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Amit M. Momaya, Despina Stavrinos, Benjamin McManus, Shannon M. Witting, Benton Emblom, Reed Estes
Clinical Journal of Sport Medicine, Volume 28, No. 3, May 2018
Hip arthroscopy represents one of the most common procedures performed to help alleviate hip pain and improve quality of life. Driving represents one of the most important topics that patients will ask physicians about, especially in the primary care setting after they have been discharged from hospital and are looking to get back to their daily routine. The purpose of this study was to use a modern driving simulator and assess patients’ braking performance after undergoing a right hip arthroscopy.
This prospective study involved 14 patients scheduled to undergo right hip arthroscopy (perfumed by a single surgeon at 1 institution) and a control group (healthy volunteers who denied musculoskeletal problems) of 17 participants to account for a potential learning phenomenon. The two groups did not differ in age, sex, height, weight, and driving experience as measured by years since licensure. The control group did not undergo any type of surgical procedure. All were between the ages of 16 and 60, licensed drivers, and regularly drove using automatic transmission. All participants drove in the simulator initially to establish a baseline, and then at 2, 4, 6, and 8 weeks post-operatively. The following variables were measured:
- Initial reaction time (IRT): time between stimulus and initiation of release of accelerator
- Throttle release time (TRT): time from initiation to full release of foot from accelerator
- Foot movement time (FMT): time between release of accelerator and initial contact with brake
- Brake travel time (BTT): time to apply 200N of force from initial brake press
- Braking reaction time (BRT): the sum of IRT + TRT + FMT
- Total braking time (TBT): the sum of BRT + BTT
The results of the study revealed that the experimental group exhibited significant improvements in INT, TRT, FMT, and BRT at between the pre-operative and 2 weeks post-operative driving sessions in the simulator, however there was no significant change thereafter. There was no significant change in BTT in the experimental group over the 8-week period. No learning phenomenon was noted in the control group.
This study, which was the first to address driving after hip arthroscopy, suggests that most patients may return to driving at the 2 week mark, as indicated by breaking performance. However, there are several limitations to this study. Perhaps the most obvious limitation is that the participants are operating in a simulation and not in an actual vehicle. In addition, despite the fact that all patients in the experimental arm underwent a hip arthroscopy, the procedures themselves differed with respect to degree of soft tissue and bony surgery. For example, an osteoplasty may affect braking performance significantly more than a simple debridement. The relatively small sample size was a barrier to attempt to look at whether these differences existed. Also, it is important to note that currently, there are no single legally mandated or universally accepted numbers for BRTs. While this study provides some evidence for driving after right hip arthroscopy, it is recommended that primary care physicians, surgeons and patients communicate openly with one another to create individualized timelines for safe return to driving.
Sean Mindra, MD, CCFP
PGY3 – Sport and Exercise Medicine, University of Ottawa
Advisor: Dr. Taryn Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport & Exercise Medicine
2018 Consensus statement on exercise therapy and physical interventions (orthoses, taping and manual therapy) to treat patellofemoral pain: recommendations from the 5th International Patellofemoral Pain Research Retreat, Gold Coast, Australia, 2017
Collins NJ, Barton CJ, van Middelkoop M, et al
Br J Sports Med Published Online First: 20 June 2018.
One of the most common sources of knee pain is from patellofemoral pain and is a common condition that family physicians have to manage. Patients often report significant burden due to a limitation in activity and daily tasks, hence it is imperative to have a firm grasp of the evidence behind current treatment. This past year, the 5th International Patellofemoral Research Retreat gathered in Australia to review the interventions for patellofemoral pain and published the 2018 consensus statement for patellofemoral pain treatment.
6 systematic reviews and 13 RCTs that were published since the last meeting were reviewed and used to update the 2016 consensus statement. No significant changes were made from the previous consensus statements but several new statements were added to address new modalities.
Some highlights of the consensus-based recommendations are as follows
- Exercise therapy is recommended and reduces pain in the short, medium, and long terms. It also improves function in the medium and long-term.
- Combining hip and knee exercises is superior to knee exercises alone
- Combined interventions are recommended to reduce pain in the short and medium term. This means exercise therapy in conjunction with other therapies such as foot orthoses, patellar taping, or manual therapy
- Foot orthoses are recommended to reduce pain in the short term
- Electrophysical agents (ultrasound, phonophoresis, laser therapy) are not recommended
- Patellofemoral, knee and lumbar mobilisations are not recommended
- in isolation
- It is uncertain whether patellar taping and bracing are helpful with pain in the short, medium, or long term.
- It is uncertain whether acupuncture or dry needling reduces pain in the short and medium term
- It is uncertain whether manual soft tissue techniques are beneficial in the short term
- It is uncertain whether blood flow restriction training is superior to exercise therapy with regards to reducing pain in the short term
- It is uncertain whether gait retraining is effective in reducing pain and improving function in the short term
Given there are many areas of uncertainty, it is important for the family physician to be aware of these treatment modalities and how they may apply to the individual seeking treatment. However, there remains a lot of questions to be answered and will require physicians to continually update themselves on the latest available evidence.
Jim Niu MD, CCFP
Sport and Exercise Medicine Fellow, University of Ottawa
Advisor Dr. Taryn Taylor BKIN, MSC, MD, CCFP (SEM), Dip Sport Med
Don’t have to see it to believe it – The Effect of Magnetic Resonance Imaging Scans on Knee Arthroscopy
Don’t have to see it to believe it:
The Effect of Magnetic Resonance Imaging Scans on Knee Arthroscopy: Randomized Controlled Trial Arthroscopy. 2007 Nov;23(11):1167-1173.e1
Multiple pathologies of the knee cannot be picked up on x-ray and ultrasound. Increasing prevalence of MRI has led to increased use. We as physicians may not see the bill for these investigations but they are still a considerable expense for our system. Due to long wait times, the National Health Service (UK) has started to perform MRIs to try and reduce the number of patients that will actually require surgery while in the US, they are questioning whether MRI will actually add value.
A randomized control trial was performed using 252 patients on a waiting list for knee arthroscopy. All patients had an MRI of their knee performed. They were then randomized into two groups; one had their MRIs read by their surgeons prior to surgery and the other did not. Even though the group whose MRIs were read had a diagnosis change in 47% of cases, compared to 1% in the control group, ultimately, the rate of surgery was the same.
Important to highlight that this is American data and they may be more likely to proceed with arthroscopy than their Canadian colleagues. Important to note that a diagnosis change occurred in 47% meaning information from MRI was still of value.
Take away message to consider: Don’t wait for an MRI report to refer to orthopaedics because it is unlikely to change the management plan in patients you suspect will require arthroscopy but still order the MRI as it can provide valuable information for operative planning.
Anthony Caragianis, PGY3
Advisor Dr. Taryn Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport Med
CME Certified Fall Prevention module
In a cross Canada review, there were few certified Fall Prevention programs targeted towards Primary Care physicians and their healthcare professional teams. Dr. Frank Molnar, Geriatrician, and his team have changed that! The Champlain Fall Prevention Steering Committee, Dr. Molnar and the Regional Geriatric Program of Eastern Ontario have worked together to deliver an interactive Fall Prevention module which utilizes the Champlain Fall Prevention tools. This online group learning program meets the certification criteria of the College of Family Physicians of Canada and has been certified by the University of Ottawa’s Office of Continuing Professional Development for up to 2 MainPro+ credits.
The sequential modules focus on education, client self-screening using the Staying Independent Checklist, and delivery of the appropriate and evidence-based follow up assessment and diagnosis to determine the root cause of the fall. Selecting the right intervention and referral is also covered in the module.
A complement to this CME program includes access for non-registered health care workers to an online PSW Fall Prevention module. It can be useful for volunteers, receptionists and other non-registered team members as it provides information to enable them to act as a coach and guide for their older clients and to understand the importance of self-screening and the use of the Staying Independent Checklist as part of the Champlain Fall Prevention Algorithm.
These two modules are components of the Fall Prevention education framework to reinforce the delivery of the best practices in Fall Prevention across the continuum. Work is now being undertaken to provide other registered healthcare professionals with similar support,
All of these resources and the link to sign up for the CME module can be found through the www.stopfalls.ca website
Falls Prevention Planning in Champlain: Article 6 – Exercise Class Navigation Flow Chart: Evaluation
As described in our last article physical activity plays a very important role in Fall Prevention but it has often been complicated in the past, for seniors to find the class with the right fit for them to enable them to continue to participate. The purpose of developing the exercise class navigation tool was to make it easier for seniors to access LHIN funded exercise classes across the region. The Champlainhealthline.ca link “Exercise Classes for Seniors” shows the “Which Exercise Class is Best for Me” flowchart and a list of the available classes in the senior’s locality.
The chart was launched nine months ago for Fall prevention month in November 2016 and the time has come to ask users what they think of it, and to understand whether it has achieved its purpose and what improvements can be made.
To do this a questionnaire has been developed and will be visible when seniors, family members, and caregivers as well as referrers use the Champlain Healthline at www.champlainhealthline.ca
We would like to ask you as referrers and health care providers to give us your feedback as well as encouraging your patients and clients to complete the very short survey which can also be found here.
Thank you for your time and your help in making sure that the navigation chart is relevant and useful for seniors and their care providers alike.
Become one of our 2017 Champions for Social Change
In collaboration with the Ontario Seniors’ Secretariat, Elder Abuse Ontario and Western University invite you to be part of a provincial initiative to engage our citizens in challenging social norms and encouraging bystander interventions in support of at-risk seniors.
What YOU can do to get involved:
Contact us to register for a one-day workshop in your region (below)
At the one-day regional workshop,
- You will learn about It’s Not Right! Neighbours, Friends and Families for Older Adults (INR-NFF) – a proven, high performing education and engagement tool
- You will meet other passionate advocates and professionals who have been identified as leaders and influencers
- Together, we will set highly ‘do-able’ goals and make a coordinated regional plan to engage your community
- You will take-away the INR-NFF tools and materials to be able to deliver presentations. Each participant will commit to delivering a minimum of 3 INR-NFF presentations by March 2018 and supporting the roll-out of their regional plan.
There is no cost for registration or for the materials.
See how little things YOU do can make a BIG difference to change attitudes and behaviours to stop abuse of older adults
Regional workshops are being held across the province.
A workshop will be held in your region from 10am – 3pm:
|Dec. 1st||Eganville and District Seniors’ Centre (30 Bell St, Eganville, ON)|
Why you were chosen to attend: You are a professional, advocate or citizen who has been recognized by peers for your leadership and work in the area of older adults’ safety or elder abuse awareness in your community.
What the champion role requires: Participants should have experience with public speaking and making presentations. Be prepared to take action by committing to making a minimum of 3 INR-NFF presentations by March 2018 and supporting the roll out of a regional plan to engage your community in elder abuse prevention and intervention.
Register today! Spaces are limited. Registration is FREE. Please contact Stéphanie Cadieux at firstname.lastname@example.org
Lunch will be provided (Please inform us of any food restrictions when registering)
Travel subsidies of up to $250 are available if you are traveling over 150 km to attend.
Falls are a leading cause of injury among seniors. 20-30% of seniors (age 65+) experience one or more falls each year and 85% of seniors’ injury-related hospitalizations are due to falls.
The Champlain LHIN IMPACTT Centre is conducting a research project supported with Ontario Centres of Excellence funding from the MOHLTC Ontario Chief Innovation Strategist.
This project will ddetermine the value of a falls prediction model that leverages a new technology; QTUGTM and uses trained technicians (non-professionals such as personal support workers) to engage seniors that are normally not being actively screened for falls, and to identify those at higher risk of falling prior to their first fall.
If a senior has been identified with a moderate to very high falls risk, we are suggesting they take the handout materials and speak with their physician or other healthcare professionals to better understand what may be contributing to their risk of falls and what they can do to help prevent falls.
What is QTUGTM?
The “Timed Up and Go” or TUG test is one tool that health professionals use during a falls assessment. It consists of the person getting up from a chair walking 3 meters, turning around, walking back the 3 meters and sitting down while the professional monitors the time it takes, the gait, steadiness, etc.
The QTUGTM uses sensors worn on the shins (over clothing) and a hand-held tablet to track the person during the TUG test. With proven qualitative input, analytical data and algorithms it produces a Falls Risk Score.
First, the person is asked a few questions about age, weight, height, recent falls, any problems with mobility, medications, blood pressure, dizziness and/or vision. The sensors and tablet then measure the time taken to stand, average stride time, average stride velocity, step time variability, time taken to turn, number of steps in turn and time to complete the test. The sensor information combined with the short falls questionnaire determines your risk of falling.
For more information contact the IMPACTT Centre.
Email: Judy Marshall-Brunke
Tel: 613-745-8124, ext. 5879 | Toll Free: 1.800-538-0520
Tom A Ranger, Andrea M Y Wong, Jill L Cook, Jamie E Gaida
Ranger TA et al. Br J Sports Med 2016; 50: 982-989
The prevalence of Diabetes in our population is increasing, as is the morbidity and mortality associated with this chronic disease. As a primary care provider, we are well aware of the role ‘lifestyle’ plays in the development and control of Type 2 diabetes mellitus. For this reason, the guidelines recommend exercise and diet as first line treatment for this condition. It has been shown that up to 50% of participants who quit exercise as part of their management do so because of musculoskeletal symptoms. So the question arises: Does tendinopathy, a condition that reduces exercise tolerance, have a role to play in lack of adherence to an exercise program in diabetics?
Earlier studies have shown that hyperglycemia does change the collagen cross-linking of tendons and reduced their proteoglycan content (Reddy, 2003) leading to weakened tendons and predisposing them to tendinopathy. This study investigated the potential association between diabetes and tendinopathy by systematically reviewing and meta-analysing case control, cross sectional, and studies that considered both of these conditions. In total 31 studies were selected for the final analysis with good attention paid to exclusion criteria and reduction of bias. Confounding variables were identified: age, sex, adiposity, statin use and hyperglycemia. There is observational evidence that statins may induce tendinopathy (Marie I, Arthritis Rheum 2008;59:367-72) as well as an association between adiposity and tendinopathy (Gaida, Arthritis Rheum 2009; 61 840-9).
This systematic review showed that “diabetics had greater than three times the odds of tendinopathy compared to controls; and people with tendinopathy had 1.3 times increased odds of diabetes compared to controls. Therefore there is evidence of a strong link between diabetes and tendinopathy however cause and effect cannot be established even though there are plausible biological pathways by which high blood glucose can affect tendon structures.” It was also shown that those diabetics with tendinopathy have had a longer duration of diabetes.
Regardless of the cofounders that may exist, the compelling evidence supports the link between diabetes and tendinopathy. This has important clinical implications such as careful monitoring and structuring of load progression when initiating exercise to prevent the development of tendinopathy. A slower, more graduated approach would be crucial for these patients. As well, those who have tendinopathy and require rehabilitation should ensure tight glycemic control to speed resolution.
“Co-management by medical and allied health practitioners may be indicated for people with tendinopathy and long standing diabetes.”
Keith Morgan BSC, MD, CCFP, Sport Medicine Fellow February 2017
Advisor: Dr. Taryn Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport & Exercise Med
With populations aging in much of the world, the decline of mental capacity in later years is of increasing concern. There has been hope in the medical community that effectively treating hypertension and atherosclerosis could slow or delay this decline.
In the HOPE-3 clinical trial, a study of people over the age of 70 taking either blood pressure medication or statins for the prevention of heart disease, neither drug slowed cognitive decline during treatment. These results, presented at the American Heart Association 2016 Scientific Sessions, were disappointing for researchers looking to delay or even prevent the cognitive decline that comes with aging.
However, the findings were encouraging in one respect. There have been persistent concerns among patients and regulators that the use of statins to control cholesterol could negatively impact cognitive function and memory. The trial found that the patients taking statins did not have a larger decline in cognitive ability than other participants.
Patients were randomly assigned to receive either one of three drug regimens (combination blood pressure medication, a statin, or both) or to corresponding placebo groups. At the beginning and end of the study, 1,626 older adults completed several questionnaires and tests of mental processing speed and cognitive function.
While participants in all groups experienced a decline in cognitive function over the time of the study, there was no difference in the amount of this decline between treatment or placebo groups.
Data from the trial seemed to suggest that there might be some prevention of cognitive decline in patients with the highest blood pressure and LDL cholesterol levels at the start of the study, but this would need to be confirmed in other trials, said Jackie Bosch, PhD, of McMaster University, who presented the study results at AHA.
Dr. Bosch indicated that the results of this and other recent studies should put to rest concerns about statins and cognitive decline. “We have the data…that show that there is no adverse effect of statins” on cognition, she concluded.
[This article originally appeared in The Beat.]
Exercise Class Navigation Flow Chart
Encouraging seniors to exercise and to be physically active is an important part of a fall prevention strategy. Exercise programs that promote balance training combined with strength and flexibility have been shown to be effective in significantly reducing falls and the injuries resulting from a fall. LHIN funded exercise and Fall Prevention programs are available across the Champlain region, and different levels of programs for people of different abilities are provided. However, determining which class is the right one is key to ensuring that participants gain maximum benefit from the class. Choosing the wrong level of class can be a lost opportunity to promote increased activity.
To simplify the choices and decisions for older adults, their families and health care providers, the Navigation Working Group of Champlain Fall Prevention Steering Committee has developed a flow chart. Each region has its own flow chart with local class details and contact information, but the descriptions for each level have been standardized across Champlain with consistent wording for each level of class.
List of locations (Renfrew County and District)
On the reverse of the chart is the Staying Independent Checklist and seniors are urged to complete this fall-risk screening tool, although it is not a determinant of exercise and activity levels. This screen is a key first step in the Champlain Fall Prevention Algorithm of Detection, Diagnosis and Intervention. Primary care providers should encourage their older patients to complete the Staying Independent Checklist annually and to bring issues and concerns to the primary care team.
The exercise class flow chart will be launched in November 2016 (Fall Prevention month) and will be distributed to public health units, community support services, primary care providers and other agencies, to encourage seniors to choose an active lifestyle. The flow charts can be found on the www.stopfalls.ca website under the community resources tab, and also on the Champlainhealthline website , under the Exercise Classes for Seniors button, “Which Exercise Class for me?”
For more information contact:
Champlain Falls Prevention Strategy
Regional Geriatric Program of Eastern Ontario
Cell Phone 519 639 3000