#Physio14: Where will the next 100 years take us?

This post has been slightly delayed partly due to me gallivanting in Vietnam for 2 weeks but also due to my change in shift pattern on Trauma and Orthopaedics I have less time in the evenings to sit and write my blog. This post will mainly cover my trip to Physiotherapy UK and will touch on future exciting developments in the pipe line.

Attending Physiotherapy UK was a relatively last minute decision. I had been to the conference for the last 5 or so years as a student and newly qualified, however this year with me going to Vietnam for a couple of weeks I was definitely counting my pennies.

I can tell you the decision not to go did not last long as everyone kept messaging me  asking “Are you going to Physio UK?” and in the end I just didn’t want to miss out! It was a great 2 day event which was credit to the organisers  and council, a truly inspiring event with lots of learning to take away. I have written this blog  in blocks so you can skip to the presentation summary you want,( I have not included all of the presentations as I would be here all night). Each one will be divided by a horizontal line.

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Rob Webster- Meeting the 201 Challenge: Opportunity and Threat. NHS Confederation.

It was great for Rob Webster, Chief Executive of NHS Confederation, to come and deliver a talk at Physio UK. Rob really did set the scene for the challenges faced by the NHS in the near future and where Physiotherapy can play its part.

So the current Challenges:

  • Generational Challenge- A society becoming dependent on the health service.
  • Ageing Population- An increasing demand on the Health service.
  • NHS Reform
  • Funding Cuts
  • A population with multiple issues.

We have a leadership role to be optimistic: 7 Themes the NHS needs to address.

  1. The Need challenge-changing population
  2. The Culture challenge
  3. The Design Challenge
  4. The Finance Challenge
  5. The Leadership Challenge
  6. The Workforce Challenge
  7. The Technology Challenge.

So we need ambition for the future- Where is the NHS going?

The vision and asks: The 2015 Challenge Manifesto a time for action.

  • Start with Prevention
  • Long Term Conditions- supported self care
  • Seven day services- local hospitals
  • Hyper acute trusts to save your life in need.

Things we need to remember as Physiotherapists and other Health Professionals.

  • We are guests in other peoples lives. We need to put ourselves in our patients’ shoes to truly understand what they are going through.
  • Our outcomes should be theirs.
  • We should organise around them and not our professional egos.

The Opportunities.

  • Integration working as one team across community and across organisations
  • Cost effective- using and promoting the work being done by Physio Works.
  • Right Person, Right Care.

Threats

  • Misunderstood Role- we need to learn to shout a bit louder about our profession.
  • The Heft of Status Quo.- “If you always do what you have always done you will always get what you have always got”
  • Visibility- Do commissioners know what we can do?
  • Unintended consequences of safe staffing
  • Plurality.

My take home message: We are facing a challenging environment within NHS whether it be cuts, increasing pressure to meet demands or trying to make Physiotherapy heard. We could easily just sit on our laurels and wait for someone to make a plan for us however we all have a responsibility to push our profession forwards and demonstrate how we can be a major part of the transformation of the NHS.


Centenary Founders Lecture 1912-2014 Karen Middleton.

I think I must have done 3 blog posts including a speech from Karen but each time I take away something different. The lecture was focused on how Physiotherapy has transformed over the last 100 years. How we take for granted our Autonomy and need to look back at how our founders over came the challenges to achieve this. Physiotherapy has a great future if we continue to push the boundaries of our profession.

Karen’s Leadership Lessons.

  1. Take Responsibility for your own development- I have taken this forwards by finding a mentor to guide my development.
  2. Things that Karen reflects on: What are you known for? What do you want to be known for? What challenges you? What have you learnt? What have you recently added to your CV? Why should anyone be lead by you?
  3. We need to be flexible! Learn to live with a bit of mess!
  4. What level of risk can you accept? What can you get away with?
  5. Learn to act quickly but not rashly. Don’t over think.
  6. Leadership takes guts
  7. Speak out when others are silent when integrity is at stake. Would you stand up for Physiotherapy?
  8. Everything in your body will tell you you can’t do it. Imposter syndrome we diminish our own value.
  9. We must be authentic
  10. People need a reason to follow you. People need to feel empowered.

If you want to see the video to Karen’s inspirational lecture please click the link below.

http://www.csp.org.uk/news/2014/10/10/karen-middleton-calls-action-stop-physiotherapy-sleepwalking-obscurity


Supporting People with Long Term Conditions- Prof Ann Ashburn

Patients need:

  • Support, Information, choice- patient preference, self-management, Information about their condition, prevention+ health promotion, psycho-social, point of contact when things go wrong, feedback from patients for service improvement and Training for all.

The Strengths of Physiotherapy

  • Active participants
  • Targets set and agreed
  • Collaboration
  • People views of Physiotherapists.

Challenges

  • Limited Research
  • Psycho-social aspect
  • Leisure activities- health promotion
  • Utilising Technology

Disempowerment and Psycho-social factors in long term conditions

  • Attention
  • Diminished concentration affects learning
  • Not being given enough time to think
  • Too many instructions
  • Background noise
  • Fatigue
  • Day to day variability, medication cycle & sleeping patterns. Affected by dehydration (as a result of slowness to swallow,concern about bladder control) so could have headaches, fatigue, constipation all of which will affect performance.
  •  Answering phone – better face to face

Empowerment

  • Allow patients to achieve
  • Recognition of previous life and the patient as a person
  • Choice
  • Support

The final part of Ann’s presentation looked at some of the health promotion activities that Physiotherapists could be involved in such as a scheme called Life after Parkinson’s. For example they set up a dance group for patients with PD . This was just one example of how we need to be creative to improve patient experience and that there is life after a diagnosis of a long term condition.


Assessment and Treatment Planning for MS- Dr Jenny Freeman

Symptoms of MS

  • Fatigue
  • Weakness
  • Poor Coordination
  • Spasticity
  • Sensory Disturbance
  • Visual Disturbance
  • Poor Swallow
  • Bladder and Bowel etc

Some questions and top tips for people with MS.

What are you currently doing to manage your health? What exercise?

Is there anything putting you off?

Do you ever Fall? Impaired  balance during Transfers, STS, Turning./Delayed motor response/Alteration of 2 sensory inputs/use of walking aids.

Exercise is proven to be beneficial and is not associated with relapse. Transient symptoms should settle down.

Should be aiming to complete Resistance training 2-3/week at mod intensity 60-80% 1rep max 1-3sets for min 8 weeks. Aerobic training 2-3 times a week 30 mins 4x a week.

Some of the balance interventions: Increase sway in quiet stance, delayed anticipatory + autonomic postural adjustments. Evidence suggests the benefits for balance interventions.

Current Outcome Measures Used.

10m Timed Walk, Single leg stance, lateral reach, confidence scale ABC, MS Walking scale, Activities specific MS, Grip strength, 9 hole peg test.

Useful Resources: Rehabilitation Measures Database- Neurology/ MS edge outcome measures database.


Measuring Respiratory Symptoms in Advanced MS? What’s the point? What’s the evidence? What are the options? by Rachel Moses.

This was a regular problem when I was working on an acute respiratory ward, MS patients being picked up too late for respiratory Ax. If these patients are caught early there are many interventions which can be taught to prevent admission to hospital but the new NICE guideline for MS have removed speech/swallow and respiratory management from the guidelines even though anecdotal evidence suggests there is a need.

MS pulmonary dysfunction and function 

  • Marked expiratory dysfunction – poor cough
  • Severe diaphragm weakness ? Indication or higher cervical cord lesion.
  • Limited ability to maximally exhale
  • reduced vital capacity for patients who desaturate over night.
  • MS- abnormalities in breathing control, resp muscle weakness, bulbar dysfunction.

What’s the Point?

So when we are assessing a patient we want to be looking at their peak cough flow. If the patients peak cough flow falls below 270ml then it is likely they will need some support to have an effective cough.

  • Lung Volume recruitment bags would be the first port of call this aids breath stacking to increase lung volume for a more effective cough.
  • If LVR isn’t enough some patients may need a Manual assisted cough as well.
  • The final port of call would be manual Insufflation: Exsufflation. This is a machine which delivers a volume and then switches the pressure release the volume and augment a cough. MI:E has been shown to be a cost effective admission avoidance strategy for patients with advanced NMD.

From this presentation it reiterated the importance of early respiratory assessment to prevent acute admissions. It also highlighted a need to educate commissioners on the benefit of respiratory management for patients with MS.


The Dementia Challenge- Iain Lang

What is Dementia?

  • A set of symptoms, progressive condition.
  • Not easy to differentiate between different types of dementia
  • variable condition day to day.

Why is dementia important?

  • Common
  • It’s frightening- most feared health condition, reliance on others
  • £26 billion cost to UK Economy
  • people with dementia stay an average five days longer in hospital.

How can we respond to the challenge?

  • Diagnosis more than 1/2 of people with dementia are not diagnosed.
  • Treatment- drugs are used to reduce symptoms and deal with psychosis, anxiety or depression. No current drug developments.
  • Understand how to communicate with patients with dementia- now mandatory training.
  1. Prevention- managing other commorbidities  HTN, Diabetes.
  2. Don’t smoke this increases the risk of dementia
  3. Eat a Mediterranean diet
  4. stay engaged prevent social isolation, learn new things
  5. Exercise best evidence to prevent dementia

Implicit memory- how you do things?

  • Evidence suggests the way forwards
  • error less learning
  • positive experience
  • repetition guiding what you want.

Implicit vs Explicit

  • Priming
  • errorless learning
  • repeated constant practice
  •  avoid multitasking

Dual Tasking

  • Capactiy overaload
  • Structural interface- sensory overload- for example during standing use fingers instead of hands to support patient.
  • be patient
  • don’t overload senses
  • one thing at a time
  • may choose to do this as part of rehab.

Communication

  • Dementia questionnaire inpatient- what do they enjoy?
  • Smile
  • Understand where people come from.

Pain

  • Very overlooked
  • most unable to verbalise
  • unable to process pain
  • unable to identify pain
  • unable to understand why they are in pain
  • What were they taking before?
  • Pain scale- Abbey pain scale.

People with dementia should be given the opportunity to maximise their potential.

  • Approach from the front good eye contact
  • think about what they are called
  • short commands and being courteous
  • keep hand movements open
  • use positive tone
  • goal based- lets go and look out the window
  • stand up tall
  • use gesture or tap where
  • avoid jargon
  • use of equipment be aware may not understand how to use.

I have been able to take this learning into practice in the acute setting by adapting my communication and limiting sensory bombardment, in turn I have found my patients with dementia have made good progress. Sometimes you need to be patient and try and build rapport  before asking them to do something but if you can get them on your side you will make your job a lot easier. I have also found that by reducing my handling has encouraged patients to be more active during the treatment session which has limited the manual handling load for me.


So that was just a review of some of the presentations I attended whilst at Physio UK. During the event I was able to catch up and network with many different people who I aim to stay in contact with. Physio UK always offers a great opportunity to speak to new people who share a similar interest to you whether that be Management, Education, MSK, Respiratory, Neurology and more. Whilst at the drinks reception I got talking to Paula Manning, outgoing Vice Chair East Midlands Regional network and Catherine Pope, Vice Chair of council. They asked me whether I would be prepared to stand as Vice Chair for the East Midlands Network. I was ecstatic to have been asked but I suggested that I would need to confirm this with my manager. My manager has now agreed to support me and I have been selected to run as Vice Chair of EMRN. The role will be a challenge but it will give me valuable experience which can be transferable to my professional developent. I have lots of people to support me so I am looking forward to taking the role forwards into 2015.

One final thing in the pipe line, I have been asked by the CSP student reps to speak at the annual rep development weekend.  I am really looking forward to sharing my experience as a new graduate with reps and hopefully inspiring them to do great things and take the future of our profession forwards.

Apologies for the length of this blog, but Thank you for taking an interest. Wishing everyone a Merry Christmas and a Happy 2015! Any comments or questions please leave a message below or tweet me @LCphysio.

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Better Together!

Hi everyone this post is really just to give you a bit of a background of the work being done by the Industrial Relations Committee. The last meeting was on the 1st October at CSP head quarters. It was a really productive meeting and the key messages were produced by Claire Sullivan ERUS Director (See below).

Key messages arising from the IR Committee.

1. Members agreed to take it in turns to contribute a ‘guest blog’ on an area of interest to them, for the IRC news bulletin each month. Jill Barker and Kim Gainsborough will be covering October and November.

2. Lesley Mercer joined the committee for lunch and a presentation of thanks on her first full day of retirement from the CSP as ERUS Director!

3. The new Director, Claire Sullivan, talked briefly to the committee about some of her ideas and plans and some of the likely key challenges ahead.

4. Elaine Sparkes (currently SNO for the East Midlands) has been appointed as interim Assistant Director. The post will be recruited to permanently next April

5. Heledd Tomos has joined the committee as the nominated representative for Wales, replacing John Walpole. The committee is also seeking a new directly elected member for Northern Ireland and all ideas and expressions of interest are welcome

6. A number of issues have been thrown up by the recent exercise to update the CSP membership lists for a possible industrial action ballot. These will be discussed in more detail over the coming months. Please can I just encourage people to access their online CSP account and update your details. The stewards have been doing a great job to update membership lists but it has been a big struggle for them on a national front.

7. The committee considered the current position regarding NHS pay across the UK. It was agreed to continue to update the membership lists for NHS members in England and to convene a meeting of the pay reference group in late October to review whether or not the CSP wishes to proceed to ballot members for industrial action short of strike. Feedback and views from members on this issue continues to be mixed. It is worth noting some of the successes from previous action the link below provides a small summary.
http://www.csp.org.uk/frontline/article/making-commitment-jill-barker-industrial-relations-committee

  1. In relation to Wales the committee agreed to consult members over any offer of a longer-term deal and then to refer the outcome of that to the pay reference group for further consideration9. In Northern Ireland, the committee agreed that we should continue to apply concerted pressure for a Ministerial decision as there has still been no announcement as to whether or not NI will implement the PRB recommendation

    10. The committee agreed that we should gather information on vacancy procedures and long recruitment delays through both stewards and managers. Also, that members would be encouraged to feed in information about recruitment difficulties to the CSP

    11. It was agreed to request a slot to hold an IRC fringe meeting at ARC on future sustainability of the NHS

    12. It was also agreed that an ‘easy guide’ for members should be drawn up on future sustainability of the NHS

    13. The committee agreed to promote the TUC’s video encouraging young workers to join unions to the SEC and wider student community and also to seek a delegate to attend the TUC Youth Conference in 2015 (delegates need to be under 26) and interested volunteers are welcomed

    14. The committee agreed a number of action points arising out of the TUC Congress this year, which had been attended by 5 first time CSP member delegates. These included:
    • to publicise to members the new online petition to repeal part of the health and social care bill and the value of lobbying MPs locally ahead of a debate on this private member’s bill on 21st of November.
    • to be aware of, and support, the Stand up for Justice campaign. The justice system is currently undergoing extensive privatisation and fragmentation and this is resulting in deleterious effects to quality services and accountability
    • to publicise a new film called ‘Pride’ to CSP members. The film, which has attracted excellent reviews, is about the role of LGBT members in the 1984/5 miners’ strike.

15. Don’t forget the TUC march this weekend Oct 18th: Britain Needs a Pay Rise- see video below and reasons to go.

http://www.csp.org.uk/news-events/events/march-rally-18-october

The main message to take away from this blog is that we are better together. The society needs members to engage and update their memberships details so that we can we truly represent what members want. Likewise if you have suggestions  you would like to take forward to CSP council please attend your regional network meetings so that regional council members can take your ideas forwards.

Thanks for taking an interest in my blog any questions or comments please leave a message below or tweet me @LCphysio.

My next post will give a round up of Physiotherapy UK 2014.

Physiotherapy Works!

Last Friday I was fortunate to be able to attend the Physiotherapy Works Locally event as part of the East Midlands Regional Network. I have been asked by the network to be a core part of the committee. This will hopefully allow me to build some momentum with social media and help get students and newly qualified members involved. This will aid the discussion regarding key decisions about the region and society which can be fed back to council. The Physio Works locally event was a joint event between East Midlands and Yorkshire/ Humber  Regions. The event was a fantastic success with a lot of social buzz and pledges being made.

Photos from Anne Jackson CSP

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The event kicked off with Karen Middleton CEO of the Chartered Society of Physiotherapy giving a talk on: “The Case for Change”

Whenever I listen to a speech by Karen I feel so empowered, I want to run outside and tell everyone how fantastic we are as Physiotherapists and that we can really make a difference to peoples lives. Her talk was powerful and to the point. She said that we as Physiotherapists need to start talking about the benefits of Physio before we miss out on our golden opportunity. The health climate in 2014 is creating an environment where people are living longer. This creates a society with patients with more long term conditions and people needing to be fit for work for longer.

 

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Physiotherapy can influence all of these groups!!

So what are you going to do about it?

The quality of a service is essential to achieve positive outcomes. We need to be effective, collect outcomes, safe and develop positive patient experiences.  However, how are we going to do this? We have less money available and a dependent medicalised society. So what innovative ideas can we take forward? The profession of physiotherapists is far too modest regarding what we can bring to the table in terms of healthcare. Overcoming this apprehension will enable us to take our ideas forward and make them reality before it is too late.

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So here are few of the things Karen suggested we should be doing:

  • See opportunities and take them.
  • Realise our potential as leaders.
  • Come of age as autonomous practitioners.
  • Use CSP support, materials and tools.
  • Make a lasting difference to patients.
  • Nobody will do this for us.

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So some tips:

  • Be flexible.
  • Connect, build, link and network!!!!
  • Think ahead and talk solutions.
  • Know how local decision makers think.
  • Use the evidence.
  • Show our impact through data collection.
  • Talk about money as well as outcomes.

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Action Point:

Think about becoming a pioneer for Physiotherapy Works –  for more information:

Web: www.csp.org.uk/physioworks

Twitter: #physioworks

Email: physioworks@csp.org.uk 

  • So what?  Now what? What difference does it make? Be Brave, Physiotherapy Works.

 

Change is the Only Constant- Alison Hughes NHS ENGLAND

Alison Hughes was another fantastic speaker of the day. She is currently Director of West and South Yorkshire and Bassetlaw Commissioning Support Unit.  She was initially a physiotherapist and an advocate for clinicians leading the NHS. As physiotherapists we are ideally placed to lead. We are able to diagnose, listen, work as an individual and as a team.

However the change you want to see starts with you!

And you need to be clear on what success looks like.

To me success looks like : Everyone in the general public knows what a Physiotherapist is and what they can do.

What are your barriers to change?

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I thought this image summed up a lot of clinicians anxiety to change. Mostly due to hidden barriers created by a Top down  organisational structure created by management. To overcome this we need  to be brave and inform management of the challenges faced by front-line staff and the solutions to overcome these difficulties (this may be where physiotherapy comes in)

Alison referred everyone to a book by Robert Kegan- Immunity to change. Which links to the image above. http://www.amazon.co.uk/Immunity-Change-Potential-Organization-Leadership/dp/1422117367 n

When planning a strategy for change, below is a great diagram to help you organise your contacts so that you target certain individuals to help promote specific campaigns.

Importance of Stakeholders

Influence of Stakeholder

Unknown

Little/ No importance

Moderate

Significant

Unknown
Little/ No importance
Moderate
Significant

So in summary:

  • In creating change we need to clarify what success looks like.
  • Set realistic goals
  • Grow and use the support you have.
  • Understand stakeholders
  • Understand hidden competing commitments for yourself and others.

 

Physiotherapy Works- Make Every Contact Count. Knowing Your Service.

The principles of this focused on:

  • The context of change
  • Knowing your Service
  • Knowing your Population
  • Knowing your Evidence.

Know where you fit in our healthcare system.

Knowing your service

Quality is based on:

  • Effectiveness
  • Patient Experience
  • Patient Safety

+COST

Quality +COST= Value.

The CSP is developing tools to give bite size pieces of evidence to show the value of Physiotherapy. This will be based on for every £ spent on Physiotherapy will save the NHS…. compared to without. The cost of Falls Tool will be launched alongside Older Peoples Day on the 1st October 2014 (and more to follow).

Knowing your Population

A population is made up of – current users of the service and future users of your service.

Accessing Health Profiles can give you  information regarding the demographics and problems in your region.

http://www.apho.org.uk/default.aspx?QN=P_HEALTH_PROFILES

Knowing the Evidence

  • Published research
  • National guidance
  • Local data- audit, patient experience, satisfaction, outcome, KPI’s
  • Other
  • This can be used to challenge the status quo!

There was a great emphasis on developing your service and having your elevator pitch in mind, so if you were stood next to a commissioner in a lift you could quite happily deliver your message.

My service is…

Delivers to this population…

Based on this Evidence…

At this price!!

So you might be thinking where do you go from this… So the next steps might be..

  • Why do you need to change?
  • What will you do differently?
  • When?
  • How can you improve?
  • Who will you influence?

This will give you a starting point for change !


In the afternoon the Physio Works team did a great job in setting up mini workshops to get us thinking about innovative ideas which could form part of our future NHS!  We looked at regional health profiles, developed  ideas and then presented them to the group. There were some great ideas being thrown around the room and it was an effective way which made everybody feel ready to go and talk about how versatile the profession of Physiotherapy really is.

The East Midlands (@CSPEastMidlands) and Yorkshire and Humber (@CSPYorksHumber) Regional Networks did a great job in organising the event and are always looking for more members to attend regional meetings, I would actively encourage you to attend. More information can be found here:

http://www.csp.org.uk/nations-regions/east-midlands

http://www.csp.org.uk/nations-regions/east-midlands-regional-priorities

http://www.csp.org.uk/nations-regions/yorkshire-humber

http://www.csp.org.uk/nations-regions/yorkshire-humber-regional-priorities

http://www.csp.org.uk/your-health/physiotherapy-works

 

Thank you again for taking an interest in my blog. As always please feel free to leave a comment below or tweet me @LCphysio.

Finally the first part of my campaign was to get my Mr to make a pledge!

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This time last Year!

How crazy around this time last year I was starting to write my blog. Now a year qualified looking through my posts it is crazy to think how much I have achieved in that time. So this blog post is going to update people on my progress through rotations and will also touch on a recent course I have been on for Strength and Conditioning combined with Physiotherapy.

Currently I am working within the Specialist Medicine team at Derby, covering one of the acute respiratory wards and the High Dependency Unit. My first impression of starting my respiratory rotation was although respiratory physiotherapy isn’t my comfort zone, it was a skill I needed to develop. I naively thought “well at least I won’t have the same level of social sort out as elderly medicine….” (How wrong I was). You forget that elderly people may also have a respiratory condition and even if they are not elderly you may have to deal with breathlessness management, oxygen requirements and anxiety to prevent people being readmitted to hospital. Initially I found myself being very slow with my assessment an acute ward is very different from ITU. On ITU a lot of the patients did not necessarily have predisposing respiratory conditions (not all of them) or they were intubated so management was focused on chest clearance and early rehab. Whereas on an acute ward you are looking at how patients will manage at home with ADL’s, the need for long term oxygen therapy, occupational therapy involvement and  the need for social services involement. On the ward we work closely with the OT, one of the things we look at is equipment to help with energy conservation, as this can help to maintain a patients’ independence.

On the ward we have around 28 beds including a 4 bed High Dependency Unit. The high dependency unit has 1 nurse for 2 beds and is mainly for patients who are needing Acute NIV, Tracheotomies who need regular management, patients who have the ability to deteriorate who need escalation to ITU and patients who have reached there ceiling of care on HDU (so they are not for escalation to ITU if they deteriorate likely because their respiratory function is limited due to predisposing lung condition). The sort of patients I have been exposed to on HDU are Spinal cord injuries, Stroke, Neuro-muscular conditions such as GBS , acute exacerbation of COPD, vasculitis and severe pneumonia (So a range of conditions to get stuck into). In HDU all the patients have the ability to go off quickly so you have to keep your eye on the ball, however, it is worth noting that not all of the patients in HDU need physio. For example the patients dependent on NIV who do not have sputum retention normally just need time for their blood gases to normalise so we would hold off unless they need us for mobility Ax.

So objectives I have set myself on Respiratory:

1. To be able to carry out a Subjective and Objective Assessment on a:  i)Critically unwell patient ii)Ward Based patient iii) create a problem list and Rx plan.

2. To be confident using different Rx techniques and demonstrating clinical reasoning. i) Mechanical devices ii) Manual techniques iii) Suction iv) Advice and Education v) Postural Drainage.

3. To be confident in interpreting observations i) HDU charts ii) Auscultation iii) ABG’s

4. Prioritisation of a respiratory ward. i) HDU II) Ward Management iii) Discharge planning.

5. To be on call competent and safe

Through this rotation I will spend half of my time on the ward with HDU and half of my time on a general respiratory ward. To become on call competent through supervision sessions I am slowly working through my competencies. So far I have been fortunate for the experiences I have gained which will set me up for going on call.  However, I don’t think you can ever be prepared for the adrenaline kick of an on call situation. I think the best advice I have been given is always to go back to basics and question why someone has ended up in the situation they are in. What can we have an effect on? And what can’t we have an effect on? What is the main problem: Lung volume, Sputum or work of breathing or both? (This is how I would look at my patients but obviously everyone has different methods you would also complete a thorough respiratory assessment to reach your conclusion).

So slowly but surely my confidence with respiratory is slowly increasing and I am hoping to be ready for the September rota eeeek!! I will try to keep you updated with my progress.

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So very much away from respiratory physiotherapy. I recently attended a course: The Integration of Strength & Conditioning and Athletic Screening to the Management of the Sporting Client: Recreational to Elite Level. The course was run by Harborne Physio and was taken by Simon Noad (West Brom Physiotherapist) and Ray Jackman (S+C coach based on Uni of Birmingham). I wanted to attend this course because there is a known gap between physio and S+C. We should be working in partnership to help athletes or clients achieve their goals. So I wanted to gain a bit more knowledge of S+C and how this would fit into my practice. Just to say people may have differing opinions regarding this process this is just one example. How I have written this up may be a bit jumpy because I have jumped through different principles discussed on the course.

The course was fantastic and it is the first combined S+C/ Physio course in the UK. Simon and Ray were great teachers and explained the principles and practical elements very clearly. The course highlighted that we should be focusing on training athletes not specific “Footballers, rugby players or runners”. The process of S+C is to help develop an individual to perform at the best of their ability.Obviously you will reach a point where you need to be looking at sport specific requirements but we must create foundations first. Is the athlete fit to undertake a training regime without breaking down. There are many elements which must be incorporated into a training regime to account for this for example: Nutrition, Speed, Strength, Power, Recovery,RSA, Endurance, Injury prevention, Flexibility, Anaerobic, Research. If we just breakdown recovery we should be looking at: Sleep (10 hours for an athlete), Hydration, Nutrition, Foam rolling, Mobility work, compression, ?Ice Baths so all of the elements can be deconstructed to create a comprehensive Ax and Plan.

So back to athletic profiling things to consider?

1: When do we screen:Pre season, End of season, following significant injury, return to training or objective Ax. There is no right or wrong answer.

2. Where?: Where do you work, what are you trying to measure?

3. How?: Single station, multi-station, single practitioner or multiple, number of athletes.

After devising a plan we should be doing a medical screen, if you do not have  medical support. This may highlight risks such as Cardiac problems which may need to be screened. http://www.c-r-y.org.uk/ . If in doubt refer to a Doctor or advise client to seek GP advice. (No your scope of practice).

The Screen

Habits/ Daily activities- may lead to motor control restrictions. This links to Poor training regimes which may cause soft tissue restrictions and finally previous injuries which may lead to movement dysfunctions linking back to habits.

How we are born to squat

Some of the things we may include in a initial screen are a Squat, Lunge, Single leg dip, box drop, forward hop and a combination. We should be marking these against normal movement to pre-empt restrictions and weakness. The testing must be standardised and you don’t have to include all of the movements to get what you want (look at the specifics of the sport).

Then we would move onto NMSK assessment some of the tings you might look at. (Not an extensive list)

  • Spinal position
  • Spinal AROM
  • Ankle ROM
  • SIJ mobility
  • Prone internal rotation
  • Thoracic Spine AROM
  • Hamstring AROM
  • ITB length
  • Hip flexor lengthon
  • Groin Strength
  • Quadriceps length
  • Hyper mobility
  • Motor/Core Control- looking at timing of muscle activation

There was a lot of practical elements looking at exercise prescription and how you would take your data forwards into a profile. The process I will incorporate into my practice will look at:

  1. Mobility
  2. Motor Control
  3. Functional Patterning.

We can incorporate this method into practice to formulate a comprehensive treatment or exercise prescription. It is difficult to demonstrate this in a blog post but basically the rational for this is because quality stability is driven by quality proprioception. And Quality functional movements cannot occur with restriction. So we should be addressing restrictions in RX, fire up the NMSK system and then consolidate learning with functional patterning.

For mobility we should be addressing myofascial length and Joint Range this links back to muscle slings which may impact of an athletes training. I am not going to go through the different slings and predisposition to different injuries as I will be here all day but some good examples can be found here: http://www.mobilitywod.com/#[/

or in the book “How to become a Supple Leopard”

After Mobility we can address motor control which is looking at stabilisation working in the new range of movement you have achieved. Some of the things which may be included are: Rolling, Dead lifting and chop and lift. This element demonstrates perfectly how much of MSK physio can relate to Neuro physio.

Finally we look at motor patterning using new control and range and incorporating them into functional movements. Something people might want to read around is Reactive Neuromuscular Training.

Your client should now be ready for S+C training however the whole process falls under the broad umbrella of S+C so there are links between the two, highlighting the need for more integration and a holistic approach.

The second part of the course focused very much on the principles of S+C incorporating RAMP principles into training. Work by Ian Jeffery’s comes into this. Elements we should be including within S+C are :

  • Needs Analysis: Requirements of the sport, movement Ax and Physiological Ax.
  • Warm Up: Raise- Increase HR etc, Activate- key muscle groups, Mobilise- look at movements not muscles and  Potentiate- sport specific drills.
  • Have an understanding of SPORT and FITT principles (not just giving 3x sets of 10)

So this was just a whistle stop tour of the course and this blog is not an exhaustive program of what you would consider but may give you some prompts to look at different elements of your practice. The main learning points I took away from the course are:

  1. When, Where and How to conduct an athletic screen and profile.
  2. The importance of looking at Mobility>>Motor Control >> Functional Patterning
  3. RAMP principles
  4. The importance of specific and tailored training regimes.
  5. The importance of understanding the needs of your athlete.

Thank you for taking an interest in my blog.  Next week I will be attending the CSP industrial relations committee meeting at CSP head quarters so my next blog is likely to be centred around that.

If you have any comments please post to my wall or tweet me @LCphysio

Create Foundations First!

It has been a while again since my last blog! I have been very busy with work, gym and trying to tame a new ex racehorse I have obtained!! Most people who know me know I like to keep myself busy! The last time I wrote my blog I had just started my job at Derby Hospitals NHS FT, moving onto elderly medicine. I am now talking to you on my second to last day oN my rotation and I am now going to talk a little bit out my progress and some of the things I have come to realise on my journey!

From past experience working at the Queen Elizabeth hospital, on a medicine ward. I had identified I needed to continue to develop my ward prioritisation and management skills to be successful on my new rotation of elderly medicine. It was difficult coming to Derby because having only experienced physiotherapy in Birmingham there were different policies and procedures to follow. For example in the morning we have a daily board round to discuss patients with the MDT whereas in Birmingham we had a weekly MDT meeting. I have found the board round has worked quite well because it creates an opportunity to discuss problems and identify patients earlier who are becoming medically fit for discharge. Although I am from Derbyshire, I never realised how huge the county is, so figuring out where patients are located was initially a challenge however this was made easier with the fantastic nurses completing  inpatient rehab forms for us after completing goals (what a luxury!).

So I wanted to talk about some of the things I have learnt along the journey which I hope will be useful to all physiotherapists not just students and graduates. My opinions are not gold standard they are just an opinion so please formulate your own clinical reasoning.

Prioritisation 

This is a skill I have really had to refine. In day to day life I am a very organised person however  my problem in terms of the ward management were I wanted everyone to have daily physiotherapy sessions. But unfortunately i realised this is not always possible due to the complex busy caseload . I Initially I found it difficult to lead the caseload partly because there was more than one physio  on the ward, my supervisor (which is great for learning). So we tried not to tread on each others toes. Further more I also lacked confidence and experience to challenge some of the views of the MDT with regards to discharge planning which hindered my initial development. With the complexity of some of the cases on the ward it took me a bit of time to demonstrate my full prioritisation skills, but over the last 4 months I have progressed to the point of feeling confident that I could transfer my ward management skills to any acute ward based setting. 

 

So below are some of the things I have learnt along the way:

  • Everyone has different methods for prioritising, but the way I have gone about it in a simplistic view due to the many factors which interplay : Respiratory patients not managing their own secretions, new patients who need a full assessment (prioritising patients who are requiring chest physio and those coming up to be medically fit for discharge), patients who are medically fit for discharge without a plan for discharge, patients at risk of deterioration if they are not seen and finally patients who are being monitored on the ward.
  • Prioritise patients who require assistance of  2 to ensure staffing can match the need in the afternoon.
  • Unfortunately when you want to see patients on the ward most of the time they do not always fit in your specific time slot so you have to be flexible with your management. 
  • Don’t be afraid to delegate you are not alone (hopefully). If you work with a physio assistant is there any patients that they could see for you on their own? Is there any admin needs they could complete for you?
  • And finally relax! You can only do what you can do! You are not superman or woman! (although I try to be),,, you are better to complete assessments thoroughly to create a plan rather than coming out of your assessment thinking what information have I gained from that?

Multidisciplinary Team Working

I have been very fortunate on my ward to work with a fantastic MDT who are very pro therapy to facilitate discharge. Coming onto my ward I initially felt the high bed pressures looming! However, this has encouraged me to devise a plan earlier and ensure I was continuously liaising with members of the MDT to create a discharge plan with the aim of preventing readmission. Working with the Frail elderly you will be presented with some complex cases such as patients at risk of falls, cognitive impairment, patients refusing social services or patients who do not meet social services funding, patients with complex commodities and finally patients with varying conditions.

Sometimes you are presented with some very emotive cases and you can feel as though you are playing with peoples lives. From our point of view we can only recommend what a patient should do to maintain there safety. However, if patient has capacity to accept risk or go home ignoring recommendations then that is their choice to make. We should be facilitators not dictators. I sometimes felt quite stressed with some of the situations I was faced with, with some patients being border line whether they are safe at home or not. However that stress is important because it ensures I am conscious of my decisions to strive for the best care for each individual patient. I think if you don’t have some form of internal stress and are going through the motions in your job this may come back and bite you in some point of your career. For patients we should be assessing them holistically and taking a 24 hour approach to theIR discharge…. Are they able to manage hygiene needs between care calls? Are they able to sit between care calls? Do they have any pressure sores? Do they have a cognitive impairment? Are they safe with there mobility? Are they able to complete bed/chair and toilet transfers? and finally Are they any safety hazards or risks for the patient returning home? These complex discharges cannot be completed seamlessly without an MDT approach so get to know your team and start communicating!

Preceptorship

It wasn’t long ago I was talking about starting my preceptorship! I am pleased to say I have now completed it to 6 months and have gathered evidence throughout my rotation to support my objectives, The objectives I was set were:

Working with patients and groups: I demonstrated this through joint sessions with my supervisor and a self evaluation form,

Working with colleagues and other agencies: I demonstrated this through a complex case study with a reflective piece and copies of some of my record keeping demonstrating liaison with different members of the team.

Written Communication: I demonstrated this by taking 5 sets of notes and analysing what was good and bad about them.

Using Local and clinical policies relating to working practice: I completed a reflection on infection control and completed a notes audit for the team.

Aside from my preceptorship I was set rotation objectives which interlinked with the programme. It might be a bit geeky but lets face it not many people spend time to document their experiences like me anyway ,but, the preceptorship process really did hone my reflective skills which will support a career long commitment to reflection and CPD in future practice. 

I have loved my time working with the elderly medicine team and I have had ample opportunities to develop my clinical reasoning, prioritisation and overall ward management. I now feel confident that I can transfer these skills to another acute ward based setting, to deliver a quality service to my patients. It was fed back to me that I sometimes set my expectations too high of myself. This has been the case for many years but it is the driving force which allows me to strive for the best. On the other hand, I realise that it is important to get the foundations right first to  develop a solid base for development and that there is no need to rush, at the end of the day I am only still in my 1st year of graduating :-S!

 

Action Plan and the Future.

So in the pipe line for me…. next Tuesday I will be starting on my respiratory rotation (eek), I have completed the 2 week intensive training given by the trust so it is now up to me to get my head in the books to get my head back into respiratory management! Aside from this you may be aware from my last post I wanted to find a mentor to help refine my leadership skills…. well I am pleased to say I have found one and not just anyone. Sarah Bazin OBE has happily agreed to help me and we will be meeting next week :-). Sarah is the current chair of the European Region of the World Confederation for Physical Therapy (ER-WCPT) so I am honored to be working with her over the coming months!

My latest action plan…

  • Revisiting my respiratory assessments
  • Thinking of objectives for my respiratory rotation
  • Creating a 5-10 year plan with the help of Sarah as appropriate

I think that will be enough to keep me going for now. Thank you for taking an interest in my blog! Please feel free to leave a comment or Tweet me @LCphysio . 

Decisions, Dilemmas and Diversion

It has been a while since I wrote my last post. I have been very busy since starting my new job at the Queen Elizabeth Hospital Birmingham and I have also continued to  work at West Bromwich Albion FC and Harborne Physio at Barefoot Birmingham. So I have barely had time to sit down never mind write my blog. As you may be aware from my last post my first rotation has been critical care rehab which has been incredible. I have been able to see some of the long term rehab patients who are ventilated and non-ventilated and I am getting to see some of the post operative patients which all will stand me in good stead when I come to complete my respiratory competencies. It has been great to get stuck back into respiratory as I only had the one placement in my second year and everyday my confidence is building as the team I am working with is great!! We do a lot of doubles together, teaching sessions and in service training.

Now this all sounds all well and good but the last couple of weeks have been pretty stressful for me, a couple of weeks into my job at the QE I got an email through from a manager at Derby Hospitals. As you may know from previous posts I had been for an interview there but was unsuccessful (which I was disappointed with as I had done my best on the day). The email read along the lines of:

Dear Lucy

I hope you are well.

We have had some extra movement in the trust and I would like to offer you a permanent contract at Derby Hospitals…..

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At this point I read the email about 50 times before I made sense of it! Due to my interview being within 3 months they could recruit me straight away! Of course at this point I accepted but was wary that a permanent post was coming up at the QE so I was still hopeful to remain in trust so I attended the interview to give myself options.

I turned up at the QE interview consciously fine, I went in sat the written paper which asked questions on Chronic non-specific lower back pain and what the management would be? Prioritisation of a list of patients, a respiratory patient assessment, treatment with relation to the on call rota and another question which I can’t remember. I came back to sit down after the paper feeling relatively calm and waited to be seen for the individual interview…. I was being interviewed by the head of therapies and a band 7. I went in and the first few questions were absolutely fine and then it hit me….. My nerves suddenly took over me and I couldn’t physically speak the further questions weren’t particularly ambiguous and if you had asked me later that day I could have gone on for hours but instead I felt like I was outside my body looking in and couldn’t do anything to help myself…. So unfortunately I can’t recall any of the questions from that interview and you can guess I didn’t get the permanent contract…. however they were very understanding of how much the job meant to me on the day and did extend my contract if I wanted.

Now for most people this would be a simple decision to take the permanent contract, but for me not so much. I really had to sit down and right the pros and cons of each hospital and location which did keep me awake most of the night. In the end I chose the permanent contract although I have settled into the QE and I love the hospital I had to be selfish in thinking about my further development…. so I opted for continuity. So as you can imagine I am ecstatic!!! I am now a proud owner of a permanent band 5 contract and all the events and opportunities that have lead to this day have sometimes been hard but totally worth it in the end. I just wanted to say that if you are newly qualified physiotherapist looking for an NHS job don’t give up! I have had several interviews which have been unsuccessful but you can’t take it personally and you have to move on to the next one. Eventually something will come your way and it will be the reason you didn’t get the previous jobs you applied for, because everything happens for a reason.

So since I have now got a permanent band 5 post as promised I wanted to give students and new grads tips on how to write their supporting information. So firstly here are my top 10 tips for writing an application and attending an interview:

1. Read the PERSON SPECIFICATION….. this is the point all managers come back to that applicants haven’t done what they have asked. Sometimes there will be hidden questions to how they want you to approach the application. Basically don’t give them a reason to turn you away, use buzz words that are included in the person spec.

2. Make it personal to the trust, show them how you meet their vision and values if you don’t do this you might as well not even submit your application.

3. Demonstrate your transferable skills. If you have been involved in other activities outside of physiotherapy… what skills have you developed and how can you transfer them into practice.

4. Include your HCPC number and CSP membership number at the top. This means the recruiters don’t have to look through your application when it is staring them in the face.

5.Make sure you review the NHS jobs website daily. The website sends emails of new jobs at the end of the day not when a job goes out.

6. Get your application in early some NHS jobs can close within a couple of hours like the QE. Have a basic template for your application ready so you are ready to go when the job goes live.

7. Don’t make it any longer than 2 pages A4 treat it as a CV otherwise the recruiters will get bored if you are not keeping everything concise.

8.Attend interviews that you don’t want, you might change your mind when you get there and have a look around (and lets face it we can’t be fussy). Try and book an informal visit before the interview as this is something you can talk about during the face to face interview if you have one.

9. Prepare but don’t over prepare. Try and practice questions by answering them out loud as this is how you will be responding in the interview. But try to relax at the end of the day it is not the end of the world if you don’t get the job, nobody died and it is their loss.

10. Finally take in your CPD folder and make it relevant to the post you are applying for, that way they know you are dedicated to that specific post.

I can’t give you any real tips for interviews as they are all different but it is a skill you do develop…. so if you have a shocking one don’t beat yourself up about it. Below I have posted one of my applications with the name of the trust removed, I hope some of you may find it useful.

Physiotherapy BSc: Class 1 (Hons)

HCPC Registered: PH101564

Full member: Chartered Society of Physiotherapy.

Full driving license.

As a very enthusiastic, driven, and dedicated person I believe I would provide a valuable contribution to the teams within X Hospitals NHS Foundation Trust. I believe X Hospital would facilitate me to achieve excellence, whilst allowing me to gain a firm grounding for a successful career in physiotherapy.

I wish to emulate the trusts vision of “……”. I believe I am a very personable, polite and enjoy taking the time to take a holistic approach with my patients. I feel the best outcomes are achieved when patients feel empowered and listened to. On clinical placement one of my patients lacked confidence and I felt by taking the time to understand their goals, this aided my treatment and their outcome. Conversely, I had a situation where I had to break bad news to a patient. The gentleman was likely to remain wheelchair bound due to him demonstrating no improvement over several months. Although I was presented with the harsh reality of stroke, the process was made easier due to the patient and family trusting me as I always aimed to answer any of their concerns and provide information when they required.

Through clinical placements I have been fortunate to gain experience in Intermediate Care, Acute Stroke, MSK x 2 and Orthopaedic Outpatients, Intensive Care at a major trauma centre and Elderly Rehabilitation. During this process I have been able to demonstrate my strengths in communication, time management and ownership of my own caseload, whilst also ensuring I am providing patient-centred care. This has been evidenced by feedback from my clinical educators in my CPD portfolio.

On my last two placements I demonstrated safe, effective and autonomous caseload management in an inpatient and outpatient setting. In both cases I was responsible for discharge planning and referral to appropriate services following MDT meetings or by written communication. I have been able to successfully demonstrate this through positive feedback received from educators, patients and from the wider MDT.

Clinical placement has allowed me to develop my problem solving skills. This can be demonstrated from my experience on intensive care. Coordination of care is essential in all settings; however, in intensive care it is vital due to patients being prone to fatigue. To ensure the MDT were working in a coordinated way I helped to implement the idea of writing a treatment timetable.  The timetable allowed for patients to feel empowered by them deciding when they wanted to be seen and it allowed staff to work together efficiently.

Data protection and patient confidentiality is a requirement for any practicing physiotherapist. I have demonstrated my awareness of this in my portfolio following completion of information governance modules: Patient Confidentiality, secure handling of confidential information and Records management and the NHS codes of practice.

At University I have maintained my manual handling training which I have applied to a practice setting. An example of this was when a patient had slipped out of her chair. To resolve this I autonomously worked with a physiotherapy assistant and used a slide sheet to ensure safety and dignity was maintained by the patient.

With the new changes being implemented in the NHS, it is important for physiotherapy services to provide evidence of positive outcomes. In light of recent failings in the NHS, it is essential for a practicing physiotherapist to adopt clinical governance to ensure patient safety remains the priority. Furthermore, I understand I have a personal responsibility to provide a clinically effective service by basing my practice on evidence and working within my scope of practice. As part of my elderly rehabilitation placement, I conducted a documentation audit using the quality assurance tool and presented this to staff. The audit highlighted shortcomings in record keeping which needed to be addressed, as it had the potential to impact patient outcomes. If I was to gain this post, X NHSFT would gain a physiotherapist dedicated to the profession who is flexible, proactive and who takes a positive approach to managing change and challenges.

Alongside clinical experience, I have been an active member of the CSP. For the last 4 years, I have been a student representative and I have served as Midlands Regional Coordinator for the Student Executive Committee (SEC) from 2011-2013. This role required the ability to organise and coordinate meetings between student reps at Coventry, Keele, Nottingham, Leicester and Birmingham. The meetings discussed relevant physiotherapy issues within the student population and ensured student input was applied to the wider society. Through this role, I have had the opportunity to present at conferences, contribute to policy, sit on the West Midlands Regional network and set up an Unemployed Graduate Scheme. The scheme was set up by myself to provide free evening CPD lectures for new graduates who were in the transition between graduation and employment. These opportunities have allowed me to develop my leadership, communication, organisational and presentation skills. My contributions to the society have been recognised this year as I was nominated and received highly commended CSP student representative of the year 2013.

I am an active learner and seek out any opportunities to further enhance my professional development. An example of this was applying to work with the University Rugby League team as their pitch side support .To enable me to take on this position I had to complete a pitch side first aid course and show further evidence of CPD activities related to the post. During this role I have had to work alone in high pressure situations which have enhanced my lateral thinking skills. I have had to negotiate with players and coaches on a regular basis to ensure players who were unfit to play remained on the side line. This role has highlighted my diplomacy skills to achieve ‘win win’ situation.

Outside of physiotherapy I have a passion for horse riding, which has continued through University. For the last 2 years I have been elected as 1st Team Captain, for the University Equestrian Club, and I have represented the University at British University and College Sport over the past 4 years. This role has enhanced my leadership and teamwork skills and has demonstrated my dedication to activities I am involved in as we were crowned national champions in 2013.

I enjoy being challenged in my work and I believe that physiotherapy should remain a seven day service for the benefit of the patients. Recent news discussing how patients who have elective surgery on a Friday are more likely to have complications highlights this. I would be willing to be flexible in my work as I believe my time management skills have ensured I can create a work life balance, evidenced by my commitment to my hobbies.

As a newly qualified graduate, I am aware of my scope of practice; which includes recognising personal weaknesses and critically appraising my performance and learning. I welcome the opportunity to discuss cases with colleagues, to share best practice and further develop my clinical reasoning skills. I am excited about the new learning opportunities X NHS trust would bring.

Thank you for this opportunity and I look forward to hearing from you.

And that is really it I hope to keep you all updated with my progress as a new band 5 at Derby. Thank you to everyone who follows the blog, the support has been great and has really kept me going when times have been tough.

Feel free to leave me a comment or tweet me @LCphysio

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.