AHPS CLINICAL WEEKLY 22nd Edition 19.12.14

#CHRISTMASPARTYFRIDAY What a top drawer CPD year if I don’t say so myself. Thank you to all that have helped and contributed and most importantly thank you to all those that read each week. #AHPSClinicalWeekly, #Specialtestfriday, #Podcasttuesday and #AHPSPodcasts takes a breather for 2 weeks. Last thank you and I’m sure everyone will join me in saying thank you to the management team and directors for laying on the christmas party and for the vouchers we received in the post this week. Happy Christmas to one and all.

#PODCASTTUESDAY W/C 5.1.15 AM Problem Solving The Kinesiology tape debate: ‘To KT or not to KT’ with Paul Coker and Paul Westwood http://chewshealth.co.uk/the-physio-matters-podcast/ Treating Tendons Part 3

Shoulder

New thing out of the conference was the focus on central changes in upper limb tendinopathies o It’s worth checking out Littlewood et al (2013) for some reading on this

‘A review of systematic reviews of the effectiveness of conservative interventions for rotator cuff tendinopathy’ I have this paper if people want it just email me.

Rotator cuff tendinopathy is an insertional tendinopathy therefore we must reduce compression first and foremost o Lift up into slight abduction when starting to load eg. Isometrics

Isometrics important o 20 degrees of abduction so out of compression and work on abduction and external rotation o Work on patient progressing to pushing harder- use this as outcome measure for patient to recognise

progress

Then move on to isotonic- Theraband and then on to strength training and endurance o Important to include static load and compressive load e.g. wall press, 4-point kneeling, STS pushing

through o By compressing through arm you can fire up the cuff better

Positional tendon o Not so much an energy storage tendon tends to work more in static positions against gravity

Important to manage people’s activity- load still the key- fine details important for upper limb as people don’t realise what they are doing with arm

Can use tape to make them realise Tennis Elbow (Bill Vincenzino’s your man for this)

Radial head in pronated position raises up and becomes more anterior compressing into ECRB and ECRL- not a true distal tendinopathy but compressive from where bone is pushing up into it. Could be where we see cartilage formation in tendons.

Need to retrain extensor muscles in supinated position to reduce some of the compression

Need to reduce time spent in pronated position

Agg: In pronated position where extensors are being told to hold position to allow flexors to work e.g. keyboard, writing, drawing

Drop off radial head- will likely be most painful point

Involve radial deviation when testing

Tests not specific but a good marker for pain

Grip strength good test, if reduced clasp hands around to spread load, if reduces pain response then will benefit from strap

MWM’s effective, should use as part of assessment for differential diagnosis and as part of treatment

AHPS CLINICAL WEEKLY 22nd Edition 19.12.14

#SPECIALTESTFRIDAY Fri 19.12.14 Carpal Tunnel Compression Test – for carpal tunnel Sensitivity: 87% Specificity: 90% Place patient into supination and apply pressure with thumb over median nerve. A positive test is if patient gets pins and needles and numbness in median nerve distribution within 30 seconds.

#COURSEOFTHEWEEK- Cognitive Behavioural Therapy for MSK Conditions Right….the trilogy last week was incomplete. My source in fact sent me a draft copy. So here is the full version that you should have had last week. Apologies on their behalf, they have been reprimanded ; ). The third and final episode from the CBT course covers unhelpful thinking and thought identification. It also covers elements that are involved in the change process, baseline setting, pacing and goal setting. Remember the hot crossed bun model thoughts, mood, behaviour and biology - covered in episode

We discovered that thoughts are an important ingredient to this cycle, and if these thoughts are incorrect, they can have a negative impact on the cycle.

Thoughts

Behaviour

Biology Mood

AHPS CLINICAL WEEKLY 22nd Edition 19.12.14

‘Thinking errors’ are commonly derived from the automatic thoughts that we have (and come

from the frontal lobe), however if we are able to help the patients understand those thoughts, think about them ‘logically’ then they can hopefully derive an alternative thought. See the table below for some examples:

Try it yourself !

The use of Socratic Questions can be useful in challenging these automatic, unhelpful thoughts and helping the patient to explore their reasoning behind their thoughts. It is more effective in changing behavior than ‘telling’ a patient what to do. Try it with someone else- get them to complete the situation, mood and automatic thought above then explore this automatic thought with some of these questions…… Examples of Socratic Questions: Clarifying questions What do you mean by ? Could you put that another way ? Let me see if I understand you – do you mean … or ….. ? Could you give me an example ? Can you expand on that ? Assumption questions What are you assuming? You seem to be assuming ….. Do I understand you correctly : you are assuming ….?

Situation mood Automatic thought

Supportive evidence

Does this match

Alternative thought

Mood

If I bend, I get pain in my back

Fear, depression

I must not bend ever again

I originally hurt my back by bending, and now when I bend it hurts a bit.

No, Other people with back pain manage to get back to normal activities

If I follow the physios advice regarding rehab I may get better

Relief, hope

Phone call from manager asking me to call back asap

Nervous, anxious

What have I done wrong now !

Past experience in previous job, urgent call would mean I was in trouble

Current boss is nice and never told me off, I haven’t done anything wrong

Probably just wants to ask me something

Less anxious

I keep getting pain in my hip after running

Angry, nervous

Will need to give up running and have a THR

I know I have OA, friends have had THR for hip pain

I often get aches and pains but they soon go.

I need to pace better and manage the hip so I can continue to run

Less angry and nervous

AHPS CLINICAL WEEKLY 22nd Edition 19.12.14

Is this always the case What is it that makes you make that assumption? Reason and evidence questions: How do you know ? Why do you think that may be true? What are your reasons for saying that? Do you have any evidence for that? Can you explain how you logically got from …. to ….. ? Do you see any potential issues with that reasoning ? What would change your mind? What would you say to somebody who said …? A change in the thought box of the hot cross bun will have an effect on the mood, the behavior and subsequently the biology. Now that the patient is ready to change, we need to look at finding an appropriate baseline for the individual patient in front of you, this is more than likely going to be different for every patient, ( so don’t just prescribe x10 reps 3x day ) !!

Baseline setting lets the patient decide on the number of reps or time that they spend exercising.

It’s best if you show the patient the exercise and then ask them how many they think they can do. If for example this is x5 reps, that’s fine. On Day 1 they do the x5 reps – if this is too much, they can reduce for day 2, if ok, continues with x5 reps for day 2 and if easy, slightly increase. Then take an average of the 3 days to get a baseline for the patient. They then continue exercising at this baseline amount until you next see them. This method is very much set and then lead by the patient.

Pacing is really important and something that we all probably discuss with our patients, however

how often is it really understood. I often try to use analogies to help explain what I mean. Ie: if you have £50 to spend for the week, is it sensible to spend it all on the Monday and then have no money for the rest of the week ? Ie: if you are going to mow the lawn, is it worth doing it all in the morning then spending the rest of the day and next day laid up with pain, or is it better to do it in 2-3 sessions over the 2 days and not experience the same amount of pain, getting the same amount of work done ? It is also worth asking your patient to summarize what they have understood regarding pacing, in their own words, a way of validation

AHPS CLINICAL WEEKLY 22nd Edition 19.12.14

COMINGSOON 1. #PATHOLOGYOFTHEWEEK-

Dequervains 2. Scaphoid Shift Test 3. #EXERCISEOFTHEWEEK 4. #PODCASTTUESDAY- Summary of

K-tape podcast 5. #HEALING- ligaments

Goal setting is again another fundamental aspect of our collaborative treatment sessions,

however we urge you to have the patient set their own goals, both short and long term, making them both personal and important to the patient. You can use the Socratic Questioning to challenge unrealistic goals and we recommend focusing on functional rather than pain focused attainment. Happy ‘’CBT’’ ing

#INTHENEWS In keeping with the above theme here is a nice link to some more types of Socratic questions www.umich.edu/~elements/probsolv/strategy/cthinking.htm

Can I also direct you to the Clinical Forum great question posed this week by Ady regarding pain in the shoulder at night and what to do about it. Let’s get on, discuss and try and help each other out. http://www.ahpsuffolk.co.uk/Intranet/StaffForum/tabid/178/aft/47/Default.aspx

#EXERCISEOFTHEWEEK – ‘T’ and ‘W’ raise

T-raise- thumbs pointing up to get external rotation. Can do on bed, floor, gym ball and progress with weights. Engages posterior cuff Opens clavicles up Significant posterior tilt, upward rotation and retraction of scapula W-raise- same exercise but with elbows bent. Good for the patient with impingement symptoms. Engages posterior cuff Opens clavicles up Significant posterior tilt, upward rotation and retraction of scapula

Interesting read for you here: Trapezius muscle timing during selected shoulder rehabilitation exercises (De Mey 2009 JOSPT) http://www.ncbi.nlm.nih.gov/pubmed/19801813

#FROMTHEEDITORS #HAPPYCHRISTMAS

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