2014 in review

The WordPress.com stats helper monkeys prepared a 2014 annual report for this blog.

Here’s an excerpt:

A San Francisco cable car holds 60 people. This blog was viewed about 1,100 times in 2014. If it were a cable car, it would take about 18 trips to carry that many people.

Click here to see the complete report.

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Roll Out! Roll Out! Come and see the Amazing Abs Circus

I am a skinny sparrow and not sure why people would like to see their abs over having boulder-shoulders or mega-quads. But I get asked about it in the clinic because I go on about exercise and body composition to my patients like a loony and they reckon I might know how to get a ‘summer-body’. Again why not look good all year instead of just the summer?

Here is the question, How do we get abs of steel? How do we look we have walked straight off the set of 300? Here is an answer… Photoshop… Seriously though, Sit-ups? Crunches? Electro-abdo stimulator? Nah, Waste of time and the last one a massive waste of cash.

1

Read this http://www.jospt.org/doi/abs/10.2519/jospt.2010.3073#.U9-vZXaPPxU if you are fascinated my muscle contractions and co-contractions like me, or continue reading.

Essentially they tested 8 exercises with electrodes on various parts of the abdominal musculature, Hip flexors and spinal extensors. To see which ones caused the strongest contractions of the muscles. Stronger contractions mean more muscle Hypertrophy (enlargement), you don’t get stronger lifting pencils, tree trunks on the other hand…

Here is what they found:

The Crunch and Sit-up were worse in all but one category than the Roll out and the Pike and pretty bad at contracting your oblique muscles which were fired up nicely by the other exercises. If you look at the form of the exercises you are also working other muscle groups like Shoulders, Chest and Bum to attain the start and end positions.

Ok, if you do Crunches and Sit-ups you will work your abdominal muscles but no way as hard as Roll Out or Pike, barely work your oblique muscles, and not work any other muscle groups very hard.

Not a hard decision really. Oh yeah, eating properly is going to be your best chance of seeing these muscles, not much point making them strong (and more visible) if you then cover them with chub.

These are all exercises based on a gym ball which is great! They are cheap, increase home seating possibilities and the kids play with them. You could however get yourself an ab-wheel for your Roll Outs. Also cheap, don’t take up space and the DOMS are a killer, and as we all know we bloody love DOMS (https://physiojack.wordpress.com/2014/04/27/my-friend-doms/).

If you also look at EMG studies of the core stabilisers, Lumbar Multifidus and Quadratus Lumborum (They are spinal stabilisers often rightly or wrongly indicated as weak in low back pain. That’s a debate that is well outside the scope of this blog/rant) they also kick in great doing squats and dead lifts, Pike and Roll out so no need to bother doing specific core stability exercises either if you are strapped on time.

Morals arising from this story, get your abs a ticket to the gymball circus, the snacks are healthy and the DOMS are savage.

Pics

Pike http://www.leanitup.com/carve-out-your-abs-with-these-swiss-ball-exercises/8/

Roll Out http://www.leanitup.com/carve-out-your-abs-with-these-swiss-ball-exercises/4/

If you have any questions feedback or just want to hear more of my ideas you can follow me on Twitter (@physiojack)

 

Treatment of Fibromyalgia Is an Exercise in Pain Management

Following on from Assessing Fibromyalgia Is Not An Exercise In Pain this blog aims to provide some practical tips on how to go about treating a Fibromyalgia (FM) patient after successfully assessing them.

Pain Education

“For chronic MSK pain disorders, there is compelling evidence that an educational strategy addressing neurophysiology and neurobiology of pain can have a positive effect on pain, disability, catastrophization, and physical performance.” (1)

Clearly there is no direct effect to reducing pain from this approach. There are however significant less tangible effects reducing the fear or perception of pain which leads to a reduction.

My advice is to teach your FM patients as much as you are able to about pain in as much depth as possible. I have received excellent feedback immediately following the education and they continue to quote me months down the line appropriately as we introduce new interventions. There is an overview here:

(https://physiojack.wordpress.com/2014/05/05/pain-is-an-exercise/)

Treat the Biomechanical Issues

Assuming you have found the biomechanical issues, treat them. Treat them as you normally would.

Graded exercise program (Hydrotherapy?)

There is evidence that exercise therapy works in FM patients to decrease pain, improve function and reduce disability (2). You can read a bit more about how here:

(https://physiojack.wordpress.com/2014/05/12/exercise-is-a-pain/)

The real crux of the problem here though is how we get FM patients participating in regular exercise when walking up the stairs increases their pain significantly. One answer lies in the treatment of the Biomechanics issues uncovered in the assessment. If a muscle is weak it clearly needs strengthening and exercise is usually the most effective way of doing that, patients can relate to this easily. I use these exercises to build into more general exercises and aerobic work.

Aerobic work is always tolerated better with minimal impact so cross-trainer and static bike are my first port of call. There is evidence to suggest that light-moderate Aerobic exercise is tolerated better than higher intensity exercise with regards to post exercise symptom increases.

Hydrotherapy is often a mainstay of treatment for FM patients in Physio departments and there is certainly evidence to suggest its effectiveness in the short term. I use it sparingly. I stay away from Hydrotherapy in patients that have no interest in keeping it up outside of the hospital setting. 1 session per week for 6 weeks is going to have had zero effect 6 months after it finishes unless the patient keeps it up. Patients sometimes arrive at appointments expecting it and unless they give signs to indicate keeping it up they don’t get referred. Harsh? Maybe. My advice on Hydro for FM is think carefully about what you are trying to achieve. If you need it to best treat a biomechanical issue or the patient wants to carry it on then it is a good treatment option. If they won’t carry it on and it is not the best treatment option for a biomechanical issue, don’t refer. 

What I do in Hydro is treat it like a water gym. Strengthening, CV and stretching/mobility work in all programs to optimize performance. Remember that the patient will likely feel great in the water but will still have the short term adverse reaction to exercise so be careful with the time/intensity of the first few sessions. 

Pacing

Teach the patient how to pace activities, use specific examples of their activities and get them to focus on one at a time. When they improve at the skill they will either naturally adapt or can take on more activity change at a time. 

This is the way I teach patients to pace:

Activity X causes or increases pain after 20 mins. Do Activity X for 20% less time (16 mins) then stop. After 1 week add 10% (18 mins) if no increase in pain continue for one week then add 10%. Continue. If a stage is reached where pain increases again then return to previous time and continue for a while, maybe a month and try increasing it by 10% again. 

N.B.1 dependent on the frequency of the activity you may need to leave increases longer than a week.

N.B.2 If you never do too much how do you know what you can do? 

Focus away from pain

Try and give strategies or interventions to improve the patients other symptoms. For example: Fatigue – Sleep hygiene or relaxation techniques. General education regarding diet, smoking or alcohol for example can also help to improve energy levels and overall health. As said previously you can make a lot of improvements in function without affecting the patients pain levels.

Don’t expect smooth sailing

  1. Short term response to exercise in FM patients increases their pain levels
  2. The variable nature of FM means patients will peak and trough despite interventions provided
  3. Biomechanical issues may occur or worsen just as with populations without FM
  4. Be patient, lifestyle changes don’t happen overnight

If you have any questions, feedback or just want to hear more of my ideas you can follow me on Twitter (@physiojack).

 

1. Louw, A., Diener, I., Butler, D. S., & Puentedura, E. J. (2011). The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Archives of Physical Medicine & Rehabilitation, 92(12), 2041-2056

 

 

2. Busch AJ, Barber KA, Overend TJ, Peloso PMJ, Schachter CL. Exercise for treating fibromyalgia syndrome. Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD003786. DOI: 10.1002/14651858.CD003786.pub2.

 

Assessing Fibromyalgia Is Not an Exercise in Pain

Fibromyalgia (FM) is a controversial diagnosis that divides Doctors, Therapists and Patients alike. Whatever your beliefs about this condition it is clear that it is difficult to assess and even harder to treat. Working in Rheumatology I have had the opportunity to assess and treat many FM patients, some successfully others not so successfully. A lot of my pure Musculoskeletal colleagues ask me often how I go about it and begin pulling their hair out when a set of notes land on their desk. This two part Blog aims to give practical tips on assessment and treatment of this condition.

 

Forget the body chart

 

I don’t use a body chart with FM patients for a number of reasons. Principally because very often you might as well get a thick felt pen and shade in the whole thing. What’s the point? I ask them to describe 3 areas of pain that limit them the most, not necessarily the most intense but the most limiting. This will give clues as to any Biomechanical issues to be highlighted later in the assessment.

 

Focus away from pain

 

We are not necessarily going to treat the patient’s pain directly; they tried and failed this with analgesia to greater or lesser extent. If Paracetamol had worked they wouldn’t be sitting on the treatment couch talking to us.

 

Try to focus the patient away from pain, concentrate instead on functional difficulties/limitations or leisure activities they find they are struggling with. The symptoms are so wide ranging with FM you will likely find things that you can work on, fatigue, strength, Range Of Motion (ROM), concentration…. These things might be limited/caused by pain but other strategies can be employed to improve them such as exercise to improve strength and ROM or Pacing for Fatigue and Concentration.

 

Find any triggers that worsen the patients symptoms, lack of sleep is very prevalent and stress equally so. Physical activity especially in the form of harmful boom/bust cycles is often associated with symptom increase, unpicking what the patient is doing, how much and why is often the key to successful education around pacing.

 

Find the Biomechanical problems

 

It is very difficult to reduce pain in FM patients; they have usually tried every analgesia available, every adjunct treatment and had pain for a long time. Even the most hardened opposition of FM as a diagnosis will have to concede that most of the patients become deconditioned and have biomechanical problems just like anyone else who is unable to complete daily tasks or exercise. Finding these biomechanical problems is the first hurdle.

 

Here is how I do it.

 

Lets assume the three areas of pain most limiting that the patient mentioned are Right knee pain, Left foot/ankle pain and Back pain. All potentially linked Biomechanical pains (it is a little more difficult if they say Jaw, Elbow and foot pain!). I ask the patient to perform some functional movements to assess movement patterns, Single leg stand, Heel Raises, Squats, Gait (walking), Step-ups/downs. This will lead to conclusions about any limitations. I don’t entirely ignore the pain especially if it correlates with what you would expect but it is not my main focus. Look for things you want to investigate further just as you would with any other patient, decreased ROM, poor balance, and muscle weakness etc. This might lead you to assessing more specifically with palpation and muscle strength testing. (I hope this sounds familiar!). I almost without fail find a tendinopathy, bursitis or altered joint loading which is contributing to the patient’s pain and can be (relatively) easily treated.

 

Don’t allow yourself to bogged down by the vast areas of pain or the very irritable nature of the pain. Remember that central and peripheral sensitivity does not mean there are not specific problem areas, especially biomechanical ones that could be treated as you would with any other patient. It is a good opportunity to start introducing some exercises, especially if these have a positive effect.

 

Manage expectations

 

Anyone with FM as a diagnosis is likely to have had pain for a long time. No matter what interventions we offer, they are not going to be better by next Wednesday. If it took 10 years to get to where they are now, it is entirely unrealistic to expect improvement overnight or even resolution in a few months. We must ensure as a therapist we understand how long things are going to take so there aren’t unfair expectations of the patient. Think along the lines of times to gain muscle strength and lifestyle modification. It is equally as important that the Patient understands this as well.

 

I make a point of discussing how long the patient thinks it will take (if they say never that is a whole other conversation) and how long I realistically think it will take to see some improvement. I also ensure I spend time explaining that they may get more pain with a newly introduced exercise program or become slightly less functional with Pacing as we step their activities back a little.

 

Take time

 

It is rare that I complete a subjective and Objective assessment in one session with FM patients. Concentration, pain, fatigue and a lot of symptoms to discuss are limiting factors to this but also I like the patient to go home and think about their three areas of pain/limitation, particular aggravating factors/activities that affect them and any self management strategies that they already have in place. This will help guide objective assessment looking for those Biomechanical issues.

 

Following the objective assessment I take time to explain the different treatment routes and that it is unlikely one intervention will help significantly but small improvements in lots of areas will improve function. We then discuss goals and aim to make these function based, walking further etc. Pain levels and using these as a goal is a really tricky minefield and very often a losing battle. In my experience function definitely improves far quicker than pain and can be maintained at a more stable level. This makes function a more appropriate goal and can help to keep patients focused and motivated.

 

It sounds cliché but without the sound basis of a good subjective assessment you can’t hope to treat any patient appropriately. There is more to come in the follow up to this Blog “Treatment of Fibromyalgia Is an Exercise in Pain Management”

If you have any questions, feedback or just want to hear more of my ideas you can follow me on Twitter (@physiojack)

6 Unwritten (now written) Interview Tips

I have interviewed and been interviewed, it is weirdly something I enjoy quite a lot. Being challenged in an unfamiliar environment is a good way of finding out what you know and what you don’t. I also like interviewing potential candidates; it is a challenge to pitch questions at a suitable level and to create good questions. Below are some tips I have learned through being the interviewer that I have not seen elsewhere that I hope will make others especially new Physios enjoy their interviews more! As such these are aimed at prospective Band 5s…

  1. Answer simple first

It seems obvious but this causes loads of problems for candidates. Get the easy stuff out first then try to impress. I remember my first ever interview and the question was “how would you begin an initial assessment?” I launched off into a complex description of a subjective exam and how I would observe the patient walking in; I thought I was a genius! Great answer my brain said as I caught my breath after rambling on. Turns out they wanted me to say I would introduce myself and my job title. Oops. Of course I would do that but my brain thought that too simple an answer to be correct. The interviewers are (hopefully) not trying to catch you out! Lesson learned.

  1. Dress for success

Any Physio interview worth its salt will have a practical component, if you can’t easily go down on your haunches or lift your arms over your head, get back in your wardrobe for a different outfit. I have seen someone not get a job because they couldn’t do the practical in the clothes they were wearing and keep their modesty. If you aren’t sure practice the night before. It is not a fashion competition.

  1. Practical component

My favourite opening question is as follows: can you assess the integrity of the ACL? The reason I like it is because it requires the patient to be handled, the leg to be lifted and there is more than one way to do it. Before you begin answering the first practical question look around you. What equipment is available? We lay out alcohol gel, goniometer, tape measure and some others. No-one to date has ever used the alcohol gel before approaching the patient. If these things are not available tell the interviewers you would do it. I refer you back to point number 1.

As you begin to answer the question treat the model as you would a patient, introduce yourself and remember to tell them what you are going to do, ask consent and don’t forget to ask how it feels. Expect a follow up question, for example if my candidate does an anterior draw test in isolation I then ask “if the test is positive how do you know it is the ACL not PCL that is ruptured?”

  1. CPD

I stumbled over this question, with jobs a little scarce I spent a few months unemployed. “How have you kept up your professional development?” S**t. I haven’t done anything, I thought I could wing it and remember my degree! My answer must have been so bad I can’t even remember it. It is hard to keep up CPD when you have no job but it is getting a lot easier, here are a few ways:

1. Shadow a friendly Physio. Ask a supervisor you got on well with on placement or anyone else you can.

2. Read journals. Anything that interests you, google scholar is useful if your Athens account from uni has expired.

3. Do courses. These usually cost but at least you don’t have to ask for time off work at the moment, nothing too complex just anything you can access. Think of the money as investing in your future. Beg or borrow (not steal) to go.

4. Take part in twitter debates (@physiotalk is a good starting point)

5. Keep on iCSP lots of good ideas and info on there!

As a side note don’t forget to take evidence with you!!

  1. Perfection

Aiming for the perfect answer with your first sentence is asking for disaster. Get the answer right then expand. As band a band 5 we want you to be safe, on the right track and willing to ask for help, not a clinical specialist!

  1. Panicking 

Sounds simple but don’t panic! Here are two reasons why.

Panicking can lead to guessing, even if you get the answer right it is often obvious. Guessings leads the interviewer to think that maybe you would guess while on the wards, maybe that would be incorrect, maybe that would be dangerous… Don’t want maybes creeping into their thinking.

Panicking can lead to a loss of composure, something no one wants to happen to their candidates or their band 5s under pressure. My tip is take a bottle of water with you, if you feel you don’t know an answer have a sip, thus affording you a little more time to think and not look like a lemon. If you still are unsure start your clinical reasoning out loud. This shows the interviewer you have a clue and again avoids the looking like a lemon situation.

I hope that you find these helpful, if anyone has anymore tips (the more unusual the better I would like to hear them!

If you have any questions, feedback or just want to hear more of my ideas you can follow me on Twitter (@physiojack)

…Exercise is a Pain

Following on from Pain is an Exercise… I plan to write about some of my thoughts on how we go about exercising when in pain. First things first is to know as much as you can, for the patient this might well involve knowing who is best placed to help you. Everything should be individual only you will know who you will respond best to, however from a very biased opinion a Physio would be a good place to start.

 

If you are a healthcare professional and have a patient in front of you with a lot of pain, make sure you know as much as you can about the biology of pain, their condition/s and the health benefits of exercise even if this involves booking them back for another session having given yourself the time to get informed. Then have a discussion about exercise, what their obstructions to exercise are, goals and how exercise can improve their life. I guarantee you will convince most people to at least try some exercise.

 

Brilliant, we are ready to try! The next question quickly becomes where in the name of all that is holy do we start? People in chronic pain often have a pain distribution that covers most of the body and a list of aggravating factors that could fill an A3 page. Here are some ideas, by no way exhaustive and applicable in different measures to individuals.

 

  • Be conservative

 

Start off easy, real easy. Once you have a baseline you know you can complete then you can build upon it. Even if this is normal daily activity plus 5 step ups. Something that guarantees none or just a tiny amount of increased pain that reduces within a minute or so of the exercise.

 

  • Exercise non painful parts of the body

 

Exercising non painful parts of the body has been shown to reduce pain generally and will desensitize the nervous system, with less risk of symptom flare ups.

 

  • Be a patient patient

 

I know you want to be better now but remember this takes time. Minor symptom flares are normal on initiation of exercise programs and should settle within a few weeks. Ensure completion of the current level of exercise for at least a fortnight with no significant problems before increasing, and then allow that to bed in for a fortnight before the next increase.

 

  • Exercise should be fun!

 

I don’t run because I hate running, I bounce around on a trampoline mad as a bag of cats with my son because it’s fun. It gets my heart rate up at least as much as running and as a result I do a lot more of it and therefore get more of a benefit. Try something gently active with the kids or a friend. Swimming pools are a great place to start, reduced weight through the joints because of buoyancy etc. No need to swim necessarily, you can walk, squat, lunge, float…..

 

  • Exercise with a friend/partner

 

Exercising with someone else can help to keep up motivation and enjoyment.  You need to be pretty dedicated to exercise for months on end in isolation.

 

  • Plan for success

 

Nothing gets done without planning. Plan around your commitments so you are not exercising prior to a highly important journey or meeting. Plan your analgesia so you take it with the right amount of time prior to exercise to give it the best chance of being effective.

 

So if you have a long term condition or a lot of pain, please try a form of exercise, if you have a fear (it is normal if you do) then get referred to an appropriate healthcare professional and discuss it with them. If you are a healthcare professional learn as much as you can, about everything.

 

If you would like to know more I refer you back to the articles mentioned in Pain is an Exercise…

 

If you have any questions, feedback or just want to hear more of my ideas you can follow me on Twitter (@physiojack)

 

Pain is an Exercise…

During my day to day clinical work in Rheumatology I encounter a lot of people in a lot of pain. When it is suggested by me that they exercise I am often met with surprise, fear, and doubts over my expertise. I can spot from a long distance the people who are going to respond in this fashion and I have, over time, adapted my approach to this suggestion to hopefully prevent it being bombshell-esque.

 

Pain is a skill, unfortunately for us humans we are extremely adept at learning skills and repeating these skills in response to given stimuli (just watch a Rory Mcilroy on a golf course). This occurs internally via our nerves, spinal cord and Brain, in response to stimuli from our sensory organs (eyes, ears etc.). In effect people who have pain for a long period of time are repeating the skill of producing a pain output in the brain.

Rory_McIlroy

Rory Mcilroy – Sees target, feels golf club -> Brain computes -> perfect golf swing -> Ball near hole -> sees target…

 

Person with Chronic pain – Bends back, feels danger signals -> Brain computes -> Pain response -> Bends back…

 

An important point is that the brain does not receive “Pain Signals” it receives danger signals e.g. high temperature on skin, lots of pressure from hammer hitting thumb and computes these into a response our consciousness understands as pain. Over time a repeat of these danger signals will heighten/strengthen the brain’s response (i.e. more pain to same input) and increase the body’s ability to sense the input (i.e. pain response to less input). This means not only are you feeling more pain from the same movement/activity but less of that movement/activity will bring on your pain.

 

Exercise has been shown to decrease pain directly through the release of the body’s natural pain relief Opiods (Morphine is an Opiod so this stuff is strong!) and by generally desensitizing the nervous system (nerves, spinal cord, brain) to the sensations that generate a pain response in the brain. The Opiods last about 30 minutes and the desensitizing given enough time will be permanent.

 

*Just a note, In Fibromyalgia, Chronic Fatigue Syndrome and ME the short term reduction in pain (opiod release etc.) is not present and exercise can temporarily increase local sensitivity to pain, however desensitization of the nervous system over time is still present.*

 

If you offered people a pill to take 5 times per week that offers a short term reduction in pain and a potential long term reduction of sensitivity to pain stimuli to patients with chronic pain they would engulf your hand with the pill in it. This becomes even more potent when you add in nearly zero side effects and the added general health benefits which are too numerous to list.

 

So the burning question is why is exercise met with such opposition from the people that would potentially benefit the most? In my opinion a large portion of blame is down to fear. Most people in pain are scared of more pain and a lot of health professionals are scared of causing people with pain more pain. If you have a lot of pain from walking for example it is going to be a hurdle to consider doing, on the face of it anyway, something more strenuous than walking.

 

For Healthcare Professionals, learning as much as possible about how pain is generated within the body and its significant complexity of interactions can help to understand why the person has gotten into a downward spiral of inactivity and chronic pain. Maybe more importantly though for the patient, if you understand the brain learned to become this way then it can learn again to change. It will be slow, often demoralizing in its slowness. Imagine you spent a year learning French, could you forget French in a few weeks? Nope.

 

So how do we go about getting all these lovely effects of exercise when walking up the stairs can mean an increase in pain for days? This is a question I am confronted with daily and there is no easy answer. I will go through my thoughts on this in …Exercise is a Pain.

 

If you want to know more about the effects of exercise on pain two very (and I mean VERY) detailed articles are:

 

1. Daenen et al 2014 Exercise, not to exercise or how to exercise in patients with chronic pain? Applying science to practice The Clinical Journal of Pain

 

2. Nijs et al 2012 Dysfunctional endogenous analgesia during exercise in patients with chronic pain: to exercise or not to exercise? Pain Physician. 2012 Jul;15(3 Suppl)

 

You can also listen to http://chewshealth.co.uk/tpmpsession4/ and http://chewshealth.co.uk/session-5-know-pain-metaphoric-expression-with-mike-stewart-part-2/

 

If you have any questions, feedback or just want to hear more of my ideas you can follow me on Twitter (@physiojack)