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.