AHPS CLINICAL WEEKLY 64th Edition 13.11.2015

Welcome all from this weeks guest editor. Brad will be back next week.

#PODCASTTUESDAY W/C 2.11.15 AM Problem Solving Prof Peter O’Sullivan considers surgery for back pain: Tiger Woods’ 2015 re-operation W/C 16.11.15 AM Problem Solving The Physio Matters Podcast - Ankle Sprains, Research Methodology & EBM with Prof Sallie Lamb

#WHATSNEWFRIDAY – Nocebo Nocebo - a detrimental effect on health produced by psychological or psychosomatic factors such as negative expectations of treatment or prognosis. (Oxford Dictionary) Everyone has commented on ‘that video’. It is important we look at what is available online. One of the first things patients will do with a diagnosis is Google it; these are the results they are getting Loads of great feedback and pictures from this week’s discussions: Haverhill – Beth and Rob looked at the skeletons that we have in our clinics, do these reinforce negative ideas?

Prof Peter O’Sullivan considers surgery for back pain: Tiger Woods’ 2015 re-operation - BJSM

Tiger Woods 2nd

surgery for back pain (only going from media reports) o Struggling to play, only getting occasional discomfort o Scanned on routine check up o Disc fragment seen o Micro-discectomy respite absence of radiculopathy

Evidence shows poor correlation between imaging finding and symptoms o Asymptomatic individuals = 70% degenerative disc, 50% disc bulge, 30% prolapse o Should we be scanning any patient on routine check-up?

Is there a culture of ‘overscanning’ in healthcare globally?

Tiger has scan findings = immediate descision for surgery o ? is this the correct management o Was reported as a ‘clean up’ for the back

We know this doesn’t work long term eg: knee arthroscopy ? are we making it worse

o Is there negative fallout from being told has pathology and needs surgery? Are we setting of an escalating cascade psychologically, causing hypervigilance?

Would physiotherapy been a suitable alternative in this scenario? o Maybe o We would have likely looked at his beliefs and behaviours

Are we fostering structural distrust when blaming anatomical structures? o Is this even more pronounced in athletes who trust their bodies at a higher level?

AHPS CLINICAL WEEKLY 64th Edition 13.11.2015

Newmarket – Kevin and I found a potentially priming poster in our waiting area. Removed! Sudbury – James highlights the vending machine in the waiting area. “A great advert for health in our increasingly obese/diabetic society!!!” Bury – Tom and the team discussed information in the media. The self-centre sell ‘What Doctors Don’t Tell You’ which last month focused on pain. They also looked at how we can meet our KPI’s regarding VAS scores without actually asking patients their pain score; they suggest using MI strategies to ‘drop the question in’ – check out the MI podcast with Matt Coombes.

AHPS CLINICAL WEEKLY 64th Edition 13.11.2015

Coming up next: 13.11.15 - Extension-rotation cervical spine test 20.11.15 – TBC (any ideas welcome email us your suggestions!) #COURSEOFTHEWEEK – Know Pain with Mike Stewart – Part 1 We had a really great turn out for the Know Pain course with great representation from across the company. Mike was a great speaker and I am sure that everyone would recommend it if and when the opportunity arises again. Definitely worth a follow on twitter too @knowpainmike. Setting the scene:

Pain is a sense and is perceived by the brain: like sight, touch, hearing o “Perception is the brain’s best guess about what is happening in the outside

world”. Atul Gawande

Pain demands an explanation – or does it? o Mike was keen to highlight that a firm diagnosis does not need to be made

for us to treat patients with pain – acute or persistent Let’s use our bio psychosocial brains more than our biomedical ones

o Knowledge is power for patients in pain. o Patients who understand their pain are happier. Are we any good at

education?

Moving away from the Cartesian model of pain o Pain is more complex than a simple reflex arc and is modulated by ascending

and descending components

Fear avoidance can be addressed through education o The 2 slides below show fear avoidance and how the correct management of

it can lead to improved function and possibly pain reduction

AHPS CLINICAL WEEKLY 64th Edition 13.11.2015

Understanding Pain Biology:

Pain is a critical protective system o Persistent pain is an maladaptive sensitisation of the nervous system

Mike reminded us of Hebb’s theory o Nerves that fire together, wire together! o We generate a pain ‘neurotag’ in the brain o If we keep stimulating pain, we make the pain system more effective at

activating

Can be likened to a fire or car alarm system o You can set of the alarm without the full stimulus o Long term potentiation turns up the sensitivity o Burnt toast = Fire engines

Hypersensitivity that is out of proportion and useless o Find someone who went on the course any they will explain how Mike

describes this to be used with our patients.

Central sensitisation o The somatosensory map of the body can be changed in response to pain o Can happen within 30mins of injury

Often a combination of these changes ‘turns the volume of pain up’ and patients often need ‘the stamp of approval’ to get going again. Reassurance & encouragement

#NEWSOFTHEWEEK 1st: Humeral head location A nice article looking at the position of the humeral head (HOH) during shoulder muscle fatigue. Recreational athletes demonstrate an inferior shift of the HOH following overhead muscle activity; they suggest this could be an ‘impingement sparing situation’. Is this clinically relevant? I would suggest we will need to see a study in a symptomatic population

first. http://www.ncbi.nlm.nih.gov/pubmed/25594913

2nd: Pregnancy in physio Not directly news but Beth Harrison gave a great IST in Newmarket last week about providing pregnant ladies with physiotherapy care. Very reassuring as a B5. See below for a list of do’s and don’ts:

AHPS CLINICAL WEEKLY 64th Edition 13.11.2015

3rd: Bariatric surgery pre joint replacement Most surgeons require patients with a very high BMI to lose weight or undergo bariatric surgery before they will be considered for knee or hip replacement. This latest study suggests that this may not provide superior outcomes following bariatric surgery and arthroplasty when compared to matched controls. An interesting one to watch but weight control remains a significant component in the management of patients awaiting arthroplasty. http://www.bjj.boneandjoint.org.uk/content/97-B/11/1501.abstract

4th: Post op rotator cuff rehab A systematic review was published this week in Physiotherapy looking at whether there was a superior protocol for rehabbing post-operative rotator cuffs. The authors concluded that no one protocol lead to better outcomes than another but that further research was required http://www.ncbi.nlm.nih.gov/m/pubmed/26510584/

5th: Karen Middleton calls for more self-referral Karen Middleton, CSP chief executive, has published an article on the BBC website calling for more self-referral access to physiotherapy in primary care. The services she describes sound a lot like the ones we offer. Go team! http://www.bbc.co.uk/news/health-34745681

6th: Fit legs = fit brain Some good and bad journalism on show here. The BBC reported on a paper published in the Journal of Gerontology that reports leg strength as a predictor of brain function in older women. They report this is likely associated with getting enough exercise to remain healthy. I have also seen this being reported on cycling sites as ‘Cycling gives you a fitter brain’, maybe a slight stretch of this evidence. http://www.bbc.co.uk/news/health-34764693

#EXERCISEOFTHEWEEK Dinosaur walking Uses: Soleus strengthening as part of Achilles rehab. As previously discussed in the weekly soleus has a greater attachment to the Achilles tendon. Revisit that here: http://www.biomechanics.completesportscare.com.au/rehab/important-soleus-managing-midportion-achilles-tendinopathy-seth-oneil/ Function: Links back to stairs and walking on gradients. Progression: On an inclined slope or stairs, theraband around knees or forefoot

AHPS CLINICAL WEEKLY 64th Edition 13.11.2015

COMINGSOON 1. #WHATSNEWFRIDAY- Extension-

rotation cervical spine test 2. #PODCASTTUESDAY – ankle sprain 3. Muscle tech network conference

review 4. #EXERCISEOFTHEWEEK 5. #COURSEOFTHEWEEK – KnowPain

– Part 2

#MOVEMBER Several great Mo’s going on in the West at the moment. The balls in East’s court now. Show us what you got! Donations on the Movember website please.

#FROMTHEEDITORS Thanks to Brad for letting me take the reins for this week, hopefully lived up to the high standards

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