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Critical questions when considering MRI

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 MRI are used as a diagnostic tool in the healthcare industry. There is some controversy in the validity of findings. Here’s an overview to help you give patients appropriate information so that they can make an informed decision about their own care.

MRI Studies

Back

Jenson et al (1994) High prevalence of abnormalities in the lumbar spine on MRI examination of people without back pain.Only 36% had NORMAL disks at all levels.MRIs on individuals who had never experienced low back pain revealed that one third had a substantial spinal abnormality.

52% of asymptomatic participants had at least one buldging disk or other MRI abnormality.

“Conclusion, on MRI examination of the lumbar spine, many people without back pain have disk bulges or protrusions but not extrusions.Because bulges and protrusions on MRI scans in people with low back pain or even radiculopathy may be coincidental, a patient’s clinical situation must be carefully evaluated in conjunction with the results of MRI studies.”

 

Hip

AOSSM (2010) Pain free hockey players studied.54% had labral tears on MRI70% found to have abnormal pelvis or hips on MRI.
 

 

 

Knee

Beattie et al (2005) Meniscal degeneration and tears are highly prevalence in asymptomatic individuals using peripheral MRI.Forty four volunteers examined, age 20-68, with no history of knee pain. 60% showed abnormalities in at least three of the four regions of the knee.
 

Shoulder

Tempelhof et al (1999) Studies asymptomatic patients (ie no symptoms/no pain) 23% of all patients showed a rotator cuff tear.

In group 1 (aged 50 to 59 years), 13% (22 of 167) of the patients had tears;in group 2 (aged 60 to 69 years), 20% (22 of 108) of the patients had tears;

in group 3 (aged 70 to 79 years), 31% (27 of 87) of the patients had tears;

and in group 4 (age >80 years), 51% (25 of 49) of the patients had tears.

Shoulder II

Connor et al (2003) Eight of 20 (40%) dominant shoulders had findings (on MRI) consistent with partial- or full-thickness tears of the rotator cuff as compared with none (0%) of the nondominant shoulders.

None of the athletes interviewed 5 years later had any subjective symptoms or had required any evaluation or treatment for shoulder-related problems during the study period.

Critical questions for cliniciansPrevalence of MRI findings in asymptomatic patients

  • Can you attribute back pain to MRI findings if 52% of asymptomatic (ie no symptoms) patients have abnormal findings or is this purely coincidental?
  • Can you attribute pain to a rotator cuff tear (based on MRI) if top athletes are performing at elite level with full or partial thickness tears with no pain and high level function?
  • How much can you rely on MRI imaging?

 

Critical Questions for patients?

  • Have you exhausted conservative therapy?     (ie relative rest, medication, physiotherapy)
  • Is an MRI going to change your management because if not do you want to risk negative effects of undergoing it? (non effective surgery, nocebo, changes within the brain).
  • Surgery is necessary in some cases but should only be under taken if conservative management has failed.
  • Have you truly exhausted physiotherapy?
  • Have you seen a specialist in your condition (ie chronic pain/sports/back/hip/etc)
  • Have you followed exact guidelines? Ie avoidance of agg factors/exercises as prescribed (not just when I’ve remembered!)
  • Given it an adequate time for tissue adaption and change?

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The habits of happiness

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 I’m sure you have already seen this bouncing around twitter but The Physiowizz team felt it was fitting to bring the New Year in!!  

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Getting a Grip on Pain

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Understanding pain is something that underpins our practice and is something Physiowizz would urge you to become familiar with to help educate patients and aid your own treatment approach and clinical reasoning skills.

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The Nocebo Effect

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Project Ghandi

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  An interesting blog we came across earlier in the week! Be sure to have a look!

 

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MIMDTP Conference 2013 Presentations

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McKenzie Institute Mechanical Diagnosis & Therapy Practitioners.

Below you will find some links to presentations held at the 2013 MIMDTP conference. All can be found from their original source on the Mckenzie institutes website (please click for links directly to their site.)

Chris Littlewood’s presentation – Pain, the brain and rotator cuff tendinopathy.

Chris Littlewood’s presentation – Patients with rotator cuff tendinopathy can self-manage, but with certain caveats.

James Selfe’s presentation – Targeted Interventions for Patellofemoral Pain (TIPPs).

Rachel Chester’s presentation – Shoulder Pain: Predicting response to Physiotherapy Treatment.

Stephen May’s presentation – A Survey of the McKenzie Classification System in the Extremities.

Want to learn more ? Check out blogs, websites and free e-learning resources here..

OR further physio websites here..

Want to know EVEN more? Here’s some from the 2012 conference

Osteoporosis: Bone Health and Update on Management
Reassurance: What is it and how does it work?
Thoracic Spine Red Flags
The Thoracic Spine : Differential Diagnosis, Investigations and Management
The Bit in the Middle : The Thoracic Spine
The Bit in the Middle : What can we do for the Thoracic Spine?

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5 things to remember when looking for work experience

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Whether it’s prior to university or you are looking for a bit of extra experience make sure you are ahead of the game to secure your placement.

1. Are you prepared? The great saying “Fail to prepare, prepare to fail.” It is so important to take time planning a task before you do it. What do you want to say? What do you need to remember? How can you change your tone/behaviours/wording which will improve your success rate? Do you remember the first time you hit a tennis ball ? I suspect you were like me un-co-ordinated, clumsy and slow? Communication is a skill. It must be learned and you may already have good communications skills but practising the conversation first will make sure you come across articulated and professional (two attributes which will take you far in any career). Try a role play with a friend/parent to ensure you have practised and ironed out a nervousness!

Write down what you would like to say and key points so that you do not forget anything. That in mind try to keep things brief (particularly if leaving a telephone message).

ie

  • Hi my name is…
  • I am 16 years etc…
  • I am doing my GCSE’s/ A-levels/undergrad …
  • I  am looking for an opportunity to improve my knowledge/ skills
  • I am extremely flexibly and can work around you … (Only if you are! Remember they (the physio) are doing you a favour so if you have to cycle a mile because your mum can’t drop you- if you want it you’ll have to do it and it will also help show commitment for something you are passionate about!)
  • If this would be possible please could you give me a call on …….

2. Please and thank you. It sounds obvious but be polite. These connections may get you a job in the future and manners cost nothing. At the end of the day people are likely to employ/give placements to people who are likeable – skills can be trained. These are all qualities which will help you in your role as a physiotherapists and are easy things to improve your chances!

3. Remember they are doing you a favour!!  Try changing perspectives and imagine you have a friend with you at school. Imagine how hard a day would be if you had to show them round, explain where everything was , explain what maths test you are doing, how to do algebra all whilst completing your own work at the same time.  Physio’s often love having students but it is hard work. Often they will have to spend time explaining things to you (which they dont mind) but normally they could be writing notes etc. So be grateful and try to be helpful and fit in around the clinician (physio).  Ask the physio if they mind you asking questions when the client (patient) is in the room because some may prefer to explain after.

Thing not to do:

“Hi my name is Fred, I want to be a sports therapist and need some experience. Please call me back asap on this number.”

Things that I thought when receiving this call.

a) I have many students looking for experience perhaps my time would be better dedicated to those who want to do physiotherapy.

b)I have just worked a 10 hour day I’m not sure I want to get back to him ASAP.

c) 10 people have called since his call I don’t know his number.

4. Take a deep breath before you call. This will help reduce your nervousness. It does get easier the more times you have to do it!

5. Be sure you understand what physiotherapy is. everyone knows that physios run onto sports fields but taht is only one fraction of their contribution in healthcare. read up on their roles in mental health, women’s health, in hospital, on the wards and following surgery to make sure that physiotherapy is definitely for you! Why not check out some reflections to see how other physiotherapists have found working as a physio?

 Got a question? Be sure to post it on the forum or through twitter/facebook and we’ll try and answer it for you.

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3 Reasons why a physiotherapists may refer to a IBC

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Three reasons why a Physiotherapist may choose to refer to, or work alongside an Intrinsic Biomechanics Coach

Three reasons why a Physiotherapist may choose to refer to, or work alongside an intrinsic biomechanics coach.

Written by Andrew Rouse of ARBodyworks

 

One of the most common things I encounter when approaching physiotherapists about referral links or working together as an intrinsic biomechanics coach (IBC), is an uncertainty as to what an IBC does and how that differs to physiotherapy. Two other points raised are; why a physio would need the skills of an IBC when they study injury and biomechanics as part of their degree and “wont your set of skills reduce the amount of clients/patients I treat?”

Firstly I think it would be pertinent to describe the role of an IBC so that no misconceptions remain about what we do.

An IBC is able to understand the internal movement mechanics of the human body, which enables them to reduce the risk of orthopaedic overuse injuries (OOI’s): Indirectly, when the body adopts abnormal movement the biological tissue of the human body is loaded incorrectly, although there may be no pain or sign of this, the low intensity loads that accumulate over time create these orthopaedic overuse injuries i.e. bursitis, tendonitis etc.   These loads and changes in tissue function of the bodies sub systems (neural, muscular and skeletal) need to be recognised, measured and approached intrinsically: the criteria of an Intrinsic Biomechanics Coach. In a preventative sense an IBC is able to predict the risk ratio of an OOI occurring before it becomes acute, which is invaluable when looking at sporting performance. However the majority of people are unaware of any OOI until it becomes acute. In a rehabilitative sense an IBC’s role is to identify and categorise which system has become dysfunctional, to plan treatment, to correct this dysfunction using an isolated to integrated exercise protocol and lastly to predict whether any other OOI’s are likely to occur due to the current dysfunction. An IBC indirectly treats pain, by reducing the load and changing the tissue mechanic properties that may be causing the pain.

Reason 1: Because we are different with different skills!!!

The next point which is frustrating is the question “why would I need an IBC when I do injury rehabilitation and biomechanics as part of my degree level education?” the answer IMO is that having clinicians that approach diagnosis from different angles to give a more holistic service to clients can only be a good thing. To be able to give different opinions about the cause of the problem and how best to treat and prevent it, IMO is a very powerful tool. Yes you may have studied biomechanics as part of your degree, but do you consider the same aspects of biomechanics as me? Would you treat it the same way as me? Can you evolve an exercise program and execute the coaching/teaching as well as me as an IBC?

 

Reason 2: Yes you may have been taught similar skills but we use them in different ways and approach things differently to get to the same result.

Building from that point, why would a physiotherapist working in collaboration with an IBC treat less people any less effectively than alone? Working alongside or through a referral pathway will boost success in treatment and also increase/improve feedback and word of mouth advertising from happy clients.

 

Reason 3: Collaborations will always be a good thing for clients and an IBC is an asset to add to a clinic or to have as a referral link.

In conclusion, skepticism is to be expected when a new type of therapist starts to achieve results with clients. It is also understandable to be nervous about “stepping on toes” or “why would I need you we do the same thing”. However how can a new set of eyes and skills applied to a problem, ever be a bad thing? For too many years therapists and clinicians and researchers have all worn the “hats” of their specific disciplines – maybe it is time to work together to develop a superior management system for injury prevention optimal performance and management of injury?

If any of you want to feedback, comment or connect with me; find me at @ARBodyworks on twitter or ARBodyworks on Facebook…

Links to my blog can be found here…

I run the company ARBody works which can be found here…

If you have any further comments on this blog or have any experiences to share about  working within a team and the benefits/challenges why not share on our forum? Start a topic on the forum tweet it to @Physiowizz and we’ll retweet it to get everyones opinions.  #learnsharedevelop

Many thanks to Andy for taking the time to write this guest blog. If you’re interested in writing a guest blog please contact nicole@physiowizz.co.uk.

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5 pointers for a Physiotherapy University Interview

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One of the most frequently asked questions I get from pre uni students is regarding physiotherapy university interviews. Be sure to check out all the resources on the site but remember they won’t expect you to know in depth knowledge on each subject (thats what uni is for) but they want to make sure your know that this is what you want to do ! Here’s a few little pointers….

1. Professionalism

The chartered society of physiotherapy is our national governing body. Members hold 8 core values which can be found here (at the bottom of the page)Interview questions for physiotherapy univeristy interview.

  • It might be a good idea to have a read and see where you fit into those values.
  • Are you professional? Prove it. Turn up on time, in smart clothes and well prepared. Arrive way before your interview time to make sure you’re are not stressed or nervous and so that if disaster strikes or the traffic isn’t moving it doesn’t matter because you have left generous time).
  • Remember they want you to be the right candidate all you need to do is show them who you are and why you would be suitable. Finding examples of how you fit into these values will help show that you are committed to becoming a great physiotherapist.

photo credit: _skynet via photopin cc

A likely question may be what qualities do you have and why do you think they will make you a good physiotherapist? Things like:

  • Time keeping is important because you will have to be highly organized to ensure you see all your patients in a day.
  • Being compassionate is important and understanding a patients needs to enable you address these.
  • Being open to all cultures, backgrounds and listening to each patients story and adopting yourself to different settings a responding to change.
  • Having strong communication skills to enable you to help people understand new information and retain it.
  • If you are unsure if an example is suitable post it on our forum to share with others and get ideas.

 

As you are probably becoming familiar with already, you should try to evidence all claims. Ie If you try to show that you could fit into the values by demonstrating times when you have ‘upheld someone’s dignity’ or showed one of those qualities try to think of a time when you perhaps helped a friends, grandparent and explain it. Physiotherapists do a lot of reflection on practice to continue to evaluate our behaviour and develop as clinicians and continue to learn and improve. Learning these skills will benefit you throughout your career so try to reflect on situations you have been involve in, highlighting things you have done well and things that perhaps you could have handled slightly differently to allow adaptation and improve on your behaviour should the situation arise again.

2. Knowledge of the varied areas of physiotherapy. They don’t expect you to know about conditions and treatments in depth they just want to know that you have researched physiotherapy thoroughly so that you know that you are making the right choice in your career and that you truly want to do it. It is good to understand the three core areas of physiotherapy cardiorespiratory, neurology and musculoskeletal. The general public still have an ancient view that physiotherapists only do massage and run onto sports fields. This is only the tip of the ice berg in how much physiotherapists are involved with the public and I would l suggest that if you want to be a sports physio don’t over play this aspect so that those interviewing you get the idea that you are serious about all aspects of the profession.

Cardiorespiratory will involve helping people with conditions related to the heart and lungs. This may mean Cardiorespiratorylistening to their chest to establish whether you may help to assist them to clear sputum to establish good oxygen transfer. It may mean teaching breathing exercises to someone with asthma or cystic fibrosis.

Neurology looks at helping those with conditions which involve the nervous system ie the brain, the spinal cord and the peripheral nerves (nerves away from the spine). This may involve helping people who have acquired brain injuries, spinal cord injuries or multiple sclerosis.

Musculoskeletal refers to conditions that effect the ‘muscle’ and ‘skeletal systems which can include most things people normally associate physio’s with such as sports injuries, neck pain, back pain, etc.

Specialities: Paediatrics, Womens Health, Mental Health

photo credit: jesse.millan via photopin cc

3. Smile and relax! Most physios are a chilled, friendly bunch and this makes the job a lot easier. First impressions are everything and showing your positive attitude and ability to work hard will be key in your success as a physio therefore are always good things to show.

Choose an interesting point about yourself!

4. Try and find some unique about yourself that is interesting. Communication is an integral part of physiotherapy and a skill that can be learned with hard work. Try to speak coherently and take your time when answering questions. They will be interviewing a lot of people and first impressions are important to make sure you stand out in the crowd but for the right reasons.  A smile may be enough (people generally like happy, enthusiastic people!) Think about your appearance. A fantastic book which has helped me in my career is by Dan Siegel (Mindsight) which talks about the brain and how it works at such a complex levels its hard to comprehend. First impressions are subconscious as well as conscious and are based on feelings and past experiences  therefore its best to be polite and  to offer the best ‘cleanest’ first impression possible! When you qualify you are restricted on jewellery and piercings due to infection control (bacteria can transfer via metal) so these should be left out for job interviews (following your degree) in case they ask you to complete a practical element.

photo credit: Josiah Mackenzie via photopin cc

 

5. Plan and prepare some questions and practice with a friend/ parent. Then when you come to answer questions in the interview you can reply confidently.

  • Give an example of problems that you might come across in performing your job as a physio, and how you would overcome them.
  • Tell me about yourself
  • Tell me about your interests and hobbies
  • Why do you want to be a physiotherapist?

 

 Good luck!!! If you have any questions please post them on the forum (Click here) and I’ll do my best to answer them at the end of the day!

  

Useful resources

Interview Questions and answers (Band 5)

Cardiorespiratory

Neurology

Paediatrics, 

Womens Health,

Mental Health

Student Room

 

 

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5 Ways To Improve Health Promotion As Physiotherapists.

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Health promotion is a tricky area which sometimes we are hesitant to dive into. Make every patient contact count. We know that stroke, cardiac problems, depression, alcoholism and obesity cost the NHS millions every year. So why when we recognise potential risk factors as we not educating, motivating and minimising barriers for people? Isn’t that our job? 

If you could educate and minimise the risk of general health issues for 5 patients per year you could help not only them but reduce cost to the NHS.

55,000+ physios registered with the CSP x 5 patient = 275,000 patients per year!

Health promotion

Health promotion

  • 275,000 educated patients who tell their friends at coffee morning that they are starting aqua aerobics, pilates, the gym and would anyone else like to try?
  • Runners who tell their friends not to run through posterior heel pain and to get it checked by a physio because if  a tendinopathy is in ‘disrepair stage’ it will take longer to recover if the problem is ignored.
  • Make every contact count. We all need to work hard to promote our profession and health to remain muscle and movement specialists aiding people back to optimal function.

photo credit: Edson Hong via photopin cc

Here are some simple observations of ways to promote health.

  1. Educate. This is the easiest way to implement knowledge. Following a detailed assessment you should have highlighted your problem list and then treatments to address these. During manual therapy or acupuncture this is a great time to find out more about the patients perception of their problem and help promote health at the same time (always linking back to your patient and its relevance to them.
  • Did you know that long term smoking and alcohol can increase your sensitivity to pain? (Girdler et al, 2005)
  • Did you know that depression causes a physical change via a hormone called cortisol which effects how pain is perceived in the brain?
  • Did you know that regular exercises can help regulate serotonin and cortisol there is some evidence that shows it has a positive effect on depression? (Stanton and Reaburn, 2013)
  • (In cases of knee OA): Have you ever considered getting in a pool 3 times a week: it would not only be beneficial for your mobility but exercising for 20mins x 3 weekly can dramatically reduce the risk of (enter patient history ie stroke/diabetes/ family history of heart failure)… too.
  • Did you know that chronic pain (pain felt for more than 6 months) causes changes within the brain?
  • Did you know to can get supplemented gym memberships through your GP.

2. In service training: Provide an inservice training to thought shower how health is currently promoted. Are there easily assessable information sheets in every waiting room about NHS choices, how to complete your BMI online, government initiatives to help lose weight, dietry help online or from weight watchers/slimming world?  One exercise you could try would be to give each physio a small sheet with a list of all health initiatives and scan to see if any would be suitable for each patient selected on their background/assessment.

 

                 Health promotion/ Education Pt A B C D
Balance classes
Personal trainer? x
Government schemes
Weight loss advice x
Weight watchers/slimming world
BMI calculator (NHS choices) x
Onward referral counselor?
Onward referral nutrition ?
NHS Dietary advice x
Couch to 5k x

 

Here are some examples of things you could implement into practice.

3. Promotion through social media. Not sure what you should be tweeting about? NHS choices makes it easy! Just pick a new page every day. This presents a good image of your company and will improve people’s interaction with your site and NHS choices. Of course this doesn’t reach everyone but it’s a powerful tool in reaching people, particularly the generations coming through. I strongly feel that all NHS departments, GP practices and private practices should have a twitter/facebook account to improve public appearance and understanding of procedures, to highlight ill attendance and provide health/physio promotion.  This health promotion could be as simple as congratulating a local team on their win or highlighting a sponsored walk achievement inspiring others to get involved. If this is an area you feel uncomfortable with then speak to someone who does because it may take an hour a week but promotes physio and our value which is extremely important when defending against cuts.

 

4. Integration. There is so much research showing that for people to learn and retain information they must buy into the piece of information, understand what it means and choose to act on it.  The more people promoting will inevitably have a positive effect on retention of information. It is important not to forget the MDT! Why not refer to a personal trainer/strength and conditioning coach for weight loss/fitness advice?

5. Easily accessible information in waiting rooms. This is a no brainer if people have time and are bored they will read. Make sure leaflets are easily accessible.

 

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