My First Entry into the World of Back Pain and Patient Interaction

I am currently out and about gaining experience and working on some assignments for university. This morning I came across my first patient who has been dealing with a history of back pain for 8 years. Now I will admit I was very nervous from the outset as I have no experience of dealing with or treating back pain and my exposure to back pathologies etc was over a year ago in college. I felt the subjective assessment went well and I delved into all elements of the biopsychosocial model. I did feel that a small element of the persistent nature of the pain was linked to a lack of understanding of what the pain was, the anatomy of it and “protecting” it by guarding the area with a lack of movement.

However the point of this post is about the objective assessment and how I interacted with the patient in relation to their pain. The patient had quite a pronounced loss of ROM in lateral flexion, extension and all their mobility was coming from their thoracic spine. There was a distinct lack of mobility in the lumbar spine and this is where I fell down completely. I was unable to maintain a neutral facial expression and my body language wasn’t great, the patient picked up on this and I could tell it was influencing them. I was giving away too much and it wasn’t helping the patient. I wasn’t sure what language to use to describe their issues and fell into the trap of trying to “simplify” it for them which in my mind is incredibly ignorant and downgrading so I cannot see why I did this.

Even worse was the language I used. As the patient was coming from a manual labour and construction world I decided likening something to concrete as a joke was a great idea. Let me tell you it wasn’t. I could see the patient running with this and within seconds was already trying to fix my mistake. However I did manage to turn it around and I could see the patient coming around.  Reflecting on today I have a huge amount of work to do on my patient interaction and understanding pain. I can see how easy the traps are to fall into but also how easy it is to influence a patient in a bad way. I also came to the conclusion that when you try to “simplify” the message this is where things go wrong.

It was a bad first day, unfortunately for the patient (unfairly) and myself. I take full responsibility and I know I need to do better. Doing a course is something I definitely feel is necessary. I have bought Louis Giffords and Lorimer Moseleys books and I hope they will help in the long run. What I have learnt from today is that nothing can substitute experience, language is just as important as the treatment and I have a lot to learn.

Thankfully I have another opportunity to meet the patient again this week and I can rectify my mistakes.

PART 4

Welcome to Part 4 of “What Inspired you to be a Physio?”. Again we have two great stories from two very experienced and talented physiotherapist’s. 
First up is Gill Dean Lofthouse who has 25+ years experience as a chartered physiotherapist specialising in TBI, SCI, Neuro, Orthopaedic & Respiratory physio. 

“I grew up fascinated by hospitals and all things medical. I was a quiet myopic child who preferred reading and had insatiable curiosity.
My best friend at primary school had an older sister who had been ‘knocked down’ age 7 and consequently was a wheelchair dependent hemiplegic who I helped feed jelly to.
My parents were teachers in mainstream then special needs education – and had an ex pupil who was severely injured when he fell 100 foot off scaffolding at work. During his recovery my dad would bring him to our house.
I still remember my dad carrying him from the car into the house. He was an inspiration as he later became a professional dancer! My mum became the manager of one of the first PH daycare centres in the 70’s – I physically stopped growing at at 12 being 5ft 7 and strong and in the absence of hoists, over the years learned to stand transfer any size and disability of client.
At age 15 and knowing I wanted to do an active job in something medical, a community Physio who was visiting clients at the PH day centre took me with her for a few days to Burnley General  hospital.
I never looked back. I have the best job in the world and would never change it. I’ve worked internationally and around the Uk in the NHS (16 years) and privately and I’ve never stopped learning skills to put in my ‘toolbox’ to enable make me the most effective and efficient I now can be. I’m all about enablement and independence. I will always be a physiotherapist first. Lucky lucky me.”

Following this we have Alan J.Taylor MSc MCSP HCPC Reg PGCHE who is  an Assistant Professor/Module Convenor in the Division of Physiotherapy & Rehabilitation Sciences in the University of Nottingham. I think it is clear Alan is a very talented man from his piece. Alan also has a blog that can be found here.


A bicycle ride into physiotherapy and beyond … (Alan J Taylor)

A few years ago (!), aged about 14 years of age, I took off on a long, long bicycle ride over the hills of Derbyshire … the ride took me up the infamously steep Winnat’s Pass and many other painful climbs. I’d done a bit of preparation, but that ride made my legs hurt more than any other. I remember wondering about the mechanisms that led to that deep ache inside my legs, and instinctively gave them a rub or massage, as best as I knew how. Of course, you know what happened. Almost miraculously, they began to feel immediately better, looser, more supple … the pain had seemed to drain away. Frankly I was flabbergasted, how could that simple ‘leg rub’ make my aching muscles feel fresh and new again and ready for another pounding in Derbyshire?

I set out to find myself a regular ‘masseur’ who was also a coach, and used massage (to good effect) as part of my preparation from that day on. The experience had stimulated an on going interest in the complex physiology and psychology of the human body. I decided to explore ways in which I could be a part of that, and soon came across the profession of Physiotherapy … A confused teenager had found his metier, almost by accident. I’d discovered a profession (and physical modality) that would blend my love of sport, cycling in particular, and would feed my fascination with the human body and mind for a lifetime.

As a cyclist, I became moderately successful. I learnt how to suffer (I can safely say, I ‘know pain’) and I learnt how to win. I won many exciting races during a long career as an amateur cyclist and spent three years as a professional, completing the Professional ‘Kellogg’s Tour of Britain’ in 1988.

My physiotherapy training took place at the ‘Nottingham School of Physiotherapy’, and after qualification, I had the pleasure of working in a variety of countries and different settings. I had the experience of working for a Pro-cycling team, and on many top ranked events from triathlon to tennis. My journey took me all around the World and back again.

I still ride my bike for enjoyment, and regularly commute the 12 miles each way to my work at the University of Nottingham, School of Health Sciences. That is where I try to pass on my on going passion and enthusiasm for EBP and physiotherapy, to both undergraduate and post graduate students. I keep up a small amount of clinical work and devote my energy into physiotherapy education … Striving to keep up to date with the ever changing World of evidence based medicine, and it’s application to our profession.

Each day I remind myself as an educator, that we must “prepare our students for their future, not our past” … and that means keeping abreast of a dynamic landscape and embracing change.

As a physiotherapist I like to think I’ve helped a lot of patients and no doubt … hindered a few too, but I’ve never stopped learning. I am lucky enough to travel the World as a lecturer on various topics within Physiotherapy, and collaborate with some amazing and knowledgeable people, on peer-reviewed publications and other projects. I developed and maintain a passion for writing, which was sparked by my MSc in Sports Med, where I finally learnt to think. I do my utmost to pass that skill on to EVERY student (and clinician) I meet. I also write as music ‘critic’ and can occasionally be found strumming a guitar or banjolele myself.

My all time favourite quote comes from the legendary singer, musician, philosopher and poet Leonard Cohen  

 

“There is a crack in everything … that’s where the light gets in”.

The way I personally use that immortal line, is to remind myself (and others) that no one, and nothing is 100% ‘right’, and that blind, unquestioning followers of any teacher, guru, god, school of thought or otherwise are not really thinking critically

So never allow yourself to be lead along by the nose. My advice is to develop the art of healthy critique and THINKING … that way, ‘new paths are made’.

Incidentally, most folk would say that my pain relief from the massage was ‘psychological’, I would (still) say, with a smile on my face, ‘au contraire’ … sometimes we have to agree to disagree … enjoy the journey ☺

You can read some of Alans peer-reviewed papers here and here


 Again thank you to all who participated.

The Future of Physiotherapy

The future of physiotherapy in my mind is very bright however some changes are required before we can reach a level that is fully satisfactory. To me a fully satisfactory level is one where patients are in control of their outcome, the physiotherapist has taken an open minded and informed approach to the patient’s pain where all causes are taken into account, exercise is promoted and all practice is evidence based with clinical reasoning applied in a large dose. For me that would be the ideal formula with room for variance and experimentation. Now I am not dismissing the great work that is being done as we speak and there are plenty of physiotherapists who are already implementing this strategy. I take my hat off to them; those are the people who are driving the profession forward.

Physiotherapists are perhaps the most adaptable healthcare profession because of the type of skills the job demands. We are problem solvers and creative thinkers by nature and that is why I see physiotherapists at the forefront of an improved healthcare service if we really want it. A recent physiotalk on twitter and a great question of the day from Tom Goom got me thinking on a physiotherapist’s scope of practice. Really if taken seriously we have a lot of room for growth. Tom asked a question along the lines of can a physiotherapist have a role in “performance” and I would be inclined to say yes, but let me explain why. What other profession has such a wide range of skills and knowledge relating to the human body its anatomy, its physiology.  Don’t we all study the brain, the skeleton, muscles, organs, the body’s chemistry and physics? So why not I say?

For me exercise prescription and health promotion is well within our scope and we must really take charge and control of this because society has lapsed into inactivity, and, obesity is starting become far too common a word. I believe that, in the next few years, physiotherapists will be the leaders that change this whether it is in a community, sporting or medical setting. We must give our profession the respect it deserves but also ensure others do too. That is why in the future we must be the leaders that get society running, jumping, chasing……… living.

To be a leader you must also be a teacher or educator and I think that in our future this will be a big facet of our job. Right now through blogs and research many physiotherapists are pushing the profession forward by imparting their wisdom to their colleagues and those who are in university. We must now focus on educating patients whether it is about their treatment, exercise, diet or health in general we must get the message out there and let it spread.

I raised the question of physiotherapy and nutrition yesterday and I really don’t think it is outside of our scope if we get the required training, whether it is part of our undergraduate programme or upskilling once qualified. We are in a great position to change our patient’s lives in a sustainable and healthy way. I am not saying that we take over the job of sport scientists or nutritionists but why not work in sync with them? Why not back up their message and add our own?

For example look at the role of Gerard Hartmann, the Physio to 61 Olympic medallists. He radically changed the preparation, training and, to some extent, the running style of Paula Radcliffe which ultimately had a huge role to play in her success. A brilliant article on this can be found here. I know this is a very extreme example but why can’t this be done on a smaller scale?

Evidence based practice is the cornerstone of physiotherapy now and in the future. We must be led by the research for the sake of every patient that falls under our care, ourselves legally but also for success because quick fixes aren’t the way forward for anyone. We must aim to return each patient to optimum functionality without having a reason to return to us and without evidence this will not be achievable. However with this we must be able to take the research with a huge pinch of salt because really there isn’t the perfect article with results that applies to every patient so we must be guided by our own conscious as well as the evidence. This is not a call for the return to the dark days of the “guru” led approach, far from it.

There is at the minute a movement away from the biomechanical approach and to incorporate a much more wholesome view of the patient. In other words viewing them as a person made up of complex systems that are interlinked rather than a patient with damaged tissue. This is something that will hopefully revolutionise the world of physiotherapy because no injury or pain is simply structural and everything must be taken into account. How I remember this and validate it to myself is by thinking of my previous injuries and how I felt. Were those little twinges I felt in my hamstring when I made my return to football all in my head or was I about to break down again? The answer? both because the fear I had was holding me back causing me to hold back and I broke down again not physically but mentally and I never played properly again because of it. It is my aim to never let this happen to my patients because I hope that I will incorporate every aspect of that person’s life, pain and injury into their treatment to allow them to live their life to the full. I hope that this is the future of physiotherapy where every physiotherapist uses evidence, compassion, understanding and an open mind to ensure the best care is given to every patient.

UFC/MMA information and Injury Prevention Day

Having a very small interest and knowledge of MMA/UFC I recently attended a information day on injury prevention in the sport set up by Professor Dan Healy of RCSI along with the support of John Kavanagh. John Kavanagh is Conor McGregor’s coach and is trying to promote MMA in Ireland but most importantly in a safe manner. UFC was subject to some bad press from a Senator recently, I can see why if you aren’t fully involved in the sport, however on the day James Walsh, a Surgeon from Beaumont hospital, presented research that stated the rate of injury was quite similar to other sports. This was eye opening especially because of the physicality and high impact nature of the sport. 

He also presented a case study of a young fighter who skipped stages in his rehab programme while nursing a broken hand. I found this interesting because it threw up the issue of compliance and dealing with patients who want to return to sport no  matter what the stakes are. For someone training to be a physiotherapist it was a very good learning experience, because something like that is something you only experience once you are qualified and practising. What I took from that was how important education was, how the patient must understand the time frame and why at times tailoring training is necessary to avoid further injury. He used the phrase “time is important respect the injury”” and that is something that as physiotherapist and a sports person I will take on board.

Next up was Mr Gary O Toole, Consultant Orthopaedic surgeon, St Vincents Hospital Dublin, Olympic Swimmer and 1989 European 200m silver medalist to speak about “Twisted Knees” in MMA. He spoke about the common pathologies, how they are treated(surgically), including some very nice MRI images of torn Menisci and ligaments, and the mechanism of injury. I felt in particular the the MRI images were interesting because you could see the anatomy and injury so clearly. Secondary to this, seeing how an ACL tear is repaired surgically gave me a better understanding of the need for protection as well as  some loading early on in rehab. It also made me aware of how incredible it was for Conor McGregor to return from an ACL tear in the time frame he did. Mr.O’Toole also spoke about how the surgical approach to meniscal injuries have changed, repairing rather than removing, and he emphasised how rehab with a physiotherapist is vital to managing this appropriately. He quickly ran through the where most of the injuries occur i.e. ACL injuries are very common while grappling.

Following this was Performance Enhancing Drugs in MMA by Dr Conor ‘O Brien, Former Chairman of Anti doping committee 1999-2005, WADA committee member 2005-7 and Irish Olympic Team Doctor 1996. This was a bit of testing topic considering one of the main stars, Jon Jones, (and now Anderson Silva) had tested positive for drugs after his last fight. Mr.O’Brien talked about the set up of drug testing in UFC and how it is self managed within the union and called for stricter sentences and a more transparent system. He did however state that the UFC were beginning to handle it well and stated just his involvement in the day showed how they were making progress. Congratulations must go to John Kavanagh on this because it was a major step in the right direction for the safety and reputation of the sport.

Next up was “How to cut weight safely and effectively” with Mr Mark Ellison, Chief Performance Nutritionist to GB Boxing and Manchester United FC. This was an excellent talk, really well presented, full of evidence and actual insight how a professional diets, losses weight and prepares for a fight or match. One bit of info I picked up was that you burn fat faster when doing fasted cardio work. Something I found fascinating was how hydration was managed pre fight and how dehydration leads to injury, CNS dysfunction, an increased core temperature and cardiovascular strain. A simple fact that he provided was if you are 3% below optimum hydration your endurance begins to drop and at 4% strength begins decreasing. In relation to weight loss, in his camps, they work to a limit of 1% of body fat per week to maintain safe levels. A lot of his talk was about preventing radical weight loss and dehydration, especially using dangerous methods such as hours in a sauna. I learnt a lot about nutrition and hydration from Mr.Ellison and it may not be 100% applicable to a physiotherapist but in a team setting it may be valuable.

following that was perhaps the part I found most interesting “How the brain actually processes in a fight” by Professor Daniel G Healy, Consultant Neurologist Beaumont hospital and RCSI who was ably assisted by Owen Roddy, providing experience of being in the octagon. Professor Healy had actual brain scans from Conor Mcgregor, picture available on John Kavanagh’s twitter, to assist him and it was a master class of teaching. He explained how the brain dealt with fear and pain, how it processed the movement of the opponent and the ability of throwing fake shots to muddle the opponents thought process, using mirror neurons. I loved his line “the joints, muscles and bones are only tools of the brain” a line that all physiotherapist’s should use. He spoke of how fighters have a larger colliculus which helps drown out the noise of the crowd.

Sadly I had to leave after this due to other commitments but it was a very enjoyable day and it really opened my eyes to what safety and injury prevention in sport means. Congratulations must be offered to Professor Dan Healy and John Kavanagh for organising this fantastic event and safeguarding the future of the sport and its participants. I am sure it was the first step of many however it was certainly it a step in the right direction. It brought transparency to the sport and made it more accessible. I learnt a lot from the day both as a physiotherapist and a fan of sport in general.

The outline of the day that was held in January can  be found here http://www.rcsi.ie/files/facultyofsportsexercise/20150107030621_MMA%20event%20-%20Saturday%2024th%20Janu.pdf

Also John Kavanagh’s twitter can be found here …https://twitter.com/john_kavanagh