Good start to 2011

22 01 2011

Well it has been a productive start to 2011 both personally and with the Centre for Human Performance, Rehabilitation and Sports Medicine. We have a large programme for the year and it has started already, we are investigating the conundrum of Chronic Anterior and posterior Exertional compartment syndrome.  If you are aware of the literature on this  you will be aware there are no pathophysiological signs of compartment syndrome and it surely must be a misnomer….but where does the pain come from. Well we are studying a group of patients with both conditions and using 3d Kinematics and EMG technology to  see if we can alleviate their symptoms with a comprehensive running retraining programme over 1 week in patient stay … Further more we have a prospective study looking at correlation between a new Questionnaire HELP8, to differentiate for  causes of exertional limb pain, along with a massive 5000 patient trial for plantar pressure data.

With respect to the groin we are looking at  the shear force across pelvis and muscle instability in patients with non hip pathology groin pain, and also the action of gluteus medius and TFL in Iliotibial band syndrome – it may well be laxity not tightness, read my paper last year for the background,  http://www.ncbi.nlm.nih.gov/pubmed/19706004

In terms of gait we are addressing the  muscle activation patterns and stability in patients who have lost their limbs through traumatic amputation and also the locomotory Index and RER costs of their ambulation, much nonsense has been written about this and we hope to benefit the rehabilitation process significantly.

One thing we have learnt in the last few years is the building blocks of exercise really need to be well drilled and these movement skills are now part of our inpatient assessment and discharge, giving  objective data on function, program development and homework — we have seen a a real benefit and will publish the results soon.

 

On an Elite sport basis their is a need to recognise these skills early on and I continue to work on a system for Rugby Union incorporating coaching cues, coaches and warm ups , with reference to the excellent FIFA-11 programme and its injury prevention. I recently spoke at Warwick school to the  Heads of Sport from HMC School at an RFU Elite Rugby day and  was impressed by the engagement and feedback on the need to incorporate these skills back into warm up and training drills, further to this I was asked by NIKE to attend the Performance SPARQ summit in the UK and again their is real recognition of athletic development and talent ID – things I remain passionate about.

I continue to see mainly professional footballers for second consultations on groin pain and utilise biomechanical imagery and rehabilitation pogrammes to make an objective recovery plan not aided by surgery! Although I am not seeing public private patients at present due to workload.

 

Now to UKSEM, we have a fantastic programme lined up which we will be able to announce in the next few weeks and it again is at ExCeL, London 23-26th November and we have on offer an early bird discount of £300 in total for the 4 full days of dual programme with over 50 workshops to choose from. Great Academic prizes for posters and oral presentations and we will have a great exhibition with the worlds leading manufacturers and institutions. Take a look at last years videos if you attended at http://www.uksem.org

 

I have also taken over as the Education chair of BASEM, http://www.basem.co.uk and we will be announcing great member online learning opportunities with  podcasts, blog and discounts for membres in the revised website which will be launched inthe next 2 weeks- Check it our soon, and if you are not a member you get the BJSM for free and also a CPD education programme to boot!

Finally I have been appointed to the Board of the Institute of Sports and Exercise Medicine and also an associate editor to the British Journal of Sports Medicine – truly honoured by both

 

 





Athletic Competencies and 5 in 5

8 12 2010

I have had much interest in athletic competencies and Kelvin Giles “5 in 5” program since I appeared on BBC Breakfast  at the end of November in conjunction with the UKSEM conference I organised in London (www.uksem.org). This is quite possibly the most exciting concept in sports injury prevention and physical exercise and unsurprisingly the media has taken a significant interest along with very many of you.

www.uksem.org

Basic  building blocks-  When we walk, squat, run, twist and turn we need to coordinate simple muscle activity in order to perform these tasks such as a squat or lunge. We learn these as part of paediatric development and as part of evolution, prior to us spending large parts of the day sitting in offices or at school desks these skills were fundamental parts of development but now inactivity and lack of formal exercise training we are losing these simple tasks. In screening  two International sports teams in the last 12 months over 50% of these athletes were unable to perform a coordinated  bodyweight squat correctly , despite many of them squatting in excess of 200Kg in a smith machine. Is this a good thing? It cannot. When we run, commonly at low speed we transmit up to 2.5x our body weight through a single leg at impact – if we are unable to keep  our knee ankle and hip in line, our pelvis  tilted and lumbar spine not hyerextended we are not maximising efficient movement. The consequences are:

1. Decreased performance and power generation

2. Loss of control of force potentially creating injury

3. loss of change of direction speed

 

These are all fundamental skills we require whether developmentally or in improving performance through athletic development or in Elite sport.

Criticism

There hae been critics of the 5 in 5 programme – harking back to  past times for today’s It generation say the critics , or ‘we already do it’. The response to this has to be, it requires no or little equipment, takes 5-10 minutes and although some kids may be doing this they are not doing it with good form and appropriate feedback as bourne out be studies looking at the very best kids in talent id programmes in International sport – they still do not display athletic competence and all benefit from these skills being incorprated in their warm up and rehbailitation. 

FIFA have recognised this and introduced a standardised warm up FIFA 11, http://www.ncbi.nlm.nih.gov/pubmed/20956263 which although  was advertised at the World Cup in South Africa did not make mainstream media, but has been demonstrated to reduce injury and improve performance . We at UKSEM asked the government to consider making 5 minute warm ups mandatory as part of the curriculum – The idea is that kids could take it home, what other  programme requires no equipment and takes 5 minutes, by taking it home kids might do it 2 or 3 times a day and studies show the earlier exercise patterns are made, adherence later in life is significantly better. The feedback was the Department of Education want to focus on team sport! This is integral to team sport and not separate something which was lost – it is not the whole session of PE merely a physical hard and active warm up with added benefits.

 

Kelvin and his collaborators are working hard to develop 5 in 5 further and will update via http://movementdynamics.com/pages/fiveinfive





Review of www.uksem.org

1 12 2010

Well, I have finally recovered after running and putting together the ASICS UKSEM. This was Europe’s largest Sport and Exercise Medicine Conference held at ExCeL between 24th and 26th November. A fantastic gathering of some of the most challenging and inspirational speakers along with over 550 delegates. The feedback from the event continues to stream in from across the world and it was fantastic to catch up with freinds and colleagues and share discussions and learn new things.

Highlights for me certainly included Lord Sebastian Coe on some very practical messages about sport and exercise medicine and Michael Kjaer from University for Copenhagen  with a fantastic summary of where the evidence lies in current tendon treatment ( There are many ‘experts’ on this condition but few who are actually researching in the condition and can give 1st hand knowledge and interpretation.) We were delighted that Mr Raymond Verhaijen was able to make it across and challenge many with his views on periodisation in football, and from feedback he would be welcomed back as part of a panel on football conditioning in the future. Professor Paul McCrory from Melbourne gave an entertaining gallop through exercise medicine and the conundrums that we face in prescribing exercise, while Dr John Searle gave a history of gym instructor to personal trainer. We were unfortunate not to see Charlotte Ord who sustained injury but were given a thorough background in conditioning by the trimuruvate of Kelvin Giles, Vern Gambetta and Frans Bosch led by home grown talent Nick Grantham giving  clear and challenging advice regarding training programme design.

The 5 in 5 exercise for kids programme took the Conference and the BBc by storm with some excellent coverage on BBC Breakfast and beyond http://www.bbc.co.uk/news/health-11846666

 

More to come





Thoughts on Sports Medicine in 2010

17 09 2010

Getting injured, if you are either starting a gym class for the first time or preparing for a charity run, the London triathlon or even the  Olympic Games is more than literally a pain, but incredibly common. Whilst you are suffering, you may take heart from the fact that nearly 60% of runners report an injury in every season so you are in good company. In team sports injury is even more common with musculoskeletal injuries responsible for the predominance of weekend Accident and Emergency presentations. The question is why this happens? Is this because running or doing sport is bad for us, of course not, but much more likely it is because  like building a house on poor foundations, we would expect it to crumble and that is what is happening to your body.

The problem starts in schools , the decline in the robustness of physical education and the previous governments unwillingness to see competition in the curriculum means very few children break into a sweat during organised class sport. Of course there are some excellent examples of School PE with innovative lesson plans and children who are physically pushed, but all too often the showers are never used and games become not an opportunity to learn  sporting skills but an excuse to avoid them. It is great though to see hundreds of children at a weekend in parks across the country playing football and rugby and experiences in Australia where the AusKick programme sees ovals covered in children from 5 to 18  swarming over  balss and following structured learning programmes. This is reproduced here though on a lesser scale with some notable exceptions,  my local rugby club in Cobham has 6 pitches full of children all weekend in the season  coordinating over 200 kids, in organised sport and is a fantastic sight to see with the hundreds of volunteers working to keep it in motion.

The danger though is that we rely on governing bodies and their programmes which are sport specific and can avoid the fundamental building blocks which are general to all. The need to recognise in coaching junior sports, too often we are focused on short term goals such as teaching our children to win a rugby match as an 8 or 12  year old rather than concentrate on taking the essential skills of movement and building a robust  structure to make those gains at a later stage. These foundations skills are essential, the ability to develop flexibility, range of joint range of movement and more functional sports specific skills balance on one leg and hop forward a metre is tricky, go on try it, without falling over.

If we cannot balance on one leg, without wobbling, imagine what happens to our hips, knees , ankle and back when jogging in the Park, or sprinting for a ball. What happens to the control of your knee when  slowing for a low shot at the net in tennis or how your swing is affected  by balance on the 11th hole. which means we stand on one leg hundreds and thousands of time with greater forces  being transmitted then when we walk. These skills although often basic are the fundamentals  from which complex skills are learnt, they are often overlooked both in coaching and particularly in rehabilitation by those recovering from injury. It is be gained this muscle control, which takes many repetitions of training to achieve that we can condition the body correctly to withstand the demands of sport. Without them we lie mercy to injury.

In the elite sportsman and women we can use biomechanical analysis using motion capture cameras to analyse the  movements and control of our joints, to identify risks of injury. These systems such as Vicon and Qualysis,  are  only available in limited centres, usually linked with University research departments,  but allow accurate retraining and assessment of  movement patterning. In particular it can allow the understanding of causes of injury such as groin pain in sportsmen and women,which is often presumed to be a hernia or muscle strain when many differential diagnosis exist. At not quite so advanced a level, recently published studies highlight the pressure pattern the foot makes in contact with the ground can both predict injury risk but also can be used to intervene with a temporary shoe insert ‘orthotic’ designed from your running foot pattern or gait to allow the muscle of the leg, thigh and hip to relearn patterns that  should have been ingrained from an early age. Injury prevention is key as we all would prefer not to be exposed to injury in the first instance.

There have been significant advances in the management of acute and chronic injuries over recent years.  In the past doctors with an interest in looking after Sports and Exercise Medicine were mostly General Practitioners or Orthopaedic Surgeons doing so in their spare time. The Department of Health introduced Sport and Exercise Medicine as a new medical speciality  with a recognised training programme in 2005. Since then the appearance of NHS Consultants has been a slow process, but there are emerging NHS services in London , Sheffield, Leeds and Cardiff with over 30 doctors in training as specialists. This may have been prompted by the London 2012 Olympic games but should leave a more permanent legacy than many buildings.

The training programme ensures expertise in the recognition , diagnosis and treatment of all sports injuries but also in the designing and management of exercise of those with  other illnesses. The benefits of exercise in depression, cardiovascular disease and diabetes are all too well recognised but until now the advice on what type , how much and how often was difficult to come by. The injury prevention strategies and overall health promotion within the community and specialist groups, also is part of the training of this new speciality and the education of  the nations exercise professional’s, therapists and colleagues in the medical profession is important. Europe’s largest Sports and Exercise Medicine Conference, ASICS UKSEM is to be held in November at ExCeL in London and  here cutting edge innovation and education will be seen.

Recent advances in the management of soft tissue injuries such as muscle strains and ligament injuries focus the possible interventions.  Treatment of acute ankle ligament strains often frustrates Accident and Emergency departments  as in the past there was little to do to accelerate the outcome but you will read about work done in Canada in a high quality study which may be about to change all that. This study was done in the recreational athlete world and the trial was of a comparable quality to the normal standards of research in clinical medicine , often lacking in similar studies, and is the first to show real benefit of a novel intervention.

The treatment of many chronic conditions such as Plantar fasciitis and ‘Tennis Elbow’ and  Achilles tendinopathy have undergone rapid change with the development of the use of novel treatments. The understanding of these conditions  has resulted in the realoisation that they are not inflammation but degeneration and we have moved away from anti-inflammatory therapy to newer modalities. Shock wave therapy which uses the same technology that breaks up kidney stones from outside the body to shock the  injured structures to responding to treatment. Work is still going on to identify the mechanism  by which this takes effect but the  The National Institute of Clinical Excellence(NICE) recognise the work done in this area is worthy of use in many conditions including Shoulder tendinopathy and Tennis elbow.

The treatments used to get Elite athletes back on the track as rapidly as possible have started to filter down to recreational sport. Groin pain and hamstring injuries are less common in running  but certainly feature highly in team sports and the use of muscle injections has flourished in recent years. Whilst the use of homeopathic medicines, injected into the muscle injury have faded  from view ,as  the scientific evidence failed to match up to the purported benefits. New hope is offered by the use of ones own blood to accelerate the healing process. This is termed either autologous blood injection or platelet enriched plasma injection , and the process although different,  works on a similar basis, a sample of your own blood is taken and then spun down and concentrated so that the  beneficial  agents can be re-injected to the damaged area. Some encouraging results have been published both in acute injury but also in chronic injury where all else has failed. Avoiding the surgeons knife is all important in these conditions and increasing evidence supports their use.

The days of  injecting cortisone into a shoulder, knee or joint based on knowing the underlying anatomy and best guesswork are over. Modern medical imaging allows the use of small portable ultrasound machines to assess injures either pitch-side or in the clinic and most Sports Physicians will use this to guide their injections, often taking screen images of the route of the injection showing you the injured structure and the delivery of any therapeutic agent. Consultant Musculoskeletal radiologists are the experts in matching these images with the latest Magnetic Resonance imaging(MRI) scans to provide accurate and specific information of injuries and allowing the physician and therapy team to guide rehabilitation as accurately as possible, or direct the surgeon to the exact injury. Many providers are offering  reduced fees for rapid access scanning making it affordable for many even without private health insurance and a developing network of expert musculoskeletal radiologist report these images via a secure network allowing the radiologist to see and report the mages and send these to your physician who can show you them on a PC screen in their surgery or indeed on a laptop by the pitch. This allows rapid diagnosis  for the patient benefit.

Where  sports injury treatment differs form many other injuries is the need for a truly multi disciplinary team to get back to fitness is essential the integration of physician, physiotherapist, soft tissue therapist, podiatrist and fitness professional is all too important and  we still need to improve the communication between the fitness trainer and the  therapists to accelerate the rehabilitation process, the therapist will often guide the patient back to health but is the job of the trainer to bring them back to sport and this integrated approach is seen in the private sector in clinics such as Pure Sports Medicine in London but as yet does not fully integrate in the NHS and this is the challenge for the future.

Prevention is better than cure and as such this editorial focusses on many ways in which that can be achieved whether for your kids or for yourself, and when you do  suffer the setback of injury it highlights many innovate approaches currently employed by specialists to maximise your potential.





Athletic Competence

14 12 2009

Efficiency of movement should develop progressively throughout childhood and into early adolescence but is highly dependent on the development environment (Birrer and Levine, 1987). Successive reductions in the emphasis on school competitive sport have resulted in significantly decreased exposure from an early age to physical development skills learnt in outdoor play and sport (Boyle et al., 2008). The reduction in organised sport at a primary and secondary level results in lower anaerobic and aerobic capacity, reducing performance in the child and adolescent (Balyi and Hamilton, 2004).

Pressure on young athletes to succeed is at an all time high.(Davison and Lawson, 2006, Nicholls et al., 2009) The pathway from child participant to 1st team player is often accelerated based on physical size. There is excellent evidence that being born in 1st quarter (Baker and Logan, 2007) correlates well with selection for sport and that little thought is made on the long term development and safety of the athlete.

All movements, as part of rugby specific skills, i.e. jumping, catching, tackling all require that the athlete demonstrate force production, reduction and stabilisation. These require multi-dimensional movement efficiency.

Commonly used tests in assessing ‘talent’ use tests designed for senior athletes i.e. Multi stage fitness test (MSFT), Vertical Jump, 10m/40m Sprint times. Younger athletes focus on the results, not the technique required and what level of physical competency is required to achieve this.(Balyi, 2002, Balyi et al., 2005)

If the aim of age group representation is, in part, to develop the long-term athletic ability, to enhance the National talent pool, then the focus should be on enhancing these competencies or ‘building blocks’

Movement Dynamics use a test battery of 60 movement tests to produce a progressive assessment-training tool. The aim of which is to allow balanced development of key skills including stability, flexibility and movement technique.(Giles, 2009) It has been demonstrated that whilst considered fundamental, many of these skills are not mastered even by international athletes.(Balyi et al., 2005)

We are planning a study aims to assess the athletic competencies of those trialling for U16 England Rugby Union selection and identify if there is a trend between physical competency score and selection. It will additionally provide invaluable insight into movement skills of development rugby athletes, strengthen collaborative links between Roehampton University and National Sports Governing Bodies and contribute strongly to a key growth area of academic research.

It may well highlight any association between deficiencies in competencies and injury patterns in the future

We will update with the results as soon as possible





Biomechanical Assessment for Groin Pain

25 11 2009

Recent advances we have made in terms of understanding the potential causes of groin pain, allow us to look at the 3D kinematic analysis of the aggravating movements in the lab. Testing takes about an hour and allows us to give an objective accurate analysis of moments, forces and alignment. This is way in excess of a video analysis as it recreates your body based on joint placement. It allows us to map the rehabilitation and design appropriate intervention reducing the need for surgical intervention, and more importantly identifying potential injury prevention mechanisms. Repeat scanning allows a visual and numeric evaluation of  the success of the rehabilitation programme and allows us to fine tune your rehabilitation. Analysis can be performed at any stage of your pathway to recovery. http://bjsm.bmj.com/content/43/3/213.short. Contact us via the website to hear more www.sportsphysician.org.uk

Knee and pelvic alignment





Athletic competencies

25 11 2009

I have just spent a fascinating 2 hours with Kelvin Giles of Movement Dynamics, for those of you who haven’t heard of him or Athletic competencies then look up his website www.movementdynamics.com . This is really the approach to injury prevention and something we all should take seriously.. I will talk about his 5in5 and 10in10 later but we brainstormed hamstring injury rehab and prehab, along with OP and Adductor tendonopathy.
We are soon to start a research study with England RFU on the Athletic Competencies which we will report here
Have a look at his site, even better listen to him speak at BASEMs Spring Meeting BASEM