Defining the role of sport and exercise physicians: the experience of different referrer types in New Zealand.

The aim of this study was to analyse the reasons health professionals refer to sport and exercise physicians (SEPs) and to define what service gap the specialty fills. This was a qualitative study design using thematic analysis. Online focus group interviews consisting of 4-6 participants in each group were conducted separately with physiotherapists, emergency clinicians, general practitioners and orthopaedic surgeons practising in New Zealand. Thematic analysis of the focus group interviews was then used for the identification of common themes around referral tendencies towards SEPs. Three primary themes were identified relating to referrals towards SEPs: (1) role utilisation of SEPs, (2) collaboration and (3) accessibility. SEPs are viewed as experts in the assessment, investigation and diagnosis of musculoskeletal (MSK) conditions, including some which might traditionally be viewed as surgical diagnoses. Some confusion or lack of understanding exists regarding the range of conditions that SEPs can treat and manage, with some referrers assuming that SEPs only treat sport-related injuries. SEPs are often used alongside other specialist practitioners in the management of patients with MSK conditions. This requires collaboration with other health professionals who also treat MSK conditions to ensure the best patient outcome. A common feeling towards SEPs is they are easily accessible compared with other potential health providers who may also treat MSK conditions such as orthopaedic surgeons and general practitioners, and that SEPs provide sound management plans and access to investigations such as MRI, in a timely fashion.

Suggested improvements to the 11+ as identified by coaches, players, strength and conditioning staff and medical staff in New Zealand Football.

The aim of this study was to investigate the experience with the 11+, attitudes towards injury prevention, and potential improvements to the 11+ and the delivery of injury prevention strategies within football. A qualitative study design was used to investigate the views of four stakeholder groups (players, coaches, strength and conditioning staff and clinicians). Twenty-two adults participated (nine women; median age 35.5 years). Participants were purposively recruited and were based in New Zealand. They represented various levels of football, including different genders, ages and levels of play. Focus group interviews were conducted, which were recorded, transcribed and subject to thematic analysis. Four key themes were identified: understanding of the 11+ injury prevention warm-up, content of an ideal injury prevention programme, structure of the programme and education, adherence and dissemination. The study found that while participants appeared to have good awareness of the existing 11+ programme and an interest in injury prevention, adherence and enthusiasm towards the programme was limited. Participants highlighted a number of elements that may help shape the development of a new injury prevention strategy, including a desire to retain many of the elements of the 11+ and to have a proven programme. Participants wanted greater variety, more football-specific elements and to implement a new strategy throughout a session, rather than being seen as a stand-alone warm-up. Whether the intervention should also include strength-based exercises, or whether this should be promoted outside of a football training session, was less certain.

Professional footballers have a limited understanding of the precompetition medical assessment and the possible outcomes including disqualification: a cross-sectional survey.

OBJECTIVES: To determine professional footballers' level of understanding of the purpose of the precompetition medical assessment (PCMA) and to evaluate their knowledge of potential outcomes following a PCMA, including disqualification. METHODS: Professional footballers from the Australasian A-League and Westfield W-League were asked to complete a 25-question survey. The relationship between dichotomised outcomes and explanatory variables was analysed with multivariate logistic regression; p<0.05 was considered statistically significant. RESULTS: A total of 212 players participated (response rate=48.8%). Most respondents selected 'To detect medical conditions that may affect performance' and 'To detect current injuries' (n=137, 64.6%; n=130, 61.3%) as the purpose of a PCMA. Approximately one-third (n=74, 38.1%) were neutral or believed that a normal PCMA prevented cardiac arrest. Receiving more PCMAs (p<0.0003) and receiving an explanation during their PCMA (p=0.0175) led to greater awareness of the assessment's limitations. Most participants did not know the definitions of syncope (n=181, 93.3%) or Marfan syndrome (n=183, 94.3%). Fifty players (28.1%) did not know that disqualification was a possible outcome of a PCMA, and younger players were less aware of this possible outcome (p=0.0216). CONCLUSION: Professional footballers appear to have a limited understanding of the purpose of a PCMA, emphasising the musculoskeletal system and performance. They also appear unfamiliar with the components of the PCMA and medical terms. Finally, many are unaware that disqualification can result from an abnormal PCMA. Player health knowledge must be improved; the informed consent process appears an ideal time to provide this education.

Attitudes, beliefs and factors influencing football coaches' adherence to the 11+ injury prevention programme.

OBJECTIVE: To explore football coaches' beliefs and attitudes about injury prevention and the 11+ injury prevention programme, and to investigate factors that may influence adherence to the 11+ injury prevention programme. METHODS: A total of 538 football coaches who had completed an injury prevention education workshop were invited to participate in a web-based nationwide survey. The survey questions explored beliefs and attitudes about injury prevention and the 11+ injury prevention programme, self-reported adherence to the 11+ programme, as well as perceived barriers and facilitators to the use of the 11+ programme. RESULTS: There were 158 respondents. The majority believe that injury prevention is part of their coaching role (94%) that a structured warm-up is an important part of their team's preparation for training and games (96%), and that the 11+ is effective (92%). While most respondents (95%) use the 11+, modifications are common. Participants with greater coaching experience are more likely to use the programme. Time constraints are the main barriers to adherence, while knowing that the programme enhances performance is seen as a major facilitator. CONCLUSIONS: Coaches who attended an injury prevention workshop have positive attitudes towards injury prevention and the 11+ programme. However, coaches with less coaching experience may be less likely to use the 11+ and could therefore be the target population for future education workshops. Promoting the performance enhancing effects of the 11+ and encouraging modifications could improve acceptability and adherence.

Elite coaches have a similar prevalence of depressive symptoms to the general population and lower rates than elite athletes.

OBJECTIVE: The primary aim of this study was to estimate the prevalence of depressive symptoms and life stress in elite coaches. The secondary aim was to explore the associations of depressive symptoms and life stress with demographic and lifestyle variables. METHODS: National-level coaches were invited to participate in an online survey. Depressive symptoms were measured by the Centre for Epidemiological Studies Depression Scale-Revised (CESD-R). Life stress was measured using daily life hassle frequency and severity scores calculated from the Daily Hassles Questionnaire, with associations evaluated using linear regression. RESULTS: Of 110 potential participants, 69 completed and two partially completed surveys were received. The majority of respondents were male (77%), coaching individual sports (70%) and aged under 50 (71%). Overall, 14% of coaches reported at least moderate depressive symptoms according to the CESD-R. Those contemplating retirement were more likely to show depressive symptoms. Reported life stress was higher in females and in those contemplating retirement. There was a strong association between life stress and the odds of experiencing depressive symptoms (p=0.006). CONCLUSIONS: Depressive symptoms are as prevalent in elite coaches as in general population, with potential risk factors including high levels of life stress and impending retirement.

Can a short neuromuscular warmup before tackling improve shoulder joint position sense in rugby players?

BACKGROUND: In rugby the tackle is a complex task requiring joint position sense (JPS). Injuries commonly occur during the tackle and these account for significant time lost from training and play. Simulated tackling tasks have previously shown a reduction in shoulder joint position sense and it is possible that this may contribute to injury. There is growing evidence in support of injury prevention programs, but none so far are dedicated specifically to tackling. We postulate that a brief neuromuscular warmup could alter the negative effects of fatigue on shoulder JPS. METHODS: In this field based, repeated measures design study, 25 semi-professional Rugby players participated. JPS was measured at criterion angles of 45° and 80° of right arm shoulder external rotation. Reproduction accuracy prior to and following a neuromuscular warmup and simulated tackling task was then assessed. RESULTS: In pre-warmup JPS measures, the spread of angle errors were larger at the 80° positions. Adding the warmup, the spread of the angle errors at the 80° positions decreased compared to pre-intervention measures. Two one-sided tests (TOST) analysis comparing pre- and post-testing angle errors, with the addition of the warmup, indicated no difference in JPS. CONCLUSIONS: The neuromuscular warmup resulted in a decrease in JPS error variance meaning fewer individuals made extreme errors. The TOST analysis results also suggest the neuromuscular warmup used in this study could mitigate the negative effects of tackling on JPS that has been seen in prior research. This neuromuscular warmup could play a role in preventing shoulder injuries. It can easily be added to existing successful injury prevention programs.

Does the Beighton Score Correlate With Specific Measures of Shoulder Joint Laxity?

BACKGROUND: Evaluation of shoulder joint laxity is an important component of the shoulder examination, especially in the setting of shoulder instability. Measures of generalized joint laxity, particularly the Beighton score, are often recorded and used to help make management decisions in these cases. However, no evidence is available to show that the Beighton score corresponds to specific measures of shoulder joint laxity. PURPOSE: To assess the correlation between the Beighton score and validated measures of shoulder joint laxity. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A total of 160 participants (age range, 16-35 years) with no history of shoulder joint abnormality were examined. The Beighton score, glenohumeral external rotation (standing and lying), glenohumeral abduction, and the sulcus sign were recorded. The relationship between the Beighton score and each measure of shoulder joint laxity was assessed. RESULTS: A high proportion of participants (34%) had a Beighton score of 4 or higher. Rates of positive shoulder laxity tests were lower (11%-19%). A positive Beighton score was a poor predictor of abnormal shoulder laxity, with low sensitivity (range, 0.40-0.48) and low positive predictive values (range, 0.13-0.31). Spearman correlation coefficients demonstrated poor correlation between the Beighton score and all measures of shoulder joint laxity when assessed as continuous variables (range, 0.29-0.45). CONCLUSION: The Beighton score has poor correlation with specific measures of shoulder joint laxity and should not be considered equivalent to these tests as a method of clinical assessment.

Text messaging between clinicians and patients - Hve we got thngs unda cntrl?

INTRODUCTION Patients are interested in receiving text messages (texts) related to their health care. However, anecdotes are emerging of associated problems and it is possible that many of the potential pitfalls are not recognised. AIM To assess clinicians' attitudes and behaviours towards text messaging (texting) with patients. METHODS A voluntary, anonymous, online survey was created and distributed to general practitioners and physiotherapists in New Zealand and to Sports Medicine Fellows and Sports Medicine Registrars in New Zealand and Australia. RESULTS In total, 322 clinicians completed the survey. Texting behaviours relating to accuracy, privacy and security were identified. A range of sensitive and important medical information was frequently conveyed and at times forwarded to third parties. The clinicians generally felt uneasy communicating this way and some felt pressured into it. Most thought that guidelines are insufficient and that they had not received sufficient education on the issues. Most were interested in further education. CONCLUSION This study has demonstrated frequent texting between clinicians and patients. It has highlighted potential risks to the privacy, accuracy and security of medical information. Current guidelines and education may be insufficient. Clinicians were interested in receiving readily available best practice guidelines and education regarding texting.

Republished research: Impact of autologous blood injections in treatment of mid-portion Achilles tendinopathy: double blind randomised controlled trial.

STUDY QUESTION: Do peritendinous autologous blood injections improve pain and function in people with mid-portion Achilles tendinopathy? SUMMARY ANSWER: The administration of two unguided peritendinous autologous blood injections one month apart, in addition to a standardised eccentric training programme, provides no additional benefit in the treatment of mid-portion Achilles tendinopathy. WHAT IS KNOWN AND WHAT THIS PAPER ADDS: Several studies have suggested that injection of autologous blood can help in the treatment of various tendinopathies. There is a lack of high quality evidence showing relevant benefit for autologous blood injections, particularly in the management of mid-portion Achilles tendinopathy. We found no additional reduction in pain or improvement in function when these injections were combined with an eccentric calf training programme.

Standardised criteria improve accuracy of ECG interpretation in competitive athletes: a randomised controlled trial.

BACKGROUND: Screening to prevent sudden cardiac death remains a contentious topic in sport and exercise medicine. The aim of this study was to assess whether the use of a standardised criteria tool improves the accuracy of ECG interpretation by physicians screening athletes. METHODS: Design: Randomised control trial. Study Population: General practitioners with an interest in sports medicine, sports physicians, sports medicine registrars and cardiologists from Australia and New Zealand were eligible to participate. Outcome Measures: Accuracy, sensitivity, specificity and false-positive rates of screening ECG interpretation of athletes. Intervention: A two-page standardised ECG criteria tool was provided to intervention participants. Control participants undertook 'usual' interpretation. RESULTS: 62 physicians, with a mean duration of practice of 16 years, were randomised to intervention and control. 10 baseline and 30 postrandomisation athlete ECGs were interpreted by the participants. Intervention participants were more likely to be correct: OR 1.72 (95% CI 1.31 to 2.27, p<0.001). Correct ECG interpretation was higher in the intervention group, 88.4% (95% CI 85.7% to 91.2%), than in the control group, 82.2% (95% CI 78.8% to 85.5%; p=0.005). Sensitivity was 95% in the intervention group and 92% in the control group (p=0.4), with specificity of 86% and 78%, respectively (p=0.006). There were 36% fewer false positives in the intervention group (p=0.006). CONCLUSIONS: ECG interpretation in athletes can be improved by using a standardised ECG criteria tool. Use of the tool results in lower false-positive rates; this may have implications for screening recommendations. TRIAL REGISTRATION NUMBER: ACTRN12612000641897.

Impact of autologous blood injections in treatment of mid-portion Achilles tendinopathy: double blind randomised controlled trial.

OBJECTIVE: To assess the effectiveness of two peritendinous autologous blood injections in addition to a standardised eccentric calf strengthening programme in improving pain and function in patients with mid-portion Achilles tendinopathy. DESIGN: Single centre, participant and single assessor blinded, parallel group, randomised, controlled trial. SETTING: Single sports medicine clinic in New Zealand. PARTICIPANTS: 53 adults (mean age 49, 53% men) with symptoms of unilateral mid-portion Achilles tendinopathy for at least three months. Participants were excluded if they had a history of previous Achilles tendon rupture or surgery or had undergone previous adjuvant treatments such as injectable therapies, glyceryl trinitrate patches, or extracorporeal shockwave therapy. INTERVENTIONS: All participants underwent two unguided peritendinous injections one month apart with a standardised protocol. The treatment group had 3 mL of their own whole blood injected while the control group had no substance injected (needling only). Participants in both groups carried out a standardised and monitored 12 week eccentric calf training programme. Follow-up was at one, two, three and six months. MAIN OUTCOME MEASURES: The primary outcome measure was the change in symptoms and function from baseline to six months with the Victorian Institute of Sport Assessment-Achilles (VISA-A) score. Secondary outcomes were the participant's perceived rehabilitation and their ability to return to sport. RESULTS: 26 participants were randomly assigned to the treatment group and 27 to the control group. In total, 50 (94%) completed the six month study, with 25 in each group. Clear and clinically worthwhile improvements in the VISA-A score were evident at six months in both the treatment (change in score 18.7, 95% confidence interval 12.3 to 25.1) and control (19.9, 13.6 to 26.2) groups. The overall effect of treatment was not significant (P=0.689) and the 95% confidence intervals at all points precluded clinically meaningful benefit or harm. There was no significant difference between groups in secondary outcomes or in the levels of compliance with the eccentric calf strengthening programme. No adverse events were reported. CONCLUSION: The administration of two unguided peritendinous autologous blood injections one month apart, in addition to a standardised eccentric training programme, provides no additional benefit in the treatment of mid-portion Achilles tendinopathy. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12610000824066, WHO U1111-1117-2641.

Normative values of hip strength in adult male association football players assessed by handheld dynamometry.

Chronic groin pain is a common problem in association football players. Normative values for the strength of hip muscles, measured in an accurate and accessible manner, are needed to gauge strength and inform return to play decisions in this group. The purpose of this study was to define normative values of hip muscle strength using handheld dynamometry. A series of reliable clinical tests that are commonly used when making return to sport decisions in athletes with chronic adductor related groin pain have been selected. One hundred and twenty adult male association football players, free from injury, were recruited. Isometric strength of the hip flexors and adductor muscles was measured using a handheld dynamometer. Mean age was 24.9 years (SD 5.9). Eighty participants (67%) had experienced groin pain in the past. Mean strength for dominant leg hip flexion was 47.3 kg (95% confidence interval 45.6-49.0), non-dominant leg hip flexion was 42.5 kg (41.1-43.9), adduction at 0 degrees hip flexion was 35.6 kg (34.1-37.1), adduction at 45 degrees was 32.0 kg (30.9-33.1), and adduction at 90 degrees was 25.5 kg (24.4-26.5). This study establishes reference ranges and predictive equations for maximal isometric contraction strength of the hip muscles in non-injured adult male association football players. This information will assist assessment and management of an athlete's return to play following injury.

Reliability of handheld dynamometry in assessment of hip strength in adult male football players.

The aim of this study was to evaluate the intra- and interrater reliability of handheld dynamometry (HHD) for measuring hip muscle strength in a sample of 30 healthy semi-professional adult male football players. The reliability of HHD had not been assessed in athletes who were likely to be stronger than populations tested previously. Maximal isometric strength of resisted hip flexion and adduction were measured. Mean strength ranged from 51.5 kg for dominant hip flexion to 26.7 kg for hip adduction at 90 degrees of hip flexion. Intrarater reliability intraclass correlation coefficients (ICCs) ranged from 0.70 to 0.89. ICCs for interrater reliability ranged from 0.66 to 0.87. As expected, muscle strength in this group of athletes was significantly higher than that of populations in which HHD reliability has been assessed. Despite this, muscle strength testing of hip flexor and adductor muscles can be performed with good to excellent intra- and interrater reliability in this population.