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Placebo vs Nocebo

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The mystery of chronic pain

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Chris Littlewood: RC Survey PUK

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Chris Littlewood has kindly donated some presentations to Physiowizz. To find out more about Chris please click here or follow him on twitter @physiochrisChris Littlewood_1

Chris Littlewood is a research fellow at the University of Sheffield, UK. He is a chartered physiotherapist by background having previously worked clinically in the UK National Health Service and also in private practice before taking up a post as a senior lecturer in physiotherapy at Sheffield Hallam University, UK. Chris has published widely in the field of musculoskeletal physiotherapy and research methods in national and international journals.

Click the top of the sphere to begin the presentation….

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Claire Robertson : Clinical reasoning in PFPS

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claire robertson Claire Robertson qualified in 1994 with a BSc(hons) Physiotherapy. She has since obtained her MSc Physiotherapy, in 2003, and PGCE in 2006. Claire has worked in both the NHS and private practice, and currently splits her time between two posts; she lectured at St George’s University of London/Kingtson University where she was a senior lecturer on the physiotherapy and medical degrees until October 2012, and set up and now lectures on the MSc Exercise for Health. Secondly Claire runs a specialist patellofemoral clinic at Wimbledon Clinics spending an hour per patient. In addition to this she runs a ski service aimed at helping previously injured skiers return to skiing, and is the physiotherapist for the Warren Smith ski academy. Claire has lectured internationally and has several research papers and editorials published in internationally peer-reviewed journals. She is also a reviewer herself for Physiotherapy Research International. She also runs a post-graduate course on patello femoral problems for physiotherapists. In December 2012 Claire was awarded a research grant by the Physiotherapy Research Foundation to investigate the meaning of crepitus to patients with patella femoral pain syndrome.

Physiowizz who like to thank Claire for donating a new presentation to the site. To find out more about Claire please follow @clairepatella or click here…

Do you believe in sharing knowledge? Do you have a presentation you could share with students and other physios? Please support Physiowizz and send to and include the statement “I give permission for this article/presentation to be displayed on a physiotherapy learning site.” We couldn’t do it without your support!

Please click the top of the sphere to start the presentation!

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“Staff care: How to engage staff in the NHS and why it matters”

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We all know how those white papers are a little hard to take in. Luckily for you my inner geek takes over every Tuesday as I spend more time updating Physiowizz and trying to develop my own knowledge but also to share as much as possible with our followers.

This particular document is of particular interest to me

“Staff care: How to engage staff in the NHS and why it matters”

Frustrated Staff

I don’t work directly for the NHS. They didn’t want me. I applied as a new grad for hundreds of jobs with a CV that included work experience at sports clubs, NHS hospitals, 3 months in Africa and the work ethic of someone who wanted to create change.

Perhaps my personal statement wasn’t up to it, perhaps I didn’t have the right attitude but I still feel there was a lack of help and guidance to help me get that job hence why Physiowizz was created.  Perhaps it is the responsibility of the CSP who do have some fantastic resources see here or the universities. But why not combine our knowledge, share our resources to benefit the whole profession?

Before we get onto investing in improving HOW staff feel how about investing in staff? A few years after I graduated I was employed as locum within the NHS. They paid me £5 extra an hour to do the same job. The irony, when they could have hired me as bank and I would have worked for less money and been just as happy. There appears to be so much false economy within the NHS and replacing senior staff with lower bands will never ensure that services stay valuable.

WE NEED those experienced members to be valued to educate and teach those coming through. If you want to be the best surely you need to surround yourself with the best?

‘Investing in improving how staff feel is not just a “good thing”; it is nothing less than a necessary condition for a sustainable future as an NHS organisation.’


“Satisfaction is slowly improving, but only two in five feel their work is sufficiently valued.”

2/5 feel valued!  This is a poor statistic and how I felt when working on my student placements.

One particular reflection sticks in my mind. It was 5.15pm we finished at 5pm and I had been doing some extra reading. As a third year I had my own caseload and had been seeing patients independently.  My educator was still doing notes and I asked if I could pop up to remind one of my patients to do his exercises and check he’d received pain relief (the nurse had been too busy to get it following our treatment earlier).

My educator had replied “ Well you can if you want but it shows poor time management skills which may be reflected in your mark, you are making others look bad you know?”

I had pretended to leave and then gone straight up to check on Mr. X who had not received pain relief. Now for me, this comment made me very angry and frustrated. I was aware it was the end of the day however this was something I felt I needed to do otherwise I would be worrying at 11pm that night whether he had received his pain relief or not.  Surely this compassion and care beyond the line of work should have been praised and encouraged? If it had been me I would have wanted someone to do that for me. Thats why we became physio’s right for that vocation? That feel good factor? Its hardly to become a millionaire!

So how do we make people feel more valued? We know that one of the biggest motivators is recognition. This costs nothing! Within a practice/department ‘physio of the month’ or praise on achievements is something easily implemented.

But its not just a managers responsibility. Promoting recognition within the team is easy. As an individual complimenting a member of staff particularly when working in doubles is important ie “That was a really good assessment. It was difficult because of Mrs. Jones family and I felt you handled that very well.” When complimenting some one in a different profession it is perhaps more valuable as you have a different skill set ie “Thank you for encouraging Mrs. Jones with her exercises, she must be working hard because they are improving quickly and I feel your input has helped.”

How do you think staff would feel more valued? Have your say  on our forum….

Staff engagement

“Levels of stress and presenteeism (where people feel pressure to attend work even though they are unwell) are striking.”

My special interest is in pain and the brain and how stress affects our pain. Presenteeism (people coming to work even if feeling unwell) is also counter productive and inefficient. In larger corporations they invest in hot stone massage therapist coming in to give massages every two weeks because they recognize the importance of removal from stressful environments.  With an average of 40 physios in large hospitals is this not a service we could provide?!

Offering acupuncture/massage (an hour out of some ones day) as a service funded by the hospital could help reduce stress levels and would help build relationships and respect for physios within the hospital.  38% felt unwell because of work related stress.

Of course sourcing reasons for stress and changing these is also important.

“Try out small changes rather than one transformation”

Task: identify irritating things for staff during the day. Discuss solutions and trial them.

Only 55% would recommend their organization as a place to work!

Why do you think this is? Have you say on our forum.

A thought to leave you with…..

“The NHS could release as many as 3.4m additional available working days each year if it reduced current rates of sickness absence by a third – a potential saving of £555m (Boorman, 2009). The number of staff who intend to leave is significantly related to the proportion of staff costs spent on agency staff “

The report included other interesting points on engagement and simple ways to improve this within the NHS. Click here to learn more….


1. “Staff care: How to engage staff in the NHS and why it matters”

2.Independent Review Team led by Steven Boorman, 2009. The Boorman Review: Interim Report.

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Patient Resource Print out

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We all know how little patients remember after that first visit. There is a lot of new information and it may be useful to provide handouts to your patient. I seem to spend a lot of time scribbling down websites, videos and names on scrap pieces of paper. This handout can easily be printed or emailed to promote NHS choices, better understanding of how and why we feel pain and also gives an area to write a clear diagnosis (if possible). If you already have a template that you use and would like to share please email to

Also printable here: Patient Resources



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Motivational Interviewing: The spirit and principles

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Interesting video on motivational interviewing. Check out further videos through you tube.

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The 10 tips for success with physiotherapy

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A questions I often get asked as a physiotherapist is how can I speed up my recovery? Heres a few tips for getting the most out of physiotherapy….

  1. Approaching physiotherapy with an open mind.
  2. Improve your understanding on how and why we feel pain.
  3. Use resources given to you and read up around the area. We retain very little information that is given to us in our first assessment.
  4. Complete exercises as prescribed. Not just when you remember/feel like it. Set an alarm/diary. If you wanted to run a marathon you couldn’t get ‘fit’ to do it by sitting at home on the couch.
  5. Progress as your body allows and spend time with your physio understanding when you can push through pain and when you should take things more gently.
  6. Taking note of what aggravates / eases pain.  Movement, stress, time of day?
  7. FITT principle : frequency, intensity, time or type. Change ONE variable at a time to allow optimal progression without irritation.
  8. Allow time. Bodies are incredible. If you find this hard to believe watch the video below. The body can withstand incredible forces and repair structures that you would thing are irreparable. Give it time let it do its job.
  9. Hollistic. Take an objective view on your life and consider all factors ie stress, job, other illnesses, dependents, sleep.  These can cause hormonal/chemical changes in the body ,which can affect pain/healing so consider CBT, counselling or mindfulness to achieve long term goals.
  10. As a general rule you should see improvement in symptoms  within 3-4 sessions(if completed the exercises as prescribed).
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Patient stories: Lloyd Major

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Lloyd Major: GIII Acromioclavicular joint subluxation

Nicole Jones who is a physiotherapist based at The Newbury Clinic in Berkshire would like to share a patient story. Lloyd Major started physiotherapy in February this year and has kindly taken the time to write an article on his experiences and changes that have helped him move forward and get back to normal activities.

After injuring my shoulder nearly 3 years ago whilst manoeuvring heavy scaffolding poles above my head I suffered a shoulder trauma , giving me severe shoulder pains through out the day and most of the night over several weeks.  After visiting my GP  he  could see that my shoulder was damaged and that I was suffering from rotator cuff impingement and that it may heal on its own and prescribed me some anti inflammatory drugs to ease the pain and enable me to sleep at night.

I took the drugs for over 2 months until the pain subsided but quickly realised that I could no longer use my right arm in any over head position, any levering of my arm over shoulder hight caused great discomfort  which would continue well into the next day.

This situation was very difficult for me at work as I am a self employed builder , I also could no longer  throw anything such as a ball to my dog and  also had to stop swimming ,which I did on a regular basis.

After visiting my GP earlier this year for another matter I complained about the shoulder again and was offered an appointment with Nicole Jones a physio therapist through the NHS to which I agreed.

Meeting with Nicole at my local GPs surgery She carried out an examination of my shoulder and determined that I had a GIII acromioclavicular subluxation. She also recognised that I did not hold my shoulders in the correct position due to over development front shoulder/arm muscles due to the type of work that I did .

Nicole gave me 2 simple exercises to do over the following 3 weeks which simply entailed moving my shoulder blades together in my back and to lift my arm from my hip to a horizontal position whilst keeping it straight and tensing against an elastic ribbon held under my foot (0-90 degree GHJ abduction with theraband).

At the end of the 3 weeks  I was able to do more work with my arm without causing any great pain as long as I was careful . I had a further 2 appointments with Nicole over the next 4 weeks during which time she gave me stronger elastic ribbons the odd shoulder strap/tape (to provide proprioceptive feedback) and some ultrasound on the muscle (supraspinatus).

After these final treatments I was able to resume swimming and I am able to swim front crawl  for a good 30 minutes without causing any irritation in my shoulder. Its been over 3 months since this treatment and I have felt  hardly any discomfort at all in my shoulder although I am aware of not over stressing it , the simplicity of the treatment has been amazing and I am very grateful to Nicole for this.

Regards Lloyd Major

The Physiowizz team would like to thank Lloyd and other patients who have taken the time to share their experiences to help physiotherapists learn and inspire others.





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Guest Blog NMES: Case Study (Part 1)

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Guest Blog: Rich Griffin

Richard has been kind enough to share this case study with us. Be sure to check out his valuable tweets through twitter @Fitness_Griffin. Join in the discussion. What are your thoughts? Do you have any experience to share yourself? Click here for the forum..


3 year old boy born with unilateral talipes, from birth patient was treated with ponseti method. However surgeon was considering a tibialis anterior transfer at time of assessment due to over activity of tibialis anterior plus lack of peroneal activity/action. Surgeon also mentioned peroneal nerve innovation may be lost thus peroneals can not perform their action. A tibialis transfer is a common procedure for patients with talipes and those demonstrating excessive supination in the gait cycle.

The parents of the child/patient wanted to avoid any more surgery to the right limb, a tendo-achilles subcutaneously had been preformed to increase dorsiflexion and foot position in line with Ponseti protocol.

What is Talipes: Clubfoot? How many does it effect? 

Congenital talipes equinovarus (CTEV) often know as “clubfoot” is a common but little studied developmental disorder of the lower limb.  It is defined as fixation of the foot in abduction, in supination and in varus ie. Inclined inwards, axially rotated outwards and pointing downwards.1

About 1 in 1,000 babies born in the UK has talipes equinovarus.2

What Is The Ponseti Method Of Treatment?

Based on early concepts, Ponseti3 developed his treatment guidelines:

All the components of the clubfoot deformity have to be corrected simultaneously with the exception of the equinus which should be corrected last.

The cavus results from a pronation of the forefoot in relation to the hindfoot, and is corrected as the foot is abducted by supinating the forefoot and thereby placing it in proper alignment with the midfoot.

While the whole foot is held in supination and in flexion, it can be gently and gradually abducted under the talus, and secured against rotation in the ankle mortise by applying counter-pressure with the thumb against the lateral aspect of the head of the talus.

The heel varus and foot supination will correct when the entire foot is fully abducted in maximum external rotation under the talus. The foot should never be everted.

After the above is accomplished, the equinus can be corrected by dorsiflexing the foot. The tendo-Achilles may need to be subcutaneously sectioned to facilitate this correction.

When proper treatment of clubfoot with manipulation and plaster casts has been started shortly after birth, a good clinical correction can be obtained in the vast majority of cases. A plaster cast is applied after each weekly session to retain the degree of correction and soften the ligaments. After two months of manipulation and casting the foot often appears slightly overcorrected. As mentioned, the percutaneous tenotomy of the Achilles tendon is an office procedure and is done in 85% of Ponseti’s patients to correct the equinus deformity. Open lengthening of the tendo Achilles is indicated for children over one year of age. This is done under general anesthesia. Excessive lengthening of the tendon must be avoided since it may permanently weaken the gastrocsoleus. Transfer of the tibialis anterior tendon to the third cuneiform is done after the first or second relapse in children older than two-and-a-half years of age, when the tibialis anterior has a strong supinatory action. The relapsed clubfoot deformity must be well corrected with manipulations and two or three plaster casts left on for two weeks each before transfer of the tendon. With appropriate early manipulations and plaster casts, surgery of the ligaments and joints should only be rarely necessary.4

Treatment design is to provide patients with a functional, pain-free, normal- looking foot, with good mobility, without calluses, and requiring no special shoes, and to obtain this in a cost-effective way, further research will be needed to fully understand the pathogenesis of clubfoot and the effects of treatment, not only in terms of foot correction, but also of long-term results and quality of life. One thing that is definitely missing in the literature is a long term follow up study on surgically treated clubfeet. The authors of this paper are currently involved in a multi-center retrospective study to look at this group of patients.4

Figure 1 shows the use of serial plastering to manipulate the symptomatic limb.

Figure 1 


  Read more..


  1. Miedzybrodzka Z, Congenital talipes equinovarus (clubfoot): a disorder of the foot but not the hand. 2003
  3. Morcuende J, Lori A, At El, Radical Reduction in the rate of extensive corrective surgery for clubfoot using the ponseti method. Pediatrics Vol.113. 2004.
  4. Dobbs M, Nunley R, Schoenecker M, Long-term follow-up of patients with clubfeet treated with extensive soft-tissue release. 2006.
  5. Critchley J, Taylor R, Transfer of the tibialis anterior tendon for relapsed club-foot. 1952.
  6. Haasbeek JF, Wright IG, A comparision of the long term results of posterior and comprehensive release in the treatment of club foot. J Pediatr Orthop, 17: 29-35. 1997
  7. Templeton P, Flowers M, Et Al, Factors predicting the outcome of primary clubfoot surgery. 2005.
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