Take a chance rather than make a plan!

For the last couple of days I have been at Physiotherapy UK. It was a fantastic conference but I must say I am quite happy to be now on the sofa writing this in front of X factor! This post is going to hopefully give an insight into some of the talks I went to and maybe inspire people to attend next year. The problem I find every year I go to Physio UK is I want to see everything so its difficult to make a choice on which talks you go to see especially since I haven’t really specialised in a specific area yet. However it really makes you a appreciate the power and diversity of our profession!

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For those who haven’t been to Physio UK lectures go on throughout the day but there are also lots of trade stands (lots of freebies to be had!) and opportunities to network. The first day kicked off with the Founders Lecture by Dr Emma Stokes! It was such an inspirational start to the day, the thing that stood out to me was the statement “Take a chance rather than make a plan”. This is so true we create our own luck and you really just have to latch on to any opportunities  that come your way(This blog is credit to that) . Take a chance even if you can’t see where it will take you because then looking back you won’t have to say what if…. I think the other main point to take from the lecture was that we need to allow ourselves time for creative thought. Sometimes as physios we make ourselves so busy we don’t have time to open our minds (I am one to say I need to make time for myself sometimes). Please find the link for a further summary of the founders lecture. http://www.csp.org.uk/news/2013/10/11/physio13-founders-lecture-calls-physios-think-creatively You can also follow Emma @ekstokes and watch out for her up and coming blog!!

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Just to highlight that this is my interpretation of the lectures I went to see as I don’t have the slides in front of me and I will only be covering a select few to keep everything concise. Each one will have a title so you can pick and choose which you read if you wish.

Lecture 1: Tendinopathy By Dr Dylan Morrissey

I have not read much about tendinopathy except for my undergraduate training and a few odd posts from twitter but this lecture gave a really good view of current practice and where we need to take it in the future. Now this was a surprise to me but a third of people with tendinopathy are sedentary! I had always assumed that running or elite sport were contributing factors.

So current practice currently involves:

  • Progressive loading- based on theories of mechanotransduction probably. This load needs to individualised to the client so it is appropriate and needs to be slow.

Conservative management of mid-portion Achilles Tendon.

Younger Active people:

  • Reasonable strength, high load- Rx: isometrics- reactive stage. Eccentric exercises, con-ecc, power.

Middle Aged recreational people:

  • Reasonable strength lower loads-Rx: eccentric exercises, concentric- eccentric, Strength and Endurance.

Elderly sedentary people:

  • focus should be to get them moving I missed this part of the slide but Rx: Concentric eccentric exercises.

Some of the top tickets for treatment,

  • Tendon Loading- tendon loading= tendon health. Potentially need to avoid casting to allow for appropriate loading to take place.
  • RSWT- Radial shockwave therapy. The ASSERT trial showed immediate and long term effect with shock wave.
  • Diagnostic suspicion- need to be aware of Intra-tendinous Tears this may be seen in younger, athletic people, presenting with impact related pain who fail with eccentric loading. Another would be Fascia Cura Tears as above but a subtle difference in client group.
  • Prevention
  • High volume image guided injections- reduce pain and allow for loading.
  • Educate and reassure.

So what should be our potential treatment time line?

  • Clinical diagnosis- Week 1
  • Stick with the manual therapy- i.e mobilisation, massage etc.
  • RSWT or HVIGI if the first doesn’t work try the other a couple of weeks later.
  • It is not until 20 weeks you would be considering minimally invasive surgery and 24 weeks for open surgery.

So what are some of the risk factors for tendinopathy:

  • Hamstring / calf strain
  • Tight hamstrings
  • back pain
  • hypertension
  • tight calf muscles.

Lecture 2: Surgical Outcomes for Achilles Tendinopathy and Tendon Rupture- Mike Carmont

So the biggest thing to get across is surgery is normally a last resort! The incident of mid portion Achilles Tendinopathy in the general population is Prox: 9-25% Mid-portion 55-66% and Insertion 20-25%. Patients are normally quite good at locating the problem subjectively during an objective assessment. The main thinks to look for during objective assessment are a gap in the tendon, compare alignment and squeeze calf.  A treatment Algorithm can be found here  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2658946/#!po=28.1250 which links to the main article http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2658946/#!po=28.1250 by Alfredson (2007).

Mike went onto say that the best treatment is exercise however other surgical options are:

  • Stripping
  • Percutaneous-  Day case, the problem with this is pain normally returns.
  • Tenotomy- open debridement sometimes with plantaris release.

All of this is all well and good but you now need to select your patients.

  • Do they need to return to sport or work quickly.
  • Surgery decreases the chance of re-rupture

However some of the complications are:

  • re-rupture
  • deep infection
  • DVT
  • Sural nerve injury
  • adhesions
  • prominent sutures
  • superficial infection

So like with any surgery the risks and benefits must be weighed up as some patients may still be in pain post surgery.

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Lecture 3: Demonstrating Improvement: how neuro-physiotherapy services are leading the way forward- Jill Lockhart

I have to admit I was a bit late for this one but what is on the horizon? :

  • Patient experience
  • Integrated Care
  • Personalised budgets
  • 7 day service
  • Emergency care challenge
  • SPOA
  • Open referral
  • Strategic approach- pathways cross boundaries
  • Workforce changes
  • LTC- Prehab, self management and integrated care.
  • Year of care.

Lecture 4: Bastion to Birmingham: Lessons learnt + future aspirations Sir Keith Porter

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I have to say that after this talk I was so unbelievably proud to say I work at the Queen Elizabeth in Birmingham, especially now I am currently working on intensive care. The talk was based on the fact that a trend had formed where on matched injuries the military appeared to have better care and outcomes for their patients. At the point of injury the main thing integrated into the military was the self help and buddy help so the soldiers knew what to do in time of crisis. It is a real shame this didn’t go through as part of the national curriculum as teaching people early may mirror the training of military personnel.

So to compare:

999 response to injured casualty:

  • First Responder- who will typically have to still wait for an ambulance to arrive for serious cases.
  • Ambulance who can either be manned with a paramedic+emergency care assistant, technician + emergency care assistant or voluntary aid.

Military

  • Helicopter
  • Consultant in emergency medicine or anesthetics
  • Military paramedic
  • Military Nurse.

In the military emergency department there will be an emergency 24/7 consultant who is exclusively trauma. There are dedicated theatres and a  massive transfusion policy (there has been shown to be a reduced mortality in patients receiving the transfusion policy). At the moment places like the Queen Elizabeth are trying to mirror this in hospital.

The main things to be aware of in serious injuries is the lethal triad:

  • Hypothermia
  • Acidosis
  • Coagulopathy

Damage control resuscitation is then implemented. This is to prevent a secondary hit  from Systemic Inflammatory Response Syndrome. So in resuscitation medics will be permissive of hypotension, blood products will be given for volume and surgery will be limited initially. The more critically injured you are the bigger capillary leak you may have which may lead to multi organ failure through second hit SIRS.

So the critical factors to look out for are:

  • Severe metabolic acidosis ph <7.3
  • Hypothermia
  • More than 10 units of blood.

And the aims of treatment should be:

  • save life maximise function
  • manage infection
  • repair damaged structures
  • achieve soft tissue cover and stable skeleton.

There was plenty  of other lectures I attended on the day but hopefully this will give you an insight into some of the talks going on. Keep looking to the CSP website for updates of some of the presentations as they normally get posted online here is the link from last years presentations http://www.csp.org.uk/purchase/video-access

The final talk of the day was looking Physiotherapy: Post Francis. There was some great discussion which can be reviewed on the #physio13 or from posts collated by the CSP twitter feed @thecsp or follow this link http://www.csp.org.uk/frontline/article/mind-your-ps-send-us-your-qs

So overall the conference was great, I got to network with lots of physiotherapists, students and companies (which is another key reason to go to Physiotherapy UK and for students your University normally has a few funded places so take advantage whilst you can). It was great to catch up with some of the main physios on twitter to finally but a face to their name and it is likely that I will be returning next year.

I am sorry I have not been able to cover all the sessions in my blog but I hope you find the post useful. I have had lots of positive comments in Birmingham over the last 2 days so I will continue to keep updating my journey as a newly qualified physiotherapist.

As always any comments either post on here or tweet me @LCphysio.

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Day 1 of the rest of your life!

I have had a pretty hectic week in all fairness and writing this blog has become quite therapeutic to help me find time for me (which is so important whether you are qualified or student, don’t burn yourself out!).  So all of my checks have now gone through so I am now officially employed by UHB! I spoke to my manager yesterday to confirm a start date which is now MONDAY!!! Scary times. Now if that wasn’t scary enough my first rotation is on critical care!! (better get the respiratory books out!) I am very lucky because as a student I worked in the same area so at least I have some idea of where things are. One thing I will be doing is writing down some of the keys things like ABG’s, contraindications and indications for certain treatments as I know that in a new environment sometimes your mind can go completely blank so better to be prepared. I also did this as a student which was useful if I was quizzed by an educator. The things I included were:

  • blood gas values
  • Normal HR, BP, MAP values etc…
  • auscultation sounds
  • mini neuro assessment
  • contraindications for suction
  • contraindications for manual techniques
  • contraindications for manual hyperinflation
  • weaning protocols
  • decannulation protocols
  • Areas of the brain
  • Manchester Mobility Scale.

This is not an extensive list but it really helped me during placement. Alternatively you can now get mini pocket books from Flipio which has the same sort of things in a published book. See link below:

http://www.flipio.co.uk/

I am very excited to get started so I will update you on how my first day goes !!

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So last weekend I was running Seth O’Neil’s LBP: Using Sub classification to Achieve Better Patient Management course. The course gave a great insight into LBP classification which could be implemented into practice. I am going to talk about some of the stuff I took from the course . However,because it is my interpretation I will try to reference some of the main sources if you want to learn more as I think I need to go away and read around the topic myself to get a wider understanding. A great place to start would be to listen to Kieran O’Sullivan’s podcast on chronic LBP http://physioedge.com.au/pe-022-chronic-low-back-pain-with-dr-kieran-osullivan/ and the Pain Education Group website. Obviously this is not the only way to treat Lower back pain as there are many other theories but is good to attend courses so you can make an informed choice.

So as pre course reading we were given 2 papers one by Fersum et al 2012 and the other by O’Sullivan 2005. The reasoning behind classifying back pain is similar to any joint, we wouldn’t necessarily treat an OA ankle the same as an inversion sprain? So if we could why would we not classify a patient’s specific LBP problem to help direct our treatments? It is little bit more complicated than that but a good place to start is what pain mechanism is causing the patient’s pain?

So in this case we are going to look at three:

  1. Nociceptive/Mechanical Pain
  2. Peripheral Neuropathic Pain
  3. Centrally Mediated Pain

Nociceptive Pain is from activity in tissues such as muscle, joint,  skin ans viscera and can be classified by pain which is local, sharp/dull, normal aggs and eases (mechanical), predictable, antalgic pattern, absence of dysesthesias i.e. pins and needles or numbness.

Peripheral Neuropathic Pain is caused by a primary lesion or dysfunction in the peripheral nervous system. Symptoms include dysesthisa, allodynia (pain on non-painful stimulation), hyperalgesia, dermatomal pain and aggs and eases in line with neural tissue. eg. CRPS, Pain generated from the nerve. Physiology of a nerve can generate pain.

Centrally Mediated Pain is caused by a primary lesion or dysfunction in the central nervous system this can be seen from diffuse/ non anatomic areas of pain on palpation. It may be unpredictable, pain disproportionate to the nature of lesion, strong association with maladaptive psycho-social factors. e.g. fibromyalgia

A great way that Seth explains chronic pain to his patients’ is by stating:

“Firstly your pain is real!! If you can imagine doing a crossword everyday for a year- you get very good at it. This is because your brain gets bigger and creates more neurones in this area due to repetition. Therefore if your brain constantly receives pain signals your brain learns to feel pain better and becomes hard wired. So we need to think of strategies we can use to retrain your brain.”

or you can try this video how to explain pain:

There are many classification systems however this event was focused on O’Sullivan Classification (CB-CFT). Through the Fersum et al study the CB-CFT approach had far superior results compared to normal physio (MT + Exercise).

With AQP affecting MSK services in the UK it is vital we have statistics to back up our treatment effects. To begin patients should be screened using either the StartBack or Oreobro tool (these also have mobile apps).  These tools allow us to see who needs secondary intervention i.e  pain team and it also helps with prioritising  patients. One of the biggest risk factors for chronic back pain is psychological screening. One outcome measure which can be used to monitor LBP is the Oswestry Disability Index (which can be downloaded for free on if you search on Google).

The O’sullivan Classification addresses whether Back pain is:

  • Specific or non- specific
  • maladaptive or adaptive
  • movement impairments vs control behaviour

To understand this you might want to read: Diagnosis of classification of chronic low back pain disorders: maladaptive movement and motor control impairments as underlying mechanism. Peter O’Sullivan 2005.

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When assessing a patient why is it that some of us ignore passive movements of the spine whereas if we were looking at a knee joint this would not even cross our mind? So if we don’t assess passive movement of the spine how do we know whether the problem is a movement disorder so loss of movement or a control disorder full ROM but painful. It is is difficult to explain this with out providing images but please refer to the resources available.

Movement Impairment Classification- Management

  • education- regarding pain mechanism
  • reduce fear
  • CBT approach
  • restore movement impairment
  • graded movement restoration
  • graded pain exposure
  • functional restoration
  • normalise movement behaviour

Control Impairment Classification- Management

  • Education- regarding pain mechanism
  • Cognitive behavioural  motor control
  • intervention
  • pain control
  • retrain faulty postures and movements
  • self control of pain
  • functional restoration
  • normalise movement behaviour.

So at large the treatment should be direction specific, control or movement specific and should take into account psych profile.

This post is more to create awareness of the classification as I am aware I need to clarify some of my knowledge so I can further implement this approach into my practice. I think as a new graduate it is difficult to reason through some of these processes without actually getting the chance to assess patients in an MSK setting on a regular basis. One thing I will be trialing will be looking at passive movements to see how this affects my clinical reasoning in practice.

Seth was a fantastic teacher and he had great feedback from the course. Seth is one of the key Physiotherapists on twitter and his feed attracts a lot of UK and international physios so it is well worth a follow @Seth0Neill.

Some other useful resources below are:

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Comments are welcome especially if it involves discussion around Sub-classification of LBP or tweet me @LCphysio

Thank you for taking an interest.