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Shoulder dislocations: A tricky area

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A few questions to ask yourself before trying to relocate a shoulder dislocation.

Following a recent course (The Advanced Shoulder Course) in Reading it made me challenge my views on pitch side relocation/reduction of shoulder dislocations. One thing I learnt from the course is that even when you have clinical experts in a room they disagree and have different approaches to often the same clinical case (like us physios). The following article is by no means to sway your own clinical judgement but to highlight some areas I had not considered before. I have also under gone the pitch side RFU ICIS course which advise to use your own judgement. Physiowizz continues to provide information from both sides of the coin and it is up to you to develop your clinical reasoning skills and apply this to your practice as you wish.

I asked top shoulder/bone surgeons from various locations around the world “What are your feelings on reducing shoulders pitch side” and of I course was greeted with an awkward polite smile.

“Well of course this is different for every individual but how do you know there is no fracture?”

The general consensus from a surgeons point of view was that a force with large enough impact to dislocate how can you clinically rule out fracture and more importantly if you try to reduce it without a pre XRay what if you complicate the fracture?

Are your qualified to do the procedure?

By this I mean do you have adequate skill to relocate a fracture? This, like any competency should be taught, practiced, ideally supervised by a senior and updated regularly which is not ideal in a pitch side role where these are relatively rare.

How far is the nearest hospital?

Most hospitals are within 30 minutes. When I questioned the surgeons about  axillary nerve palsy their feelings were that the majority of damage would come from the initial impact and that if you watched shoulder surgery the joint was dislocated for long periods of time and dislocated repeated to change view (of course anaesthetic affects muscle spasm/pain). They felt that an extra 30 minutes would be unlikely to cause the nerve palsy although I have not found any evidence to suggest either way. If anyone knows any specific evidence for this area could you please add to forum discussion.

Are they a secondary offender?

If the patients have dislocated before (and have not had a repair) they are more likely to dislocate again due to the soft tissue damage of previous dislocations. This could be intepretated that they may be more likely to dislocated with a lesser force however how you judge the force is difficult. Remember 30-50% of adult dislocations have associated fracture (check out ref below for population group).

What is the age of the patient?

Reid et al (2013) describe that there is a lower risk of associated fracture in paediatric patients and questioned whether pre reduction radiographs were required. If the patient is elderly and at risk of osteoporosis this again is going to increase your index of suspicion that there may be a fracture and treat conservatively. Rugby/ contact sport players tend to be young fit and healthy however it it very difficult to assess force of impact and A and E would certainly routinely take pre and post reduction radiographs.

Is the limb vascularly compromised?

If the limb is vascularly compromise (ie no distal pulses) it is potentially a limb threatening injury unless treated immediately.

Do you have sufficient pain relief should there be a problem with reduction?

Top clubs have entonox and team doctors however if you are treating club level and are on your own do you have the resources if things don’t go to plan?

What does the patient want?

This is a discussion to have with players prior to any injury/re offenders and explain pros/cons of both. They could have the option to give written consent once understanding the risks. This is something you would need to ask the CSP for advice on. Remember the player will thank you for reduction if  it all goes ok but if it doesn’t you will have to prove you were working within your scope of practice and make a good clinical decision.

Pro/Con for reducing shoulder dislocations

Have your say!

What is your opinion on this controversial subject? What is your experience and view on this? Do you already have a system, care pathway in place? Please take the time to share your experience and help others. Click here to go to our forum now and have your say.

  1. Wilson SR et al;(2009) Dislocation, Shoulder, eMedicine,
  2. Reid et al (2013) Anterior shoulder dislocations in pediatric patients: are routine prereduction radiographs necessary? Pediatr Emerg Care. 2013 Jan;29(1):39-42.

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Useful reference from ShoulderCommunity.com

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Wanna catch up on some shoulder literature?

This great resource is developing a community of practice for those specialising/interested in shoulders. Here are some references from their site (well worth a read). To find out more about their site click here ….

de Jesus, J.O., Parker, L., Frangos, A.J., Nazarian, L.N. (2009). Accuracy of MRI, MR Arthrography, and Ultrasound in the Diagnosis of Rotator Cuff Tears: A Meta-Analysis. American Journal of Roentgenology 192:1701-1707

Lo IKY, Nonweiler B, Woolfrey M, Litchfield R, Kirkley A (2004) An Evaluation of the Apprehension, Relocation, and Surprise Tests for Anterior Shoulder Instability. American Journal of Sports Medicine, 32(2): 301-7

Struyf F, Nijs J, Mottram S, Roussel NA, Cools AMJ, Meeusen R (2012) Clinical assessment of the scapula: a review of the literature. Br J Sports Med0:1-8. doi:10.1136/bjsports-2012-091059

Alqunaee M, Galvin R, Fahey T. (2012). Diagnostic accuracy of clinical tests for subacromial impingement syndrome: a systematic review and meta-analysis. Arch Phys Med Rehabil. 93(2):229-36

Uhl TL, Kibler B, Gecewich B, Tripp BL (2009). Evaluation of Clinical Assessment Methods for Scapular Dyskinesis. Arthroscopy: The Journal of Arthroscopic and Related Surgery. 25(11):1240-1248

Michener LA, Walsworth MK, Doukas WC, Murphy KP (2009) Reliability and diagnostic accuracy of 5 physical examination tests and combination of tests for subacromial impingement. Arch Phys Med Rehabil. 90(11):1898-903

Cadogan A, McNair P, Laslett M, Hing W (2013). Shoulder pain in primary care: diagnostic accuracy of clinical examination tests for non-traumatic acromioclavicular joint pain. BMC Musculoskeletal Disorders 14:156

Cook C, Beaty S, Kissenberth MJ, Siffri P, Pill SG, Hawkins RJ (2012) Diagnostic accuracy of five orthopedic clinical tests for diagnosis of superior labrum anterior posterior (SLAP) lesions. J Shoulder Elbow Surg 21:13-22

Munro W, Healy R. The validity and accuracy of clinical tests used to detect labral pathology of the shoulder-a systematic review. Man Ther2009;14:119-30

Seung Han Shin, Du Hyun Ro, O-Sung Lee, Joo Han Oh, Sae Hoon Kim 2012 Within-day reliability of shoulder range of motion measurement with a smartphone. Man Ther. 17 (4):298-304

Refs:

Hegedus EJ, Goode AP, Cook CE, Michener L, Myer CA, Myer DM, Wright AA. 2012 Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests.Br J Sports Med. 46(14):964-78. doi: 10.1136/bjsports-2012-091066.

Hermans J, Luime JL, Meuffels DE, et al 2013 Does This Patient With Shoulder Pain Have Rotator Cuff Disease?: The Rational Clinical Examination Systematic Review. JAMA310(8):837-847. doi:.05217510.1001/jama.2013.276187.

Lewis, J.S. (2009). Rotator cuff tendinopathy. Br J Sports Med 43:236-241. doi:10.1136/bjsm.2008

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Useful Resources from Arthritis Research UK

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Ultrasound scans can be great for learning anatomy, learning how to interpretate ultrasound scans and and learning technique for scanning.  Arthritis Research Uk have some great resources on their site. Here are a list of a few ….

And so much more!!

Have you discovered any good resources recently? Either tweet us @physiowizz or drop us an email at nicole@physiowizz.co.uk. Thanks!

 

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5 things learnt from post graduate study in the vet field

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We can learn a lot from horses as athletes!  Heres a few things I learnt from my Vet Physio training...

My passion for horses was my original drive to become a physiotherapist, realising that without the 3years undergraduate I could not take the 2 year PGDip to become a Veterinary Physio. Once I started treating human patients I got a bit distracted (because I loved it so much) and I’m yet to fully pursue my vet physio qualifications.  I really noticed some differences in approach to learning/training between courses and these are a few thoughts on how I think they differed and how we could further improve. Of course everyone learns differently so these may not be useful for all students.

photo credit: myprofe via photopin cc

1. Preparation: Throughout my undergraduate degree there was a lack of resources to prepare me for placements/assessment/treatment/evidence and it wasn’t because I wasn’t looking (trust me I was keen). With the internet and new technology this is so easy! You can get access to clinic experts in whatever field you’re interested in. Reading lists/ course hand books/ prezi presentations/ easy access all at your finger tips from a computer/phone/IOS. Google drive is a fantastic resource where you can share information/documents. Most of us have created a presentation for in service training at some point. If every one of our visitors posted something on our site in the next week we could have over 20,000 documents. Don’t leave it for someone else to do, share your knowledge, your expertise, support others learning. Please share to today to develop our profession and aid learning for everyone.

Learn. Share. Develop.

To Join Google Drive: PhysioWizz and access/share information … Click here!

2. Expectation: In my undergraduate degree when I shadowed doctors and senior physiotherapists they appeared to take for granted their own wealth of experience and did not seem to understand that as a student I could not have the  in depth knowledge they now took for granted. I never felt that they withheld information but rather did not have time, or take time to share that knowledge. In my vet physio training I was surrounded by those oozing enthusiasm to share their own knowledge and insights into their paths and encouraging exploration of other ways not simply their own.

photo credit: Rennett Stowe via photopin cc

3. Sharing knowledge: During my vet physio training if you had a question the vet would answer it: there and then. On placements I found the grueling “well work it out/go read about it at home/you tell me the answer” stressful and when already absorbing huge amounts of information I found it slightly unnecessary. Quick answers I found reinforced the information in my mind immediately. Thats not to say working it out is not a good exercise but there are many ways to learn.

4. Relaxed and open: A educator-student relationship is a difficult one to get right and needs to adapt and evolve. The relaxed manner in which I was taught in some placements allowed me to gain confidence and ask questions without feeling like I was asking silly questions. Care was always taken by my educators in their responses to ensure I wasn’t embarrassed or spoken to in a condescending manner.

5. A push on practical skills. All placements included assessments on educators own animals/themselves to ensure techniques were perfected with supervision of those who knew how the treatments should feel/look (ie mobilisations) rather than practicing with another inexperienced student. This provided a safe environment to learn ( on asymptomatic patients).

Other posts you my find interesting..

5 things your granny might find difficult that you dont.

Reflect. Learn. Implement.

5 reasons to turn your mobile phone off in meetings

Physio: Five books you can’t do without

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Improving the learning experience for students

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Students1. Spending equal time with Band 5’s and seniors. Spending time with more junior staff is great for students because they may feel they can ask more ‘silly questions.’ However ‘dumping’ the student with other staff the entire time due to own time pressures and restraints does not expose that student to your own clinical expertise, knowledge and experience.

2. Initiative: Yes, students should use initiative but what many seniors forget is that some initiative, to a degree, is learned. For example if you have written reflection every 3 months for 10 years then when you get a free slot of time you will automatically think to fill it by doing that.

Lets show a non medical example.

On my first lesson at a riding school I was asked to put a horse out in the field (1st on the left). I had read many books, loved horses and cared about horses. I did so and half an hour later heard my name being called.” What are you doing? You have put it out with another horse and its got its head collar on?! Why didn’t you use your initiative and put it in the second field and take the head collar off?”

Why didnt I?

a) The field had two sections. I had previous knowledge of horses being put out together in a field, hundreds of pictures during my childhood of them roaming in fields together.

b) I had no previous experience of horses kicking and injuring each other. I had no experience/knowledge of horses injuring themselves with a head collar on.

c) It was a new environment and I didn’t have knowledge of their protocols.

So was I lacking initiative? I should have asked and specified exactly where to go/ what exactly to do, but again, would I have been met with a large sigh and impatience or marked down for lack of initiative?”

My point is, if you have years of experience and are used to doing your job, lit reviews, reading, reflective writing in free time and know this is acceptable behaviour then you are more likely do do this. For those who do not know they may well “hang around” awaiting instruction in fear of being marked down/doing something wrong. Never forget the layering of knowledge you have achieved over the years and the in depth multi faceted understanding that students are so desperately trying to cram in in the 3 years of their degrees to prepare them for the working world.

One good way to resolve these issues could be to have a resource that students can go to that shows different types of CPD and you can explain guidelines/what is expected from students. With such an overload of information something written can make preparation easier. Following a phone conversation with my educator I spent a panicked week trying to read up on ‘necofemia’ which I could find no where – What she was actually referring to was ‘neck of femur (fractures)’

photo credit: lulazzo [non vede, non sente, non parla] via photopin cc

3. Communication with your own boss: There needs to be good communication and understanding from all parties that students should get a decent amount of one to one learning time to practice skills. One of the biggest complaints is that hands on skills and assessment are weak with students. So take time to go through one aspect of this so that the student can practice, learn and develop. Yes students are with you to gain exposure but part of the learning experience is preparation. I was asked to assess a day 1 post op knee replacement (6 months into my first year) when all we had learnt was anatomy, sociology and some physiology. Looking back yes, static quads, straight leg raise, knee bends seem pretty straight forward now but I was too busy trying to memories my normal values of blood pressure, oxygen and heart rate. Storing information is hard – learning and layering/integration of knowledge needs to be better utilised.

4. Approachability: Explain to students day one that you are happy to answer questions. If you would rather they ask questions after the treatment then provide these guidelines at the beginning. It is sometimes a good tip that they write the question down on a pad so they don’t forget them. If you want the student to find the question out this is ok but sometimes it is helpful to have the answer immediately to help with brain mapping and memory (3 day, 3 week, 3 month rule). Cast your mind back to when you were on placement – one on my educators had me doing 3 hours of reading a night (my worst placement and I learnt the least).

5. Explain. Demonstrate. Practice.  Development of a skill is not easy and although something might seem obvious to you even assisting an elderly patient out of bed there is a lot to consider (obs/conditions/ability/likelihood to faint/risk assessment/etc).

 

 

 

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Cervical spine ‘Risk Assessment & rehab’ via @TaylorAlanJ

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Promote Physio today!

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Physio Promotion

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Want to read some free articles?

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 So tonight I’ve embraced my inner geek and dug out some articles so you don’t have to! Theres a lot of FREE access out there so explore get involved and don’t forget to check out our reading list.

photo credit: estherase via photopin cc

Other things that might interest you …

Student room

Interview questions

Assessments

Anatomy 

Dissections

 

 

 

 

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Reflect. Learn. Implement

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Throughout our physiotherapy degrees we are taught the importance of life long learning and continued professional development (CPD). Through sharing experience and knowledge we can learn through others and help improve our service and communicate with patients more effectively.

Patient opinions are vital to our practice. They allow us to gain information on how those at the centre of our service view us and in what ways we can adapt and change to accommodate people. There are physios doing fantastic things across the country but none of us are perfect and we should strive to become experts in our field and be able to deliver that knowledge in a way that patients can appreciate our skills. Often in business it is said for every negative comment said about your business it will take three positives to regain the balance.

photo credit: estherase via photopin cc

Some think we should not look at the NHS as a business. But why not? We have the same goals? In a privatised company if patient care wasn’t exceptional people would not return and the business would fail. With this in mind perhaps it is important for physios to read patient opinions (https://www.patientopinion.org.uk) to see whether we are doing the most we can and if small changes could help iron out these discrepancies. Of course there is lots of good feedback which should be commended and published in the public domain to strengthening our reputation as a profession and maintain standards throughout.

Firstly we will touch on comments expressed by patients through patientopinon.org.uk and discuss possible changes in practice that could help prevent these in the future. Secondly we will talk about positive feedback and how we can draw on what makes a patients experience good and how we can continue to implement these into practice.

 Positive Comments – Reflection

 

“The physiotherapist is a brilliant motivator, and encourages you to work very hard, he really checks that you are doing the exercises correctly”

  • To be motivation you need to be positive, enthusiastic and have good communications of goals to be achieved.
  • Checking exercises is extremely important to ensure that good technique and appropriate muscle activation is occurring.
 

“Following on with the physio, again she has been great. I am still attending as the recovery is a long slow process but she seems determined to find a way to solve the problem.” Stepping hill Hospital”

  • From these comments perhaps we can draw that the patient felt listened to and felt the physio provided solutions to problems.

“Also had physio appointment on same day. Very friendly again and took a lot of time to explain exercises to me.” Gartnavel royal Hospital

  • From these comments we can draw the importance of explaining the exercises.
  •  Again, first impressions are hugely important. How hard is it to smile and be friendly? This comes up in a lot of the comments. We all have down days but a simple change in our practice ( a smile on greeting) may make all the difference. I think most physios are already quite good at this!
 photo credit: Thomas Hawk via photopin cc 

Negative Comments Reflection

 

“ I also feel the 12 week delay for a physio appointment is much too long.”

Chase Farm Hospital

  • Waiting lists are always something that we are contending with. Adequate management and securing funding is very important. One objective comment on this would be the locum work. As a fairly junior physio I was employed by an agency to work in a community setting. They were paying me £18/hour and I’m sure the agency fee was probably the same on top.  This seemed ridiculous to me when actually they could have hired me on a bank contract for a few pounds less. I would have reduced waiting lists without them having to pay the agency.
  • This inefficiency is something that could be addressed to open more positions than pay excessively for locums last minute to ensure targets are met. Just a thought…

“Delay before seeing physio (inpatient)”

  • Perhaps we could minimise the impact for a patient by popping in to inform them that we may be slightly later.

“Having had recent knee replacement surgery, I was told that physiotherapy is the key for getting back to normality.

..the half hour sessions once every 2 weeks is simply not worth it. Not at any time has the physiotherapist been hands on or manipulated my joint.”

  • From these comments perhaps we need to explain our treatment choices to the patient. Where clinically indicated consider hands on treatment too – clinical massage, PNF: contract relax, soft tissue mobilisations and mobilisation with movement.
  • Something else from these comments is that the patient’s expectation was that ‘physio is the key’ but perhaps education on the fact that physio exercises are also key may have been beneficial,  ie “completing them at least 4 times a day (pt dependent) is key to your recovering”. This may have changed the patient’s perspective and laid the responsibility back into their hands rather than feeling it was ‘physio contact’ that was necessary. Healthcare professionals words help formulate a patients perspective and we need to be careful with ours to promote the right message, to motivate and to empower patients.
 

 (physio) I felt like they spoke to me as if I was something stuck to their shoe.

  • This may have just been a personality/ perception issue. No patient should feel that we are looking down on them.
  • Assume the position that the patient is the centre of the process and we should do our best to explain their condition and educate them on the processes through their care.

 

“I didn’t see anyone from physio on the Friday or Saturday. I found that I didn’t get enough pain relief (inpatient)”

 

  • Perhaps here we could help time pain relief by coordinating with the nursing staff?
  • If we are not going to see patient perhaps a quick check in to explain when we will be coming would keep the patient better informed of their care and manage expectation.

Positive comments

There are a lot of people doing great work across the UK. A few shout outs for those who deserve credit…

“Excellent physio in the Coronation Hospital”

 

“Clean, the staff friendly and efficient and the medical care outstanding. The OT and Physio staff were also excellent. ” Royal Alexandra Hospital, Paisley

“Excellent initial physio assessment at Princess Royal Telford with Liz. Appointment with Mr Fallows physio consultant was excellent, extremely professional in every way.” Princess Royal Hospital

” Physio after each operation was excellent.and I am now able to do many activities I was struggling with.” Milton Keynes Hospital

“Care of nurses and Physio after surgery was excellent “ Rowley Hall

“Physio’s were marvellous” Upton Hospital

“Up until now I have received excellent care and this is still ongoing in the physio department” Mile End Hospital

“Physio team at Helston and I really cant fault them,friendly,attentive and very knowledgable staff, I would recommend them to anyone.”

 

 Visit Patient Opinions to help reflect and improve ….

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Cranial nerves via @TaylorAlanJ

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