hull

PART ONE - Managing load to avoid injury: Is it right to wrap yourself up in cotton wool?

Welcome to the latest instalment of our CONSORTIUM CHARTERED PHYSIOTHERAPISTS educational blog. This article is guest written by one of our colleagues Chris John. He is a very talented physio who we feel has a very promising future ahead of him.    

Hello! Let me introduce myself...

I'm Chris John, a senior MSK physiotherapist working within the NHS and also in the sporting setting with Hull City AFC Academy. In the past I have worked with Hull Kingston Rovers, Yorkshire Carnegie Academy, Northampton Saints Community and Dewsbury Rams so it’s fair to say I have an interest in keeping elite sportspeople injury free! My passion lies in exercise led therapy, this has motivated me to write this.... my first ever blog! This blog will highlight the importance of using an evidence based approach to understanding load management as an injured patient or simply as someone that exercises/trains. It should provide you with a basic understanding of how to monitor your loads as well as the actual importance of monitoring loads in order to make you fitter and stronger! Reading this will also guide you through the process of recovering from injuries and more importantly reduce your risk of getting injured in the first place!

So...... what does load actually mean?

LOAD is an umbrella term that in this case refers to the stresses (training or competition) that you subject yourself to during exercise... this can include all types of exercise and their intensities and volumes...

As a general rule of thumb... if you take on more load than you are capable of handling then you are more likely to get injured. However... if you do the opposite and take on less load than you are capable of you will end up doing the same, as this will only result in deconditioning, leaving you in a position where again you are more likely to get injured!

So... ideally you need to find the happy medium. You need enough load to get you fitter and stronger but… not too much as to risk injury. Conversely… do too little and you run the risk of getting injured when you do compete! This fine balance is not necessarily guess work as many people often resort to! Instead…I suggest you use a science based approach and learn about the multiple factors that influence load and try to sensibly control as many of them as you can. These factors are often completely individual to you. The main advantage to controlling them is to

 - Reduce the likelihood of you ending up injured!  

-  Get fitter, stronger, faster and more efficient whilst avoiding injury set backs

-  Prevent injuries re occurring

So… does load actually relate to injury then?

YES….of course! As a physiotherapist that is relatively new in my senior position, I have quickly realised that we cannot eradicate all possibilities of anyone getting injured. However..... decreasing your risk of injury is absolutely achievable!

So with this in mind... I want to educate you on the factors that are out there that both increase or decrease your risk of injury?

FACTORS THAT INFLUENCE YOUR LOAD & INJURY RISK

Risk factors obviously make you more susceptible to injury. These can be intrinsic or extrinsic (source).

 INTRINSIC FACTORS

An intrinsic risk factor can be biological or physiological (Brukner 2012) source. This means it is often personal to you, some internal factors you can control e.g. how much training you choose to do, how hard you go and how long you go for. Other factors can include the type of training you choose to do and in what environmental conditions you choose to train in. Some internal factors are still personal to you while you cannot control them e.g. your age, weight, medical history and previous history of injuries. None of these factors are dictated to you.

EXTRINSIC FACTORS

An extrinsic risk factor is defined as something you CANNOT BE IN CONTROL OF. Extrinsic factors may for that reason increase your chance of injury Brukner 2012 (source).

For example.... if you perform at a high level then how you train or how hard you go may be dictated to you by a coach. You also have very minimal control over the loads that you subject yourself to during competition. During competition you will also have no choice over the environment you often compete in e.g. the type of surface you are, the weather conditions or even the instructions given to you dictating how you should compete by a coach/manager.

So in order to try to stay injury free you ideally need to be as sensible as possible when it comes to the things WITHIN your control. This can often include modifying your training appropriately in order to make sure it sensibly suits you. Alongside this you need to ensure that you only subject yourself to external factors (i.e. competition) if you are fit enough or adequately prepared for them in the first place.

Is there a link between internal and external factors?

Yes…. there is a very important link! This needs careful consideration. For example.....if you are a novice runner that ends up heading out on a training run with another runner that is more conditioned than you then the external loads you are subject too will be exactly the same for both of you e.g. you both run 10k at the same pace and in the same conditions. However the internal loads accumulated will be far higher for the previously injured, older and more novice runner. This leaves him in a position where he is far more likely to get injured.

All the factors mentioned previously will also have an important influence on how you will potentially recover from injury and whether you will successful return to competing.

What are the effects of loading?

The optimal amount of load is described as an 'envelope of function' by Scott Dye (Dye, 2005) source. This optimal amount of load is the capacity in which a person can safely load and maintain BENEFICIAL tissue homeostasis. If you underload or overload you create DETRIMENTAL homeostatic changes and are therefore more likely to cause an injury. This is demonstrated clearly in the diagram below....(John 2017)

How do I know if I have loaded too much?

Am I running the risk of getting injured?

Often if you have over loaded yourself you will become injured and experience symptoms, this may not be immediate as often we see a delayed ‘post traumatic cytokine flare’ production that can occur 6 to 24 hours after your loading. Therefore you may not know if you have done too much and become injured until after the event. This is an important factor to monitor when you are returning from injury and will guide your progress during this time.

What are the signs that I am doing too much?

Obviously the most common way in which people realise they are doing too much is when they find themselves injured. Sometimes we do end up pushing ourselves more than we sensibly should and there can be early warning signs… if this is the case you may start to notice changes in mood, higher stress levels, lower energy levels, poor sleeping and worse stiffness than you would usually expect following exercise.

What if I am doing too little training?

Research now suggests that training hard will actually leave you less likely to become injured during competition (Gabbett, 2016) source. If you find training too easy and find that it doesn't challenge your body enough you may find that you are not adequately prepared for exercise and therefore you are more likely to get injured when you do actually compete.

OK so… obviously I should monitor my loading to try and stay fit?

Absolutely, monitoring load as a tactic to help avoid over use and injury is becoming increasingly popular.

How can you monitor load?

You probably all already use simple methods to monitor loads…for example

You may calculate how many miles you run per week and progress it by a certain percentage each week, usually this is quoted as a maximum of 10% per week to avoid injury. However, this has limitations, mainly as it only takes into account the previous one weeks’ worth of running.

Another option is proposed by Gabbett (2016) source.

Not so long back I had the pleasure of attending a course ran by Dr Tim Gabbett. Tim holds a PhD and has had more than 20 years of experience working as a sports scientist with a number of high performance athletes and various elite teams around the world. He has written a lot of research looking at load progression and has proposed the acute to chronic workload ratio (acute:chronic) (Gabbett, 2016) source.

This is basically the ratio you need to work out in order to achieve the optimal 'happy medium' we discussed.

ACUTE : CHRONIC as a more advanced method

To work out your acute to chronic workload ratio you need to find a way to quantify the loads you undertake.

To demonstrate this using a simple example we could use a runner’s average weekly mileage

This provides you with a more accurate figure over a 4 week period rather than just one or two weeks.

WHAT RATIO DO YOU WANT?

0.8 - 1.3  is ideal

*** More than 1.5 danger zone ***
(Please consider that 1.5 is only a general guide as some people can respond differently to load) source

So, how is monitoring your load going to help you !?!?!

Gabbetts evidence suggests that….

Your acute load should not be 10% higher than your chronic load or you are at increased risk of injury. He suggests the zone in which you should function or train in as the ‘safe zone’ – using the acute:chronic workload ratio this equates to (1.0)

Most injuries were sustained a week after the actual spike in loads (source). Therefore… if you have a spiked week then this should be a warning sign to remind you to re manage your load and make sure you get the next weeks training load right! Rule: Don’t spike on a spike or you are more likely to get injured! This suggests using a model that takes into account training over a 4 week period as suggested above is a far more sensible method than just simply progressing mileage based upon the previous week.

If you are to have a period of time off training (for example it’s the end of season or you are going on holiday), if you can maintain some training load during this time off you are less likely to get injured on your return.  Again showing the importance of not then underloading.

Gabbett describes a person that gets injured frequently as a “chronic rehabber”. As a physio we want you to get back to normal activities injury free; however… if you already have a history of continually getting injured then you are at a much higher injury risk! Unfortunately I feel that sometimes as physios we can be very guilty of wrapping up our patients in cotton wool and often end up doing very little with types of people in fear of causing re injury! The chronic rehabber may also be frightened to do much after having been injured because they are then more scared of re-injury. Gabbetts data shows a low amount of loading (as often happens in scenarios such as this) puts you at an increased risk of injury instead! Therefore… high chronic loads that are built up gradually and safely are the key to staying symptom free!

train hard to stay injury free 

Basically, the fitter you are, the less likely you are to be injured. So don’t be scared to load and train hard! Just do it properly and sensibly and consider using the acute to chronic workload ratio.

I hope you all haven’t under loaded yourselves prior to the New Year and now ended up over loading and becoming injured! Please monitor things sensibly…OR…seek advice from my specialist physiotherapy colleagues at the CONSORTIUM CHARTERED PHYSIOSTHERAPISTS clinic in Hull who will be more than happy to discuss the subtle details of load management with you.

As this is my first blog any feedback can be directly messaged via my LinkedIn and would be hugely appreciated.

If you enjoyed reading this blog then please look out for the second part that is due to be published in combination with my consortium physio colleagues. This will provide you with more advanced methods of load management in order to keep you injury free.

Thank you for reading,

Chris

Back pain during sitting? Will spending money on a fancy new desk chair help?

Changing your chair to an often more expensive 'back friendly' one is a traditional tactic in trying to tackle lower back pain. Chair type and sitting posture is a topic that patients frequently ask us about during consultations. There is no doubt that office based jobs that involve prolonged periods of sitting can be known to commonly aggravate preexisting lower back pain (source). However... interestingly... it seems highly unlikely that occupation roles involving prolonged sitting are actually an independent cause of lower back pain! (source)

Should we recommend special chairs? Are you wasting money? What does the research say?

Use of chairs with lumbar supports

There is mixed opinion on the use of lumbar supports. Some studies have found that chairs with lumbar supports provide relief (source). Others have found that using a back support reduces muscle tension (source). Other authors have reviewed the literature and decided that there is little evidence to support modifying chairs to reduce lower back pain (source).

What about chairs that create tiny movements in your back as you are sitting?

This is generally referred to as dynamic sitting. There is some support for using dynamic sitting (source) to help promote micro movements in the spine while sat e.g using gym balls and also using kneeling stools (source) to promote more extension of your back whilst sat. However... some argue that while these types of seats may reduce back pain they often create symptoms elsewhere in your body. There are also conflicting reports as to whether spinal muscle activity is either increased or decreased.

So.., obviously a mixed bag of opinions and outcomes...

So what do we recommend you should believe and what should you actually do?

Interestingly...if you read the studies mentioned/referenced so far it is clear that they have many limitations! Perhaps the most common criticism we can make is that the researchers seem to only trial the use of one particular chair for all types of back pain. When we assess people's spines in the clinic each one can be very different. Some have flat/straight backed postures, others have over exaggerated curves. We would treat each type of back pain with different types of physiotherapy, so why don’t we apply this same principle to picking chair types? Surely there should be types of chairs that suit certain types of spine!

One of the most recent papers looking at this specifically is by Mary O’Keefe and her team in 2013 (source). They looked at trying two different types of chair on one particular sub group of back pain patients (people whose symptoms were worse with bending and better with straightening).  The first chair they trialled was a traditional office chair with supportive back rest keeping you relatively still (type of chair you would get through your occupation heath dept). The second chair however was one that sloped forwards providing a small dynamic element and a straighter spine when sitting. Interestingly... this group of back pain patients experienced significantly less pain when sitting on the sloping chair. This essentially means that those with worse back pain in bending are better sat with a chair tilted forward in order to increase their extension (arching of their spine) and that for those whom have pain that is worse when they extend (arch) their spines will be better sat in a chair promoting a bent/slumped posture.

Perhaps the main lesson we can learn from this is that there may be some value in investing in specifically designed chairs...but...only ones that are matched to your spinal type. the current approach in occupational health departments seems to look only for a generic norm, assuming all spines and symptoms are the same... it is unlikely therefore that this will work .

You may be best to seek a spinal assessment from a physiotherapist or medic that can match your back type to a certain chair type and work out what is best for you. It is also widely acknowledged that lower back pain has a variety of underlying components. Simply addressing the mechanics of sitting on its own is likely to only effect a small proportion of the underlying causes of most people’s back pain. It is therefore likely that looking at sitting postures in isolation will never really be an effective measure.

If you think this article will be of use to people you know then please share and follow our facebook page. Our main aim as a clinic is to provide you with the highest levels of evidence based care that we can. This is why we read and continue to bring you heavily referenced articles to help you stay healthy!

Thanks for reading

The Consortium Team

 

 

 

 

Our staff

 

 

Graham Morgan, BSc Physiotherapy, MSc Musculoskeletal Medicine, MCSP, HCPC registered

Graham has been working as a musculoskeletal physiotherapist for nearly a decade. He has studied to gain an additional masters degree in musculoskeletal medicine alongside his previous physiotherapy degree. His main speciality is management of complex spinal conditions. This includes recent and long term spinal pain, lower back pain with leg symptoms, neck pain with arm symptoms, post operative spines and management of patients with neurological deficits. He is experienced at interpreting spinal imaging as well as recognising when imaging is appropriate. Graham is now an experienced injection therapist and is used to administering steroid and hyaluronic acid such as synvisc and ostenil to help patients manage chronic conditions. His other interests include rehabilitation of anterior knee pain and chronic tendinopathies.

 

Niall Carter, BSc Physiotherapy, MSc Advanced Musculoskeletal Physiotherapy, MCSP, HCPC registered

Niall qualified as a physiotherapist in 2004 having previously studied sports science.  He has worked locally for the NHS since 2004 during which time he has gained in depth experience in a variety of specialties.  He has held various senior posts in the NHS that have given him experience of managing patients with complex musculoskeletal conditions and neurological conditions such as stroke, multiple sclerosis and Parkinson’s.  He also works for a private provider of NHS surgical services as a Spinal Extended Scope Practitioner.

He has completed an MSc in Advanced Musculoskeletal Physiotherapy and as such is a skilled manual and exercise therapist.  He specialises in the management of complex spinal conditions, working in spinal surgical clinics and also providing physiotherapy for patients both post-operatively and as part of their conservative management.  As such he has a balanced viewpoint on the management options available to people with spinal problems.  In addition, he has particular interests in cervicogenic headaches, sacroiliac joint pain and lower limb tendinopathies.

 

Danny Brunton, BSc Physiotherapy, MCSP, HCPC registered

Danny has been working as a qualified physiotherapist for over 10 years. During this period he has gained vast experience in musculoskeletal physiotherapy, building a broad understanding of medical presentations. Alongside his physiotherapy degree he has completed additional masters level modules.

As a Clinical Lead Physiotherapist, his main interests and skills have developed around the management of knee and ankle injuries/conditions. Danny has developed his assessment and treatment skills over a long period of time by working in clinics alongside the area’s leading ankle and knee consultants.

Other special interests of Danny’s include the management of post-operative patients such as Anterior Cruciate Ligament Reconstruction (having written locally used post operation guidelines), treatment of acute/chronic tendinopathies, management of soft tissue injuries and the use of Maitland mobilisation techniques and rehabilitation with the aim of return to sporting activity and hobbies such as running.

Chris John Bsc Physiotherapy, MCSP HCPC registered 

Chris is a Specialist Musculoskeletal Physiotherapist with a special interest in sports based physiotherapy. Alongside his work at the Consortium clinic he works in professional rugby for Hull FC as a 1st team physiotherapist.  Aswell as working at the elite end of rugby league Chris has vast experience in professional football, rugby union and the NHS. Chris believes strongly in the importance of planning effective loading programmes in order to decrease the risk of getting injured during sporting activities. His expertise lies specifically in managing sports based injuries.  In addition to his degree in Physiotherapy Chris has embarked upon a Masters in Sports and Exercise Medicine in Leeds. Chris also has an advanced trauma medical management qualification endorsed by the Royal College of Surgeons. 

MASSAGE TEAM : RACHEL MARSON (Sports Massage Therapist LSCP assoc), LAURA EGAN & Jordan Mounsey

Rachel, Laura and Jordan are highly trained and vastly experienced with 25 years of clinical practice between them. They cater for both top level athletes and for clients who simply want to de-stress and enhance their well-being. To find out more about the Consortium Sports Massage service please use this link. 

So you have back pain - do you actually need a MRI?

This video is another fantastic resource and an absolute must see for any patient with lower back pain 

It provides some good examples of where a MRI scan is needed and where, as in many cases, it can distract you from getting better 

Should you present to us with symptoms that require a MRI scan to be performed, then this is something we can arrange for you quickly and have it reviewed by our spinal surgeon 

If a scan is not be needed then we can focus immediately on the most important thing, getting you better 

 

Thanks for reading

Chronic pain cycle

This diagram will be familiar territory for many people living with pain. We encounter patients on a daily basis who are stuck in this cycle...

TRYING TO EXERCISE BUT YOU CAN’T BECAUSE OF PAIN? LEADING TO MORE WEIGHT GAIN, MORE TISSUE DECONDITIONING, MORE TIME OFF WORK, MORE STRESS, MORE SLEEPLESS NIGHTS, MORE DEPRESSION, MORE PAIN… 

Diagram reproduced with permission from Pete Moore/paintoolkit.org

In many patients this cycle can be minimised to varying degrees. Consortium provides physiotherapy including: pacing, CBT (Cognitive Behavioural Therapy), acupuncture, TENS therapy, education, sensibly prescribed simple and graded exercises, medications, injections and manual therapy. These are all valid ways to intervene. Alongside this we offer support, encouraging patients to reach acceptance. Many of these can be easily implemented in simple ways, without significant costs. 

There are many free, easily accessible resources available for patients living with pain. Here are two that we often direct people towards:

LEAFLET explain pain - click here 

video understanding PAIn in less than 5 minutes

Thanks for reading 

 

 

Tissue Regulation

Perhaps the best way to introduce this topic would be to pose the following questions..

Why do some runners demonstrate a poor style with limbs thrown all over the place with no obvious control yet they can continue uninjured?

So how are these lucky individuals able to continue to exercise pain free while many people with better style and form continually run into strings of injuries?

It seems clear therefore that injury does not solely relate to style, biomechanics or perfect alignment.

Each of us has a certain amount of capacity in our tissues to tolerate stresses and loads. Some may have a huge amount of leeway (the sloppy runner who is injury free) and others very little (the perfect runner who is always injured). Some people may be able to suddenly and drastically increase their training loads without injury, while others only have to make the most minimal of changes and they run into trouble. As a general rule of thumb however large changes in activity does seem to be a precursor to injury. The concept of tissue regulation and capabilities of tissues to tolerate load is not something new, in fact it was first described by Scott Dye an American knee surgeon in 2005 (Source).

The model that Scott puts forward should have huge influence in the way we treat patients today. We feel this is a very important concept for the majority of our patients to understand and we have tried to explain it in its most simple terms. 

Tissue homeostatis original.jpg

OPTIMAL LOADING - sensible appropriate loads at the right intensity, speed and position with the correct amount of recovery will in time improve the capability of that tissue to tolerate load. No different from training for a marathon, take it too quick and you run the risk of injury, take it too slow and you waste time. It is a balancing act.

UNDERLOADING/SUBOPTIMAL - e.g complete rest! This will create the reverse effect and decrease the tissues capability to deal with load, as it would when you take time out injured. This can result in malnourishment, pain and pathology. The same principle applies with overloading. This is why we will try to avoid at all costs and will very rarely prevent you from having to stop participating in your activity.

How do you know if your exercises are pitched into the right zone for you?

If you can tolerate your current exercises/training load or activity in a pain free manner, with no flare up of pain on the second day after exercise then you are likely to be working within a capable zone for that tissue.  Be careful though as it is common for tissues to flare up 24 hours later. This can often be due to a latent production of an inflammatory chemical called cytokines.

No pain, no gain in the majority of cases is therefore not applicable what so ever!

What is the ideal?

Theoretically it is best to remain working at the upper limit of your optimal zone. Loading OPTIMALLY and allowing correct progression and recovery time will increase the capability of that tissue to deal with a task in a healthy manner.

What to do if I'm injured?

You will need to work in a lesser zone and then slowly build back up again. Even injured joints can function very well with certain activities. Examples of this can be using swimming and cycling where there is less direct impact yet you can still maintain strength and movement without continuing to overload and worsen your injury.

In summary, your tissues don't take well to sudden changes. Changes such as increases in training need careful grading. Think of your tissues like employees, if you drastically change someone's job role overnight without prior warning, you will have outrage and backlash on your hands. If you make small changes and are appropriately prepared it will make for a smoother transition. This is an especially important principle when dealing with patients chronic pain, they may well need to take much smaller steps and take them over a much longer period of time.

Exercise prescription is therefore something that should be taken extremely seriously. It is not just a case of picking exercises, giving them a go and quickly abandoning them if they don't give you the results you want. Exercises and training regimes must consist of OPTIMAL loads and need to be sensibly and accurately applied. The volume and intensity of your exercises needs to be monitored in order to be able to progress and regress them appropriately. The principles we have discussed here about regulating tissues must be applied in order to ensure successful recovery.

Thanks for reading 

Are you a victim of misleading medical imaging?

It is only natural if you have a problem to want to resort to some form of imaging to try to identify a cause. From a patients perspective this is understandable, for patients, it makes logical sense. Unfortunately, as with most things there is far more to consider here as we will go on to explain... Patients are misled by imaging so frequently that we feel it is very important to cover this topic early on. 


ARE SCANS USEFUL? 
Absolutely this is a yes, they are key to many things. This is not a one sided argument about the problems we encounter with misleading images however. Obviously scans are essential for surgical planning, identifying major/serious pathology, fractures, lesions and dislocations etc. 


Will my scan ACCURATELY identify my problem? 
It is very common for scans to show abnormalities that do not relate to a person's symptoms. These findings are often purely radiological incidental findings! Our clinicians interpret images in daily surgical clinics and constantly encounter these issues when analysing the hundreds of MRI and Ultrasound scans we come across a year. We find ourselves often explaining to patients why it is that their MRI scan shows a huge disc prolapse clearly compressing a nerve on the right side but yet their symptoms are only on the left! 

 

FACTS AND FIGURES


SPINAL MRIS
48% of 20-22 year olds with absolutely no back pain or any issues had at least one degenerative disc seen on their scan, at least 25% had a disc bulge showing. (Source)

40% of individuals under the age of 30 and 90% of people over the age of 50 have disc degeneration, yet they are pain free. (Source)

One study found 98% of men and women with no neck pain had degenerative changes seen on their MRI scan. (Source)

 

SHOULDER ULTRASOUND SCANS
20% of pain free adults had a partial rotator cuff tear on MRI scan with 15% showing a major full thickness tear! For those people over 60, at least half have a rotator cuff tear they never even knew about. (Source)

 

KNEE XRAYS
If you x-ray a normal population of adults with no actual knee pain, at least 85% of the x-rays taken will show arthritis. (Source)

In one study, 48% of professional basketball players were shown to have cartilage damage on their knee MRI scans, none had any pain. (Source)
 

WHAT DO WE TAKE FROM THIS? 
Degenerative changes are simply normal. What we see on our scans, often does not represent reality. There is no need to worry if your scan shows certain changes, they are not necessarily associated with pain. If you allow your images to mislead you, theoretically you could end up in higher amounts of pain for longer amounts of time.

Don't get us wrong, as previously mentioned, where appropriate, imaging is an important part of a patients care. Our clinicians at consortium rely upon images to make surgical decisions in conjunction with the surgeons we work with. What is essential is that a patients symptoms directly correlate with the symptoms that they present with. Both us, and patients need to make sure we do not get side tracked with purely incidental findings. Next time you somebody tells you that your discs are worn out or your shoulder is torn then I hope you can see there is no reason to immediately panic! It is absolutely feasible for patients with worn out joints to function at high levels with no symptoms. 

Thanks
The Consortium Team