Are you in need of a modern approach to manage your persistent lower back pain?

Looking for a modern and revolutionary approach to treating lower back pain? Tried every treatment before with no improvement..?

Most people with severe non specific chronic lower back pain (back pain with no specific structural cause found) have two things in common, they usually have severe pain and also a lack of function. Many of them have undergone treatments including manual therapy, exercise therapy, core exercises, stabilising exercises, manipulation, electrotherapy, massage, pilates, yoga , medications, injections etc (the list goes on....). The evidence base for management of back pain has evolved immensely over the last decade but despite this many patients continue to be treated with all of these traditional therapies with little effect.

Even the latest national guidance from NICE (National Institute for Health and Care Excellence) clearly state that practitioners should not be offering acupuncture, injections and electrotherapy for treatment of lower back pain (source). 

Frustratingly, these types treatments are still marketed and sold to people in pain on a daily basis. There is therefore a clear need for physiotherapists, doctors, surgeons, osteopaths and chiropractors to improve the quality of what we offer for conservative management of non specific lower back pain and in the process move to a more contemporary approach. 

(USEFUL ARTICLE TO READ ON NEED FOR DRASTIC CHANGES IN CURRENT MANAGEMENT OF LOWER BACK PAIN)  

Since its inception, the Consortium clinic has always listed Cognitive Functional Therapy as a service provided for its patients. The research has shown this approach to be significantly more effective than any previous approaches we have traditionally used to manage back pain (source). This is exciting news for the future for those of you who suffer from severe disabling back pain. 

What is Cognitive Functional Therapy (CFT)?

When it comes to treating lower back pain - a one size fits all approach simply does not work.

CFT is most importantly patient centred. This means it is focused entirely around you as a person, your life and your goals. CFT looks at the way you move and analyses some of the strategies you have adopted as a result of living in pain. It targets the fears and beliefs that are associated with performing spinal movements and the movement behaviours you often display around your back. It will help you understand that pain will not necessarily cause your back any damage. We will look through your MRI scan with you and help you to dethreaten some of the worrying things you may have been told about it. CFT will try to get you out of the vicious circle that so many patients find themselves trapped within. Often all of these things lead to a significant increase in the tension around your back and this often drives the nervous system to be over sensitised.

CFT will look to undo and change many of these things to provide you with better strategies to ease your pain and lessen your disabilities. It will help empower you to get back to doing the things in life that are of value to you.

What does the research say that Cognitive functional therapy achieves?

The trials for CFT suggest that this approach is far more effective than the traditional management of being manipulated, mobilised or exercised. It has been shown to significantly reduce peoples levels of pain, disability and fear of movement. It often improves your mood and mental wellbeing. Patients who have had CFT often have less need for ongoing treatments or time off work (source).  

Is Cognitive Functional Therapy appropriate for everybody?

CFT can be applied to the majority of back pain. It is most appropriate for people with non specific back pain that is provoked by certain movements, postures or activities (85% of back pain). It is often even more appropriate for the more complex and disabled patients. It is also used successfully for those people with mild to moderate levels of back pain. However, CFT is not for everybody..... there are some patients (less than 15%) who have had a very specific structural cause of lower back pain identified, this approach is still beneficial but may focus on specific structural cause of symptoms aswell as all of the other contributing factors.

Want to learn more?

This video interviews one of the key researchers in CFT, it discusses what cognitive functional therapy actually is and the significant effects it can have....

Interested?

The Consortium clinic believes strongly in the use of the CFT approach for lower back pain. Should you wish to discuss with one of our clinicians then please contact our enquiries line on 01482 847705. We can always schedule one of our spinal specialists to ring you if needed. Alternatively you can email us at enquiries@consortiumphysio.co.uk

 

PART TWO - Managing load to avoid injury: How to not wrap yourself up in cotton wool

Welcome to the latest edition of the CONSORTIUM CHARTERED PHYSIOTHERAPISTS blog. Thank you for reading part 1 of ‘managing load to avoid injury’... If you have not read it yet and want to reduce your risk of injury then please click here to do so!

This article has been written by myself (Chris John) and another fellow Physiotherapist and friend Rob Parkinson. Rob is highly skilled physio and works in elite rugby alongside running his own private practice in Gloucester called Pro Performance. You can follow us both on twitter @chrisjohnphysio and @properformrehab

After reading the first blog you will have summarised a few points:

  • The optimal amount of load is best for getting fit and trying to avoid risk of injury. Overloading or under loading can result in an increased risk of injury (Dye, 2005).
  • The acute to chronic workload load ratio is a useful method to monitor your training and ensure you are not over or under loading. The ideal ratio is 0.8 to 1.3 (Gabbett et al, 2016).
  • Calculating your acute:chronic ratio will help prepare you for competition, improve your performance and should decrease your risk of injury.

My previous blog explains how to use this in a very simple way and is relatively easy to remember. However, the disadvantages to using a simple version like this is that everybody is different. Some of us are tolerant enough to be able to drastically increase our training and not end up getting injured. Some will find the opposite and only need to make small changes and often end up with problems. Some amount of this you cannot control, it will just depend on how you were put together and is simply the way you are. However... there are other factors that will influence how quickly you can progress.  Things like your past medical history, age, weight and previous training levels will all have some influence. Using the simple acute to chronic workload ratio that we previously described in part one unfortunately does not account for any of these factors. The other downsides of keeping to a very simplistic model is that it is also very objective as it focuses purely on distance or volume of training and doesn't take into account how hard you went.

For this reason I present to you a more advanced way of calculating your training progression and I will go on to explain this below.

THE ADVANCED VERSION

Uses Rate of Perceived Exertion (RPE) (ie 0 no effort, 10 maximum effort)

Calculate your time spent training into units ie. (RPE x number of minutes you undertook that activity for)

You then CALCULATE THE TOTAL FOR THE ENTIRE WEEK

So what is a rating scale?

The ‘Rate of Perceived Exertion’ is a well-known tool in the world of professional sport that is used to measure how the athlete perceives the intensity of workload given (Brito et al, 2016).

THIS CAN BE a game, running, cycling, training, strength and conditioning session, gym session and so on…

The Table below shows the Rate of Perceived Exertion scale. 

(Borg, 1982)

Rate percieved exertion.PNG

So how do you work out your acute:chronic ratio using RPE?

You multiple your RPE by the training session time in minutes

(RPE x training session time = units)

EXAMPLE: A 30 minute gym session was an intensity of 7/10 (30 x 7 = 210 units)

You then use this to work out your total units for the acute and chronic weeks

ACUTE LOAD DEFINITION: The sum of load over 7 days

CHRONIC LOAD DEFINITION: The average acute load over the previous 4 weeks (or however many week you chose)

The following example demonstrates how you would calculate the total volume of units for one week of training

you then use this to work out your figure to see if you are in the safe zone or whether you are at risk as demonstrated below 

table.PNG

SO LETS RECAP THE BENEFITS OF USING THE ADVANCED VERSION

  • It takes into account internal and external factors as YOU score how YOU feel after that specific session (Coutts et al, 2004).
  • How YOU progress is then specific to you only (Abbiss et al, 2015). For example, using a prescribed marathon website training program will provide you only with a generic protocol. It is not designed exactly for YOU and does not take into account any of the factors that will affect how quickly you can progress in comparison to someone else.
  • You are in then in total control of your own programme; progressing yourself in a SMARTER way, trying to ensure you always work in your ‘sweet spot.' This will leave you better prepared for competition and less likely to get injured (Gabbett, 2016).

So remember, train hard…but train smart!


Thank you for reading.
 

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

 

 

 

 

'Runners' Knee

Patellofemoral joint problems (usually pain at the front of the knee) is a common problem reported by many runners. This often starts gradually with no obvious cause of injury and no direct trauma. Patients with Patellofemoral Joint (PFJ) symptoms can often become very frustrated as their pain often appears to settle down with rest/treatment but can quickly re-occur when they return to running or any activities that place an increased pressure through the front of the knee such as going up and down the stairs (source)

the cause

The reasoning behind the repetitive 're-occurrence' of symptoms lies within the complexity of the condition. Although the discomfort is normally quite specific to the front of the knee, there can be variety of underlying sources as the cause. A selection of these include: the patella femoral joint itself, Ilio-tibial band, synovial plica, patella tendon, quadriceps tendon, fat pad and a number of bursa. Also.... to make things just a little bit more complicated... the problem can often be a combination of these things and not necessarily just one of these alone! (source)

Due to the various sources of symptoms here... it is important in the early stages of rehabilitation to identify the exact cause/causes using a thorough assessment. Once this is established, the following steps can be used in order to get back on the road towards pain free running!

Steps

1. Reduce the pain

2. Address contributing/aggravating factors

3. Gradually increase the patellofemoral joint’s (movement of knee cap with thigh/shin bone) work load (source)

 

So... How do I reduce the pain??

As a runner myself it’s quite hard to say this but in the initial phases, running may have to be modified/reduced or even stopped in order to temporarily reduce the patellofemoral joints load, this allows the symptoms to settle. After the initial groans of disappointment.... I can hear you asking.... how do I know if what I am doing is still too much?? Unfortunately there is no simple black and white answer to this as it depends on a number of factors. This is unfortunately one aspect that would need thorough discussion with your physiotherapist and ideally one that has an interest and understanding of running injuries management. However.... if running does have to stop or become reduced for a short while, non aggravating cross training activities such as cycling are highly recommended to maintain fitness. 

There are a variety of other methods to try and help manage/reduce pain initially.... these often include ice/analgesia, Non-Steroidal Anti-inflammatories, soft tissue massage, joint/patella mobilisations and taping. However .... unfortunately with anterior knee pain using these methods alone will not necessarily get you better. In order to get best use of them you will need to skilfully use them as adjuncts alongside a thorough rehabilitation programme in order to ensure you get long term benefit and not just a temporary short term fix. The key thing here is to make sure the underlying problems are directly addressed (source).

So.. what could the contributing factors be??

A recent review by Lankhorst et al (2013) suggested there could be up to as many as 500 contributing factors to patellofemoral joint pain! Again, this highlights just how complex the nature of this condition can be! However.... with a skilled and thorough initial assessment it is feasible to identify a small number of more likely contributing factors. You can then identify in order of priority which ones will have the most influence on that specific individual’s presentation. 

              Often the main factors include:         

1.   Quadriceps, Gluteal, Hamstring, Soleus strength plus timing of contractions

2.   Altered movement control e.g. increased hip adduction during running gait  

3.   Reduced flexibility of Quadriceps/Hamstrings/Gluteal Maximus/Tensor Fascia Lata/Gastroc/Soleus and hip flexors   

4.   Reduced joint range of movement E.g. Ankle dorsiflexion(Foot pointing upwards)

5.   Recent/sudden increase/change in activities/work loads

(source) (source) 

So what next....

So as long as some attention has been paid to the above factors, a gradual increase of the patellofemoral joints work load and a return to running can begin!

The concept behind a gradual return and 'gradual increase in joint load' can be found in more detail by reading our previous blog on          TISSUE REGULATION

In order to gradually build back up to running, our knees require being able to tolerate from 4.3-7.6 times our body weight! Therefore.... in order to return to injury free running you would need to adopt a gradual phased return that is graded in an appropriate manor towards your goal. So.... one example of this could be by starting loading the patellofemoral joint using a static 45 degree squat. This was suggested by Powers and his team as a good starting point when injured (source) as they found any weight bearing loading of the PFJ between 0-45 degrees placed minimal force through the joint as was likely to be tolerated well.  In order to achieve loading of the joint between 45 and 90 degrees they advised avoiding weight bearing and instead using a leg extension machine (or resistance band) to access this range. This is a good example of using specific research that focuses on the amount of force that is put through the PFJ during different joint ranges and also during different activities in order to keep the joint as active as possible (to help it heal) without flaring up symptoms. This is just one example of many clever methods that your physiotherapist can use to get your rehabilitation on track when you are in an injured state. Similar principles also apply throughout every progressive stage of your rehabilitation with the aim of returning to high impact activities/running.

Although problems with the patellofemoral joint  can appear to be a very complex problem to manage.... you will be pleased to know that with the right guidance and advice.... a return to normal high level activities and running can realistically be achieved. 

If you are currently suffering with this problem and require any help or advice, please get in touch and one of our physiotherapy team will be more than happy to help. Hope you have enjoyed reading our latest blog. Keep a look out for our next instalment!

Best wishes,

The Consortium Team

 

 

 

 

 

 

Do lumbar disc protrusions heal on their own accord?

What does the research show?

Several studies have shown that large extruded discs appear to have the greatest tendency to dramatically decrease in size and resolve with conservative management or even if left completely alone (source).

Here is an example of a large disc on an mri scan that has healed over a 12 month period

So.. How much do discs improve?

How long do they take to heal?

Does it depend on what direction my disc has bulged?  

One paper looked at a large group of patients with large disc prolapses over a 2 year period by repeatedly scanning them and monitoring what was happening to their disc prolapses over time. A large proportion of these patients had severe sciatica initially but then began to experience less pain as time went on despite having a large disc herniation on their scan. They found that 83% of the people they studied had a complete and sustained recovery when followed up two years later with only four patients requiring surgery! On average, over the two years, the size of the disc protrusions were reduced by 64% (source). It didn't matter if your disc was bulged in the middle (centrally) or out to the side (far laterally) as the results found were both similar.

Another paper found that 38% of all the disc prolapses they observed became smaller in size when left completely alone. Among their results they found that more specifically, extruded disc 'fragments' resolved 100% of the time and disc 'herniation's' resolved in 83% of cases! They proposed that the reasons for disc fragments doing so remarkably well was that they have clear disc material that extrudes and actually detaches itself from the disc so it no longer receives nutrients and supplies. This leads to an inflammatory response that begins reabsorbing the disc fragment. Over a six month period most disc protrusions were on average 1/3 of their original size (source).

Can we predict what will happen?

Where early improvement is seen then the outlook is far better (source).

If there is no improvement at 1 year then resolution is less likely to happen on its own (source) & (source).

Does this apply to all discs?

Unfortunately it is not as simple as that.....

Just because disc prolapses have been shown to improve without surgery, it does not mean you should ignore your disc prolapse completely! Some can get worse and lead to permanent problems. If you have been diagnosed with a disc prolapse or even if you just have back pain then there are a number of things to look out for as the following warning signs..... (source).

  • Saddle anaesthesia (loss of feeling between the legs, numbness in or around your back passage or genitals)
  • Bladder disturbance (inability to urinate or difficulty initiating urination, loss of sensation when passing urine, inability to stop of control urination, loss of feeling your bladder is full)
  • Bowel disturbance (inability to stop a bowel movement, constipation, numbness when passing a bowel movement)
  • Sexual problems (inability to achieve an erection or ejaculate, loss of sensation during intercourse)
  • Nerve root pain (worsening pain into one of both legs with weakness in your legs)

 All of the previous signs are relatively rare. The vast majority of people are very unlikely to have any of the above symptoms and it would be perfectly reasonable to just leave things alone and see how it goes. Benson et al (source) states that if there is evidence of clinical improvement, massive disc prolapses do not appear to carry a risk of major nerve damage or cauda equina syndrome.  

(This blog is not a substitute for medical advice, if you experience any of the above then you must seek prompt medical advice)

As always, we continue to prioritise educating and reassuring our patients. 

Thanks for reading

Is there an ideal running style?

Gait analysis is often assessed in various settings. A scenario many of us could probably relate to is a quick go on the treadmill when being assessed for the ‘ideal’ running shoe. For the majority of us this often results in you being told we over pronate (foot rolls inwards towards your big toe) during stance phase (the time spent with your foot in contact with the ground) and that in order to stay injury free we need to purchase the correct running trainer to prevent this… 

So... is it just as simple as that?

Unfortunately not… gait analysis for runners is both a complex and highly skilled process. It requires an individualised assessment that relies upon a wide variety clinical reasoning with the evidence suggesting that just simply adopting a 'one size fits all approach' is not good enough. 

Most of you will be able to recognise all kinds of different running styles such as Paula Radcliffe’s ‘bobbing head’ or Michael Johnson’s ‘stiff back and short stride’… so the big question must be… should we try and change the way people run? Do we need to? 

The evidence based philosophy we follow here at Consortium is yes in certain cases… but only if it has a link to both symptoms and pathology. Therefore, if you are having no problems at all.. then you're running style is likely to be best left alone.

However, if you are experiencing problems or you are injured then the evidence over the past 10 years has begun to show that accurate gait analysis and modification of your gait can be a very useful tool in managing pain. This mostly relies on modification of load on the effected tissues. Accurate gait analysis and assessment is a complex process. There are numerous factors that need careful consideration. A rational decision must then be made to decide whether any of these factors relate to that individual’s injury/pathology.

A example of the factors that should be considered are listed below, these must be thoroughly analysed by a skilled therapist throughout the entire gait cycle for that individual:  

 Arm position

Trunk position

Pelvis position

Hip extension

Bodies centre of mass

Foot strike– Rear foot/Forefoot/Pronation/Supination

Foot/Ankle transition

Stride length

Stride width

Step rate

There are many conditions and injuries that can relate to running gait such as Achilles Tendinopathy, Patella Femoral Joint pain, Medial Tibial Stress Syndrome (‘Shin splints’) and Iliotibial Band Syndrome amongst others (source).

So how does gait relate specifically to injuries? How do we go about correcting this?

As you can see there are many things to consider but with a thorough assessment and the use of video analysis all the factors listed above can be very closely observed and reasoned through to see if they do indeed relate to injury. These factors can then be adapted in order to aid recovery from injury. A good example of this is the cause of Patella Femoral Joint pain (pain at the front of the knee/knee cap). Many factors can theoretically contribute to this including increased knee flexion and the time spent in the stance phase, narrow stride width and over striding. Therefore, a way of addressing this problem could be to encourage an increase in step rate (to within acceptable boundaries as not to not cause other problems), this will reduce time you spend in stance phase, reduce your stride length and therefore reduce excess knee flexion and avoid overloading the patellofemoral joint (source) & (source).

This is just one example of how gait analysis can really help.  For more information, or if you think your running gait could be a contributing factor to your injury or any symptoms you are experiencing then please feel free to get in touch. One of our team will be more than happy to answer any questions you may have and provide guidance to whether gait assessment is right for you.

We hope you’ve enjoyed reading our blog… keep a look out for the next instalment!

Thanks for reading 

The Consortium Team

         

Achilles Tendinopathy

Do you suffer with a painful Achilles tendon?

Struggling to get better despite treatment?

 

Achilles Tendinopathy is a common problem that can easily affect both those individuals who are just beginning to gain basic fitness as well as our Olympic athletes.

 

So why is this the case?

The answer to this lies in how the condition occurs in the first place... Despite whatever level of fitness you may have, each individual’s soft tissues (muscles/tendons) have a load (stress & strain the tissues are exposed to) capacity. The problem arises when this is exceeded! source

To help explain this… there are various ways in which it is possible to exceed your body’s soft tissue’s load capacities. One of the most common examples of this is training error.  Any individual, whether they be a novice or elite athlete can easily exceed the load capacities of their soft tissues through training error alone! A simple example of this could be a sudden change in running mileage. For a short period of time the body will probably cope with this but eventually it will start to complain. Usually this is where things can become painful. source

It is important to know that there can be a variety of sources of heel/Achilles pain (usually a  physiotherapist can differentiate between these). However, an Achilles tendinopathy is usually linked to a recent change in physical activity such as training volume, intensity, frequency or type. Discomfort often increases with activity and decreases with rest. There are normally clear mechanical aggravating and easing factors present. The pain may also be local to within a finger or 2 fingers width at the mid point of your Achilles tendon or at its attachment to the heel. source

So... if this fits your presentation then I’m sure the next obvious question will be - how do I manage this effectively? Good question!

Traditional ways of thinking often still consist of advising complete rest from activities and stretching of the Achilles. However, recent research and evidence strongly suggests this is maybe the exact opposite as to what we should be doing!

So....why not stretch?

It has been suggested that this will not only prevent your Achilles problem from getting better but it could possibly make it worse (especially insertional Achilles pain). The reasons behind this are explained through the work of Cook and Purdham (2012) who found compression on the Achilles (Pressing of the tendon against bone) often aggravates the problem. Interestingly, high levels of compression are created by performing traditionally prescribed achilles and calf stretches (pulling the foot towards the shin). Performing these types of traditional exercises may be the very reason why people have often developed long term achilles problems that frequently reoccur or have never got fully better. source

So why not carry out complete rest (as if often advised)?

Usually we avoid advising people to take complete rest. If possible, it is best in the initial phase to modify your activity type and levels in order to aid reduction in pain levels.  Complete rest is often detrimental, we will explain this later on.

So what should I ACTUALLY do?

Well... firstly you need to manage the discomfort, starting by modifying your loading habits (activity type, volume, intensity and frequency) and avoid periods of tendon compression. Recent research by Rio (2015) suggests mid-range isometric holds (muscle contractions where the muscle length stays the same). This can also be a successful adjunct to aid reduction in pain. Once the discomfort is manageable, the mainstay of the treatment is to improve the load capacity of the muscle tendon unit. source

      So the next question... How do I improve the load capacity of the muscle tendon unit?

There are various schools of thought as to how to achieve this through specific loading exercise programmes. Since the work carried out by Alfredson in 1998, eccentric (tendon lengthening under load) ‘heel drops’ there has been a recent move towards advising a combination of both eccentric and concentric (tendon shortening under load) strengthening exercises (Silbernagel, 2007, Beyer, 2015) and ‘Heavy Slow Resistance’ exercise programmes (Kongsgaard’s, 2009). However, the jury remains out on whether concentric or eccentric exercises (or a combination) are the most beneficial. It is widely thought and agreed amongst experts however that in order for the muscle tendon unit to build the capacity required for physical activity, heavy resistance is required. A good example of this can be found by looking at the requirement of an Achilles tendon. This needs to be able to absorb 2.5-3 times your body weight to manage the ground reaction forces that are generated when you are running. source, sourcesource

     pERHAPS MOST importantly, it is essential that we exercise the tendon at ‘optimaL' levels SOURCE in order to improve the tendon’s load capacity. However, in trying to achieve this we also run the risk that if we do too much then we can create a detrimental effect to the tendon via excessive loading. The ideal scenario is therefore to do enough to improve the tendons capacity but not go over the top and injure it more so. Similarly, if we don't stress the tendon enough, i.e complete rest then this will reduce its load capacity even further!  Dye (2005) SOURCE explains this very well with his ‘Envelope of Function’. This is an extremely  important principle hence why we have blogged about it in the past (link).        

Achieving the ‘optimal’ loading is often the trickiest part and the biggest challenge to get right. Therefore monitoring your pain and your load response to your exercises is vitally important! Push too hard and the problem can get worse, or not pushing enough will not allow you to return to a your chosen activity in an efficient timescale!

We hope you have enjoyed reading this and that you will find this blog a helpful source. We are quickly finding ourselves becoming second opinion specialists when it comes to managing stubborn tendons issues. If you have any questions or require any additional advice with regards to managing your Achilles tendinopathy or any other tendinopathies for that matter then please do not hesitate to get in touch with one of the Consortium team who will be more than happy to help.  

 

Thanks for reading 

STAY ACTIVE - The Benefits of Exercising

Philosopher Plato (427–347 BC) said - 'The lack of activity destroys the good condition of every human being while movement and methodical physical exercise saves and preserves it’ source

Exercise is perhaps the greatest physiological stress that our bodies can experience. For example, during maximal endurance exercise, an elite athlete's cardiac output can increase up to 8 times with the working muscles receiving up to 21 times more blood each minute than when at rest! source Given the physiological stresses that are associated with exercising and the adaptations that your body makes to handle this level of stress, it is not surprising that exercise training is known to prevent or effectively treat a multitude of degenerative conditions.

Exercise is perhaps the greatest drug any of us could take. Research has undoubtedly shown exercise to ....

REDUCE cardiovascular disease, cancers, joint disease and depression source

PREVENT diabetes, alzheimers, and parkinsons source

REDUCe the relative risk of death in individuals who exercise by 25-35% source

HELP PREVENT AND TREAT CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD), HYPERTENSION, INTERMITTENT CLAUDICATION, RHEUMATOID ARTHRITIS, FIBROMYALGIA, CHRONIC FATIGUE SYNDROME AND OSTEOPOROSIS SOURCE

INACTIVITY increases cancer-related mortality by 25% when compared with physically active people source

Inactivity leads to muscle weakness, joint stiffness and a loss of bone mass. Bed rest has been shown to reduce muscle mass by 12% a week with almost half of normal muscle strength being lost with 3-5 weeks of bed rest source. Disuse of muscles not only results in physical wasting but also in the loss of your brain's ability to electrically coordinate and activate your muscles properly (neuromuscluar control) source

Perhaps the best way to really demonstrate this point is to compare the MRI scans of a 40 year triathlete with those of a 70 year old triathlete and a 70 year old sedentary person as pictured below ...source

physio hull.jpg

Hopefully reading this will encourage you to stay as active and as healthy as possible. When it comes to prescribing drugs, there are many things we need to consider. There are certain drugs that suit certain people. This is exactly the same with exercise. We know that certain types of exercise helps different chronic pain presentations (see previous 'blog exercise reduces pain'). However, we must consider the dosage of exercise in terms of its type, volume undertaken, the intensity you undertake it at and the understanding of the context of exercising with those individuals who suffer from conditions, diseases or who may be injured. This is something that all of our specialist physiotherapists at Consortium are trained to understand and advise you on if needed. 

Thanks for reading 

Exercise Reduces Pain

Most would agree that exercise is a key component for any type of rehabilitation whether it be following an injury or for when managing chronic pains.

So.... what type of exercise? How much of it should I do? Does it depend on my specific condition?  How long will any pain killing effects last? How big will these effects be? These are all sensible questions that will probably surface in your mind.

These are similar to the questions that Kelly Naugle and her team in the US at the pain research and intervention centre for excellence set out to answer when they reviewed a group of key papers addressing this topic source

Answers

In healthy people, aerobic exercise (cardiovascular exercise) , resisted isometric exercise (working a muscle while it stays the same length e.g holding a bag of shopping) and resisted dynamic (muscle changes length) exercise were all were found to have significantly large effects when it came to reducing pain.

For those with chronic lower back pain, a moderate to high level of improvement was seen with all three types of the prementioned exercises. For those with fibromyalgia and chronic fatigue a good effect was found only with low level isometric exercises while aerobic exercises at a moderate to high intensity only made symptoms worse. Interestingly, patients that presented with widespread chronic pain found that exercising their non painful muscles on their symptom free side lead to a significant reduction in their pain levels.

More specifically to chronic lower back pain patients, Hoffman and his team source found that 25 mins of cycling at 70% effort led to a reduction in pain in the regions of 2 mins later (28%) and 32 mins later (22%). The patients in his study were on average 40 years old with a 7 year history of lower back pain.

What can we take from this?

Exercise in general, has a mostly positive effect on reducing pain. How you exercise for your specific condition may be slightly different from others. This can be guided by your Consortium physiotherapist. In general however, if you suffer from chronic lower back pain, then the research strongly suggests a combination of all types of exercise and that a moderate to high intensity is likely to be most effective. The fact that Hoffman and his team had such good results from cycling may be because a bike could be less likely to aggravate their back when compared to walking and running activities. Alternatively, if you suffer from other chronic pain states such as fibromyalgia then his research suggests it may be more sensible to start with low level isometric exercises for the best analgesic effects.

It is clear therefore that exercise has a significant systemic effect (one that effects the whole body rather than an individual joint) on reducing pain levels in both healthy individuals and in those with complex pathologies. Exercise is likely to activate a number of natural pain killing hormone systems that the body possesses. These include opiod systems source (release of central endorphins), non opiod systems source (release of serotonin and noradrenaline). An increase in heart rate and blood pressure leads to the production of neurotransmitters source such as a number of neuropeptides that block signals from crossing junctions between nerves (similar to how pain killers work).

Exercise should therefore remain an essential component in any rehabilitation program, especially if you have chronic pain. Hopefully this article provides you with some insight into how best to go about this. This can obviously be guided more accurately by any of our skilled physiotherapists and used in combination with other interventions we can provide to get you as active and as symptom free as you can realistically be.

Thanks for reading 

Consortium Steroid Injection Patient Information

If you are due to have a steroid injection at the Consortium clinic then following information will be useful reading for you

It is important that you are aware of the benefits and risks associated with having a steroid injection. Hopefully reading this will pre empt and answer the majority of your questions. You will be provided with your own printed copy to read in the clinic and take home. Should you have any questions that we don't cover here, then feel free to contact us and enquire. Clare manages the clinic and can be contacted on our enquiries line 01482 847705 seven days a week between 09.00 and 19.00.

What is a corticosteroid?

Steroid is anti-inflammatory medicine that can relieve swelling, stiffness and pain.

Why have an injection?

Quite simply, a injection will help reduce your pain and settle inflammation. In some rare cares, taking away your pain may be enough to allow you to return to your normal activities and naturally recondition your body and potentially solve your issue without any further input being needed. Unfortunately this is a rare occurrence, the majority of injections aim to provide a window of opportunity where we can rehabilitate patients without their pain preventing them from progressing. This often allows you to get better quicker.

Why have an injection? Why can i not take anti-inflammatory pills instead?

Oral anti-inflammatories will spread around your body systemically, therefore a smaller dose of the medication will reach the area of your pathology. The advantage of an injection is that the majority of the medication will be placed directly where it is needed. This makes for a far more efficient process.

Reasons not to inject

We would not consider injecting you if you are unwell on that particular day, have an active or suspected infection, under 18 yrs old, pregnant or have known allergies to steroid or local anaesthetic.

What are the possible side effects?

  • Flushing of the face for a few hours
  • Small area of fat loss or a change in colour of the skin around the injection site
  • Slight vaginal bleeding
  • Diabetic patients may notice a temporary increase in blood sugar levels
  • If you are taking blood thinning drugs there may be some temporary bruising
  • Infection from injection is extremely rare, however if the area becomes hot, swollen and painful for more than 24 hours you should contact your physiotherapist or doctor immediately.
  • Post injection pain is uncommon but it is possible that your symptoms may briefly worsen for a few hours after the injection. This does not affect the injection from working as normal
  • An allergic reaction to either local anaesthetic or steroid is an extremely rare side effect. You will be asked to wait 30 minutes after the injection to ensure there is no allergic reaction to the drug. Should a reaction occur, your physiotherapist is trained to manage this.

You will be asked to wait for 30 minutes after the injection to ensure no allergic reaction to the drug occurs.

How is the injection given?

The skin is first cleaned thoroughly with an antiseptic wipe. The injecting physiotherapist or orthopaedic consultant will insert a fine needle where there is access to the injured tissues. In certain injections the solution will be injected all in one go, in other types of injection the solution will be spread around the problem area in a technique we call peppering. The type of injection you will have will depend on your condition. This will be explained to you beforehand. After the procedure a small dressing is then placed on the skin over the site of the injection.

Is the injection painful?

Any procedure using needles will have some associated discomfort, however your physiotherapist/orthopaedic consultant has had intensive training in the techniques used to maximise comfort throughout.

How fast does the injection work?

The steroid usually starts to work within 24 - 48 hours but the steroid can continue to be absorbed into the tissues for 3-4 weeks.

What should I do after the injection?

It is advisable to avoid any strenuous or repetitive activity using the part of your body where you received the injection for 1-2 weeks. You can continue the majority of your daily activities during this period. If you have any doubts then do not worry as this will be discussed in detail with you prior to the injection being given.

When will I be seen again?

Following the injection it is likely that you will be advised to continue with physiotherapy. Once the injection has reduced the discomfort, the physiotherapist can address the underlying causes of the problem to provide a longer term solution.

How long does the injection work for?

This varies from person to person and for the condition that is being treated.

If an injection has been offered to you, you will be given both verbal and written information and will have plenty of time to ask questions. You will also be asked to sign a consent form to show you have received enough information and that you have understood it. The information you receive should explain your condition, the benefits and risks of injection, and the alternative options available to you.

If after your injection you have any concerns please contact our administrator Clare who will immediately pass a message onto one of the Physiotherapists/Consultants to contact you back, our enquiries line is open between 09.00 and 19.00 on 01482 847705. Outside of these hours you should seek advice from your GP or attend Accident and Emergency if needed.

 

 

 

 

 

 

 

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.

laura lidster bsc physiotherapy, hcpc registered, specialist in neurological rehabilitation  

Laura has over 9 years post graduate experience in Physiotherapy. She has spent the last 7 years specialising in the management of complex neurological conditions. Alongside her work at Consortium she holds a full time role in the NHS as a Clinical Lead in Neuro rehab. 

Special interests of Laura's include treating Stroke, Spinal Cord Injuries and Brain injuries. She also has vast experience in managing other neurological conditions such as Multiple Sclerosis and Parkinsons disease. Laura has additional specialist training in the Bobath management of such conditions and focuses her patient goals around improving their function, mobility and quality of life. 

chris john bsc physiotherapy, hcpc registered 

Chris is a Senior Musculoskeletal Physiotherapist with a special interest in sports physiotherapy. Alongside his work at the Consortium clinic he holds a senior role for the NHS and continues to work with Hull City Tigers Academy. He has previously worked in elite rugby for Hull Kingston Rovers, Yorkshire Carnegie Academy and Northamptonshire Saints Community. Chris believes strongly in the importance of planning effective loading programmes in order to decrease the risk of getting injured during activity. He enjoys rehabilitating patients following traumatic injuries. This was something he has had to do himself during his own recovery after breaking his neck whilst playing rugby. In addition to his degree in Physiotherapy Chris has also embarked upon a Masters in Sports and Exercise Medicine.

 

 

 

 

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

Hello! Welcome to our blog...

So this is our first ever blog as Consortium physiotherapists.  We have known for a long time that we wanted to open this clinic and have spent a lot of hours discussing the ideas and principles behind our service.  

We want to provide a forward thinking evidence based approach in a completely open and honest way.  We are passionate about our profession and believe that we can provide a huge amount of expertise to boost the quality of care in our regions private physiotherapy sector.  It is important to us to empower our patients, promote activity and avoid using the long established passive treatments that unfortunately still haunt many private physiotherapy practices across the uk.

We want to utilise this blog as a way to educate our patients about recent developments within our field. We will be including posts that focus on providing valuable advice and information, dispelling many of the traditional myths that we find are still being fed to patients on a day to day basis. 

We also want our customer experience at Consortium to be comfortable, convenient and enjoyable. For that reason we have spent a lot of hours considering how we want our clinic to look and feel inside. We are renovating what will be our clinic site as we speak and let's just say it has been a labour of love. Anyway, the diggers have now finally cleared out, the excavation is complete and we are starting to see some exciting progress! The building itself is a pretty old one, with a good amount of character so we intend to make the most of this and keep its style traditional but with a modern edge. Inside there will be two large private clinic rooms, a comfortable waiting area with reading material, TV and Wi-fi for customer use (some home comforts are always good). 

Outside we have a large spacious private car park, accessed through a private gated entry for an easy parking experience. We hope to be ready to see patients early in 2016. There is quite a bit of extra land on site so once up and running we also plan to build a well equipped gym to aid aspects of our exercise therapy and movement analysis.

So that's an update on where we are at the moment with Consortium. Now that you know a bit about us as a group,  next time we'll share a bit more about us as individuals and let you know what each of us will bring to the service.  We hope you'll join us to read this from time to time and feel free to share your comments, they are always welcome.

Thanks,
The Consortium Team