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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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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