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.
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).
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:
- Motor Control
- 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:
- When, Where and How to conduct an athletic screen and profile.
- The importance of looking at Mobility>>Motor Control >> Functional Patterning
- RAMP principles
- The importance of specific and tailored training regimes.
- 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