Phy-video-therapy?

Physiotherapy and video consultations – New assessments and injury management.

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These are very worrying and strange times, for everyone.

I have been agonising over the past week about the options for continuing to offer Physiotherapy services in the current climate.

Ultimately, the combination of collective responsibility, social pressure and doing everything we can to halt the spread of this virus and help out our NHS colleagues on the front line made the decision easy.

During this unprecedented time, we all have had to adapt and find new ways to keep supporting your physical (and mental) health. The world can’t stop and now, more than ever exercise is so important.

I have now moved to all online voice only or video-call sessions via phone, facetime, skype or zoom.us app. This will continue for the short-term (I hope) and we will be able to seamlessly transition back to face-to-face and hands-on when we are able to do so safely.

I have moved all my current patients in treatment seamlessly over to video appointments where possible. But what about new assessments and acute injuries?

What can we accomplish in a new patient online session?

  • Face-to-face detailed subjective injury history taking
  • Full objective assessment including range of movement, strength tests and special tests
  • Diagnosis of the injury
  • Advice and anatomical description
  • Provide realistic timeframes for management and recovery
  • Provide recordable exercise prescription and self-mobility techniques
  • Demonstrate taping techniques
  • Goal setting for the next session
  • Online exercise programming software integration

Fitness-and-Tech

I am an experienced Physiotherapists and worked in A&E for four years as a musculoskeletal injuries specialist. I still work part-time for the NHS in a Consultant Physiotherapist role, predominantly running Orthopaedic triage clinics which means a lot of very quick assessments and decisions on care! I am also a qualified musculoskeletal Sonographer, Independent prescriber and practice injection therapy.

I thought it might be helpful to give two examples of remote sessions I have been involved with this week.

Case study 1 – 40 year-old fit and actively man was unfortunately stranded in France due to the COVID-19 outbreak. With limited equipment and self-isolating, he took up trail running. After a few runs, he missed a step and felt a sharp pull in the back of his leg. After the pain subsided he hobbled home and used the RICE (Rest Ice Compression Elevation) protocol. After a few days, he noticed some bruising at the back of the leg and then contacted me to organise a ‘zoom’ remote session. After a quick chat and subjective assessment, we moved on to an objective look at the injury. I was able to instruct him to perform some movements and tests including palpating. We were very quickly able to diagnose a likely grade 2 medial hamstring tear. After this we went through the anatomy of the injury, timescales for recovery, ‘do’s and don’t’s’ and then recorded a comprehensive rehab plan for the next two weeks. The whole session lasted 30 minutes and we will follow-up in two weeks to progress and get him back to full activity ASAP! Knowledge and correct diagnosis is key!

Case study 2 – A 33 year-old yoga teacher injured her shoulder two weeks prior. We had a brief telephone call to ascertain what the injury might be and it sounded like she may have injured her rotator cuff and was now suffering from a shoulder impingement syndrome. This was restricting her full range of movement and causing pain at night, sleeping in the shoulder. The main thing was that she was unable to teach fully with the pain and modify her practice. We agreed that a zoom appointment would be beneficial to confirm the injury and advise on rehabilitation. We arranged a zoom consultation the next day. Again, with the visual assessment, it was clear that it was in fact her acromioclavicular joint (ACJ) that was strained. This changed the advice that I would have given just over the phone. We were then able to discuss the injury fully, record a full and specifically tailored exercise plan including stretches, mobility and straight work in addition to demonstrating a. taking technique to offload the joint and reduce the pain. We will follow-up progress in one-week.

I hope these two examples help explain how useful a video consultation can be and can help you avoid long-term damage, reduce pain levels and get you back to what you want to do sooner!

If you want to discuss if a video appointment is right for you, please contact me directly at emerson@xphysio.com and I will be happy to email or call you back for an initial free 15 minute chat and advice.

Self-pay rates are £40 initial consultation (£30 CrossFit members) and £30 follow-up (£25 CrossFit members).

Insurance companies are now fully supporting and covering these sessions to allow your rehabilitation to start, progress and continue.

Stay indoors and stay healthy!

Emerson

CrossFit open 2018 and managing injuries…

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The CrossFit open 2018 is almost upon us…

Over 500,000 people will likely participate this year and it will be a test!

Managing acute soft tissue injuries!

I suppose this is as good a time as any to talk about managing acute (and in some cases chronic) soft tissue injuries when is competition and training. As a Physiotherapist that has been involved in sport, who treats athletes of all levels and also worked in A&E for four years, I think that I am well placed to comment. Plus the fact that ‘what should I do if I injure myself?’ is probably one of the most common questions that I get asked! Depending on who you speak to you, you will probably get a number of suggestions.

Most people have heard of PRICE (Protect, Rest, Ice, Compression, Elevation) but have we moved on from this?

Let’s classify soft tissue as muscle, tendon or ligament and acute as an injury less than 48 hours old. This would include muscular back or neck pain, peripheral joint strains (ankle, knee, elbow etc), tendon (muscle-to-bone) issues (achilles, rotator cuff etc) and ligaments (bone-to-bone) such as the collateral ligaments of the knee or fingers.

The basic healing cycle

healing

Pain relief – Paracetamol V NSAID (Non-steroidal anti-inflammatory drugs)

Concern has been raised over the use of Non-steroidal anti-inflammatory medications (NSAIDs – Ibuprofen, Naproxen, Diclofenac etc) in the early stage of injury management. This is largely due to the theory that the natural healing cycle requires the first inflammatory phase (see image below) to effectively repair injured tissue therefore trying to stop this stage too early may result in a delay overall. Evidence suggests that using NSAIDs too early (the first 24-48 hours) may compromise long-term healing. In addition, when specifically talking about muscular injuries, the early use of NSAIDs may promote increased bleeding and swelling due to decreasing platelet aggregation. This awareness of adverse thrombotic events is to be considered when weighing up risk v benefit. The use of Paracetamol as the first line of pain relief is therefore more universally accepted. It is just as effective an analgesic without the adverse effects. Obviously, you should always seek advice from your Doctor, prescribing therapist or Pharmacist before taking things especially if you have other medical issues.

Protect

Significant ligament and tendon injuries need to be immobilised. We are talking about a high-grade tear – most of the tissue is disrupted. You will know if it is a bad injury if you get immediate swelling (ie. you have fluid aggregating within a few hours), if you have a physical restriction and if you can’t bear weight on the joint. Lesser grade tears will benefit from being immobilised for a short period (48-72 hours) to prevent further damage before being re-assessed.

Rest – when and for how long?

General rule of thumb, if something is very painful and / or swollen, the body is telling you to rest. Allow the swelling and pain to reduce by offloading the structures (use a crutch, tape, support or modified position). If there is significant swelling or restriction on movement certainly 48- 72 hours is a must before you start to load the area by stretching or exercising. Look again at the stages of healing as to why this is important. Tendons take the bulk of the force whilst doing ballistic movements (running, jumping, kipping) and need ample time to recover after intense sessions and on performing new movements. Respect this.

Ice – has this treatment been debunked now?

CrossFit movement guru Kelly Starret has done a nice little discussion on topics including Ice (based around Gary Rienl’s work – links below) and really it is very similar to the discussion around the use of NSAIDs. The advice now is actually not to use ice in the initial stages of an injury however it may be more useful to use it as you start to rehabilitate. As you start to move more, we would consider any residual or further swelling to be a waste product that you want to remove. There is still a real lack of quality studies to date, particularly randomised control studies. There isn’t even a general consensus about how often and for long you ice the area for currently.

https://www.youtube.com/watch?v=0UmJVgEWZu4

http://garyreinl.com/

I would advocate the use of heat for muscular injuries and spasm to allow the muscles to settle and allow you to start moving more quickly.

Compression

There seems to be good evidence that compression can prevent further bleeding, prevents seepage into surrounding tissue and help disperse fluid. Compression increases hydrostatic pressure and increases the effectiveness of the muscle pump, increasing venous return. Early compression is advocated in the first 72 hours, from distal to proximal in direction. Apply the compression a minimum of six inches above and below the main injury site. Do not keep compression on when lying down (sleeping)

Elevation – transient effect?

Elevation lowers capillary hydrostatic pressure (think about the effect of the body as you descend in a pool of water). Capillary flow to the soft tissues is reduced and the buil-up of edema is consequently lowered. Unfortunately, the pressures return almost immediately when the limb is returned to below heart level. Again, there is very little clinical research on elevation. I suggest in the absence of harmful effects, elevate the limb when possible and overnight.

Return to training / modifications

Once you have managed the acute first stage, pain is negligible, and you are moving the area normally it may be safe to start loading the tissue. I would suggest gentle stretching, foam rolling and tissue mobilisation with bodyweight functional movements. For example – if you have a shoulder injury, start trying to regain normal shoulder overhead movement, before trying to do a handstand or overhead press (sounds sensible huh? You’d be amazed at the amount of people that simply head back to training to test it out or just chance it hoping for the best).

If you still have some pain, take you time and train around it. If your ankle is still sore and swollen, don’t do box jump, burpees, heavy squats – choose to modify or do some upper body stuff? The coaches are the best people to talk to this about and help you scale.

When to seek advice / investigation?

If in doubt, ask. Most sports practitioners will be happy to give you five minutes of advice over email or in person. Expect minor muscular strains to improve significantly over three to four days if given the right environment to do so. Expect ligament and tendon strains to improve over three to four weeks. Expect higher grade sprain and tears to take six to eight weeks to start feeling normal again.

If you injure yourself and you cannot weight-bear, are in excruciating pain, can see that something is obviously misplaced or missing and /or if the area is hot or looks infected (you will likely feel unwell and have a temperature) then get yourself to A&E and get checked out.

If you think you have a soft tissue injury and it doesn’t improve as expected after three to four days, book in to see someone to get a proper diagnosis. Worth the money and will get you back lifting quicker and more safely in the long run. Advice on the correct management of injuries is the key to recovery!

Have a great open guys and stay injury free!

Emerson

Greece and Turkey… not Worlds apart really.

So as I mentioned in my last mini-post, I was luck enough to visit the Greek Cyclades, Athens and then Istanbul for my honeymoon!

I loved all of them. For different reasons. Universally however the people and the history are the draw.

Here are a few pictures and some recommendations if you happen to fin yourself that way in the near future!

First stop Santorini in the Greek Cyclades! Known mainly for it’s amazing sunsets. I stayed in Oia, the north-western tip of this Volcanic Island.

Try to do a boat trip out to the volcano, swim and / or cliff jump at Armeni and obviously take in the sunsets at Oia – drink in hand!

For a quick bite to eat check out Pitogyros (https://www.facebook.com/pages/Traditional-Grill-House-pitogyros/308065952693772) – meat and bread! I also really liked Floga (http://www.floga-oia.com/) for breakfast and coffee with a great view of the dormant volcano. And I did venture out of Oia to Imerovigli and had a great feed at Avocado (http://www.avocadosantorini.gr/) with great service.

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Always time for a bit of yoga… crow pose.

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Armeni port in Oia. Brace yourselves for the the 275 steps back up on the donkey trail!

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My little mate the Praying mantis. Same spot, two nights running.

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Obligatory sunset!

Ios! Known as the party Island but there is more to this rock that that! YA few Islands south of Santorini, you can get the ferry very easily (takes about 40 minutes). Lovely people, picturesque village and beautiful beaches. Rent a jeep and go and explore the mountains and hidden coves! Religious? Ios has 365 churches – one for every day of the year!

For eating and drinking I love the Octopus Tree (https://www.facebook.com/pages/The-Octopus-Tree-Ios-Greece/130766903680203) down at the port for traditional food and to mingle with the locals. The other must is Katogi (https://www.facebook.com/katogios). Cool little hipster place with great food!

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Old Roman Amphitheatre!

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Windmills and handstands.

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After the sunset in Ios.

Still in the Cyclades – Milos. Two hours by ferry from Ios. This place feels like a traditional Greek Island. Less touristy. More spread out and again fantastic countryside, history and beaches. We rented another little jeep and explored the whole Island over three days! Visit the catacombs, hike around the the ruins of the villages (Greek and Roman) and then it is all about the beaches! Sarakiniko is pretty cool – moonscape type rocks and swimming holes! Kleftiko has the awesome oddly shaped rocks. Give the mining museum a miss…

Where to eat! Spoilt for choice here really. Check out O Hamos (http://www.ohamos-milos.gr/). Lovely food, very traditional and massive portions. At this point I had figured out that a starter and two mains max between two is more than enough. Eyes beat belly usually though don’t they! Gialos (http://www.gialos-pollonia.gr/) was good. Simple, clean food down by the port in Pollonia. The owner told us he is looking to open up in London soon too! Watch the sunset at the Utopia cafe in the capital of Plaka (https://el-gr.facebook.com/pages/Utopia-CafeMilos/225644387455126). Perfect.

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An old cave network at Sarakiniko beach. Creepy.

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Beach cat – there are cats everywhere in the cyclades! This one seemed to be living at Sarakiniko beach and was grateful for some water!

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Another sunset…

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Obligatory CrossFit movement with stunning background. Pistol squat… couldn’t resist.

I think that’s enough for now! I’ll post some bits about Athens and Istanbul next…

Back in clinic this week and we have a ultrasound clinic this Friday at Market Sports in Shoreditch so get in touch if you have any niggles you want looking at!

Emerson