Biochemistry

Radiographic imaging

Elastography

Microdialysis techniques

Integration with our current understanding of pain mechanisms

Debate has now moved beyond whether Myofascial taut bands as entities actually exist into a more refined analysis of:

Identifying patient subgroups

Alternative etiological mechanisms

Identifying optimal management strategies.

The first point to recognise is that the cause of trigger points is still a matter of speculation. Travelle and Simons originally described both active and latent trigger points – latent to describe the concept of the clinical recognition of a palpable nodule, which was not reproducing symptoms.  The working assumption is that latent trigger points can exist without pain but then become activated for some reason.  As Robert Gerwin has alluded to trigger point tenderness does not occur except in regions of muscle hardness.  But regions of muscle hardness occur without local or referred pain.

It is currently “assumed” that the muscle hardness or taut band that occurs in the absence of pain is the first abnormality and that active trigger point is a more developed or second stage of the trigger point.  However this still remains hypotheses at this point.

Jay Shah amongst others has contributed largely to our knowledge on the biochemistry of the trigger points using microdialysis techniques.  This has indicated that there is a local mechanism of nerve sensitisation involving release of local neurotransmitters, hydrogen ions, potassium and cytokines, which are all classically associated with a peripheral inflammatory response (peripheral sensitisation).  The activation of these pathways also feeds into a central sensitivity state, which can become self-sustaining and independent of the peripheral components or essentially be a mirror of the state of peripheral sensitivity.

If the mechanical hypotheses of inducing trigger points is extrapolated there is a potential cascade of events involving neurotransmitters as alluded to above and also the release of acetylcholine at the motor end plate which amplifies motor end plate discharge and is thought to be associated with the development of localised muscle contractions – however this is only one of a number of theories.

Studies many years ago by Professor Patrick Wall indicated that taut bands can be produced in muscles simply by persistent depravation of sleep over a forty-eight hour period.  Clearly this mechanism is not associated with a mechanical event.  This raises the tantalising question of the chronic persistent myofascial pain syndrome in which:

Fatigue

Sleep disturbance

Muscle pain

are part of an integrated triad which is often challenging to resolve clinically.  What does appear evident from clinical observation is that mechanical muscle overload can occur at different ends of the spectrum from an acute severe overload that doesn’t induce fibre disruption but initiates sustained physical overload of  muscle fiber with the presumption of initiating the biochemical responses alluded to earlier.

At the other end of the spectrum is a low load, sustained activity associated with postural, ergonomic or occupational factors which by its nature is a less severe mechanical effect but cumulative over a longer period of time.

Other factors associated with the development of trigger points are:

Weakness

Hypoxia

Ischaemia

Central sensitisation

Referred pain

Gender

Hypermobility

The Diagnostic challenge

According to Jay Shah regarding this particular issue “validation of clinical diagnosis by palpation with these and other objective tests e.g. magnetic resonance & elastography would help establish the reliability of the clinical examination not as interrater reliability but in terms of the reliability of the physical examination to identify those patients whose myofascial trigger points is verifiable by other mean.

Current laboratory studies that show abnormalities would have to be validated themselves by showing that they independently identify trigger points that can be treated resulting in pain relief and improved function”.

Robert Gerwin adds “ there remains a need to develop a consensus on the clinical features required to diagnose myofascial trigger points.  There is also a need to develop objective laboratory criteria that can be used to standardise a diagnosis for the purposes of research.  They may have clinical value if they can be used to confirm an examination made by physical examination.  Elastography needs to be studied in a variety of trigger point pain syndromes”.

Treatment

The current treatment spectrum encompasses:

Stretch & spray

Local soft tissue mobilisation

Direct trigger point pressure

Dry needling

Injection therapy

Comparison of these modalities is still in its infancy other than anecdotal clinical evidence.

So in summary still much to do in this area of myofascial pain syndromes.

Enjoy the clinical challenge.

David

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Post tags: chronic myofascial pain, Myofascial pain, myofascial pain dysfunction, myofascial pain myofascial pain, myofascial pain symptoms

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Commercialisation of information exchange – let the buyer beware.  Whilst recently reviewing my CPD manual I was reminded of weekend courses from times past and memorable conferences in not so exotic places.  Some were remembered more fondly than others and careful reflection revealed why.  When listening to any presentation it is easy for the listener to judge the willingness of the speaker to exchange useful information or whether they are guarded/ reserved about sharing.  This was highlighted recently at a Movement Dysfunction conference where several of the keynote speakers gave overview presentations which were essentially commercial pitches for attending workshops, buying products or purchasing books.

Whilst this has no doubt been the case since time began the overt commercialisation was striking, as was the superficial skimming of the topic under discussion.  It is easy to see the potential conflict which can arise. Academics who produce published research have effectively already received their payment as part of the their academic salary and therefore have no purpose in “re-purposing” information which is available from published resources.

Conversely when there is substantial “back-end” financial gain from accessory products then one can clearly see the conflict between exchanging information and withholding with a view to secondary profit.  Perhaps ultimately the speaker selection process and scope of content need to be more rigorously defined in advance to prevent these “pitch fests” becoming the norm.

Reflecting on my 25 years in Physiotherapy I tried to trace the chronological sequence of this commercialisation and drew the following conclusions:

The simplest strategy is mis-naming a course as of intermediate or advanced content when in fact it is not.  Whether that is a reflection of the lecturer’s perception or the natural variance of course attendees is debateable.

The next development was the multiple module model, where compulsory attendance of initial (introductory) weekends were required prior to completing parts one, two and three etc. even if the material has been covered via alternative methods.  From a lecturer’s perspective one could argue that having a cohort of students covering similar material at each stage is a desirable objective and ensures a smooth flowing of information exchange.  However, in practice there is frequently significant padding and review of the previous modules in order to fulfil the allotted time.

Another strategy is to use an attractive course title to lure subscribers and then present material on a different topic.  I had a memorable three days some years ago when an International Lecturer came to visit these shores to talk about the “Oblique Sling System” and its mechanism in pelvic stability.  After two days practising core stability assessment and reviewing theory it became clear that any systematic teaching of the sling support mechanisms was not going to occur and if we wished to pursue this topic further then the videos would be available for purchase subsequently.  Needless to say there was general dissatisfaction on that weekend!!.

Another more recent trend I have noticed is of course outlines being general without specific timetabling of content or pre-course reading.  This has the advantage of allowing the Lecturer meander across a broad number of topics whilst not making it particularly obvious that they are deviating from an outlined schedule.  As a participant trying to decide whether the course is worthy of committment, is very hard to make judgements other than to “take a flyer”

I raise these issues here because undoubtedly increasing commercialisation is not going to go away anytime soon. We need to be able to make an informed decision when we pay for a course or conference that the information we are going to be exposed to is complete or is it  merely an overview which will require further measures in order to ascertain useful, practical information to apply clinically.

How many of you felt “short-changed” by conferences or seminars you have attended?

Am I being unrealistic to expect open information exchange in a forum of professional colleagues?

Please share your thoughts.

Enjoy the clinical challenge.

David.

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Post tags: Academia, Academic publishing, Communication, Information, Social sciences

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You may be interested to know of the ongoing legal battle between Rupert Murdoch, Chief Executive of News Corporation and Alan Rusbridger, Editor of The Guardian, which is in the courts at present.  It relates to the issue of free vs paid information, in this case newspapers, but the debate applies to all information products we consume.  Mr. Murdoch contends that newspaper publishing online should be restricted to paid access and not free which is currently the situation in many newspapers.

Rusbridger contends that the basis of Murdoch’s position is that he ruthlessly cut the price of his papers below cost in order to win market share and drive out competition.  Having achieved dominance Murdoch is now being highly vocal in asserting that the reader must pay a “proper sum” for the content, whether in print or digital.

This got me thinking on the wider issue of how we as physiotherapists consume information and what calibre of information we expect to get for free and what to pay for.  Is it realistic to expect that “professor Google” can provide all the answers we seek, with no financial return other than the ability to tempt us with advertising campaigns?  Is Wikipedia, a reliable source of information given the limited editorial control and negligible requirement for corroborative evidence?  Websites which attract high volume traffic with a view to monetizing this traffic do so by ad placement and derive their income on the basis of the ‘click through rate’ on the ads placed adjacent to their content.  The cost of advertising, as in all mediums is dependent on the volume of traffic and the competitiveness of the targeted keyword search phrases.

The current reality has been a rapid evolution of the integration of the World Wide Web into our daily lives.  However, if it is to replace our traditional sources of knowledge such as peer reviewed editorial journals and respected peer postgraduate education training, then we do need to apply some criteria to determine the validity of the content, its authenticity and the reasons for its publication.  It appears that the individual professional journal subscription rates are dropping due to the large availability of institutional group subscription schemes.  The question is whether this alternate method of delivery achieves the same mental penetration which would occur with individuals having their own hard copy of the information to read on a bus, train and waiting room etc.  Maybe this is a generational difference or individual preference, but I think it is still easier and quicker to view a print version of an article (or part thereof) instead of booting up a laptop or being tied to a PC terminal in order to consume.

Regardless of the method of consumption, the key issue remains whether the information is being accessed, processed and retained or are we now operating in a culture of expecting instant access to freely available information on demand and therefore we don’t feel the need to develop our internal database of knowledge with pre-emptive learning?.  Some clinical educators tell me one of the key factors determining retention of knowledge is the process by which the information is accessed, synthesized and processed.  Instant access can equate with instant dismissal and may ultimately not achieve the imparting of knowledge that is retained.

I remember fondly my trips to the Medical Library at Liverpool University (almost daily as a basic grade I have to confess!!), accessing journals and photocopying articles for projects of the time.

Undoubtedly this was far more time consuming than downloading PDF’s but those articles still remain 22 years later in categorised box files.  And yes, they do see the light of day when I need to call upon them.

We are now in an era of information overload with vast amounts of information available for free.  The decision we need to make is whether this information is good quality information and why is it being given away.  We are undoubtedly in changing times with different ways but perhaps it’s time to reflect and take stock.

Before I am accused of being a luddite let me state than I do not swear blind allegiance to the edited journal and the gravy train of non-relevant (funded) research which increasingly fills the pages. This too is the other end of the information spectrum – being dictatorial and non-interactive with the constraints of publication inhibiting expression of ideas. Come to think of it that’s why I started this blog!!

Let us know your thoughts.

Enjoy the clinical challenge.

David.

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I’ve just had the great pleasure of listening and speaking with legendary All-Black rugby captain Sean Fitzpatrick. See: www.balls2business.com for Sean Fitzpatrick’s story and valuable information.

The conference was for clinicians and the theme of Sean’s talk was how to transfer the lessons of successful sports teams into clinical practise. Being a huge rugby fan it was great to meet a living legend but I was also really impressed with the message (as well as the messenger) and found it inspiring.

It got me thinking about applications to Physiotherapy and below are some thoughts based in Sean’s presentation.

What makes a global brand? What sets it apart from all other brands? How can lessons be learned from the All Black brand and applied to your own business?

The role of branding applied to physiotherapy can be considered in terms of the public perception of what physiotherapy has to offer (ie What is it?) or more specifically how it relates to the individual organisation/hospital/practice in which we conduct our business. The public perception of physiotherapy is very much based on their own interpretation or second-hand information unless they have been in a position where they have had previous care administered to them or a relative. Therefore, there frequently isn’t a yardstick by which to measure the competence of a therapist other than looking for familiar clues of ..

Professionalism

Communication skills

Personal presentation

Effectiveness of treatment.

Essentially patients are looking for solutions to problems and generally are not concerned about the clinical challenges which clinicians wrestle with in order to deliver optimum care.

I must confess it has taken me far too long to realise that the technical aspects of the job are only part of the essential core skills required.

“When the All Blacks win, I’d much rather be the All Blacks captain, and when they lose, I’d much rather be the prime minister.” Jim Bolger, ex-Prime Minister of New Zealand. How do you lead the All Blacks? How do you lead?

Again there are multiple levels to apply the analogy of strong leadership in physiotherapy practise. Those in a leadership role must communicate their vision and ensure that staff entrusted with delivering care are comfortable with the vision and it is consistent with their principals. It goes without saying that leaders should lead by example to have any credibility.

On an individual basis if we think about the qualities employed by effective leaders they would include..

Seeking advice

Collaboration

Decisive decision making

Implementation

Evaluation

Feedback

all of these concepts are equally applicable for a patient care plan delivered by a sole practioner – as Sean Fitzpatrick says “be the best you can”

The basis of sporting excellence is all about identifying, maximising, and then utilising your strengths. Find out how this is achieved in a sporting context, and how to transfer this understanding into your business.

No one can have all the answers. Recognising our skill limitations and the possibilities of better treatment options from other care providers is sometimes a humbling experience for a therapist. However, leaving aside the associated personal challenge our fundamental objective is to do what is best of the patient. If often seems these lines get blurred in daily practice. “Do what’s best for the patient” is a mission statement to start every therapist’s day.

Developing and implementing a plan to win a World Cup brought with it lessons and insights that might prove highly useful to those responsible for business planning.

As the saying goes “failing to plan means planning to fail.” As therapists we must have a clear vision and process of how we intend to pursue treatment and its delivery to a patient. We must also have a clear plan of recognising when our strategies are not being effective and need to be altered. Far too often patient’s failing to respond is transferred into blaming the patient for non-compliance rather than therapist self scrutiny.

Things to consider are..

Poor planning

Poor treatment delivery

Failure to recognise the potential limitations of the pathology

Failure to match expectations with reality

Sometimes the business requirement is to take the direct line, tackle the issue full-on, head to head. What can we learn from crash ball rugby about when – and how – this tactic can work best?

There are undoubtedly situations where clinicians have to take a chance and take risks As long as these risks are not reckless but calculated they are not negligent. The outcome may not always be positive, but if you don’t try you will never know. Fear of failure leads therapists to avoiding clinical decision making. Telling a player to return to a club training session with advice to “take it easy” instead of testing functional tolerance in a controlled environment or defining the boundaries loading parameters is an example of this. Having a patient “breakdown” during rehabilitation is not a pleasant experience but engineering this breakdown to happen away from the clinical environment is simply looking the other way! We need to take responsibility.

In 1986 a young team including thirteen debutants travelled half way round the world, and beat the reigning 5 Nations champions. How was this achieved? Succession planning…

Planning for continuity of care is the most obvious example that springs to mind. No matter what detail is recorded in clinical notes a 1 minute conversation between therapists can be more effective than hours of reading. Establishing a bond is a critical part of delivering care and drawing on the experience of face to face contact time is invaluable.

For example

Knowing there is an important upcoming competition

Knowing there are concerns about serious pathology

Wondering if things will ever get better

Conflicting information from healthcare providers

This type of detail not usually recorded in clinical notes but vital to shape the patient – therapist relationship.

Would you rather watch a team play beautiful rugby and lose, or watch a team grind out a win? And (whichever answer you give) which one would you rather play for? Is your business about process, or outcome?

Simply put as therapists we can get pre-occupied with technical aspects and new technologies but we need to constantly remind / test and re-test our interventions to ensure our work with a patient is effective. I’m old enough to remember using short wave diathermy and heat lamps for hours without any tangible measure of benefit. We have to make our contact time count!

Unfortunately, there isn’t a ready-made recipe. But this module includes a set of thoughts and insights from one of the great team leaders of one of the great teams in sporting history. What are the dynamics that you have to consider in order to get a collection of individuals to perform as a team at the very highest level?

The team can be within a department / practise or the wider application to multidisciplinary healthcare teams. Having “outsource” options for surgery, pain management, rheumatology, psychology, pharmacology are all necessary components of musculoskeletal pain management. Having confidence in the clinician is absolutely critical to deliver effective care.

I’ve lost count of how many times a treatment plan has been sabotaged by…

Dismissive comments

Trivialisation of symptoms

Flippant remarks

Superficial examination

Disinterest

Abrasive language

We need to know the team members if we are to have confidence in them. We don’t have to like them – just respect their clinical judgment. Matching the personality to the patient and be very valuable in the right circumstances. For example, an abrupt neurosurgeon dealing with an acute surgical disc prolapsed is far more acceptable than in a chronic pain management situation. A holistic pain specialist is more appropriate than an invasive pain specialist for a patient who fears needles!

I’m sure we’ll come back to this post in future and drill deeper into the points raised.

Some powerful lessons that we need to integrate into our practise.Please share your comments and opinions.

Enjoy the clinical challenge

David

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Post tags: chronic disease, clinical examination, detached, Exercise, failed intervention, hydrotherapy, low back pain, managing poor prognosis, pain questionnaires, Patient attitude towards collaboration between the care providers, Patient confidence in care providers, Patient expectations, peak performance, persistent ongoing symptoms, physiotherapy, Previous response to treatment, primary care, professionalism, prognosis, psychosocial flags, quality assurance, sean fitzpatrick, subjective questioning, targeted therapy, therapist credibility, Type of interventions prescribed

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>
1. How do we determine the relative amount of resistance for an individual?.

2. How many repetitions should be done?.

3. How much rest period is necessary?.

4. How do we determine the factors limiting exercise performance clinically?.

5.How do we determine which components of rehabilitation are appropriate targets?.

6. Where is the transition between rehabilitation and conditioning?.

7. What is the difference between physiotherapy prescribed exercise and sport rehabilation / fitness instructor?.

8. How do the principals of strength and conditioning apply to rehabilitation?.

9. What do we need to know about the structures we are rehabilitating?.

10. How do we improve exercise compliance?

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Post tags: Exercise, physiotherapy, prescription, rehabilitation

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1. Speed
2. Range of Motion
3. Base of Support
4. Plane of Motion

Combining different elements of these components allows progression or regression as required. It is essential that therapists are competent in applying these principals in a clinical setting

Click exercise variables to hear the lecture.

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Post tags: Exercise, rehabilitation, treatment

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Functional training from a rehabilitation perspective has been used for many decades with the obvious goal of returning an individual to their pre-injury functional status.

The astute reader will note that this implies a degree of individuality and specificity in rehabilitation strategies depending on the individual’s response to the injury in question and the planned functional goals to be achieved. In this discussion we are concerned with a return to playing sport, which has different functional requirements depending on the sport of choice.

Most rehabilitation specialists would agree that the fundamental measure of success is the ability to “perform at maximal function”. The issues of debate usually centre around:

1. Whether to use functional exercise as an initial priority.
2. Whether to place prerequisite criteria for progressing to functional exercise e.g. base line flexibility measures, stability measures, agility, coordination and power.
3. The use of over load / external resistance to achieve progressive increases in power output.
4. Key variables to manipulate in exercise progression e.g. load, speed, plane of motion, movement sequence.

Perhaps the biggest source of discussion in this regard is the use of fixed weights / machine systems relative to free weights. In the non-elite athlete there are some attractive aspects to using fixed weights as the machines themselves provide some degree of stability, are relatively safe, allow max or near max loads to be utilised and can be undertaken individually.

Unfortunately the artificial stability provided by machine systems dictates that a critical aspect of functional strength is not trained and therefore of debatable relevance in functional loading. On the other hand free weights use allow mass activation of stability and mobility muscle groups, more closely approximates functional movement patterns and requires higher levels of skill and coordination particularly if technical or explosive lifts are being attempted. Most serious athletes will incorporate some degree of free weights into their training.

The gap between these two approaches can be neatly filled by incorporating batteries of functional tests which explore movement control and coordination in varying combinations of body position, primarily with body weight as the external load, but progressing with small proportional increases in resistance as control allows. It can be reasonably argued that inability to control one’s body weight through a full functional repertoire of positions which are likely to be encountered in the course of the game situation may predispose to injury.

One of the current difficulties related to repeated tests / re-tests of functional measures are the measurement systems used. These tend to be somewhat “low tech”, can sometimes rely on the individuals perception of effort to perform a desired task or require an external examiner’s observation of the quality and sequencing of movement. Needless to say there maybe many hours of debate regarding differences of opinion on these issues!!!

Nonetheless a useful concept in this regard (popularised by American Physiotherapist Gary Gray), utilises the concept of threshold training in which the extreme position which an individual can control is measured relative to that of the other side. Any further change in position produces falling or loss of balance or some compensatory adaptive mechanism – indicating failure.

Components of a total body functional profile.

1. Safety.
2. Measurability.
3. Reliability and validity.
4. Simplicity.
5. Meaningful.
6. A full spectrum functional testing.

These concepts should be borne in mind when deciding what battery of functional tests to include for an individual or as part of a team training / screening protocol. The other critical point to recognise is that loading is occurring in three planes of motion simultaneously – tri-plane motion.

In clinical practice it is often by combining three planes of motion simultaneously that one can expose weaknesses, which do not appear evident when testing an isolated plane. If one analyses the movement patterns involved in most sports we can see that they can be broken into groups of core functional activities e.g. jogging, running, decelerating, excelerating, twisting, pivoting, jumping and pushing.

Each of these complex movement patterns can be broken down into components and each can be stressed using varying combinations of challenges e.g.

1. Range of motion.
2. Sequence of motion.
3. Eyes opened / closed.
4. Corporating simultaneous trunk and limb movement.
5. External resistance e.g. elastic tubing, bungee cords or dumbbells.

All allow varying degrees of difficulty to be explored in order to be determine the functional threshold of control.

Gray groups his functional tests under the following categorisations.

1. Balance tests.
2. Balance reach tests.
3. Excursion tests.
4. Lunge tests.
5. Step up tests.
6. Step down tests.
7. Jump tests.
8. Hop tests.

Functional self-test menu

Below are listed a group of self-test movements which can be administered and the degree of difficulty noted. Please note that there can be many different reasons for an inability to perform complex patterns which could include flexibility, stability, power, endurance or coordination deficits.

1. In- line lunge with body rotation.

Stand in a long stride position with front and rear legs in one line and feet pointing forwards in the same direction. Heels must stay on the ground. Bend front knee and hold leg position still. Add alternating twists of the upper torso to left and right side.

2. Single leg stance with toe touch.

Standing on one leg bend forwards to touch toes with the hand on the same side as your standing leg. Return to upright and reach arm overhead. Focus on maximising hip and knee bend in order to increase the leg stress. Ensure that standing leg does not roll inwards.

3. Kneeling lunge with trunk side bend.

In a kneeling lunge position, with both legs in line, side bend the upper torso from left to right. If toes grip floor strongly, tap floor to prevent fixing.

4. Single leg stance forward / downward leans.

Stand facing a wall, goal post or barrier about 3ft away initially and stand on one leg. Reach forward with the index finger to touch the ground as far out in front to reach the ground if possible. Return to upright and reach with opposite hand.

5. Single leg stance reverse pivot.

Stand on one leg with back to wall or post or barrier. Reach overhead with left and right hands alternately to try and touch behind without falling over. If it is too easy move a further distance from the barrier.

6. Incline lunge with trunk rotation

Lunge at 45° from straight ahead position, holding dumbbell in opposite arm (6 to 10kgs) reach down and across to the outside of the forward foot. Return to upright. Alternate sides.

PS to initially feel the coordination for this drill try work without weights.

There are infinite numbers of variations of these types of drills which can be exciting, fun, challenging and very revealing. We will come back to some of these concepts in the future.

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Post tags: Balance reach tests, Balance tests, Hop tests, Jump tests, Lunge test, specific strengthening, Step down tests

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No doubt many of you are aware of the competition amongst health professionals for the the mantle of key exercise prescribers.

Many therapists feel that their undergraduate training is insufficient.

Some feel that the boundaries of practise are at best “blurred” which creates confusion with the public regarding choice of therapist.

This has led to an explosion of interest in “functional training” – which is fast becomming a by-word for strength and conditioning. Understandably, physiotherapists core training does not provide these skills. This can make physiotherapists feel “inadequate” but we need to consider the type of caseload we see and whether strength & conditioning principals are the nesessary tools or whether other parameters are more relevant.

What do you think? Post your comments

David

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http://www.physiodigest.com/presentations/slides/player.html

Instructions for use:

1 Double click on link

2 Slides will play automatically

3. Pause, forward, rewind from the control panel at the bottom of the player screen.

4, Can skip to slides from the left hand side slide menu.

5 Suggestion - if you downloaded the audio previously you can use your MP3 player whilst viewing the slideshow.

Hope you enjoy

David

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