Physio Charlie - course

CSP equal ops and CPD meeting

noreply@blogspirit.com (PhysioCharlie) — Thu, 19 Nov 2009 15:55:17 +0100

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.

Occupational health course

noreply@blogspirit.com (PhysioCharlie) — Fri, 23 Oct 2009 17:45:00 +0200

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.

Foot biomechanics

noreply@blogspirit.com (PhysioCharlie) — Tue, 21 Jul 2009 01:14:12 +0200

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.

New website!!

noreply@blogspirit.com (PhysioCharlie) — Mon, 09 Mar 2009 19:22:00 +0100

I have a new website!!

http://physiocharlie.vpweb.co.uk

Shoulder course, Jeremy Lewis

noreply@blogspirit.com (PhysioCharlie) — Mon, 26 Jan 2009 15:01:00 +0100

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.

Achillies Tendonopathy

noreply@blogspirit.com (PhysioCharlie) — Fri, 28 Nov 2008 15:49:00 +0100

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

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.

Resuscitation Skills - Adult (Non-Medic) held on 28th August 2008 passed

noreply@blogspirit.com (PhysioCharlie) — Mon, 08 Sep 2008 14:02:49 +0200

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.

Clinical Educator Forum

noreply@blogspirit.com (PhysioCharlie) — Thu, 04 Oct 2007 10:06:19 +0200

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.

Introduction to learning

noreply@blogspirit.com (PhysioCharlie) — Fri, 22 Dec 2006 10:37:41 +0100

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!

Knee Reconstruction Techniques

noreply@blogspirit.com (PhysioCharlie) — Tue, 04 Jul 2006 10:35:00 +0200

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)