BJSM Podcast

Avoiding catastrophic injuries at the Rugby World Cup. We explore effective injury prevention strategies and what other sports can learn from rugby with Dr James Brown and Dr Sharief Hendricks from South Africa. Dr James Brown (@jamesbrown06) and Dr Sharief Hendricks (@Sharief_H), Post-Doctoral researchers from the division for Exercise Science and Sports Medicine (ESSM) at the University of Cape Town (UCT), share their expertise in rugby science in our “Emerging Voices” series led by BJSM editor Nicol van Dyk (@NicolVanDyk). Dr Brown focuses on rugby injury prevention for both BokSmart (www.boksmart.com) and the Chris Burger Petro Jackson Players’ Fund (www.playersfund.org.za). James’ PhD thesis evaluated the effectiveness of South Africa Rugby Union’s BokSmart programme (www.boksmart.com). Dr Sharief Hendricks holds an NRF Innovation Post-Doctoral Research Fellowship at the University of Cape Town. He has investigated the tackle in Rugby Union and he examines how training and match behaviour data can help coaches improve players’ performance, and minimise injury risk. Sharief has also contributed substantially to national strategic documents for his country’s rugby union (SARU). Both speakers contributed to the inaugural World Rugby Science Network Conference (http://rsnlive15.com), co-hosted between University of Bath and the University of Cape Town. They utilised a multi-media online platform and had an excellent line up of speakers just days before the Rugby World Cup kicked off. You can hear both speakers in the “Rugby Medicine” track upcoming Transact South African Sports Medicine Association (SASMA) Conference 2015 (http://www.sasma2015.co.za), Johannesburg South Africa, 16-22 October 2015 (@SASMA2015). This bi-ennial conference has an excellent line up of international speakers, and a clinically driven programme under the leadership of Dr. Jon Patricios (@jonpatricios) is set to deliver a great week of learning and fun. Find a list of publications from James and Sharief on their website www.rugbyscientists.com. Here are two favourites from BJSM: Are we currently underestimating the risk of scrum-related neck injuries in rugby union front-row players? http://bjsm.bmj.com/content/48/14/1127.extract An evidence-driven approach to scrum law modifications in amateur rugby played in South Africa http://bjsm.bmj.com/content/48/14/1115.abstract

“Physical Therapists are the best suited clinicians to assess and treat the movement system” says Washington University (School of Medicine in St. Louis) Department of Physical Therapy Professor Shirley Sahrmann. Physical therapist and Assistant Professor, Dr Sylvia Czuppon (@czuppons), asks the questions. Timeline 0:30 mins - What differentiates elite athletes’ movement patterns from that of ‘normal’ people and of those with abnormalities? 2:00 mins - Why physical therapists are best suited to keeping the movement system functioning optimally 3:08m - The concepts of relative stiffness, relative flexibility – Professor Sahrmann’s Movement System Impairment approach 4:30m - How to perform muscle length assessment 5:45m - The spring-like behavior of muscles – a key contributor to abnormal movement patterns 6:40m - Hypertrophy of muscles increasing the stiffness of muscles and thus increasing passive stiffness: “It’s not just about muscle shortness” 8:00m - The role of microinstability and abnormal accessory movements contributing to pain. Practical examples including a case of tight Tensor Fascia Lata illustrating the concept that the body takes the path of least resistance 10:30m - Clinical reasoning in a patient with groin pain. Are there abnormal accessory movements? 13:00m - Practical tips on the assessment of a patient with FAI – femoroacetabular impingement 14:30m - Common musculoskeletal exam errors by young clinicians – what NOT to do 16:00m - The difference between the novice and expert in movement pattern examination 18:00m - Physical therapists as lifespan practitioners – and movement is critical to health across the lifespan. Physical therapists – optimising movement to enhance the life experience 19:00m - A call for physical therapists to “take back exercise”. Of course this is much more powerful than passive therapies Other links Professor Sahrmann’s Movement System Impairment Syndromes Courses: http://ow.ly/SFnWl Professor Gwen Jull on managing neck pain - http://ow.ly/SFooy Professor Paul Hodges on the balance between mobility and stability – http://ow.ly/S4UKE Please feel free to suggest links via @BJSM_BMJ or email karim.khan@ubc.ca The Movement System Impairment (MSI) syndromes were developed by Shirley Sahrmann, PT PhD and her colleagues at Washington University Program in Physical Therapy. These syndromes are described in her books, Diagnosis and Treatment of Movement Impairment Syndromes and Movement System Impairment Syndromes of the Extremities, Cervical and Thoracic Spine.

Do you treat patients with neck pain? Do you have neck pain? Stop reading and start listening to the podcast. Professor Gwen Jull is one of the most lauded health professionals in the world right now and she shares pearls every minute of this podcast. Here's the link to the second part of the podcast: https://soundcloud.com/bmjpodcasts/managing-cervicogenic-headache-and-other-pearls-professor-gwen-jull-second-of-two-podcasts?in=bmjpodcasts/sets/bjsm-1 Timeline 0:00m - How do you approach the patient aged in the prime of life who complains of neck pain and bad cervical posture? 2:00m - “Big development in physiotherapy is the assessment /examination which then forms the basis of our treatment” - movement and also how the movement is performed. Facet joint tests, muscle coordination. 3:10m - Detailed specific assessment of posture in the patient with neck pain. Have the patient adopt the work positions. Aim to correct the posture to see if pain changes. 5:10m - How to distinguish the superficial and deep neck extensors 8:30m - 3 trajectories in whiplash patients; folks who get better fairly rapidly (50%), those who suffer persistent mild pain (> 2years, 30%), and ‘the major worry’ of those who have persistent moderate to high levels of pain for many months and sometimes going on for years. What predicts these trajectories? “The last group is a real stumbling block for all professions”. 11:00m - Predictors of the poor outcomes. 12:00m - See the link to the Jull and Sterling booklet for patients - ow.ly/Soyma. 13:00m - Treatment of a patient with uncomplicated whiplash - “Hurry slowly”. 14:00m - Contribution of post-traumatic stress disorder 14:30m - Management of the complicated case of whiplash. Multiprofessional approach. Multimodal care. Instruments to assess severity and to look for particular elements. 16:20m - Providing overall management of the patient. Avoiding the medical merry-go-round 17:00m - Exercise is important (this will appeal to you Adam!)! 17:30m - “My emphasis is on treating multimodally” 18:00m - Manual therapy in the context of multimodal programme 19:00m - Explaining imaging findings to the patient 19:33m - Trigger points and dry needling? Remember the 2nd part of this conversation (about Headache and more) will be available on the BJSM podcast site on 2nd October, 2015. Links: Grieve’s Modern Manual Physiotherapy (4th edition): Book review here http://ow.ly/Sj4cn Gwen Jill is the lead author of this physiotherapy bible Related podcast: Professor Michele Sterling: ‘Managing Whiplash’ (2013). Very practical management of Whiplash that held up over the 2 years. http://ow.ly/Sj4Jz Is the neck pain related to concussion? A related paper in BJSM: Schneider KJ, et al. Br J Sports Med. 2014 Sep;48(17):1294-8. Cervicovestibular rehabilitation in sport-related concussion: a randomised controlled trial. http://bjsm.bmj.com/content/48/17/1294.abstract

Mo Farah has great running technique. You see it, you know it. But what are the elements of Mo Farah’s running style? Can we assess running patients and guide them to improve their technique? Might gait education prove more effective than medication to treat symptoms? Andy Cornelius has the answers. He’s a Graduate Sport Rehabilitator and head running coach who works in private clinics, premiership football and with high profile clubs and athletes. Posing the questions is Stephen Aspinall, Chairman of the British Association of Sports Rehabilitators and Trainers (BASRaT - http://www.basrat.org) and Lecturer in Sport Rehabilitation at the University of Salford, England. Timeline 1:20m - What are the key elements of running assessment? 2:45m - What you can learn by watching the runner from behind (frontal plane) and the side (sagittal plane) on the track and on the treadmill. 4:08m - The runner with injuries related to overstriding. What is overstriding? What can the clinician advise? 6:00m - Assessing cadence and helping the athlete to make a change of between 5-10% in cadence. 7:00m - Role of hip extension, angle of trunk lean. 7:40m - Treatment of the runner who over-strides. Exercises for rehabilitation: split stride, triple extension position, mat sliding exercise, TRX device, verbal queues. 10:20m - Stride width: consider this in conditions like ITB friction syndrome, medial tibial stress syndrome (overloading one side). 12:00m - Risk of knee pain with widening stride. 12:20m - Detailed exercise progression to adjust stride width. 14:30m - How to couple pelvic stability with hip mobility – the need to balance stability and mobility. 15:15m - Mo Farah as an example - what he does right. 16:00m - Exercise progressions to address limitations around the hip and pelvis. Strive for Mo Farah’s stride! 17:00m - When to introduce bounding, hopping drills. 17:40m - Learn more at running workshops organised by BASRaT, including at the BASRaT Annual Symposium - Manchester City’s Etihad Stadium, November 20, 2015. http://www.basrat.org/ Links Paul Hodges on the balance between mobility and stability – http://ow.ly/S4UKE The Telegraph on Mo Farah in 2013 - http://ow.ly/S4UQh Andy Franklyn Miller et al. Biomechanical overload syndrome: defining a new diagnosis. Br J Sports Med. 2014 Mar;48(6):415-6. (OPEN ACCESS) (@AndyFranklynMiller) http://www.ncbi.nlm.nih.gov/pubmed/22983122 Andy Franklyn Miller’s related podcast - biomechanics and running injuries - http://ow.ly/S4VBF (@AndyFranklynMiller) Christopher Napier’s Systematic Review gait retraining - http://ow.ly/S4V29 (ONLINE FIRST, live October 1st 2015) BASRaT Annual Conference – Friday November 20th, Manchester - http://www.basrat.org/ Please feel free to suggest links via @BJSM_BMJ or email karim.khan@ubc.ca

Dr Pippa Bennett has the CV and life experience that aspiring sport and exercise medicine doctors dream about. How’s this for a short version: Chief Medical Officer (CMO) for England Women’s Football Teams (15 years) including UEFA European Championships x 4 and FIFA World Cups x 2; CMO to British Gymnastics working at World and European events; World University Games x 3, Commonwealth Games, Olympic Games x 2 including Team GB Women’s Football in London 2012. English Institute of Sport including archery, athletics, swimming, hockey and wheelchair basketball. She completed a Masters in Sport and Exercise Medicine at Bath University. Describes herself as a keen football player who hung up her boots “due to old age and injury.“ In conversation with Dr Markus Laupheimer, they cover (i) ACL injuries and their prevention, (ii) the medical issues formerly known as the Female Athlete Triad which the IOC Consensus Group prefers to consider as the Relative Energy Deficiency Syndrome in Sport (RED-S) and (iii) Dr Bennett’s tips for junior clinicians – secrets from 15 years in the locker rooms in leading women’s and men’s sporting teams. TIMELINE 1:30m - Why are women more prone to ACL injuries? Addressing movement patterns for prevention; making players more robust. 4:00m - Prevention strategies - Dr Bennett’s experience in screening at schools and providing customised programmes for individual athletes to prevent injury. 5:20m - Relative Energy Deficiency in Sport (RED-S) - “a more rounded concept” focusing on the real culprit – energy deficiency - “Making sure your athlete is putting enough energy into the body”. 6:20m - Menstruation (in the context of amenorrhea) as well as in relation to performance and taboos. 7:00m - A case of a bone stress injury with an unusual underlying cause - “Treat the whole athlete”. 9:15m - Moving to Team Dynamics - Pippa shares her wide experience and contrasts men's and women's events in the same sport (e.g. gymnastics). 11:15m - The FIFA World Cup experience 13:20m - Advice for women clinicians considering applying for position in men’s teams: “Apply” Podcast and paper links (podcasts OPEN, most papers OPEN too): RED-S podcast with Dr Margot Mountjoy Major debate about energy deficiency among sportspeople: http://ow.ly/RMYRq RED-S consensus statement (2014) Mountjoy M1, Sundgot-Borgen J, Burke L, et al The IOC consensus statement: beyond the Female Athlete Triad--Relative Energy Deficiency in Sport (RED-S). Br J Sports Med. 2014 48(7):491-7. doi: 10.1136/bjsports-2014-093502. Hyperlink - http://ow.ly/RN0II RED-S Clinical Assessment Tool: Mountjoy M, Sundgot-Borgen J, Burke L, et al. RED-S CAT. Relative Energy Deficiency in Sport (RED-S) Clinical Assessment Tool (CAT). Br J Sports Med. 2015 Apr;49(7):421-3. Hyperlink - http://ow.ly/RN171 Female Athlete Triad consensus statement (2014): De Souza MJ1, Nattiv A, Joy E, et al. 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad Br J Sports Med. 2014 Feb;48(4):289. doi: 10.1136/bjsports-2013-093218. hyperlink - http://ow.ly/RN0Ae ACL mechanisms – Martin Hagglund -- Which 3 on-field football scenarios precede ACL rupture? http://ow.ly/RMYw5 Management and prevention of ACL injuries: Associate Prof Grethe Myklebust http://ow.ly/RMZcX ACL prevention paper – Norwegian experience: Myklebust G et al. Skjølberg A, Bahr R ACL injury incidence in female handball 10 years after the Norwegian ACL prevention study: important lessons learned. Br J Sports Med. 2013 May; 47(8):476-9. doi: 10.1136/bjsports-2012-091862. Epub 2013 Feb 12. hyperlink - http://ow.ly/RN1jj

The Society of Sports Therapists was established in the UK in 1990 to address the growing demands from sport and leisure on everyone involved in the management and care of injured participants. Professor Graham Smith, Chairman of the Society of Sports Therapists, discusses the past, present, and future of sports therapy. The first two minutes cover the rationale for this health care profession. 3:00m - you can hear what a student learns through the 3 years of the course. 4:20m - The Master’s in Sports Therapy (with eligibility for membership) – the course for folks who already have a sports science degree and want to become clinicians. 5:50m - Final year student perspective - “students are the future of the profession” - useful tips for deciding whether sports therapy is for you or not. 9:00m - A discussion of the roles that sports therapists are filling in a wide range of sports settings. “82% of the members are self-employed” - clearly sports therapists are well suited to work in the large sports club setting or in smaller clubs. In the second half of the podcast Professor Smith also highlights hot topics such as: (i) the interaction with physiotherapists “to complement physiotherapy and to protect the people who play sport and exercise”, (ii) the 2016 scientific meeting “From Pain to Performance” (May 14th, 2016) featuring the great US knee surgeon Don Shelbourne, and (iii) the Society being a partner with BJSM: “We are pleased to be part of a global sports medicine community and appreciated as such”. Links: Home page for the Society of Sport Therapists http://www.society-of-sports-therapists.org/index.php/public_information/what-is-sports-therapy Where to study Sports Therapy (BSc Hons) http://www.society-of-sports-therapists.org/index.php/public/degree_courses_BSc Where to study Sports Therapy if you already have a relevant degree (MSc) http://www.society-of-sports-therapists.org/index.php/public/degree_courses_MSc

Dr. Joanne Kemp, research fellow at ACRISP (Australian Centre for Research into Injury in Sport and its Prevention) Federation University Australia, discusses Femoral Acetabular Impingement (FAI) and the overall health of the hip joint. Dr. Kemp completed her PhD at the University of Queensland in 2013. She remains very much involved in clinical physio practice as an APA sports physiotherapist and director of Bodysystem®. (@JoanneLKemp) An emerging voice in sports medicine, she explores some of the difficult questions regarding hip pathology. Do we know when surgery is appropriate for FAI, or when to opt for conservative treatment? Which outcomes should guide our clinical decision to treat patients with hip pathology? What are the long term implications for joint health after sports-related hip injury? Links to 3 of Dr Kemp’s papers here: Hip arthroscopy for intra-articular pathology: a systematic review of outcomes with and without femoral osteoplasty - http://bjsm.bmj.com/content/46/9/632.abstract Hip chondropathy at arthroscopy: prevalence and relationship to labral pathology, femoroacetabular impingement and patient-reported outcomes - http://bjsm.bmj.com/content/48/14/1102.abstract What fooled us in the knee may trip us up in the hip: lessons from arthroscopy - http://bjsm.bmj.com/content/48/16/1200.extract Follow @JoanneLKemp on Twitter

In-game video analysis of 39 ACL injuries provides new insight into when male football players are most at risk of ‘non-contact’ ACL rupture. At 4 mins into this podcast, Dr Markus Waldén (@MarkusWalden, Football Research Group, Linkoping, Sweden) shares the gold. The 3 key scenarios when professional male players rupture their ACLs include (i) a defender pressing and side-stepping suddenly to either stop the attacking player getting by or to reach the ball, (ii) a player regaining balance after kicking, and (iii) a player landing awkwardly after a heading duel. This differs from ‘contact’ ACL injury which was mostly caused by illegal tackles from the side that caused a forceful lateral impact and valgus collapse at the knee. These need to earn red cards. At 7m 40s Dr Waldén shares the controversy about ‘valgus collapse’. Has this ‘mechanism’ been oversold? Is it more of an immediate result of imbalance rather than a direct cause? To close around 8m 40s, Nicol van Dyk from the BJSM asks what clinicians can do to prevent ACL injuries in professional male football players. What exercise programs can be brought in now? Links: Yann Le Meur's (@YLMSportScience) popular infographic is here: http://ow.ly/QUdY3 The full paper in BJSM (free) is here: http://ow.ly/QUezQ Three distinct mechanisms predominate in non-contact anterior cruciate ligament injuries in male professional football players: a systematic video analysis of 39 cases. Waldén M, et al. Br J Sports Med. 2015 Apr 23. The special UEFA football issue of BJSM in 2013 - http://bjsm.bmj.com/content/47/12.toc

The medico-legal spotlight is shining brightly on individuals who provide medical services for athletes. With high profile lawsuits in the USA and the UK, practitioners need to be aware of how to protect themselves from any litigation pitfalls. Mr Majid Hassan is a lawyer expert in giving advice to sports clinicians. The podcast begins by explaining how the field has changed just recently – there is much more pressure on us to explain ALL risks to patients. The key cases were not in sports medicine, but their outcomes are critical for sports medicine practice. The first specific sports case is discussed at 5 mins 30 secs. It’s about the high-profile and most unfortunate case of Radwan Hamed and Tottenham Hotspur. What’s the role of the team physician, or the cardiologist? Does reading an ECG provide a duty of care? As we take the time to analyse what happened in order to try to avoid such events, our thoughts are with all involved in this tragic case. At 12.18 @Liam_West asks whether having an athlete sign a waiver can provide the clinician with protection against future legal action. At 14:22, to close, Mr Hassan shares 4 vital tips for all clinicians: minimize risk, communicate well, have detailed notes and more, but I better not give it away here. Our thanks to Mr Hassan, Partner in the Clinical Law Team at Capsticks Law Firm.

Kelly Starrett is a coach-physical therapist whose 2013 book, Becoming a Supple Leopard, is a New York Times and Wall Street Journal bestseller. He received his Doctor of Physical Therapy (DPT) degree in 2007 from Samuel Merritt College in California. He runs his own physical therapy practice that emphasises returning athletes to elite level sport and performance. In the podcast, Kelly enthusiastically draws on his background as an elite athlete and national level coach to suggest that sport physiotherapists should consider being very well trained in the practical aspects of strength and conditioning coaching. He argues that including the ‘coach’ element in the physiotherapist’s scope of practice will provide better results for patients. He calls for physios to be able to understand, and communicate, in ‘actionable language’ for customers – potentially elite athletes. He refers to the physio-coach as someone who is ideally poised to treat musculoskeletal conditions. Plenty of practical tips on how to get there. Primary link to Kelly’s resources: MobilityWOD.com Jump on to the Google+ Sports Clinicians Community page to add your comment: https://plus.google.com/u/0/communities/101520200531074507996 Become a Supple Leopard on Amazon: http://www.amazon.com/Becoming-Supple-Leopard-Preventing-Performance/dp/1936608588 Competing interest: Neither BJSM nor Karim Khan has any financial interest in the MobilityWOD company. Kelly Starrett’s role in MobilityWOD and ‘Becoming a supple leopard’ is self-evident.