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Sport Physical Therapy

Who are the biggest names in the back pain world? Correct – Peter O’Sullivan is one of them. 

He's provocative, clinically-relevant, and vastly experienced. He’s desperate to help patients, that’s obvious! But not everyone has to agree. Listen to his take on management of both chronic, and acute, back pains – does it make sense to you? 

Peter O’Sullivan is Professor of Musculoskeletal Physiotherapy at Curtin University, Perth, (http://goo.gl/Dk6beV)and a Specialist Musculoskeletal Physiotherapist who consults at bodylogicphysiotherapy.com. 

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See also:

It’s time for change with the management of non-specific chronic low back pain (2012) http://bit.ly/1nY6YxK

Professor O’Sullivan discusses the risk of clinicians ‘overservicing’ or ‘overdiagnosing’ various conditions in another BJSM podcast: http://goo.gl/7HYDiX

Successful antibiotic treatment in a subset of people with chronic low back pain: http://blogs.bmj.com/bjsm/2013/05/08/peterbrukner-discusses-todays-major-headline-successful-antibiotic-treatment-in-a-subset-of-people-with-chronic-low-back-pain/

‘Overdiagnosis’ / ‘overtreating’– relevant in sportsphysio/medicine? Professor Peter O’Sullivan: https://soundcloud.com/bmjpodcasts/overdiagnosis-overtreating-relevant-in-sportsphysiomedicine-peter-osullivan

Professor Peter O’Sullivan (Curtin) walks you through two cases of low back pain

Physical rehab (physiotherapy), behavioural rehab and combinations of these have been mainstays of back pain treatment.  Dr Kieran O’Sullivan shares his expertise on what to do and what not to do – lessons from 15 years of providing specialised clinical care and engaging in top level research. 

Specifically, what is the role of patient advice, targeted exercises, and novel therapies including injections? 

You can link to Dr O’Sullivan’s home page at the University of Limerick here: http://www.ul.ie/clinicaltherapies/node/443

Interested in back pain? Related resources: 

Editorial: Common misconceptions about back pain in sport: Tiger Woods’ case brings five fundamental questions into sharp focus
http://bjsm.bmj.com/content/early/2015/02/08/bjsports-2014-094542.extract

Podcast:  Professor Peter O’Sullivan on Tiger Woods’ back and ‘core strength’
https://soundcloud.com/bmjpodcasts/professor-peter-osullivan-peteosullivanpt-on-tiger-woods-back-and-core-strength?in=bmjpodcasts/sets/bjsm-1

Effective treatments for back pain: Kieran O'Sullivan’s practical tips within a guiding framework

Do you want to get your athletes with an acute hamstring injury back to play as quickly as possible, without the risk of a recurrence? Should you include lengthening exercises, trunk stabilisation, Nordic curls or PRP injections? Are you searching for a comprehensive, evidence-based update? 

This 10-minute podcast will answer all your questions. BOOM!  

Eminent sports physician Johannes Tol asks the hard questions. Sports physician Haiko Pas provides answers based on his recent systematic review & meta-analysis on hamstring rehab programs and PRP injections. 

Time codes: Optimal treatment for a quick return to play (2.30 min), re-injury reduction (3.50min) and the added value of PRP injections (6.20min). The podcast finishes with three evidence based take home messages for the clinician dealing with acute hamstring injuries (8.20 min).

Links: 

Pas H, Reurink G, Tol JL, Weir A, Winters M, Moen M. Br J Sports Med 2015 (BJSM issue 18)
Efficacy of rehabilitation (lengthening) exercises, platelet rich plasma injections and other conservative interventions in acute hamstring injuries: An updated systematic review and meta-analysis. http://bjsm.bmj.com/content/early/2015/07/21/bjsports-2015-094879.abstract

Brukner P. 
Hamstring injuries: prevention and treatment—an update.
Br J Sports Med. 2015 Jun 23. pii: bjsports-2014-094427. doi: 10.1136/bjsports-2014-094427. [Epub ahead of print]
http://bjsm.bmj.com/content/early/2015/06/23/bjsports-2014-094427.long

Hamilton B, Tol JL, Almusa E, Boukarroum S, Eirale C, Farooq A, Whiteley R, Chalabi H.
Platelet-rich plasma does not enhance return to play in hamstring injuries: a randomised controlled trial. 
Br J Sports Med. 2015 Jul;49(14):943-50. doi: 10.1136/bjsports-2015-094603.
http://bjsm.bmj.com/content/49/14/943.long

Bahr R, Thorborg K, Ekstrand J.
Evidence-based hamstring injury prevention is not adopted by the majority of Champions League or Norwegian Premier League football teams: the Nordic Hamstring survey.
Br J Sports Med. 2015 May 20. pii: bjsports-2015-094826. doi: 10.1136/bjsports-2015-094826. [online first and issue 22]
http://bjsm.bmj.com/content/early/2015/05/20/bjsports-2015-094826.long

Reurink G, Goudswaard GJ, Moen MH, Weir A, Verhaar JA, Bierma-Zeinstra SM, Maas M, Tol JL; Dutch HIT-study Investigators.
Rationale, secondary outcome scores and 1-year follow-up of a randomised trial of platelet-rich plasma injections in acute hamstring muscle injury: the Dutch Hamstring Injection Therapy study.
Br J Sports Med. 2015 May 4. pii: bjsports-2014-094250. doi: 10.1136/bjsports-2014-094250. [Epub ahead of print]
http://bjsm.bmj.com/content/early/2015/05/03/bjsports-2014-094250.long


Hamstring injuries: A 10-min evidence based update on optimal treatment (H Pas and H Tol)

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

Prof Peter O’Sullivan considers surgery for back pain: Tiger Woods’ 2015 re-operation

Dr Kieran O’Sullivan, PT, PhD, was one of the first podcast guests to crack 9,000 listens! From the University of Limerick, Ireland, he has vast clinical experience and he completed a PhD on the role of sitting in back pain. In this 18-minute podcast he reviews his 2015 podcast in the first 3 minutes and then rattles off at least 7 practical tips. 

Kieran was a guest of PhysioFirst (UK) when BJSM interviewed him in April 2015. The 2017 PhysioFirst conference is on April 1-2 (2017!) in Nottingham (UK) and guest speakers include Professor Paul Hodges, Dr Tania Pizzari and Dr Igor Tak. 

Timeline: 
1.00 m Back pain is neither explained by what patients and clinicians see on scans nor just by load

2.00 m When treating, you need to assess the various factors that could be playing a role, such as load, posture, stress, and address the right one. 

4.00 m Should we try to prevent all back pain? Listen to Dr O’Sullivan challenge the belief that it’s important to never have back pain. He likens back pain to conditions like sadness, constipation – not great but not a major problem as long as it doesn’t persist. Athletes need to load their bodies and adapt rather than avoid load and become vulnerable (See Gabbett papers and podcast, below). Don’t pass on fear (of back pain coming on or persisting) to athletes. 

5.00 m Screen for red flags of course, if the clinical picture warrants it – but most long-term back pain is NOT due to something listed as a red flag. 

6.00 m Reassurance – being empathetic without inducing fear. 

7.00 m Think through. What precipitated the pain? Too much load, too much stress, bad posture, movement patterns? If unknown, have patient create a pain diary. Look for trends. Examine all the dimensions of the biopsychosocial model. 

9:00 m Don’t just make the diagnosis but be practical. Patient sad? Don’t just say ‘You are sad, your back pain will go away’. Provide specific treatment for the specific threat. 

10:00 m Empower the patient to choose the exercises he or she wants and what he or she will do! Exercise has benefits across systems. 

11:00 m Don’t give up. Here Kieran walks us through a challenging real life case. A simple tissue diagnosis would not have helped this person at the centre of the case 

12:00 m Explain! Explain the pain! (HT to Professor Lorimer Moseley and Dr David Butler).  

13:00 m The period at 4-6 weeks of pain can be difficult – patient has not adapted to the contemporary model and may still be on waiting list for imaging. 

14:00 m What is the evidence for this approach? How does the evidence compare, with, for example Hamstring injuries? 

Links to previous podcast: 
2015 – Dr O’Sullivan on “Effective treatments for back pain: Kieran O'Sullivan’s practical tips within a guiding framework” http://ow.ly/4nepGu

BJSM paper: 
O'Sullivan K, O'Sullivan P. The ineffectiveness of paracetamol for spinal pain provides opportunities to better manage low back pain. Br J Sports Med. 2016 Feb;50(4):197-8. http://ow.ly/4neqbS (Members Only/subscribers)

Manual Therapy paper: 
Hurley J, …., O'Sullivan K. Effect of education on non-specific neck and low back pain: A meta-analysis of randomized controlled trials. Man Ther. 2016 Mar 10. pii: S1356-689X(16)00017-5. doi: 10.1016/j.math.2016.02.009. [Epub ahead of print] http://www.ncbi.nlm.nih.gov/pubmed/27026111


Dr Kieran O’Sullivan on managing back pain: 7 habits of highly effective clinicians. Part 2, 2016

Professor Damian Griffin talks about the Warwick Agreement, an international consensus on the management of femoroacetabular impingement syndrome. This podcast brings you right up to date on the most current thinking about hip impingement or FAI.

0.38 Aim of the consensus
1.36 Consensus methodology
2.26 What is FAI syndrome? Symptoms, clinical signs, and imaging findings.
3.40 How should FAI syndrome be diagnosed?
6.26 What is the appropriate treatment for FAI syndrome?
8.26 What is the prognosis of FAI syndrome?
10.23 How should someone with an asymptomatic hip, with cam or pincer morphology, be managed?
11.53 What research is now needed?
14.15 How is this new definition of FAI syndrome going to influence clinical care?

@DamianGriffin #WarwickAgreement

Damian Griffin is the Professor of Trauma and Orthopaedic Surgery at the University of Warwick. He trained in Cambridge, Oxford and the United States, and worked as a Consultant in Oxford before taking up the Foundation Chair in Warwick and helping to establish Warwick Medical School.

Damian’s passion is the diagnosis and treatment of hip and groin pain in young adults. His clinical practice and research focus on joint-preserving surgery for early arthritis, hip arthroscopy, the management of femoroacetabular impingement and sport injuries of the hip. He runs the largest national referral service for young and active people with hip pain in the UK, based at the University Hospital of Coventry and Warwickshire NHS Trust, and for private patients and elite athletes in London and Coventry (www.hiparthroscopyclinic.co.uk).

Damian leads a research team based at the University of Warwick, with a portfolio of hip research. In particular he is the chief investigator for the FASHioN trial, a large, multicenter randomised controlled trial of treatments for people with FAI syndrome, comparing surgery with physiotherapy-led rehabilitation:www.nets.nihr.ac.uk/projects/hta/1310302

You can follow Damian on Twitter @DamianGriffin and @WarwickOrtho or reach him on damian.griffin@warwick.ac.uk



The Warwick Agreement on the management of femoroacetabular impingement syndrome with Damian Griffin

Professor Peter O’Sullivan is among the top 3 most popular physiotherapy voices on podcasts and here he focuses on myths and harmful beliefs about back pain. He takes a swing at clinicians who rely excessively on imaging findings to attempt to explain the source of pain. He shares the story of a clinician who told a patient his spine was ‘shredded’. 

Prof O’Sullivan emphasizes the importance of history taking, finding factors that can sensitize neural tissue and gives an overview of treatment. He will be the keynote Refshauge Lecturer at Sports Medicine Australia’s 2016 Conference (#SMAConf16, @SMA_Events). 

Timeline: 
0.35 m - A sneak preview of the Refshaughe lecture plan – back pain is a big problem and those in sport can learn from what is known in back pain in the general population

2.17 m - Patients respond well to a combination of explanation, being shown ways they can get back to the things they love to do, and appropriate progressive exercises

4.21 m - A case where a patient could have been treated with early investigation, aggressive medical intervention, potentially surgery. An alternative approach to management

6.48 m - How junior clinicians can approach the patient who presents with a bag of images or a medical note that may not reflect current best practice for managing back pain

9.45 m - The biology of how neural tissue can be sensitized by lack of sleep, stress. Fascinating neuroimmunology

10.55 m - You do treat the back don’t you? It’s not just explaining pain, counseling?  

12.30 m - Parallels with work of other physiotherapists such as Prof Jill Cook (@ProfJillCook) and Dr Alison Grimaldi (@alisongrimaldi) who advocate for progressive loading as a stimulus for healing. “Backs love movement”

13.55 m - A 30-second summary!  

Related podcasts: 
Please consider downloading the mobile app “BJSM’ from iStore or GooglePlay. There are over 250 to choose from and the 10 most recent are very easy to get via the app. 

1. Professor Peter O’Sullivan (@PeteOSullivanPT) on Tiger Woods’ back and ‘core strength’
http://ow.ly/uNgj304udUI

2. Dr Kieran O’Sullivan (@KieranOSull) on how top clinicians approach back pain
http://ow.ly/18Ru304ue96



Prof Peter O’Sullivan’s sneak peek of Refshauge Lecture on Back Pain: Sports Medicine Australia 2016

Dr Clare Ardern is a sports physiotherapy researcher at Linkoping University in Sweden. She carries Australia’s prestigious NHMRC’s top scholarship for clinician researchers – the 4-year Fellowship Award.  You may know of her publications that highlight the relatively low return to play rates after ACL reconstruction. In this podcast, she addresses return to play more broadly. From 12-15th October this year she will be a keynote speaker at Sports Medicine Australia’s conference. You can follow that via BJSM Twitter #SMAConf16 and Facebook.

She was interviewed by Dr Christian Barton, who is a well-published physiotherapist PhD as well. He serves as BJSM Deputy Editor and the Editor responsible for Social Media (small job! easy!).

Timeline:
1:00m - Where did the Return To Play Consensus come from?

2:00m - Defining Return to Play; what does it mean in different settings

3:00m - The difference in RTP for o/c acute – removal from play?

4: 10 - Decision making – how should the return to play decision be made?

3:30m - Return to Play is a continuum that requires meticulous planning

4:00m - When can the athlete return to a pre-injury (or better) level of performance?

4:30m - What is the evidence for return to play decisions? Spoiler alert! – It’s limited. 

5:20m - Taking the emphasis of the ‘one day’ that players focus on to be back at sport. The concept of a continuum (from when you first see the athlete). 

6:45 - Return to play and returning to perform at the previous level. Are there important differences? What can clinicians do to help players get back to that level?

8:30m - Does ‘Return to Play’ end? It’s very different for different athletes. 

10:10m - Should athletes have ACL reconstruction after ACL injury? What does the research show? 

11:40 - Clare’s perspective on the return to play data after ACL reconstruction in the non-elite players. 

12:15 - An example of a player in the English Premier League who was ACL deficient.

Dr Clare Ardern (Sweden) shares the latest on Return to Play – World Congress Consensus Statement

In this podcast, Steffan Griffin of the BJSM speaks to Dr Andrew Murray – SEM consultant & adventurer (amongst other things!), who is currently undertaking a PhD looking into ‘Golf and Health’. We talk about how the Golf and Health project was born, and some of the notable findings from his recently published scoping review. This is a must-listen for any SEM professional/student, not only due to some of the clinical pearls, but due to the fact that this is a shining light of what other sports could also be doing!

Contents
1.00: Andrew tells us about the Golf and Health project

2.30: What are the main findings from the scoping review?

5.30: Deeper dive into the potential benefits

6.45: What about mental health?

7.30: Could spectators also be reaping some of the health rewards associated with playing?

9.45: What lessons are there for other sports?

Links
Scoping Review http://bjsm.bmj.com/content/early/2016/09/26/bjsports-2016-096625.full

Infographic http://bjsm.bmj.com/content/early/2016/09/20/bjsports-2016-096866.full.pdf+html

Golf and Health website http://www.golfandhealth.org/ 

Golf and Health twitter https://twitter.com/GolfAndHealth 

Golf and Health facebook https://www.facebook.com/GolfAndHealth/?fref=ts

Dr Andrew Murray on golf and its effects on health

Thanks to Professor Lorimer Moseley for his 4th BJSM podcast over the last 4 years. Here he chats with final year medical student Daniel Friedman who is at the coalface (@DDFriedman). How are the terms pain, nociception and central sensitisation used? Are they taught accurately or poorly? All of us can learn from Lorimer as he clarifies these concepts.

Professor Lorimer Moseley (PT, PhD) is Chair of Physiotherapy at the University of South Australia and a professor of Clinical Neurosciences. people.unisa.edu.au/lorimer.moseley
He combines Oxford rigour with a laconic and very popular Australian style of communication.

You can find his patient-focused website ‘Tame the Beast’ here: www.tamethebeast.org/#home
You can find his academic/health professional website ‘Body in Mind’ here: www.bodyinmind.org/
Lorimer’s 2014 BJSM podcast was on tendons. Still worth listening to. It has had 20K listens: ow.ly/5OGN30gkaD7.
The 2017 podcast on pain was on pain (some overlap): http://ow.ly/XgNi30kaQax
His 2018 update, focusing particularly on knowledge translation – helping the community become aware of, and benefit from contemporary pain science, is here: http://ow.ly/q3b230kIf4R

“Don’t mislabel nociceptors as pain fibres”. Lorimer Moseley on teaching pain science Ep:339

Fresh off ‘BJSM Podcast World Cup’ victory, superstar physiotherapist Dr. Alison Grimaldi returns for what is sure to be another chart-topping podcast.  On this week’s episode, Dr. Alison Grimaldi (@alisongrimaldi) joins BJSM’s Daniel Friedman (@ddfriedman) to discuss the results from her latest clinical trial – the LEAP trial - that was recently published in the BMJ.
https://www.bmj.com/content/361/bmj.k1662    
With 25 years of clinical experience and particular expertise in the management of hip, groin and lumbo-pelvic pain and dysfunction, Alison is Principal Physiotherapist at Physiotec in Brisbane, Australia, and an Adjunct Research Fellow at the University of Queensland. Alison also has a special interest in the assessment and optimisation of lumbo-pelvic and lower limb biomechanics for
running, change of direction and all weight bearing sports. She is currently involved with research studies through the University of Queensland and University of Melbourne.
https://dralisongrimaldi.com/
Alison explains the clinical significance of the findings from the LEAP trial and shares some practical
physiotherapy tips for clinicians helping patients manage gluteal tendinopathy pain. She discusses:
       Treatment options for managing gluteal tendinopathy pain
       Load management for gluteal tendinopathy
       Specific exercises for gluteal tendinopathy
Alison continues to publish, present and provide practical workshops for other health professionals, and will be coming to Vancouver in September 2018 for her hip and groin pain masterclass!
https://www.eply.com/DrGrimaldi-2018

You can listen to Dr. Grimaldi’s previous BJSM podcast on treating lateral hip pain here:
https://soundcloud.com/bmjpodcasts/dr-alison-grimaldi-with-practical-physiotherapy-tips-on-treating-lateralhippain?in=bmjpodcasts/sets/bjsm-1

Dr Alison Grimaldi on managing gluteal tendinopathy. Episode #343

What comes first—the robust athlete or the high training load? What is the role of moderating factors in training load? And is the ‘10% rule’ a myth?
On this episode, Dr. Tim Gabbett PhD x2 (T: @TimGabbett) joins BJSM’s Daniel Friedman (T: @ddfriedman) to discuss all things training load and debunk some common misconceptions.
Tim has over 20 years of experience working as an applied sport scientist with elite athletes, coaches, and high performance teams from around the world. He holds a PhD in Human Physiology (2000) and has completed a second PhD in the Applied Science of Professional Football (2011), with special reference to physical demands, injury prevention, and skill acquisition. www.gabbettperformance.com  
In this 20 minute conversation, Tim discusses:
·       The definition of training load and its different components
·       The Acute:Chronic Workload Ratio (ACWR) and its limitations
·       What separates robust from fragile athletes
·       The 10% rule ‘myth’
·        How to design a rehabilitation training program for an injured athlete
 
Further reading:
Gabbett TJ, Nielsen RO, Bertelsen ML, Bittencourt NF, Fonseca ST, Malone S, Møller M, Oetter E, Verhagen E, Windt J. In pursuit of the ‘Unbreakable’Athlete: what is the role of moderating factors and circular causation? https://bjsm.bmj.com/content/early/2018/11/13/bjsports-2018-099995
Gabbett TJ. Debunking the myths about training load, injury and performance: empirical evidence, hot topics and recommendations for practitioners. Br J Sports Med. 2018 Oct 26:bjsports-2018. https://bjsm.bmj.com/content/early/2018/10/26/bjsports-2018-099784
Gabbett TJ. The training—injury prevention paradox: should athletes be training smarter and harder?. Br J Sports Med. 2016 Mar 1;50(5):273-80. https://bjsm.bmj.com/content/50/5/273
Hulin BT, Gabbett TJ, Lawson DW, Caputi P, Sampson JA. The acute: chronic workload ratio predicts injury: high chronic workload may decrease injury risk in elite rugby league players. Br J Sports Med. 2016 Feb 1;50(4):231-6. https://bjsm.bmj.com/content/50/4/231
Soligard T, Schwellnus M, Alonso JM, Bahr R, Clarsen B, Dijkstra HP, Gabbett T, Gleeson M, Hägglund M, Hutchinson MR, Van Rensburg CJ. How much is too much?(Part 1) International Olympic Committee consensus statement on load in sport and risk of injury. Br J Sports Med. 2016 Sep 1;50(17):1030-41. https://bjsm.bmj.com/content/50/17/1030

In pursuit of the unbreakable athlete with Tim Gabbett. Episode #374

Seth is a physiotherapy lecturer at the University of Leicester with a special interest in calf & Achilles injuries, having completed his PhD on Achilles Tendinopathy. He joins us to answer some of these questions
·       What are the biggest risk factors for Achilles tendinopathy (AT)?
·       What would be your biggest bang-for-buck treatments for AT?
·       What would you say were the most useful markers for progression?
·       Where do you think people are going wrong in the treatment of AT in general – what are the most common misconceptions/mistakes?
·       How important is the role of the soleus in ankle/calf function, and sporting performance in general?
·       In terms of managing soleus injuries, what tips would you have for clinicians out there?

Talking Tendinopathies & Solving the Soleus Conundrum with Seth O’Neil. Episode #375

This week, Prof Lorimer Moseley joins us to explore how we can better apply contemporary understanding of pain in clinical practice. Lorimer is Professor of Clinical Neurosciences and Foundation Chair in Physiotherapy at the University of South Australia. Prof Moseley’s research group - Body in Mind - investigates the role of the brain and mind in chronic pain. He has over 25 years of clinical experience and has authored hundreds of articles, as well as five books.

When it comes to pain everything matters with Prof Lorimer Moseley. Episode #409

Language, and how we use it, has a powerful influence on driving performance and clinical outcomes. Nick Winkelman, Head of Athletic Performance & Science for the Irish Rugby Football Union, has spent considerable time studying how effective communication can enhance performance. During this podcast with Dr Sean Carmody, Nick draws on the content from his book The Language of Coaching: The Art & Science of Teaching Movement to assess how visual cues and metaphors can be applied to improve your clinical or coaching practice. 

The Language of Coaching: The Art & Science of Teaching Movement

The Language of Coaching Science - talking with Nick Winkelman. Episode #438

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