explains what a ‘reactive’ tendon is and what a ‘degenerative’ tendon is as well as what sort of loads should be prescribed for patients who have tendon with these pathologies. A practical masterclass. Even if you have heard Jill speak before, there will be something new for you here. Sneak peek – Part 2 focuses on the concept of ‘capacity’ and why it’s an important concept. Further reading Classic paper: Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy http://bjsm.bmj.com/content/43/6/409.abstract

Peter Ueblacker is an internationally renowned orthopaedic surgeon and sports medicine doctor who had a long and very successful career with Bayern Munich from 2009 – 2015. He works in private practice with Hans-Wilhelm Mueller-Wohlfahrt (http://ow.ly/U2mch). BJSM editor Markus Laupheimer asked the questions (English language). Timeline 1:00m - Why classify muscle injuries? 3:00m - Limitations of previous classification methods and the need for a comprehensive one – the genesis of the Munich Muscle Injury Classification system. Here is the link to this Open Access paper in BJSM (>55,000 views) http://ow.ly/U2pMG 4:18m - What are the benefits for the health professional who uses the Munich classification system? Definition of ‘direct’ and ‘indirect’ muscle injuries. 5:00m - The challenge of ‘functional’ muscle injuries. No pathology on MR imaging yet a major burden for football teams because players cannot play – time loss injuries. 6:00m - Different muscle injuries lead to different periods of time out of sport. Is this a 2-week or 5-week injury? 6:40m - Trying to predict prognosis – is it possible? What can we tell coaches? You’ll find a counter-argument here http://ow.ly/U2qFJ (not discussed in this podcast). 7:10m - Drilling down on structural muscle injuries. Tendinous injuries within the muscle are important (See @PeterBrukner paper on that here http://ow.ly/U2rBc) 8:15m - How the spine is contributing to muscle injuries. Under-rated? Clinical implications. 10:00m - A practical walk through the management of hamstring muscle injuries Additional links: http://ow.ly/U2mUG - Previous podcast with Professor Gino Kerkhoffs also considers the Munich Consensus paper. It complements the present podcast in its greater focus on the consensus process and argues of the usefulness of MR imaging in muscle injury diagnosis. http://ow.ly/U2o0Q - Previous podcast with Professor Jan Ekstrand focusing on hamstring injuries. Which of the hamstring muscles is most likely injured? How long will such an injury keep a player out of sport? Also comments on the Munich Consensus http://ow.ly/U2ova - Hamstring ‘virtual conference’ BJSM blog by Steffan Griffin (@Lifestylemedic), BJSM editor responsible for Facebook among other things. You can readily access BJSM podcasts via our Mobile App (BJSM). Latest sports medicine updates are posted via Twitter (@BJSM_BMJ) and on the Google+ community http://ow.ly/U2sNs where you are encouraged to post content too.

Sports physiotherapists provide evidence-based treatment for back pain. Unfortunately surgery for back pain has rather poor outomes. Tiger Woods has spinal surgery on March 31, 2014 and did not return to his previous level of play. He went under the knife again on September 16, 2015. In this podcast, Curtin University’s Professor Peter O’Sullivan comments on the risks and possible benefits of surgery in an elite golfer. Previous podcast (>10,000 listens): Professor Peter O’Sullivan (@PeteOSullivanPT) on Tiger Woods’ back and ‘core strength’ http://ow.ly/TK6uo