Are you Taking your Medication?

I often get exasperated people coming to see me. Being told by a GP to just take more painkillers rather than giving anything more substantial is a common cause of this frustration.

As a physiotherapist my initial reaction to someone wanting a practical solution to their problem, rather than just to carry popping pills, is a warm feeling and the thought of congratulating them on making the wise decision. That being said, ruling out medication altogether can be a bad idea. Knowing how and when it should be used as part of someones complete treatment is very important.

In this months blog I want to go over a few different types of medication, their uses, some common misconceptions and the role physio’s can play in advising on medication.

Everything is Not Equal 

Despite what the establishment will have you believe these days, not all things are equal. This also applies to medication. Here are a few of the main categories that I think are relevant in the work I do:

Non Steroidal Anti Inflammatories (NSAID’s)

The most common of this group is ibuprofen (you may know this as ‘Nurofen’ but don’t be fooled by the branding or fancy packaging, it’s the exact same thing but for way more money). Ibuprofen is most appropriately prescribed for problems with active inflammatory processes going on.

Following a line of logic, if an NSAID is making no difference to your pain, it could be a clue that your pain is not related to inflammation, and therefore may not be the right medication for your problem.

One misconception around this category is that they aid in healing and recovery of new injuries (such as a sprained, swollen ankle) by reducing the inflammation. The exact opposite is actually true. The inflammatory process is a necessary part of healing, by interfering with it, you can actually impair the recovery process, and end up with weaker scar tissue and a higher risk of re-injury. The knee-jerk reaction to pop a few Neurofen whenever you’ve got a strain or sprain is therefore not the right one. My opinion is to only take these when pain is more severe and affecting things like sleep and general movement, and if things aren’t improving with time or physiotherapy alone.

Corticosteroids


Similar in the previous category in that these drugs help to reduce inflammation. This can be in tablet form often used to treat respiratory issues, or more relevant to my area of physiotherapy; injections. ‘Cortisone injections’ are commonly used in ‘tennis elbow’s or ‘frozen or impinged shoulders’, but again, aren’t risk free. Repeated injections over time can cause weakening of connective tissue, which isn’t an ideal situation in structures like tendons that need to stay strong.

I do believe they do have some benefit in certain situations however, if someone is in excruciating pain and an injection can give a bit of short term relief, it can help someone get past a sticking point and move forward with their physiotherapy treatment.

Opioids

I like to think of opioids on a spectrum – ranging from relatively mild ones like codeine, to strong and powerful ones such as morphine. On the simplest level, opioids work by attaching to receptors in the brain, blocking pain signals.

Opioids can effect people in different ways, with some people finding profound effects from very low levels of medication, and others not finding any benefit from them at all. The same can be true of the side effects experienced; some people cope relatively well with minimal side effects even with the stronger types of opioids, and others find problems like nausea, constipation and drowsiness even with low doses of codeine.

This class of drugs highlights how individual we all are and how our bodies process things in different ways. This is why it’s important to keep your GP in the loop if you find things not working or experience side effects, as they may find you are better suited to a different medication.

Neuropathic Medication

In the context of pain, these drugs are used specifically to treat nerve related symptoms. If someone has raging nerve pain tracking down a limb that has not responded to the other medication types listed above, looking at some neuropathic medication is often appropriate.

This is the class of drug I think is most misunderstood as it is also prescribed for other unrelated conditions in other people. For example, I’ve had people come to me who’ve been prescribed Amitriptyline (which is also prescribed for depression), who are concerned the doctor thinks they’re depressed after reading the leaflet inside the box.

Nerve pain can often really affect sleep, so having something to help get a better night can make all the difference in starting to recover and breaking that pain cycle.

Muscle Relaxants

Muscle relaxants definitely deserve a mention. I often see people in very acute pain caused by high levels of muscle activity or spasm. With someone in this situation, I always see if I can get things to relax or ease off with various physio techniques, heat, exercises and activity changes, but sometimes a little extra help is needed.

A short course of muscle relaxants properly prescribed through the GP can often help people turn a corner, and start to get more out of their physio treatment if they are really struggling.

A Few Words on Paracetamol


As this is probably the most common medication we all come across, so I want to make a few points on it. Because paracetamol is such a mild medication, people often think it has very little effect inside the body. This mis-understandings of it being not being harmful can lead people to have a blasé attitude towards it. If paracetamol is taken more frequently than the recommended 4 hour gap, it can have a very harmful effect on the liver. So make sure you don’t underestimate it!

On the other side however, paracetamol does need to be taken consistently to get some base level in the bloodstream, so if you’ve got a more chronic constant pain, then try to follow the doctors advice on when to take it. Paracetamol also has a synergistic effect with other medication, so taking it alongside some other medications can be more beneficial.

Final Thoughts..

A good knowledge of types of medications, when they’re appropriate and how they work is essential as a physiotherapist. A growing trend now within the physio community is training to become an ‘independent precriber’, which takes this knowledge a stage further. This is definitely something I’m considering doing, as I feel we are often better placed to assess peoples physical symptoms than GP’s and therefore give the right type of medication along with the right advice. An added bonus here of course is the reduction in pressure on GP practices which I think everyone would be grateful for! Thats it for this month, stay tuned for our next update! 

What is Pain?

 

As a physiotherapist, the majority of work we do is centred around reducing pain. Yes, we also look to improve movement, strength, balance, coordination and general function, but all this is usually linked to trying to reduce pain as a primary goal. As a therapist then, it helps a lot to understand what pain actually is. A short answer might be anything that causes you to say “ouch!”, or anything that simply causes suffering. Pain on the most basic level is just a warning system alerting us to danger, but looking deeper, it is a much more complex phenomena that I think warrants a better, more thorough explanation.

History Lesson. Stay with me.

Throughout history pain is something that has baffled many a deep-thinker. In the very old days (this article probably won’t win any historical accuracy prizes) pain was thought of as something external, that happened to us as a punishment from God. In the centuries after that a chap called René Descartes came up with a new theory; that pain was something you experienced internally. This theory evolved over time into the idea that we had an independent sense of pain. Pain was felt through ‘pain receptors’ which sent signals to the brain telling us when we’re injured. The intensity and type of pain was thought to be directly linked to size, location and severity of the injury. Seems like a perfectly logical explanation? Well, not quite.

 


Not everything is quite as it seems..

In more recent times scientists have recognised that the level of pain experienced is not always proportional the the injury sustained. To use an example, if you imagine a boxer being punched repeatedly in the face, the damage being done, and how they are able to continue to function and focus with seemingly little pain response. Compare that to stubbing your toe on your bedside table whilst walking to the loo in the night, the boxer is probably sustaining far more tissue damage but the pain response from your big toe could seem far more intense!

How we perceive the intensity and severity of pain is to do with how the brain interprets the signals it receives from the sensory nerves. How the brain interprets the signal depends on a whole host of factors such as our internal biochemistry, the external environment, our past experiences and expectations.

One of the most prominent researchers of pain science in modern times, the very eloquent and witty Lorimer Moseley, explains this far better describing his experience with pain whilst out walking in the outbacks of Australia. The TEDx presentation he did a few years back (link here) is his story, which brings you nice and unto date with how we currently understand things.

 


 

Persistent pain

Persistent (or chronic) pain is the most interesting (and perhaps the most debilitating) part of this topic that we deal with as therapists. Lorimer Moseley touched on it at the end of the youtube video, pointing out how pain can change over time. This is because the nerve pathways are ‘plastic’, meaning the more a pain signal gets passed through a nerve, the stronger and more efficient that signal can become. I like to think of it as upgrading a rickety old set of train tracks with an old steam engine into a high speed railway with a bullet train running down it. The end result can be stronger pain signals that get set off much more easily. On top of this, our ‘threshold’ for pain can also become lowered, meaning we experience pain in response to a stimulus that normally would cause no problems. As a result, things such as cold metal on the skin or even light touch could become excruciatingly painful.

“Pain is experienced in the person, not just the brain”

With all this work into pain science being focused on the brains involvement, its important to not get too carried away and think its ALL about the brain. Mick Thacker, another prominent figure in the world of pain science, tells us that pain is something the person experiences more generally, and its not just isolated to the brain and associated nerves. Changes and reactions can occur through a number of the bodies systems including the immune system which can all influence our pain response.

 


 

Sleep and Stress

Following on from the idea that pain is part of the person as a whole, lifestyle factors such as sleep and stress can influence our pain levels. Not getting enough of restorative (deep) sleep can influence the hormone balance in our bodies and effect recovery. If we are fatigued due to lack of sleep, our perception of pain may also be greater. This may become a vicious cycle where pain affects sleep, which makes you feel worse, which then affects sleep more, and so on. This dysfunctional pattern can be something that contributes to the persistent pain mentioned above.

Acute stress should be considered a normal part of life, and can be helpful in certain situations, but chronic stress (sustained stress over long periods of time) can have a more negative effect on our hormones and increase our sensitivity to pain. Stress (like sleep) can be a significant factor in persistent pain, so monitoring pain levels and seeing if that relates to a stressful period at work for example, can be useful.

 


 

Understanding the subtleties of pain can help us as physiotherapists get the most out of the people we see. Being aware of, for example, someones past experiences of injury, can help us provide a more individualised treatment program set at the right level. Knowing to keep an eye out for factors such as stress and poor sleep, and having the tools to deal with them, means we can deliver a much more thorough treatment for those people that need it.

Treating the Shoulder… With Science!!

Another month has come and gone at Physio Direct, and in that time Remedy House have hosted another excellent course, which has kicked off the series of training opportunities focusing on the shoulder.

For me this course was of particular interest, being taught by one of my old university tutors Dr Chris Littlewood. In the time since my graduation Dr Littlewood has worked extremely hard, first in gaining his PhD, and since then being involved in many research projects and publications on the shoulder. With all the work he’s done I was very keen learn what I could from him, and put it into practice in my own day-to-day work.

Why the Shoulder?

When looking at the statistics around shoulder pain, you can understand why Dr Littlewood has spent so much of his time dedicated towards improving our knowledge and understanding of this topic. Shoulder pain is the 3rd most common (physio related) reason people to visit their GP, with generally poor outcomes for recovery (with 50% of people still having pain 6 months after seeing their GP). It should stand to reason then, that this is an area we need to understand better and treat more effectively.

What’s in a Name?

Language is important. Thats the first message Dr Littlewood wanted to get across; pointing out as our understanding of chronic shoulder pain progresses, so must our use of terminology. The interesting thing however, is that as we begin to scratch the surface of the complex nature of chronic shoulder pain, the harder it becomes to accurately describe what’s going on in simple terms and provide a ‘diagnosis’. If you turned up to a physio appointment just to be told you have ‘mechanical shoulder pain without restriction’. You might justifiably think… “well duhhh, I could have told you that”. With that reaction in mind, the term Chris favours is ‘rotator cuff tendinopathy’. A description that’s more specific about what structures might be causing your pain, but hopefully wont be alarming in a way that older terms such as ‘subacromial impingement’ might be.

”Special tests really aren’t that special.”

The topic of discussion then moved onto how to assess the shoulder. I won’t go into detail too much with this, but in summary – physio’s overcomplicate shoulder assessment, with most of the fancy orthopaedic tests not really giving us much useful information. The information someone tells us, is often far more helpful than any ‘special’ test we can perform.

 


 

Sigh… I’m about to talk about Exercise..

Dr. Chris Littlewood
Dr. Chris Littlewood

Now onto treatment. This was an area Chris was passionate about, pointing out that exercise was the most promising form of treatment for the shoulder, even compared to surgery!

“We follow dentists advice when brushing out teeth twice a day, so why don’t we when it comes to our physio exercises?”

The above quote is one Dr Littlewood emphasised during the day. I think it’s a nice reminder of how important what we do outside of the physio session is. After all, if you didn’t brush your teeth for half a year and turned upto the dentists to find you need five fillings, would you be surprised to find your teeth hadn’t stayed perfect and pearly white? Some things take a bit of work and consistency. So why do we think differently when it comes to physiotherapy and exercises? More importantly, why do so many of us just not do them at all?

One explanation might be how much we ask you to do. A more than common scenario people experience is going to see a physio, being given a long list of long and complicated exercises, and leaving the session feeling slightly confused and overwhelmed. It’s not surprising most people find it hard to stick to what they’re given.

It may be refreshing to hear that Chris proposes just one simple exercise that’s specific and relevant to your problem. One strengthening exercise done consistently every day and progressed over time. Thats it.


 

Setting Expectations

We need to be realistic. With chronic shoulder pain it is SO important to accept that things don’t change over night. Dr Littlewood’s work highlights this, showing that often with rotator cuff tendinopathy, it can take 12 weeks to see improvements. Often people go to a few sessions over a 4-6 week period, but stop persevering because thing just don’t seem to be changing. The message here.. keep going!

Isn’t this just an excuse they use in the NHS to get you in and out in 15 minutes?!

No. No it’s not. You may be surprised to hear that the research conducted was done in private physiotherapy clinics, and the feedback was pretty much positive. People bought into it! Feedback from participants highlighted these points:

  • Simplicity
  • The positive and supportive environment of the clinics
  • Clear explanations and realistic expectations from the start
  • A good understanding of the reasons for doing the exercises

 

Dr Littlewood feels the key to keeping people onboard is all down to quality of care. Giving someone the time and attention they need, along with excellent support, really makes all the difference.

Dr Littlewood was supportive of the private physiotherapy world, feeling that it lends itself to treating long term conditions such as rotator cuff tendinopathies. This is mainly as people have to actively make the choice to come and see a physio in the first place, rather than being sent by their GP, and then have to choose wether or not to come back. Having this ownership of your pain is key. The ability to drop in and out for a session here and there gives you further control over how you manage your pain, and can be reassuring in the long term knowing there’s always someone there you can touch base with.


 

All in all I found this course a refreshing take on treating shoulder pain. Its nice to know the cutting edge science doesn’t always mean mind boggling fancy treatment, but instead encourages you to keep things simple. The simple stuff, done well and consistently, is often all we need.