Thursday, November 19, 2009
CSP equal ops and CPD meeting
I atended an equal ops and CPD course yesterday (18/11/09) at the CSP headquarters.
The CPD meeting by Jane Smith and Dr Mary Morley was very timely (see handout) and made me reflect that I need to finish off my KSF and contact colleagues in Leicester to have peer group meetings with.
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Friday, October 23, 2009
Occupational health course
I attended an Occupational health course on 30 sept - 2nd Oct 2009 run by Nicoloa Hunter and Amanda Jones.
It was very informative. Things I learnt were:
1. Occupational epidemiology - statistics relating to occupational health and musculoskeletal disorders, i.e. Nurses have statistically more back pain than many other professions. In Lithuania whiplash does not exist as they have no compensation culture. NIOSH epidemiology of MSD's
2. Evidence based practice and LBP - there has been a republication of the NICE guidelines; non-specific low back pain that has lasted for more than 6 weeks, but for less than 12 months. Back in work for NHS employes is also a good guide and has soem great assessment tools. Functional restoration programmes are useful after 12/52 of LBP. The OREBRO questionnaire is a good outcome measure, scoring. The OREBRO (ÖMPQ) is a ‘yellow flag’ screening tool that predicts long-term disability and failure to return to work when completed four to 12 weeks following a soft tissue injury2. A cut-off score of 105 has been found to predict those who will recover (with 95 per cent accuracy), those who will have no further sick leave in the next six months (with 81 per cent accuracy), and those who will have long-term sick leave (with 67 per cent accuracy).
3. Evidence based practice and neck apin - there is no evidence for any clinical tests. Level 1 evidence for advising incresed movement and reassurance.
4. Confidentiality and consent - we must have the patient sign consent to discuss their problem with the occupational health dept. We can document this in our notes. The Disability Discrimination Act is important here.
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Tuesday, July 21, 2009
Foot biomechanics
On the 15/07/09 I went on a course as part of my Msc module; foot biomechanics.
The day in Northampton was very interesting. I learnt how to apply orthotics for forfoot and rearfoot pronation using podiatry felt. Steve Avery took the practical session of the course. I need to buy 7mm and 5mm mixed felting with adhesive backing.
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Monday, March 09, 2009
New website!!
19:22 Posted in Acupuncture, Ankle/foot, Ax, Course, Cx, Elbow, Electrotherapy, Ergonomics, Guru's, Hand, Head injury, Hip, IST, Knee, Lower limb, Lx, Neurology, Occupational Health, Pain, Pathologies, PDP, Pelvis, Reflection, Research, Rheumatology, S I Joint, self referral, Shoulder, Sports Physio, Supervision, Tendon and Muscles, Tx, Vascular, Wrist | Permalink | Comments (0) | Email this | Tags: http:physiocharlie.vpweb.co.uk
Monday, January 26, 2009
Shoulder course, Jeremy Lewis
I attended an excellent shoulder course yesterday by Dr Jeremy Lewis.
Things I learnt:
Common tests cannot diagnose R cuff problems as they all put pressure on the subacromial bursae causing pain. There is no way to differentiate between different muscles. Pec minor length test is not diagnostically specific, no need to use it.
There is not one "normal" posture and there is no correlation to shoulder pain.
Energy for shoulder mvt comes from the trunk and lower limbs (54%) so shoulder rehab should include general fitness, abs, glutes, hams and core. (Kibler 1995). Lower limb control is important, ie SLS.
Acromioplasty is not a good option for R cuff problems as it removes the bursae. This ends in increased r cuff tears. Also the cause of r cuff problems is not the acromion or a "Spur" it is more likely irritation of a bursae by oedema of the r cuff (not inflammation) due to overuse.
Imaging: there should be a 9-10mm subacromial space on X-ray. MRI and U/S; pts can have a tear and/or labral abnormalities but no symptoms. 40-60yrs = 28% have a r cuff tear. >60 yrs = 50% have a tear. WHY? "suspension bridge", the rotator cuff has a cable which holds the muscles onto the head of humerus.
Perceived weakness during testing may be better explained as occuring as a result of pain inhibition and not as a result of structural pathology, (Bronx et al 1997).
Oucome measures: www.oxfordshoulderandelbowclinic.org.uk He also uses inclinometers and tape from belly botton to ulnar styloid for lat rot ROM.
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Friday, November 28, 2008
Achillies Tendonopathy
Yesterday me and a colleague attended a module of advanced skills MSc and had a presentation on Achillies Tendonopathy by Richard Wood.
ACHILLES TENDINOPATHY
RICHARD WOOD
SPECIALIST PHYSIOTHERAPIST
UNIVERSITY HOSPITALS OF LEICESTER NHS TRUST.
OUTLINE OF PRESENTATION
THEORY OF CORE SUBJECT
ANATOMY AND PHYSIOLOGY
DIFFERENTIAL DIAGNOSIS- ACHILLES
DIFFERENTIAL DIAGNOSIS-POSTERIOR ANKLE PAIN
PREDISPOSING FACTORS TO INJURY
PREDISPOSING FACTORS TO RUPTURE
OUTLINE OF PRESENTATION
SUBJECT DEVELOPMENT
CLINICAL ASSESSMENT
RADIOLOGICAL ASSESSMENT
TREATMENT OPTIONS (EVIDENCE)
OUTLINE OF PRESENTATION
APPLICATION OF ADVANCED SKILLS RELATED TO SUBJECT
CASE STUDIES
(WHO TO SEE AND WHAT TO DO)
OUTLINE OF PRESENATION
CURRENT PRACTICE DISCUSSION
REFLECTION AND APPLICATION OF A REFLECTIVE MODEL, WORKING FROM EVIDENCE BASE.
ANATOMY AND PHYSIOLOGY
OVERVIEW
SOURCE OF PAIN?
LONG TERM PROGNOSIS
8 year follow up. Paavola et al (2000)
Follow up 83/107 patients
<6 month history at initial assessment
Follow up 8 years +/- 2 years
Questionnaire, CE, performance,muscle strength and US.
29% operation rate
84% full recovery average 8 years
94% asymptomatic
41% had symptoms in initially asymptomatic tendon
DIFFERENTIAL DIAGNOSIS ACHILLES
PARATENONITIS
ADHESIVE TENDINOPATHY
TENDINOSIS
‘TENDINITIS’
PARATENONITIS AND TENDINOSIS
PARTIAL RUPTURE OF ACHILLES
COMPLETE RUPTURE OF ACHILLES
INSERTIONAL DISORDERS (ZONE 2)
DIFFERENTIAL DIAGNOSIS POSTERIOR ANKLE PAIN
OSSEOUS
POSTERIOR ANKLE IMPINGEMENT
ANTERIOR ANKLE IMPINGEMENT
OS TRIGONUM SYNDROME
LOOSE BODIES
FRACTURES + AVN
TUMOUR
SEVER’S DISEASE
DIFFERENTIAL DIAGNOSIS POSTERIOR ANKLE PAIN
SOFT TISSUE
RETROCALCANEAL BURSITIS
TIBIALIS POSTERIOR TENDINOPATHY/TEAR
FHL/FDL TENDINOPATHY
PERONEAL TENDINOPATHY
GANGLIONS
PLANTAR FASCIITIS
DIFFERENTIAL DIAGNOSIS POSTERIOR ANKLE PAIN
NEURAL
SURAL NERVE ENTRAPMENT
SUP.PERONEAL NERVE ENTRAPMENT
TIBIAL NERVE ENTRAPMENT(TTS)
REFERRAL FROM Lx SPINE
DIFFERENTIAL DIAGNOSIS POSTERIOR ANKLE PAIN
OTHER
INFLAMMATORY ARTHRITIS(REITERS)
RhA/AS/CTD
GOUT
INFECTION
Abx
HYPERLIPIDAEMIA
DM
Hormone imbalance
INTRINSIC FACTORS
FOOT PRONATION/SUPINATION-STJ FUNCTION
FOOT MECHANICS
1ST MTPJ movement
TIBIAL TORSION (<25deg)
GENU VALGUM (<11 deg)
GENU VARUM
GENU RECURVATUM
INTRINSIC FACTORS
FEMORAL ANTEVERSION/RETROVERSION
LEG LENGTH (>2cm)
LENGTH OF TENDON
HYPERMOBILITY
MUSCLE IMBALANCE
AGE
BMI
HYDRATION/NUTRITION
FATIGUE
EXTRINSIC FACTORS
TYPE OF MOVEMENT
SPEED OF MOVEMENT
MOVEMENT REPETITION
FOOTWEAR
SURFACE
WEATHER
ADEQUATE MOVEMENT PATTERNS
EXTRINSIC FACTORS
TRAINING ERRORS
FREQUENCY
DURATION
INTENSITY
TECHNIQUE
APPROPRIATE REHABILITATAION (SPORT SPECIFIC)
EARLY RETURN
PREDISPOSING FACTORS TO RUPTURE
EXCESSIVE BODY WEIGHT
DIABETES
HEAVY WEIGHT LIFTING
HISTORY OR CURRENT ANABOLIC STEROID USE
HISTORY OR CURRENT STEROID INJECTIONS
JOINT IMMOBLISATION
PREDISPOSING FACTORS TO RUPTURE
MALE SEX
INFLAMMATORY ARTHROPATHIES
MUSCLE WEAKNESS AND IMBALANCE
SMOKING
SPONDYLOARTHROPATHIES
FLUOROQUINOLONE USE
GOUT
RUPTURE
SUBJECT DEVELOPMENT
CLINICAL ASSESSMENT
RADIOLOGICAL ASSESSMENT
TREATMENT OPTIONS (EVIDENCE)
CLINICAL ASSESSMENT
PUDDU(1976)
3 ZONES
ZONE 1
ZONE 2
(ZONE 3)
ZONE 1
NON-INSERTIONAL AREA
ACHILLES PARATENONITIS +/-
ACHILLES TENDINOSIS
(ACHILLES TENDINITIS)
ACHILLES TENDON RUPTURE
ADHESIVE TENDINOPATHY
ZONE 2
INSERTIONAL AREA
CALCIFIC TENDINITIS
SUPERFICIAL CALCANEAL BURSITIS
RETROCALCANEAL BURSITIS
EXOSTOSIS OF CALCANEUM
AVULSION AT CALCANEUM
‘HAGLUNDS DEFORMITY’
SEVERS DISEASE
ZONE 3
MID CALF AREA
MUSCULOTENDINOUS JUNCTION TEARS
SURAL NERVE ENTRAPMENT
SPN ENTRAPMENT
PAES
COMPARTMENT SYNDROMES
CLINICAL ASSESSMENT
RELEVANT BIOMECHANICS
GAIT
TALOCRURAL JOINT
SUBTALAR JOINT
STABILITY TESTS
SOFT TISSUE PROFILE(consider KINETIC chain)
SPECIAL TESTS
LONDON HOSPITAL ‘TEST’
VISA-A QUESTIONNAIRE
VISA-A questionnaire
Robinson et al (2001) British Journal of sports medicine.
Validated
RADIOLOGICAL ASSESSMENT
X-RAY
CALCANEAL EXOSTOSIS
CALCIFICATION AT INSERTION
POSTERIOR IMPINGEMENT
MRI v’s ULTRASOUND
Khan et al (2003)
US abnormal in 37/57 sym tendons(65%)
US normal in 19/28 asym tendons (68%)
MRI abnormal in 19/34 sym tendons(56%)
MRI normal in 15/16 asym tendons (94%)
MRI v’s ULTRASOUND
Karjalainen et al (2000)
MRI only
111/118 painful tendons
Sensitivity of 94%
Specificity of 81%
(only 23% had surgery)
IMAGING SUMMARY
BOTH MRI AND US USEFUL
ABNORMAL SIGNAL DETECTED
DIFFICULT TO ALWAYS GIVE ACCURATE DIAGNOSIS
NO PROSPECTIVE STUDIES WHICH DETECT SUBTLE PATHOLOGY
ABNORMAL SCAN AND NO SYMPTOMS
Alfredson et al (2003)
TREATMENT OPTIONS
ACHILLES PARATENONITIS
ACHILLES TENDINOSIS
(ACHILLES TENDINITIS)
ACHILLES TENDON RUPTURE
ADHESIVE TENDINOPATHY
TREATMENT OPTIONS
CALCIFIC TENDINITIS
SUPERFICIAL CALCANEAL BURSITIS
RETROCALCANEAL BURSITIS
EXOSTOSIS OF CALCANEUM
AVULSION AT CALCANEUM
‘HAGLUNDS DEFORMITY’
SEVERS DISEASE
ACUTE PARATENONITIS (CHRONIC ADHESIVE TENDINOPATHY)
Welsh (1990) 4/52 relative rest to promote healing.
? immobilise
Reduce extrinsic factors (Activity)
Address intrinsic factors (Biomechanics)
Soft tissue stretching
Ice and NSAIDS (?after 3 days) and note that inflammatory cells not found even in acute tendon problems(Alfredson 2005)
?GTFM (Cook et al 2004)
ACUTE PARATENONITIS (CHRONIC ADHESIVE TENDINOPATHY)
Early intervention (Alfredson 2003)
Prevent collagen damage.
?> 6 months to improve.
ACHILLES RUPTURE
ACHILLES TENDINOSIS
ECCENTRIC EXERCISE
PODIATRY
KADER et al (2002)
12-15 mm heel wedge may be beneficial.
Obvious biomechanical dysfunctions should be targeted( a number of papers)
PODIATRY
Clement et al (1984)
109 athletes
OVERTRAINING
61% functional overpronation
41% gastroc/soleus insufficiency
PODIATRY
Kaufman et al (1999)
Hindfoot varus
Reduced dorsiflexion
PODIATRY
Kvist (1991)
Biomechanical defects in 60% athletes
Forefoot varus
Limited sub talar joint mobility
Reduced dorsiflexion
PODIATRY
Lun et al(2004)
87 Athletes
6/12 observation
79% injured
Multifactorial – no correlation with biomechanics except PFJ pain.
GTN PATCH
Paoloni et al (2004)
84 tendons
78% asymptomatic at 6/12
49% (placebo) asymptomatic at 6/12.
INJECTIONS!
Ohberg and Alfredson (2002)
US guided sclerosis (Polidocanol)
10 patients , 80 % success
O’Dowd et al (2007)
HVIGI (local anaesthetic steroid and saline-50ml)
‘Strip’Kagers fat
30 patients , 70% improved at 30/52
INJECTIONS!(Steroid)
Shrier et al (1996)+case reports
Perrypacker (2004)
Read and Motto (1992) 83 athletes/1 rupture
Speed et al (2001)
Dacruz et al (1988) 28 patients. No benefit
Lesic et al (2004) contraindicated.
Anecdotal case series
INJECTIONS!
SALINE? (Brisement)
LOCAL ANAESTHETIC?
HEPARIN?
AUTOLOGENOUS BLOOD?
OTHER TREATMENTS
Scheel et al(2004)- manage hypercholestremia. Reduce Xanthoma formation.
ECSWT Chen et al (2004) ?? Frequency
ELECTROTHERAPY (Evidence in animal studies)
OTHER TREATMENTS
RESTING NIGHT SPLINTS
TRANSVERSE FRICTIONS
STRETCHING (How much Dorsiflexion?)
SURGICAL TREATMENT (ZONE1)
SURGICAL TREATMENT
24% - 45%
LONG STANDING TENDINOPATHY RESULTS IN POOR OUTCOMES
VARIED SURGICAL TECHNIQUE
EXCISE FIBROTIC NODULES
REMOVE PARATENON
REMOVE DEGENERATIVE NODULES
MULTIPLE LONGITUDINAL EXCISIONS
DETACH KAGERS FAT PAD
SUCCESS 70-100%?
SURGICAL TREATMENT
Leppilahiti et al (1991) 56%excellent at 4 years. (52)
Schepsis et al (1994) follow up at 1-13 years 67%(satisfactory)
Nelen et al (1989) 80% excellent . (50)
Morberg et al (1997) 80% excellent between 1.5 and 11 years. (25)
Paavola et al (2002) 67% activity fully restored, 83% asym with strenuous exercise. (42)
SURGICAL TREATMENT
Maffuli et al (1999)
14 patients with central core degeneration
87/12 since onset of symstoms
35/12 follow up
37% excellent/good results
43% re-explored
POOR RESULTS WITH LONG DURATION and CORE DEGENERATION
SURGICAL TREATMENT
Saxena (2003)
27 athletes/37 procedures
10.6 +/- 6.3 weeks to activity (E)
15 +/- 6.2 weeks to activity (NE)
Return to competition and 100%
25/52 (E) and 27/52 (NE)
SURGICAL TREATMENT (ZONE 2)
THERE IS NO GOOD EVIDENCE FOR SURGICAL TREATMENT IN THIS AREA.
LONG RECOVERY IN CASE REPORTS.
GENERALLY MUCH POORER OUTCOMES WITH SIMILAR TREATMENTS.
APPLICATION OF ADVANCED SKILLS RELATED TO SUBJECT
CASE STUDIES
(WHO TO SEE AND WHAT TO DO)
CASE STUDIES
PRIORITISE PATIENTS
PROVISIONAL DIAGNOSIS
IMMEDIATE PLAN and WHY
PROGNOSIS AND PATIENT DISUSSION
CONSULTATION SKILLS
PRINCIPLES OF I.C.E
EXPLORE AND EXPLAIN ;
R.A.P.R.I.O.P
CURRENT PRACTICE DISCUSSION
REFLECTION AND APPLICATION OF A REFLECTIVE MODEL, WORKING FROM EVIDENCE BASE.
15:49 Posted in Ankle/foot, Course, Research | Permalink | Comments (0) | Email this
Monday, September 08, 2008
Resuscitation Skills - Adult (Non-Medic) held on 28th August 2008 passed
Dear physiotherapist
Thank you for completing your training session (Course : Resuscitation Skills - Adult (Non-Medic)). Attached is your certificate of completion in the skill that you have been trained in. If you have any queries regarding the course, please speak to the people named on the certificate as your first point of contact.
Regards,
Clinical Skills Unit Administration Team.
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Thursday, October 04, 2007
Clinical Educator Forum
On 13th September I attended Coventry University's Clinical Educator Forum. I learned about dealing with an anxious student, assessment criteria and conrtibuted to the new curriculum. I also found out that at the 1/2 way assessment, do not mark or band a student, set out an action plan.
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Friday, December 22, 2006
Introduction to learning
On 19th Dec I went on an Intro to learning course at the Alfred Hill centre. It was a little useless as all they told us was that there was no funding for some of the courses and it was over in less than an hour, we had booked off a whole morning!
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Tuesday, July 04, 2006
Knee Reconstruction Techniques
On Friday 30th June I attended a half day course at Kettering General Hospital on knee reconstruction and rehab. I arranged for myself and two colleagues to attend. This is what I learnt:
Anatomy:
ACL checks the joint when it locks home the "screw home mechanism", popliteus assists. Primary stabiliser is the ACL, secondary stabiliser is the popliteus. Dynamic stabilisers also play a part; ie if the Hams are weak or fail to stabilise the joint then ACL rupture will occur. A damaged ACL ligament will take up to 2 years to completely remodel itself. Posterolateral corner resists varus load (lateral collateral lig), ext tibial rotation (popliteus) and knee ext (Popliteal fibular ligament (PFL) and gastrocs). It contains 9-13 structures including ITB, Biceps (1st line), FCL, popliteus, PFL (2nd line), capsular structures ie meniscus etc (3rd line). Medial Patellofemoral ligament (MPFL) restrains the patella against lateral glide and is torn in 80% of patella dislocations.
Diagnosis:
Method of injury; high impact sports or low impact skiing injury. Pop on twisting LL could be ACL or patella dislocation. Different types of Rx; sports injury = surgery and potential post lat structures involved. Skiing = conservative, lifestyle choice.
Ax:
Obs - Previous surgery scars, foot arches, swelling
Function - Gait; look for hyper ext "thrust"
AROM - Ext; look under heel, how many fingers can you get under? Hyper ext is a sign of PL corner insufficiency. Flx; look at big toe, 1 big toe difference = 10 degrees, 1/2 big toe = 5 degrees.
Special test - Lachman's for ACL - 20 degrees knee flx, hold femur underside and pull tibia
Anterior Draw for ACL - sit on foot, pull and push forcefully
Pivot shift test for ACL - hold leg under arm, knee ext, med rot tibia, valgus load, axial load, flx knee 0-30, feel pivot.
PCL - stand at sideand look for PCL sag, run fingers along condyles on med side.
Quads active test for PCL - stabilise foot and tell patient to push foot away.
ERRT for PL corner - lift up leg with big toe, look for hyper ext.
Dial test for PL corner - Prone, knee flx 30 degrees, turn feet laterally, look for excessive tibial rotation, also test for femoral rotation here, feel greater trochanter.
Valgus stress test for PL corner - leg under arm, thumbs either side of joint line, look for Gd 1; laxity but no joint opening, Gd 2; jt opening but firm end point, Gd 3; jt opening no end feel
Aprehension test for MPFL - lateral glide of Patella, lateral tilt test
Palpn - sit on toes, helps relax hams, palp med and lat jt line, PF tendon - 16/52 post ACL surgery may get tendonitis
Rehab: ACL goal is to gain full ext in 12/52 (see handout)
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