nd AHPS CLINICAL WEEKLY 32 Edition 20.3.15 #PODCASTTUESDAY We are going to take a week long break from the Does work matter podcast!. A really great podcast from Jack and Heather. I’m sure we have all at some point been guilty of just asking what our patients do for work and moving on but actually this is a big part of daily life (where we spend most of our time!) and deserves much bigger assessment both subjectively and objectively. What do they actually do!? Some really great advice and tips to improve you subjective and objective assessments! We will come back to it next week (see below) but how could we not turn our focus to our very own podcast this week!! #PODCASTTUESDAY this week is #AHPSPODCASTS very own. Once again huge thanks to Anju Jaggi and Professor Ginn and please excuse my dulcet Essex tones! Podcast will be available to download on TUESDAY 24th MARCH 2015.
W/C 23.3.15 AM Problem Solving Shoulders Subj, Obj, Rx With Anju Jaggi and Professor Ginn https://itunes.apple.com/gb/podcast/ahpspodcasts/id961782938 W/C 30.3.15 AM Problem Solving Does Work Matter? With Heather Watson TPMP Part 2 http://chewshealth.co.uk/the-physio-matters-podcast/ W/C 6.4.15 AM Problem Solving Does Work Matter? With Heather Watson TPMP Part 2 http://chewshealth.co.uk/the-physio-matters-podcast/
Does Work Matter? With Heather Watson TPMP Part 1 (23 minutes in)
Those off sick should be prioritised (like we do : )) First interactions can be turning point as to whether people go off work or stay at work o Ensure we are giving good advice o How can it be adapted etc? Getting people back to work quicker has better implications for long term health What you say and do will have big impact on patients confidence o Remember how you are saying things!! Language is vital, people listen to their healthcare professional (e.g. stable unstable) Work is an important part of their recovery o I always try to describe it as part of their rehab! May be helpful to relate to sport etc. Relationship between pain and work is complex o Ask enough questions to find out if pt is at risk of spending more and more time of work o Work related psychosocial factors may give some indication . We’re getting good at recognising psychosocial factors can we be more specific to work?? Identifying: o More than just asking what they do for a living o Be interested o Find out exactly what that involves…never assume o How many hours they work o Make person aware that it is something that matters Return to work not frequently related to pain o Get to root of why they can’t go to work because of pain o Tends to be beliefs related to pain i.e. if I do work then I am more likely to damage further etc. o Reassure and find solution! o Hurt vs harm Impact of being out of work = negative effects on general health and life Think to yourself: How would you feel if you had a month of work, not knowing when could return with no advice etc? How would affect you and your family? What consequences may it have? Support, encourage and keep people working Talk about work in same way as exercise- increasing movement, load on bodies, adaptation to activity o Likely you will get increase in symptoms as you are doing more. Have to adapt. o Not likely to be pain free before going back to work- educate, make realistic- going back to work with pain is ok Employers may need reassurance as well re. letting pts back to work Can there be alternative duties. Talk to employer, what are the options.
nd AHPS CLINICAL WEEKLY 32 Edition 20.3.15 #SPECIALTESTFRIDAY No special test this week due to annual leave and meetings. Friday 20th March THIRD test for hip labral pathology Friday 27th March EMPTY CAN test for shoulder something… as per podcast request of Anju and Prof.
A few other sites have been contacting to find out what special test is each week to run their own so I will endeavour to ensure a week ahead is put in the newsletter so everyone can run concurrently. Keep up the good work!
#PATHOLOGYOFTHEWEEK- Suprascapular Nerve Palsy No special test so no #Pathologyoftheweek to discuss, however my interesting patient of the week was a suprascapular nerve palsy so we’ll take a look at that.
Suprascapular nerve Comes from the superior trunk of the brachial plexus nerve roots C5 and 6. It passes inferiorly under the trapezius muscle towards top edge of scapula. Passes through scapular notch laterally and obliquely to supraspinatus (which it innervates) At supraspinatus nerve splits, one staying with supraspinatus and the other passing round the lateral edge of the base of scapula (spinoglenoid notch) to innervate infraspinatus.
Suprascapular nerve palsy Palsy means paralysis Causes: o Entrapment of the nerve in the suprascaular notch (throwers, tennis players) or spinoglenoid notch (volleyball players, weight lifters) (either could be caused by cyst, bony change etc) o Major (fracture, rc tear) or repetitive trauma (usually overhead activities or throwing action) (nerve can get stretched and kinked) o Neuralgic amyotrophy (uncommon, related to virus) Symptoms: o Reduced abduction (if supraspinatus is affected), reduced external rotation (if infraspinatus is affected). Can be both…if so site of entrapment will be suprascapular notch o Muscle wasting o Pain can be variable- normally deep and poorly localised, general ache, impingement type pain, in case of neuralgic amyotrophy pain can be severe in early stages . Often felt posteriorly and laterally in shoulder or referred to arm, neck, upper anterior chest wall o Tenderness over suprascaular notch may be present EMG can be useful in diagnosing but mainly based on clinical findings
nd AHPS CLINICAL WEEKLY 32 Edition 20.3.15 Treatment: o Cuff exercises, scapula control o Avoid aggravating factors o Usually non-operative but If no improvement surgical option may need consideration- decompression
#NEWSOFTHEWEEK Couple of nice papers concerning the hip of course! First one relates to our #Exerciseoftheweek from 2 weeks ago. Placement of bands around forefoot increases gluteal activity vs TFL in the ‘Monster’ walk exercise http://www.ncbi.nlm.nih.gov/pubmed/22464817 and second one is really nice paper going through soft tissue injuries at the hip and pelvis and the rehabiliatation of these. Some good #Exerciseoftheweek ideas in there. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4223288/pdf/ijspt-11-785.pdf Last thing that caught my eye this week was a nice little read why it is important to do a form of resistance training as we get older…particularly if you want to keep doing the same things as when you were younger! http://www.wsj.com/articles/the-benefits-of-pumping-iron-in-later-life-1426475062
#COURSEOFTHEWEEK - Hip and Groin with Professor Graham Smith Review Part 1. 1. Know your anatomy and be specific 2. To assess true hip joint range of movement you must assess where the pelvic girdle comes in 3. The hip is like the shoulder and you can apply a symptom modification process ‘HSMP’ 4. Consider the hip ligaments as a source of pain 5. Really consider what you are actually doing when prescribing stretches….psoas…piriformis….stretch at all?
Point 4, consider the ligaments. I’m going to chuck it out there….I have never tested the hip ligaments before. Certainly didn’t get taught how to at uni. Is it something I will do everytime now…probably not, but certainly in those hips I am not sure about (I can think of a few) I will be considering the ligaments as a source of pain!
There are 3 particular thickenings of the fibrous capsule which form strong accessory hip ligaments.
Pubofemoral Ligament Origin: Iliopectineal line of the pubis. Blends and thickens the joint capsule. Insertion: Anterior inter trochanteric line of femur Action: Taut in full flexion of the hip joint Examination: Knee to shoulder (ensure true hip flexion before point of transition). Ligament winds up on itself. Get patient to place finger on point of pain and keep it there when lowering, if the point of pain is
nd AHPS CLINICAL WEEKLY 32 Edition 20.3.15 on the pubic rami then likely a ligament problem. Other points: Should be 110 degrees of true hip flexion before point of transition. Pliability of this ligament is lost in dominant leg.
Iliofemoral Ligament Origin: Anterior inferior iliac spine )AIIS) Insertion: Intertrochanteric line of the femur Action: Prevents extension and abduction of the hip beyond the point where the trunk and lower limb is in line. Helps maintain erect posture- people hang on this ligament. Examination: Patient in prone, ensure hip in neutral position, no lsp lordosis. Look at symmetry, where is position of femur. First take into abduction until pelvis tilts then into extension. Positive test if pain along the ligament. Important to abduct first as if extend first then head of femur will lock into acetabulum. Other Points: Shaped like an inverted ‘V’ with a triangular appearance, the apex being the rim of the acetabulum and ASIS and the ends attach to the 2 ends of the trochanteric line. One of the thickest and strongest ligaments in the body- tensile strength of 300kg. Neurovascular bundle passes through lower 1/3. Can test joint capsule in extension and rectus femoris.
Ischiofemoral Ligament Origin: Ischium. Majority of fibres pass upwards to blend with capsule as it spirals around the neck of femur. Insertion: Posterior intertrochanteric line Action: Limits flexion, adduction and medial rotation Examination: Pt in supine. Flexion, adduction and medial rotation. Ensure pelvis doesn’t tilt. Adduction to midline. Other Points: Piriformis not involved as at 90 degrees is a medial rotator.
Main functions of ligaments: Limits unwanted movement Proprioception / joint awareness Attach bone to bone
Ligament injuries graded 1-3. Grade 3 straight to ortho.
Question: Can you ever diagnose a grade 2 ligament sprain? Do you ever get to an end feel?
Treatment / Rehabilitation Longitundinal oscillatory soft tissue mobilisations o Oscillatory mobilisations away from the point of pain in anatomical position i.e. if pubofemoral ligament the issue, oscilate into hip flexion (similar to passive physiologicals)
nd AHPS CLINICAL WEEKLY 32 Edition 20.3.15 o Get neuromuscular relaxation and ??physiological and soft tissue change- improved healing, laying down of tissue. Start joint awareness exercises straight away i.e. eyes closed and matching movement of opposite limb.
#EXERCISEOFTHEWEEK – Hip Thrust A good glut exercise for your younger hip / back / knee patients or you more advanced hip, back and knee patients. Favourited by a strength and conditioning coach Bret Contreras @bretcontreras who posts a lot of good stuff up on twitter and his website. He discusses hip thrusts on this great podcast ‘Glute training, the hip thrust and evidence based learning’ on the strength physio podcast http://www.strengthphysio.com/tspp-004-glute-training-hip-thrust-evidence-based-learning-bret- contreras/
4 effects: Improve strength of glutes. Good for back, hip and knee rehab. Increase acceleration and sprint speed Improve squat and deadlift Improve functioning of entire body
Common errors: Excessive arching of low back Neck flexion Insufficient hip extension Rising up on toes
#FROMTHEEDITORS More hip and groin…we should be buzzing for that next hip and groin patient! COMINGSOON 1. #PATHOLOGYOFTHEWEEK Release of #AHPSPodcast next week….remember to listen, 2. #SPECIALTESTFRIDAY favourite and rate on itunes! Thanks! 3. #EXERCISEOFTHEWEEK 4. #NEWSOFTHEWEEK Enjoy 5. #ARTICLEOFTHEWEEK 6. Summary of Anju and Prof pod 7. More of Hip and Groin course #AHPSCLINICALWEEKLY