So with a few hours to kill waiting in an airport lounge and now the dust has settled and whilst its still fresh in my mind I thought it would be good to reflect on the recent Danish Sports Congress I attended in the beautiful city of Copenhagen a few days ago.
It was a packed three days, with four streams of talks, symposiums, and workshops running simultaneously, this meant I had some pretty tough decisions to make of what and who I could go and listen to, and unfortunately I had to miss some great sounding talks, such as Prof. Peter McNair from New Zealand on muscle inhibition, what sounded like a controversial symposium on placebo surgery trials, and talks on concussion and ACL rehab.
However, what I did choose to go and listen too didn't disappoint at all, and as usual I was ferociously tweeting as many key points as I could, as were many others. The amount of delegates using social media to share info, have real time debate and even interact with the presenters during their talks I thought was great, and definitely the way to go in the future for other conferences. I also find tweet bullet points a great way to take concise notes that I can store on line and look up later to jog my memory, such as now!
So with all the #SportsKongres tweets in hand, here are my reflections on a great few days in Copenhagen
I cant believe I got his name wrong!
The conference opened with a key note talk from the eminent US rheumatologist Dr David Felson on Osteoarthritis, who I found out later on I had been calling Dr Felsom or Felsome… Doh!
Anyway, Dr Felson began by highlighting the growing prevelance of knee OA and how it is estimated to affect 40 million people by 2020. He discussed how there is a discordance between the imaging and pain reported by many with OA knees and referred to one of my favorite papers ever by the US orthopaedic surgeon Scott Dye who had a knee scope WITHOUT anesthetic to see what hurts when its poked from the inside (full access available here). That commitment to research deserves a Nobel Prize in my opinion!
Anyway, Dr Felson discussed how Scott Dye discovered that the synovium, fat pad and other soft tissues are extremely nociceptive and are often overlooked as source of pain in knee OA. He also discussed the role of central sensitisation in OA pain, and although some habits die hard, such as labelling the nerve fibres on his slides as 'pain' fibres, it was great to hear such a eminant Doctor highlighting the importance of this subject.
Dr Felson then went on to discuss some potential pharmacological treatment options that maybe promising in suppressing this phenomenon, but also highlighted the risks, in that they can be so effective in reducing pain they have been seen in some cases to rapidly progress degenerative changes due to patients activity levels significantly increasing.
I think this is a really important message, not all pain is maladaptive, it does have a very important primary protective role that we need to recognise.
After coffee and some pastries, Danish of course, it was a tennis elbow workshop with the legend that is Bill Vicenzino from the University of Queensland, Australia, (@Bill_Vicenzino). Bill has a great presentation style, relaxed, informal, fun and informative, just what a good educator needs to be.
After Bill finished complaining about the cold weather, he started by looking at some of the research around tennis elbow treatment and showed how physio has a similar long term effect as a wait an see option. But in my opinion this isn't really that surprising as most MSK issues show improvement in the long term, its called regression to the mean.
Anyway, Bill did highlight how physio is effective in reducing pain and improving function in the short term, and discussed which clinical tests are useful in diagnosing and differentiating tennis elbow and interestingly talked about how the long finger extensors dont seem to suffer with weakness as the shorter wrist extensors do. Bill explained how a lateral gliding MWM at the elbow can help in some, but was refreshingly honest in stating they don't work for everybody and that there sole goal is to allow patients to load and exercise more. He also emphasised how patients need to be taught to do them themselves and not rely on physios for them, again right up my street in regards to a sensible, ethical clinical approach.
After great lunch it was a tendon lecture with Professor Heinmeier and her work on using the global background radiation spike that all the nuclear bomb testing in the 50s and 60s created (paper here). This increase in Carbon 14 levels can be looked for in tissue biopsys of subjects who lived at that time, and subsequently see how quick the cells regenerate and return back to base line Carbon 14 levels.
What they found in the deeper Achilles collegen fibres is that the cells here dont regenerate at all once your fully grown and matured thats it, those cells are all you get. This means that if you damage them they dont repair… So Prof. Heinmeier's final advice was too build up as much collagen as you can when young by being really active and then look after them and don't get injured! Sobering but sound advice.
Next was a talk from a young orthopaedic surgeon call Dr Rintje Agricola from the Netherlands (@rintjeagricola) (watch out for this guy and his name, he is going to be a leading figure in hips soon I feel). Dr Agricola presented his research around femoralacetabular impingement. Key points for me was that pincer deformities dont increase the risk of hip joint degenerative changes, but cam defects do. Also the formation of cam defects is seen to be in response to excessive loading whilst the femoral growth plates are open. It doesn't seem to appear or worsen once they are closed. This obviously means younger athletes with high levels of activity and loading are at risk. It was shown that in children from 12 years old who play football more than three times a week are most at risk of cam formation (paper here) if this is in repsonse to the load or the movement isn't clear… Yet!
Incidence or prevelance?
Next up was Australian/Norwegian physio Ben Clarsen, (@benclarsen) sorry that should be Dr Ben Clarsen as he had just successfully defended his Phd two days before the conference. Dr Clarsen talked about his work on the monitoring and recording of overuse injuries in athletes in their Olympic centre in Norway. This basically came down to the difference between incidence and prevalence, which I still continue to get muddled up.
Ben demonstrasted how rather than just recording when an athlete has an injury that means they cant participate in training or competition, we should be recording daily levels of pain and problems, not just those that force them to miss training or competition. He demonstrated this can be done really quickly and simply with a telephone app and a few questions. Over a period of time this builds into a data base of body areas affected, times, severity, duration, and patterns of symtoms can be easily seen, this ultimatly means that attention can be focused in preventative strategies in areas where it matters the most.
Although it was a superb presentation and I think it is a great tool and definitely a far better monitoring system than we currently have, I have some slight concerns that in some sub groups this could lead to hypervigilence and perhaps over reporting of things such as simple exercise induced muscle soreness, possibly confounding the data and perhaps leading us to look into areas for injury prevention that maybe not really an issue.
Best quotes of the conference!
The last session of the day was again on the hip. First up was from the gracious Mike Reiman from Duke University, North Carolina, USA (@mikereiman) who it was a pleasure to meet and talk to. I just wish I had longer to pick his brains about some hip questions I had. Anyway Mike gave an excellent talk on the problems around clinical diagnosis and the specificity and sensitivity issues with orthopaedic special tests, and in my opinion gave the two best quotes of the conference….
Special tests are NOT really that special
Stop putting the 'fear' into your patients!
He highlighted how all special tests suffer with selection bias, in that they are usually all performed and studied in specialists consultation rooms, meaning most subjects already have the the pathology we are looking for before we do the test which hugely confounds the data.
Mike then later went on to talk about the conservative management of FAI and how loading and strengthening is still key and not to advice athletes to stop, rather find ways to adapt or modify technique and position and using other modalities such as bands and belts to help.
Also talking in this session was Dr Agricola on FAI again, but this time he looked into the role of imaging and diagnosis. Again a nice presentation, but some criticism here was there was no mention or recognition of the poor correlation between pathology often seen on imaging and pain and dysfuntion. This would have been good to highlight as most of the audience in this session were surgeons, who are often guilty of seeing patholgy on imaging and assuming this to be the source of pain.
Talking of orthopaedic surgeons, last up for the day was two of them Mr Otto Kraemer and Mr Mikael Sansone debating if there is a need to repair or resect labral tears. This for me was the least useful talks of the day. Nothing was really said, no one committed their opinions or thoughts convincingly, or presented any robust evidence one way or the other, and the debate at the end never happened, an all round fence sitting session.
So that wrapped up day one and it was time for some drinks, discussion and a nice buffet. I managed to speak to Dr Agricola and Dr Clarsen about how things differ on the continent in healthcare, management and facilities, needless to say the UK doesn't hold up well to our EU friends.
A surprising discussion
I also had a very interesting chat with Dr Eitzen (@ieitzen) that evening about her ACL work and her presentation that I unfortunatly missed. I found her views and opinions really refreshing, simple, and brutally honest. Simply put, Dr Eitzen told me that return to sport rates after an ACL injury are low, really low, around 55%, even in specialist rehab centres like her's in Norway where they follow all the latest evidence based protcols. This she tells me is often seen as a failure by the profession and the patient. Dr Eitzen thinks this shouldn't be the case, that in fact we should be happy, really happy with this figure.
She thinks returning to high risk pivoting and jumping sports in which ACLs are often injured is just not sensible or suitable for everyone who has ruptured an ACL and thinks we simply need to accept this and be more open and honest to our patients about it. And perhaps we need to look into seeing if we can determine who is at risk of re injury if they go back and advise them not too, I have to say I never looked at this issue from this angle before and it certainly got me thinking.
First thing on day 2 was a workshop with Mike Reiman on clinical tests for intra articular hip pathology. Mike is another great presenter, calm, confident, concise and crystal clear. He again spelt it out for us regarding issues with clinical test reliability and validity, and also this time for red flags. Although important to rule out he emphasised that one red flag alone shouldn't be relied upon as nearly 85% are false positives. Mike then gave some good simple demonstrations of clinical hip and SIJ examination.
Next it was an interesting workshop on neuromuscular exercise for ACL injury prevention with Prof Mette Zebis from Denmark. She started off by explaining the common biomechanics behind an ACL injury and how it appears that the medial hamstrings in particular the Semitendinosus are a key in limiting knee valgus and tibial external rotation and so thinks we should be looking to find exercises that specifically strengthen this muscle, and gave a really neat demonstration of a live EMG unit that I thought was cool, but thats because I do love a gadget
Is the term neuromuscular needed?
Now I have some critical thoughts generated from this workshop. First is although I have absolutely nothing against targetted isolated specific exercises, heck 99% of my own workshop on Rotator Cuff Tendinopathy was just that, can we, and do we really need to try and differentiate the Semitendinosus from the other hamstrings?
This smacks to me of the old VMO isolation game we all played a few years ago, and look how that turned out! Don't get me wrong I think strengthening the hamstrings is vital for ACL rehab and prevention for sure. I think doing this in a variety of ways, positions, speeds, loads etc is also vital but do we have to get so technical about focusing on one side more than the other? Not in my opinion, this will come with more 'functional' return to play drills and training, or whatever the term functional means to the patient.
Now talking of terms, can I please make a suggestion, no rather a plea that we all stop with the term neuromuscular before we say exercise or movement. It just seems daft and a waste of words. Last I checked all muscular action and movement is 'neuromuscular' and I think most first year students onwards take that as accepted, you simply can't actively move or do any exercise without both the muscles or the nerves, so why the need to state it?
Next up it was a couple of hours of abstract presentations of work not yet published from junior researchers. There was some good presentations here, injury monitoring from Norway again, a new device called the Bandezier that can clip onto Therabands and monitor and record when a patient is doing their exercises and ways to record the accuracy of patients loading when doing rehab.
After lunch I popped into the ACL seminar to listen to the surgeons debate about methods of reconstruction, again not much to report here, apart from an interesting comment made about using donor ACL grafts from family members. The question was posed that a 16-18 year aspiring football player ruptures his/her ACL, would/could we use his/her dads hamstring as a graft. The simple answer was no, but I thought it was an intriguing thought.
Next up it was me…
Now I wont bore you too much, that is if you have made it this far into this report, and of course I am obviously grossly biased in my reporting. My workshop was themed on the issues of exercise parameters for loading in rotator cuff tendinopathy. Basically I tried to highlight how the research is limited and inconclusive as how we should best proceed here, but argued how we can and should use work from lower limb tendinopathy combined with research from the strength and conditioning community to guide us. I also may have thrown a few hand grenades around by saying physios are too conservative in loading and too scared to push their patients into some pain, as usual it had a mixed response, but mostly good I felt.
After coffee, and a lot of debate with those who attended my workshop, the last session of the day was a competition for the best presentation of the best abstracts. Six abstracts where chosen and each had 8 minutes to present, with 2 minutes of questions to answer, a panel of judges scoring to decide the winner of a cash prize.
Topics included, chronic ankle instability, patellofemoral pain and ACL risk. The deserved winner was Cailbhe Doherty (@dohertycailbhe) from the University College Dublin on looking for ways to identify those who cope and those who dont after ankle sprains.
So that lead to the gala dinner, which I have to say was a fabulous evening of good food, good wine and great company. The hosts had some entertainment lined up, including a senior consultant doing a kind of full monty dance, some mickey taking presentations and a bit of pulp fiction dancing, which quickly lead to lots and lots of dancing, and believe me the scandinavians can dance, I may have even shaked my ass a little as well.
And I had another workshop, first thing, and with a little bit of a sore head I presented on shoulder instability, again I wont bore you too much but I went through the research on how specific and sensitve our shoulder instability tests are and some of the issues with them. I showed how bad we are at the prevention of reoccurance with the literature showing rates as high as 80% in some groups, and after my discussion with Dr Eitzen I am beginning to think that just as with ACLs are we setting our sights too high, perhaps we be looking to identify those who cant cope returning to high risk sports after a shoulder dislocation and advising them accordingly?
Saved the best till last
After coffee the last session of the conference was on patellofemoral pain syndrome (PFPS). This was hosted by the charasmatic Bill Vincenzino again, and an excellent young Phd called Micheal Rathleff (@michealrathleff) another a name too watch out for in the future.
Bill first talked about the role of orthoses in the management of PFPS and how a simple quick test of foot width difference can identify those who orthoses will or wont help. Michael then talked about the role of hip strengthening and similar to my first workshop highlighted how the research does a poor job at giving us guidance or describing how to effectively strengthen hip muscles, with the standard 3×10 prescription often being used for nearly everything.
The debate at the end was hilarious as Micheal rather bravely decided to drop an F bomb during his presentation and try and blame it on Bill, a bit of banter between them and the audience members finshed the conference the way it started with a bang
All in all it was a fantastic three days, a great venue, great content, great speakers and friendly hosts and delegates, it was an honour and pleasure to be asked to speak at such an event and it was so good meeting all the people I have interacted with on Twitter and my blog.
I must finish by saying a massive thank you to both Thomas Bandholm (@TBandholm) and Kristian Thorburg (@KThorborg) for being such gracious hosts and charming chaperones during my stay, and for making me feel at times like a real VIP.
So now the Danish Sports Kongres is firmly on my agenda for the foreseeable future and I strongly suggest it be on yours as well. I urge you all to put the 4-6 Feb 2016 in your diary for the next one in Kolding and I will see you all there…