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! 

The Part After Surgery You Haven’t Considered

The last few weeks have been challenging. Unexpectedly my dad fell and broke his main thigh bone clean in two. After the initial shock, paramedics, ambulance and subsequent surgery my dad was given the disheartening news that he would be off his feet for a good few months, with a long and slow recovery period where he wouldn’t be able to do much at all.

My father is someone who rarely sits still and always on the go. To him the news he would have to rest for an extended period was probably worse for him than the pain of actually breaking his leg.

As a physio I always see this kind of injury from a professional point of view. I think about what practical things I can suggest to make things easier at home, what exercises I can give and give about my plan going forward session by session. This time however my first thoughts were not about the rehab. Instead my mind went straight to what my dad was actually going to do to fill his days with.

Thinking without my physio hat on, I have tried to come up with a list of different activities for my dad to do, to help pass the time in between home exercises, eating and sleeping. Having done this, I thought I would share it incase you or someone you know is sat twiddling their thumbs without much to occupy themselves with. So here we go..

Box Sets

Having given up on trying to teach my dad how to use Netflix on his new smart TV, dusting off the old 24 box sets has proved an invaluable boredom killer.

Podcasts

If you have a niche interest like gardening (or classic cars in my dad’s case), chances are there’s a podcast out there for you. Podcasts can also be a great free learning tool. If you wanted to, say, learn more about history in this forced down-time then a podcast like ‘Hardcore History’ could be a great starting point to find new topics or areas to look into.

Alternative Exercise

Having an injury doesn’t always mean you have to do absolutely nothing physically. If you’ve broken a leg there are heaps of upper body only exercises you can do either at home or in a gym (even an upper body bike for cardio) to work up a sweat and keep some form of fitness going.

Learning a New Skill

Along the same lines as the podcasts, modern technology has provided such easy access to so much information and eduction, it’s never been easier to teach yourself something new. There are so many online courses or tutorials that if you wanted to learn to paint, invest in forex or even how to set up an online business, you can find all the information you need. Getting my dad to do this however may be a bit of a stretch…

Catching Up With Old Friends

Social media has meant it’s never been easier to reconnect with people you’ve lost touch with. When you’re busy rushing around it’s easy to let things slide with people you’ve been close to. Viewing your recovery period as an opportunity for this kind of stuff can certainly make the time more tolerable.
 

Final Thoughts..

As someone who’s not a huge fan of trying new things, I’m dubious how many of these ideas I came up with my dad will decide to act on. I’d still however like to think that theres a good balance of activities here for most people to keep occupied and positive whilst recovering from similar injuries.

Why I Find it Hard to Enjoy Films

Listening to a recent interview with famous astrophysicist Neil deGrasse Tyson got me thinking. He was joking about how he always analyses the films he watches to see if they’ve got the physics right. He noted how this had been picked up by the media following his comments on Twitter about inaccuracies in the film Gravity, and how some of it just couldn’t happen.

As a physio I’ve found something similar; my profession spills over into the things I watch..

Batman.. Ruined.

This became apparent whilst watching one of my favourite film trilogies. The Batman Dark Knight series directed by Christopher Nolan. I remember my eager anticipation for the last film in the series, and my excitement going to see it. This excitement, however, was slightly spoiled by my physio mind..

In the scene after Batman’s fight with Bane beneath the city (where Batman seemingly gets his back broken). Bruce Wayne lies crippled in an exotic underground prison, only to be strung up by rope from the ceiling to have his ‘protruding vertebrae’ punched back into place.. Miraculously after a period of time hanging from the ceiling.. He can walk again! Although I knew it was only a film (featuring superheroes), I couldn’t help from thinking about the anatomical impossibility of what I’d witnessed.

The Car Chase Frustration

Ok, so a one off irritation?.. Unfortunately not. My physio mind interrupts me frequently when watching a common feature of action/thriller movies; the car chase. Something that tickled me during all of the Bourne films; watching each car chase as Jason Bourne races through the streets, down steps and over jumps. I couldn’t help but think as his car collided with the side of pursuing police car what grade whiplash he might suffer from on the Quebec scale.. The over-analysis didn’t stop there; as the following scenes left me thinking how he might be far too stiff to roundhouse kick the villain if it’d happened in real life.

Recently this over analysis was brought to the forefront of my mind again, whilst watching a new addition on Netflix; the film ‘Bleed for This’. A film based on a true story about boxer Vinny Pazienza who suffered from fractured vertebrae in a car accident, only to return to the ring to win a world championship. Although this may sound wrong.. this time I was pleasantly surprised to find the injuries sustained matched the apparent severity of the accident on screen.. Terrible I know.

Not All Bad!

It didn’t end there. I also struggled to find fault with the recovery process. The physio within actually cracked a smiled at Vinnys determination to recover, and how the film showed him training with his external, steel neck brace (that was bolted to his skull) still in situ. As someone that likes to work round problems rather than use them as a reason to ‘rest up’, this appealed to me greatly.

Perhaps due to it being based on real life, this film was different. So just a one off?

Racking my brains, it turns out there were quite a few of these examples. From Hank getting mowed down in Breaking Bad, struggling emotionally and pouring with sweat learning to walk again, to Leonardo DiCaprio being mauled by a bear in The Revenant and nearly dying, to using bits of wood he found lying about to help him rehabilitate his own broken leg.

The Hollywood Factor

Although these examples undoubtedly used some poetic license make them more entertaining, a common theme that appears (and that I probably enjoy more because I’m a Physio), is the visible struggle and fighting back against the odds back to normality.

Watching these stories of recovery has certainly helped provide some fresh motivation for my work after the credits finished rolling. Going to work the next day, I’ve found an extra burst of enthusiasm wanting to help people push that bit more to get that little bit better than they thought they could.

The flip side of this ‘Hollywood factor’ is how it impacts on the people that come to see me. Many people have seen the same things on TV and in movies and assume it’s going to be a straight simple path back to recovery. The reality, however, is much less glamourous. Treatment can often be slow, tedious, repetitive with disheartening steps backwards every so often, which can often be a hard pill to swallow.

Final thoughts…

Even though it’s comforting to think that Neil deGrasse Tyson also watches films through the lens of his profession, it’s probably not a good habit to have. I think I might give films a break for a bit and go play outside.

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.

Why Physiotherapy?

Why Physiotherapy?

Welcome back to another PhysioDirect blog. This month I want to fight the corner for physiotherapy, and put forward my argument for why I think it’s so damn important. The reason for this article comes after a recent conversation I had with a personal trainer I know called Tom.

The story Tom told me involved his girlfriend, who had competed at a decent standard in sport, and sustained a knee injury not too long ago. It was interesting hearing how someone in his line of work (with a good knowledge of anatomy, human movement and appropriate loading) viewed things from an outside perspective.

A Familiar Story

After some difficulty getting an appointment with her GP, the initial advice Tom’s girlfriend received was to “rest the knee and come back in a few weeks if it hadn’t settled”. With no change and several return visits in which different painkillers were prescribed, she was finally referred to see a physiotherapist. The session involved an assessment and some exercises consisting of stretches and squeezing the knee straight when lying on her bed. Tom’s girlfriend was then given another appointment, booked for a months time.


 

sport massage model

Where does.. or CAN physiotherapy have the edge?

Tom expressed his frustration around this lengthy journey with very little improvement, as someone who works with fit and healthy people every day, and knows how much progress people are capable of making in a relatively short space of time, the prolonged period of rest and long gap between appointments seemed slightly absurd. Tom felt compelled to try and help her out a bit more. Taking some initiative and adding a few more challenging strengthening exercises, things finally started to improve.

So with all that time and professional medical intervention from a doctor and a physio, it was Tom’s personal training approach that seemed to help most. The above story does paint a picture of things not going as well as they should do, but when physiotherapy is at its best, in my (slightly biased) opinion we should be miles ahead of the competition when helping people recover from injuries. This is why:

  • Assessment – Our assessment methods should be second to none. When asking questions, we aim to cover all aspects of peoples lives leaving no stone unturned, delving into all factors that might have contributed to, or influence an injury. When it comes to the physical side of assessment we should also be at the top of the game. Using the knee as an example, the physical tests we can perform should be on par with Orthopaedic Consultants, and much more proficient than that of your average GP. Being able to tell when something is serious or not can mean we don’t waste time being too cautious, but also make sure someone gets the right medical treatment if they need it.
  • Knowledge of anatomy, injuries and pain – A good portion of our university study is dedicated to learning the underlying anatomy and physiology. Our knowledge of different injuries alongside the healing processes should also be top notch. Put that together with all the information we gain from our assessment about the factors that can affect recovery, and it means we can more accurately pitch any rehabilitation program at the right level. Physiotherapy researchers are also currently leading the way when it comes to pain science. Understanding how pain can become more complex over time can also be an important thing not to miss when helping someone.
  • Knowledge of treatment – We have a large variety of treatment options at our fingertips. We are also whats called an ‘evidence based profession’ which means we try to make sure our treatments are based on quality scientific research, with the aim of delivering the most effective form of treatment in any given situation. The current physio leaders in the science world do however tell us it’s not a ‘one size fits all’ approach, and we need to be able to use our reasoning, the information from the assessment, and consider things like the personality of the person in front of us to tailor our treatments individually.
  • Knowledge of appropriate loading – this is an area that was perhaps lacking in Tom’s girlfriends story, but as physio’s we should have the experience to know exactly how much or little to ask of someone to ensure that they make progress. This sometimes means pushing some people a bit more than others!
  • Our status in the medical world – Physiotherapists set themselves apart from professions such as Osteopaths and Chiropractors by being part of the ‘Health & Care Professions Council’ (or HCPC for short) which strives to deliver the best standards in care in keeping with the above mentioned ‘evidence based practice’ approach to treatment. The elders of the physio profession also campaigned for the right to be ‘autonomous practitioners’, meaning we can work as independent medical practitioners within our specific area . This has lead on to us gaining the ability to train to prescribe some medications and deliver injections, expanding further the list of treatment options at our fingertips.

So there are a few points on why I think physiotherapy is so great. I think it should be said that nothing was terribly wrong with any of the treatment Tom’s girlfriend was given (either by the GP or the Physio), but it goes to show how something as simple as not getting things started quickly enough, doing things that are too easy and having too longer gap between treatments can leave someone dissatisfied.

 

Private Physiotherapy

On another note, the story Tom told me made me feel quite fortunate to be working in private practice. The private world is not restricted by limited session numbers, months long waiting lists and 20 minute appointments. If someone sustains an injury they can ring up and usually get an appointment the same day. Early physiotherapy intervention with most injuries will only help to get someone better quicker. If someone needs a couple of sessions a week because they need more guidance, one-on-one rehab sessions or small changes to progress their exercises more quickly, or even just more pain relief from hands on treatment? Not a problem.

 

After mulling things over I’m very proud to be part of the physiotherapy profession, and I do believe that when it’s done well, physiotherapy should be the go-to choice for anyone with an injury. If you want to find out more or book an appointment, call us on 0115 956 2353.