PhysioGuru Blog

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Recently Independent.ie published an article about low back pain which talked about some of the most common triggers. Frankly, it was one of the most outrageous articles written on the causes of low back pain. It was as if research doesn't count for anything. One of the assertions was uterus can push back on the spine causing inflammation of spine.... just utter rubbish.... with no consideration of evidence or anything.. Twitterati went into hyperactivity in challenging the basis of assertions.. calling out the biased facts.... and finally the article was removed from their website.. 

But the positive news is that The Lancet and their Low Back Pain Series Working Group has come up with a series of articles on low back pain which summarise the state of the art. The articles have been authored by the best in the business of researching low back pain and clearly present the evidence for this most common low back clinical presentation. 

The first article is titled 'what is low back pain and why we need to pay attention.' This article presents the global burden of low back pain as the leading cause of disability worldwide. But more importantly it highlights that only a small proportion of people have a well understood pathological cause—eg, a vertebral fracture, malignancy, or infection. Most people with new episodes of low back pain recover quickly; however, recurrence is common and in a small proportion of people, low back pain becomes persistent and disabling. It goes on to discuss that that central pain-modulating mechanisms and pain cognitions have important roles in the development of persistent disabling low back pain.

The second article focusses on the prevention and treatment of low back pain. The key focus is on utilisation of education and self management as the key interventions as opposed to inappropriately high use of imaging, rest, opioids, spinal injections, and surgery. I was shocked recently when having a conversation with one of the colleagues who is starting some work in Australia and mentioned that it has been recommended that all patients will undergo an initial MRI scan... not sure who devises such recommendations... but anyway, back to the topic.. the key focus is on moving away from therapies which have little evidence for benefit but surely work to move the locus of control from the patient to the therapist and therefore ensure that the patient keeps turning up in private practice. While researchers have said that for a while now, unfortunately, both the patients and physiotherapists continue to utilise the same passive therapies to manage low back pain. The authors have also highlighted the role of psychological therapies in managing chronic persistent low back pain. If you work with low back pain patients, this article is well worth a read. 

Finally, as a call to action, the Low Back Pain Series Working Group has recommended focused strategies to implement best practice, the redesign of clinical pathways, integrated health and occupational interventions to reduce work disability, changes in compensation and disability claims policies, and public health and prevention strategies.

All these articles are available free

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Whiplash can be defined as “an acceleration–deceleration mechanism of energy transfer to the neck. It may result from rear-end or side-impact motor vehicle collisions, but can also occur during diving or other mishaps. The impact may result in bony or soft-tissue injuries (whiplash-injury), which in turn may lead to a variety of clinical manifestations called Whiplash-Associated Disorders”

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In the previous articles of the research series, I delved into the issues of choosing a research topic, formulating research questions, undertaking literature reviews as well as choosing research design. As you will note, the focus was on ‘How’ to do research and ‘what’ to research. Much like general medical and surgical research, physiotherapy research in the 20th century was also driven by focus on objective designs such as RCTs and therefore rarely discussed the underlying philosophical assumptions related to research. This article is aimed at highlighting the need for researchers to understand the basic philosophical issues which impact on the research design and conduct and to discuss the four prevalent paradigms

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There is a body of literature about research designs which focus on the methods to be used, nuances, traditions, authority, experts, paradigms, or schools of thought related to each method. This all makes it sound so complex?  As a new researcher, the question in our minds is - what design should I choose for successful completion of my dissertation? The short and clear answer to this question is -the research design should follow from and be able to answer the research question. Through this article, I aim to present a brief decision making guide for students to make it easy for them to choose a research design which will help them answer their research question and to finish their dissertation on time.

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In the Getting started with research, I discussed means of getting started in research, choosing a research area and development of a research question. This leads the research student on to the development of a research proposal, however, before the final research proposal can be developed and presented, it is imperative that the previous literature in the area is scoped and evaluated to identify the need for the proposed study and establish its context in the specific research area. In this article, I will discuss means of undertaking and presenting a literature review. While the focus of the article is presenting the literature review for dissertation purposes, I will also touch upon disseminating review in academic journals.

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The word ‘research’ has a certain mystique about it. To most of the people outside the research community, it represents an activity that is exclusive to an elite group of scientists. The perception of a researcher is one detached from the outer world, isolated in his laboratory or scholarly library. This was certainly the image in my mind as I embarked on my physiotherapy career. Over the years, this has not only been dispelled, I am now able to introduce myself to general public as a researcher. So in the next few articles in this series, I will aim to unravel some of the myths about research as well as focus on practical research methods. 

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There is no single cause for why two people experiencing same injury, receiving same interventions can go on to have very different pain experiences with the acute pain in one reducing within few days while the other goes on to experience chronic, recurrent pain. This has been attributed to physical, psychological, social, environmental or behavioural characteristics. Thus understanding pain management has remained a challenge for even the most gifted clinicians. There have been thousands of books written to explain various aspects of pain. In this article, I have highlighted the top 10 books pertaining to understanding and managing pain. 

1. Explain Pain  Explain Pain aims to demystify the process of understanding and managing pain. It brings the body to life in a way that makes an interesting read for therapists and pain sufferers alike. All pain is real, and for many people it is a debilitating part of everyday life. It is now known that understanding more about why things hurt can actually help someone understand their pain and go about their daily life. Recent advances in fields such as neurophysiology, brain imaging, immunology, psychology and cellular biology have provided an explanatory platform from which to explore pain. In everyday language accompanied by quirky illustrations, Explain Pain discusses how pain responses are produced by the brain: how responses to injury from the autonomic motor and immune systems in your body contribute to pain, and why pain can persist after tissues have had plenty of time to heal.

Explain Pain aims to give clinicians and people in pain the power to challenge pain and to consider new models for viewing what happens during pain. Once they have learnt about the processes involved they can follow a scientific route to recovery. This is one of the must read books for anyone working with pain patients. This book is an excellent resource for understanding how pain works in our brains and nervous systems. The text is delivered in a non technical way for ease of understanding and is very informative. This book is frequently recommended by the physiotherapists to their patients suffering from chronic pain and an excellent recommendation, I must say. If you are a physiotherapist and have not read Explain Pain, do it today. 

2. Managing Pain Before It Manages You, Fourth Edition - Top pain specialist and physician Margaret A. Caudill spells out 10 steps that can radically change the way pain sufferers feel--both physically and emotionally. From finding the best treatments to coping with flareups, solving everyday problems, and harnessing the power of relaxation techniques, the book is packed with tested solutions that users can tailor to their own needs. The fully updated fourth edition incorporates important advances in pain management and mind-body medicine. It features new content on mindfulness, a "Quick Skill" section in each chapter with simple exercises that can have an immediate impact, updated supplementary reading and resources (including smartphone apps), and more. Written for use by patients, it has been hailed as by far the best and most up-to-date step-by-step pain management manual on the market. It provides the tangible tools for patients to manage their own pain through alleviating anxiety and emotional stress and providing means to reduce their symptoms and improve function. 

3. Pain Medicine and Management: Just the Facts While written for Pain Medicine certification, this book is an invaluable tool for other clinicians as well. It covers the basic principles such as Pain Physiology, Epidemiology, Gender Issues, Placebo Response, Pain Taxonomy, and Ethics. It also discusses evaluation of the Patient, analgesic pharmacology, acute pain management, regional pain, chronic pain management, and special techniques in pain management. The focus is not on physiotherapy though TENS and acupuncture are discussed. 

4. Essentials of Pain Management Essentials of Pain Management is a concise, evidence-based guide that stresses a multidisciplinary approach to pain and provides a thorough review of clinical principles and procedures. Edited by faculty from Yale and Harvard Medical Schools, Essentials provides a practical approach to pain management for every type of pain management practitioner. Features: * Extensive case vignettes illustrating specific pain management challenges and solutions * Multiple-choice questions with detailed answers useful for exam preparation * In-depth discussions of palliative medicine, end-of-life care, physical therapy and acupuncture, behavioral therapy, and pediatric and elderly pain * A formulary of commonly used drugs for an easy go-to reference for every office * Special considerations for nurses and dentists From career choices in pain management to the specific drugs, procedures, and therapies that can alleviate pain, Essentials of Pain Management is a valuable resource for all pain management practitioners.

5. The Mindfulness Solution to Pain: Step-by-Step Techniques for Chronic Pain Managment While treatments like medication and physiotherapy can be enormously beneficial to the body, to maximize pain relief, it’s necessary to take advantage of the mind’s healing abilities. This book offers a revolutionary new treatment approach, mindfulness-based chronic pain management, that helps you harness your mind’s power to quiet your pain and put you in control. 

This book helps to understand how emotions and thoughts affect physical symptoms, reverse the debilitating effects of some chronic pain conditions, Prevent pain from becoming chronic or long-term, Lift the anxiety and depression that may accompany chronic pain. 

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Every year the National Autistic Society (NAS) encourages the general public to take part in activities during the seven days of World Autism Awareness Week in order to raise money and awareness with campaigns like Too Much Information. Autism Awareness Day is marked on April 2 every year, World Autism Awareness Week will be from March 26 to April 2 in 2018.

In order to celebrate the Autism Awareness Week and to encourage awareness, we present 20 facts about autism. 

1. Autism spectrum disorders (ASDs) are neurodevelopmental conditions characterized by impairment in reciprocal social interactions and communication skills, and the presence of restricted, stereotypical behaviors.

2. In 2010 there were an estimated 52 million cases of ASDs around the world, equating to a population prevalence of 7.6 per 1000 or one in 132 persons

3. The rate of autism has steadily grown over the last twenty years. In 1980 the reported rates were about 1 in 10,000 people

4. Autism Spectrum Disorders are almost 5 times more common among boys (1 in 42) than among girls (1 in 189).

5. ASD has been reported in all racial, ethnic, and socioeconomic groups.

6. Aggregated national costs of supporting children with ASDs are £3.1 billion (US $4.5 billion) per year in the United Kingdom (excluding Social Security and benefit payments, which are transfer payments and not real societal costs) and $61 billion per year in the United States.

7. About 40% of children with autism do not speak. About 25%–30% of children with autism have some words at 12 to 18 months of age and then lose them. Others might speak, but not until later in childhood

8. Common symptoms of autism are delayed or absent speech, problems listening, concentrating and understanding, frequent repetition of words and phrases, taking things literally, difficulty sensing and interpreting people’s feelings, difficulty expressing feelings, over or under sensitivity to sound, touch, taste, smell or light, rituals or repetitive behaviours, disliking changes to routine, difficulty making friends and socialising.

9. Some of the co-existing conditions along with Autism Spectrum Disorder are ADHD, allergies, asthma, epilepsy, digestive disorders, persistent viral infections, feeding disorders, sensory integration dysfunction, sleeping disorders, and more

10. One of the biggest myths about autism is that it is a childhood condition but in reality, it is a lifelong condition. In fact in the UK there are more autistic adults than children.

11. Research suggests that around 28% of autistic people have special talents but the cause is unknown and certainly not all autistic children are gifted.

12. There is no cure for Autism; however, there are a number of behavioral therapies that can drastically improve how a person with Autism Spectrum Disorder acts. Behavioral therapies can include speech, occupational therapy, or applied behavioral analysis.

13. Autism Spectrum Disorder is much more likely to happen in children born to “older” parents, meaning mothers over 35 or fathers over 40.

14. Children with autism also often have sensory processing problems—unusual sensitivity to sounds, lights, textures or smells. They may be overwhelmed by too much sensory input, or be disturbed and uncomfortable because of a lack of sensory input, which they may try to get by bumping into things, and excessively touching and smelling things.

15. Autism cannot be cured at the present time, but a structured educational program and tailored therapy have been shown to help children develop skills they are lacking and minimize behaviors that are problematic.

16. Applied behavior analysis is a psychotherapeutic regimen that actively teaches and encourages desired social and communication behaviors that other children learn intuitively.

17. An approach called developmentally based intervention uses subjects, words, and stimuli to model a typical developmental progression for an a child who doesn’t develop them independently. As every child is different, other appropriate therapies may include occupational, physical, and speech-language.

18. Dogs have been shown to improve autistic children’s quality of life, independence, and safety. The presence of a trained dog can reduce aggressive behavior, calm the child, and serve as a link to the child’s community.

19. Almost half of children with ASD have average or above average IQ but still only 16% of adults with autism go on to gain employment

20. Children with ASD can learn and succeed in the classroom and beyond. Like every child, with the help of their families, providers, doctors, specialists, and communities, kids with ASD can not only survive but thrive in the society.

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Reading and continued development is a key element of any professional's practice. The day we stop learning, that is the day we stop growing. And what happens if we don't grow? We stagnate. So today I am sharing with you a list of books which form the essential reading list for musculosksletal physiotherapists. 

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Every runner considers injuries to be their nemesis. These can vary from minor niggles to fractures and can side line runners from their practice, performance and passion for days, weeks or sometimes even months leading to them requiring rehabilitation and graded return to running.  

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Within musculoskeletal physiotherapy, adherence to exercise programs is a challenge and generally adherence has been reported to be in the range of 50% and can be even lower for unsupervised home exercise programs. If you don't take your medicine, its likely not to have its desired effect. Similarly, if you do not adhere to the prescribed exercise program, it is likely that effect of exercise program will be sub-optimal. 

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Rehabilitation adherence is an outcome of a complex interaction of physical, social, therapeutic and psychological elements. This second article, based on the findings of my doctoral research, highlights the role of social support and other social influences as a determinant of rehabilitation adherence.

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The Mulligan Concept is one of the commonly used manual therapy techniques in management of musculoskeletal conditions. Pioneered by Brian Mulligan in the 1970's, it is based on Kaltenborn's concept of restoring the accessory component of physiological joint movement. Its been over 12 years since I underwent training in Mulligan Concept. In this article, I first review the basic principles of the concept and then later look at some of the literature around the effectiveness of Mulligan Concept. 

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