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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Opening New Doors!

I have been really busy this week. Firstly, from finding out I have been offered a job at the QE, I have been house hunting like crazy.  I knew I wanted to live in Harborne because it was walking distance to the hospital, the area was great to meet other young professionals and with Gerard also living in Harborne, communication would also be easier regarding organisation of CPD courses.  The unfortunate thing is that because it is such a popular area, houses become available and go like hot cakes so I have struggled to even get a viewing on some. But I  have found one which is only a couple of mins walk from the high st and 15 min from the hospital which will be perfect. I will be living with a 2 girls and 1 guy which will be great to meet some new people (can’t wait to start a new adventure!!!)

So after I had been to the house viewing on Thursday night, after training with West Brom, I had to drive to Loughborough University. Through networking I had been given the opportunity to assist Steve McCaig at the England Cricket U19 Profiling camp. Steve is looking to complete his PHd on causes of throwing arm pain in cricketers. The work was expenses paid so I was provided with accommodation and food which suited me. Now baring in mind that on the Rugby camps I have been sleeping in the school dorms, I kind of expected the same for the cricket (which would have been fine for me as long as I have a bed and a shower). But I turned up on the Thursday evening about 9pm to be presented with a lovely hotel room, I was thinking by this point maybe cricket is the sport for me :-)!

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First day of the Camp I had to meet Steve at 7am at the ECB cricket centre. With Steve being an Ozzy it was difficult not to gloat about the previous ashes test but I soon recognised he completely backed the England team through and through. In the morning he quickly ran through the screening program and told me that we would only have 15 mins per player so it was going to be tight (I was thinking oh my god I hope I can keep up) . So the things we were looking at were(some were extras that needed to be covered for his data collection for his PHd pilot study): Scapula position at rest, elbow carrying angle, combined elevation, shoulder internal/external rotation, straight leg raise, hip rotation ROM, Sit and Reach and Knee to wall angle and distance. Steve wanted to know if any of the previous limitations predisposed players to certain injuries or arm pain.

The most common injuries seen in cricket are: Lower back pain, Side strain, Posterior ankle impingement, hamstring strains, lower limb tendinopathy and throwing related shoulder pain. From unpublished data Steve suggested that some of predisposing factors for injuries were.

  • Throwing arm pain- elbow : Reduced total ROM Gleno-humeral Joint and External Rotation on dominant side, reduced Combined elevation, reduced grip strength as a % of Body weight, strength shoulder internal and external rotn, back extension, calf raises.
  • General LBP: Reduced Back Extension and Side Plank times, L to R imbalance on Side plank, reduced Add Squeeze (Look up muscle slings that act on the pelvis to understand reduced adductor squeeze.)
  • LBP fast bowlers–Similar trunk muscle endurance scores but difference not as great, decreased Combined elevation, Dorsiflexion and Sit and Reach.
  • Posterior Ankle impingement: Reduced Dorsiflexion Rom and > L and R difference

So these were some of the reasons we were screening the players so we can look back in retrospective to see whether these limitations are the cause of problem and so players can be given appropriate management plans. Steve has been working in Cricket for about 9 Years so he was really knowledgeable of his sport. You become to realise that each physio at the top has their own ideas and clinical reasoning. At west brom there is a strict focus on prehabilitation, whereas England cricket would focus on physical Preparation. So I think when you get into the area you want to work in you have to ensure you make decisions about how you manage your players/ patients using your own clinical reasoning and judgement, whilst basing practice on evidence. I really enjoyed the first day of the camp because Steve took the time to explain his reasoning and provided some teaching on the Shoulder complex.

On the second day a lot of the drills in the morning were focused on batting, fielding and throwing. Each player was filmed using high speed cameras so their  technique and biomechanics could be recorded. Cricket is not necessarily a sport I follow but it was good to see a break down of skills and to see the difference between the spinners and fast bowlers. I was manning one of the cameras for the batting so I got a real close up of the players. In the afternoon most of our screening was based on muscle endurance so we were looking at Back extension, side planks, calf raises, bridges whilst the strength and conditioning coaches  also carried out other functional movement and strength tests. Again we were looking at imbalances and factors which may predispose players to injury. It was great to see that the physios and strength and conditioning coaches working closely together off the same page as I believe there is a real gap in everyday practice between health professionals and the fitness industry.

So what is in the pipe line for me now, well I am attending the CSP West Midlands Regional Network Meeting on Monday to see what is happening in the region. Regional network meetings are great for networking with qualified clinicians and most are very welcoming to students and new grads. Visit your individual region on the CSP website to see when their next meeting is.

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

After having so much backing for my blog there is a potential it will be promoted on the CSP website in the blog section so watch this space.

See some pictures below from the ECB Profiling Camp:

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Thanks for taking an interest in my blog, if you have any comments please feel free to leave them on this page or tweet me @LC_physio.

Everything happens for a Reason!

So I have now written this post 3 times because things keep changing so quickly. So just to catch up on what I have been doing the last couple of weeks (I hope I can remember everything).

Last week I attended my first training session with West Bromwich Albion, which was more of an induction to get to grips with how things were run. I was working with a physiotherapist called Mel as Nathan the main man was called out with another player in hospital. As a physiotherapist I was involved in the Prehabilitation of players during their warm up, this involved:

  • Sport specific skills including proprioception some of the exercises included were:
  • Hopping to four points with one foot, at each point volleying a football back to the feeder on inside foot, laces and knee/volley. On the return to the middle point the player had to head the ball.
  • Using a wobble cushion dribbling the ball to four cones whilst standing on one foot.
  • Jumping onto wobble boards with cushion upmost. Jumping two feet and one foot.
  • Foam Rolling, quads, hamstrings, ITB, gastroc’s

It is important to encourage injury prevention within the academy and to illustrate its importance. The activities involve challenging core stability and sports specific proprioception. I really enjoyed the session as I haven’t had the opportunity to work on prehab before and I think me and Mel were both thankful for the extra pair of hands as more players turned up than usual. Having enough physiotherapists to players is key to ensure form is correct throughout.

There is now good evidence that a prevention program consisting of a mixture of: Balance training, landing with increased flexion at the knee and hip, controlling body motions especially in deceleration and pivoting manoeuvres, can significantly reduce the number of ACL injuries. So for these players who are at the start off their careers it is vital to educate them on the use of prehab (Brukner, 2012).

http://www.peterbrukner.com/acl-injuries-preventable/

Since my induction I have been on my first proper session which was fantastic. Again the session focused around Prehab at the beginning, some of the exercises we used were:

  • Hopping on one foot onto 6 wobble cushions in a line.
  • Hopping onto on a wobble board cushion side up, jumping onto the ground same foot and then bounding a mini hurdle.
  • Using an agility ladder each player tied their legs together with an elastic band and side stepped through the ladder.
  • Hopping over hurdles in a zigzag pattern and volleying a ball back to the feeder.

We then were able to follow up certain players who needed specific rehab which was great to learn about some sport specific. Next week I will be leading on prehab with another physio and will be assisting with injury prevention screening using Functional exercise movement patterns. So I will follow up with a post on this.

With regards to job interviews I have had two recently, one for Bank work with Nottinghamshire Healthcare NHS trust and one for a private company called APOS Therapy. So first for Nottingham, I really was feeling a bit deflated about NHS interviews but I knew it was an opportunity for interview and although it was bank it covered all the rotations I wanted so I knew I had to give it everything. The night before I organised my CPD folder to match the person spec for the job (but of course they didn’t look at it…. Sods law) but anyway, I went in to the interview feeling a lot more relaxed than previous ones (I think it was because I was a bit half-hearted about it all… but it somehow calmed me down). The questions I got asked were:

  • Tell us about your biggest achievement to date?
  • How do you cope with stress? And how does it affect you personally?
  • Tell us about a time when you didn’t meet a deadline? What were the repercussions?
  • Why this trust?
  • What would you assess objectively for a patient with anterior knee pain?
  • How would you go about assessing a patient who has been admitted following a fall? What would you need to know subjectively? Objectively? And what would your management plan and goals be?

There was a few more which have slipped my mind.

From previous interviews I have realised the importance of not getting your hopes up.  On this interview I ensured I paused and composed my thoughts before speaking and I provided comprehensive answers for the two clinical questions. I got home that afternoon and looked at my phone; I had two missed calls from an unknown number followed by a voice mail. It was the therapy lead asking if I could call her back….. So of course I did and was subsequently offered the position! I was so ecstatic, the job was close to home and they were very positive with my feedback which was a real confidence boost. Of course I accepted the offer and then tried to prepare for the next interview still grinning.

Apos Therapy is a fast growing international company which focuses its treatment on correcting biomechanics by wearing some special boots. The product is fantastic and has had some great reviews see website for more information: http://apostherapy.co.uk/en/home . The interview was ok but it did demonstrate the simplicity of my knowledge for biomechanics but it was very interesting. Apos Therapy are very good at investing in people and providing intensive training but I was concerned as a new graduate that specialising to early would not help me to develop my hands on skills as a physiotherapist. So I decided that although I had got through to the second stage of interview at this time the job was not going to work for me, but if an opportunity arose at a later date it would definitely be something I would consider.

So I had decided the Nottingham job was for me and even though I had secured some bank work at Walsall healthcare. Nottingham would mean I could save some money. But then you will never guess what happened next….. Me, Gerard Greene and Tom Astley were just about to head out for drinks in Harborne (about 9pm) when I got a phone call from an unknown number. It was Janet Hallam from the QE ringing to say they could offer me a fixed term contract until the end of January, which could become more permanent if funding became available. I was in complete shock!! So I said I would call back in the morning! Of course I took the job it was the place I wanted to work for from the start and even if nothing comes of it, it is 6 months of NHS work on my CV J!!!

So although I have written this post three times due to circumstances changing, I can honestly say that everything happens for a reason! So hopefully my future blogs will now consist of my experiences as an employed graduate!! On a final note who’s to say networking won’t get you anywhere. Next weekend I will be working with England U19’s Cricket to assist with their injury prevention screening so hopefully this will open even more doors.

Thank you for taking an interest in my blog, feel free to comment or tweet me @lc_physio.

Pictures from the final Rugby Camp at Ellesmere College:

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Time to Reflect!

So I am feeling in a reflective mood following a hectic week  (I have to apologise to my boyfriend as he told me to reflect a bit to early on when everything was a bit raw and I wasn’t very grateful for his advice, but I have come round). When I last posted I had one interview at Birmingham. Since then I have received 3 more! At Nottingham, Derbyshire Community and Derby Hospitals NHS Trust.  This week I have had one at Nottingham, one at Birmingham  and a telephone interview with Derbyshire community. Fair to say it has been quite stressful and I feel physically and emotionally exhausted. I am going to talk about my Nottingham and Derbyshire community interviews as those are the ones I have heard back from which unfortunately have been unsuccessful, but like the title of the blog is it’s time to reflect.

So I had my Nottingham interview on the Monday, luckily for me my mum volunteered to drive me so I could chill out and focus on the interview. With the interview being in the afternoon I had spent all morning pacing up and down so I had kinda wished my interview had been in the morning to get it over and done with. When I got there I had to go straight to HR to give in documents which was a fair distance to walk and not very easy to find so I was glad I gave myself plenty of time, though I was so flustered when I finally got back to the reception to wait for my interview.

So the interview came around, I had two female interviewers who were both very pleasant and took it in turns to ask questions. The questions I can remember were:

  • Why did you want to work for the trust?
  • What attributes would you bring to the post as a band 5?
  • How would you differentiate between acute hamstring and sciatica? Treat one of them.
  • You have a patient who has a left sided infarct. What would you expect to find on assessment and what would you tell your colleagues to help them if they were going to be treating them?
  • What are your learning needs to be able to go out on respiratory on call?
  • Questions on trusts values and behaviours.
  • You have a patient who has dementia the team is happy for him to go home but you have concerns how would you deal with it?
  • How would you show a patient they were cared for?
  • What would you do if your senior wasn’t using the proper hand washing technique?
  • You are on an orthopaedic ward with 28 beds. What would you do if you were the only qualified member of staff because your senior is off sick?

I’m sure there were more but these are the ones I can remember. I am yet to receive feedback as I have to wait 2 weeks, but on reflection one of the big questions I messed up on was the orthopaedic ward one! (which I will be gutted about if that was the only thing I didn’t do right as I have been having nightmares about it). Basically I answered it by talking about getting handover, having a team meeting to see who could help out and then work from there. If I had my brain switched on I would have talked about the importance of prioritising patients and delegating to the physio assistant which I didn’t gahhhhhhh!!!!!!!!

Another question I could have gone into more detail about was my learning needs to go on call. Not only do I need more experience in dealing with respiratory patients along with the mandatory training. But I also could have talked about being trained on equipment such as mechanical ventilation etc. Hind sight is a great thing!!! There maybe more things I could have done but I will await feedback and will post as soon as I do.

This Thursday I had 2 interviews. I had Birmingham in the morning and a telephone interview in the afternoon as part of a short listing process for the community post. Like I said before I will talk more about the Birmingham interview when I get feedback not holding out too much as there was only 1 post available and 8 candidates were internal!!! Urggh physio is sooo competitive. So for my telephone interview I was asked 4 questions. This job would have been ideal as it is 5 minutes from my house but anyway. All candidates were asked the same questions the first 3 I coped with fine and the interviewer didn’t have any comments to make on them and because they were OK I can’t for the life of me remember them. I think there were:

What makes a good band 5 physiotherapist in the community?

How would you go about maintaining safety in the community?

I can’t remember the 3rd one!

But the 4th one I remember clear as day because I completely fluffed it!!! I was asked to talk about a neurological patient I had seen and to talk about there management and treatment. Now this sounds a straight forward question and it would have been if I had been asked it again but at the time I was so drained from my previous interview that my brain yet again failed me. My pure neuro placement had been my first 2nd year one and I felt I would have been to vague with my answer to discuss one of my patients because it was such a long time ago so I decided to go with one of my patients I had seen on my second to last placement (who actually really wasn’t a true neurological patient so I really shot myself in the foot). This was the question that prevented me getting shortlisted and if I was asked the same question again I would have answered it completely differently. I would have talked about one of my stroke patients, the patient’s symptoms, physio treatment, outcome measures, and MDT involvement but my brain wasn’t quick enough to process the question.

So all in all I was pretty gutted about the Nottingham post as it looked a great hospital to work at, but a better physio was found on the day. I still have the QE to hold out for which is my number one place to work but after hearing there is only one position I am starting to doubt myself :(!

So anyway lets end on a positive so apart from interviews today I have had the opportunity to attend a meeting with West Bromwich Albion Football club with Head Academy Physiotherapist Simon Noad. My role with the club will be on a voluntary basis and will involve assisting the part time physiotherapists with any of the U16 players… a foot in the door you might say. I am really grateful to Gerard Greene for passing on my CV to Simon and I look forward to telling you about my experiences.

So although I am not telling you how happy I am about securing a job I am back on a positive mind set after writing this piece and I am just taking that those jobs were not meant for me. I start the camps with Worcester Warriors next week so watch this space 🙂 !! Again if anyone has any comments please post them on here or tweet me at @LCphysio xx