Eusterby

Hip abductor and adductor machines - part two

2009-03-21T20:50:00.004Z

The post on hip abductor and adductor machines has generated quite a bit of discussion. Some of you are right, these machines will have a role for those who need these muscles strengthened when their strength is low, for example after spinal cord injury or joint replacement. I just doubt their usefulness in those with normal muscle power.

It is hard to see the machines causing any signficant problems in hip replacement in terms of dislocation, especially moving the legs apart to work the abductors, as this is the safe movement for hip replacements.

However I would be keen to know that the abductors were actually weak in these cases and if a lateral approach has been used, that the greater trochanter had healed up. Otherwise a non-union of the bone is possible with too much force put on it too early. Because everyone's case can be different, there is no substitute for asking one of the surgical team, which I would generally advise.

Sit Up Straight To Avoid Spinal Fractures

2008-08-16T15:40:00.006Z

Poor posture and bony changes in the spine occur as we get older and can cause an increased rounding of the mid and upper back. This is called a kyphosis (ky-fo-sis), and when the curve becomes exaggerated at the junction between the neck and the trunk it may be referred to as a “dowager’s hump”.

Osteoporosis, thinning of the bones, is a common finding in older adults, especially women after the menopause, although it can affect people of all ages. Spinal fractures are also common and can cause stiffness, tenderness of the area and pain.

Due to the way the bony struts inside the spinal bones are organized, the front part of the vertebrae is less strong than the rear. Combine this with the constant tendency of gravity to push us down into a bent position and this increases the forces through the fronts of our spines.

Pressure on the fronts of the vertebrae can cause compression fractures which small breaks in the interior scaffolding of the bone, causing a wedging effect in the bone.

Imagine lots of wedges on top of each other and you can see they make a curve, causing the hump posture which can also reduce a person’s height. This posture increases the forces acting on the fronts of spinal bones, causing further fractures.

Sitting upright decreases the spinal forces resulting from a bent posture. A physiotherapist can prescribe posture correction and spinal exercises to counteract the tendency to flex. Avoiding a stooped standing or sitting posture or lifting weights with a bend spine is the best strategy.

Bigger muscles by slower work

2008-08-10T19:57:00.003Z

I've started a new weight training regime and it's working well. My muscles are responding to the increased stresses by getting bigger and stronger at a rate I have not seen for many years.

I have been weight training on and off for 30 years. When I was 21 I was 6' 1' (187cm) and weighed ten and a half stone (147 pounds). Yep, that was me lite. And skinny. Weight training (and time!) have increased my weight to 13 stone and a half (189 pounds).

But it's been a slow process and as I get older I have less time for messing about in the gym. I've done weights so badly over the years! And I see that same ineffective work going on every time I go to the gym.

The Colorado Experiment is what I have based my present regime on, although the subjects of the experiment (which included Casey Viator) were very big guys before the experiment started. And I don't take it quite so seriously.

The key is intensity, that's what muscles respond to.

So what do I do? A warm up set with a very light weight first. Then just two sets with a moderate weight but very slowly. I make each half of the movement last for five seconds. Five whole seconds each way is very difficult to keep to but it racks up the intensity amazingly. I also do a full movement for the body part with no throwing.

This blasts my muscles and only takes 40 minutes for a overall body workout for the major muscle groups. It would be quicker but I get out of breath at times.

So if you want a real boost to your workouts, stick to moderate weights, good exercise form and ten seconds each rep. You will notice the difference.

Developing a "Fitness Pill"?

2008-08-02T14:10:00.002Z

So scientists are moving ever closer to developing a fitness pill. Narkar et al are about to publish their research in Cell, in which they detail how they treated mice with a chemical substance for four weeks.

The results were a surprise and may be important. The mice showed increased running endurance of 44% with the new treatment. It's possible that this chemical pathway could be used to increase adaptation to training and even to increase endurance without doing any exercise.

Wow! I can't see it all working out as it seems it might. This might be a useful technique if it can be shown to be stable and without serious side effects. People with abnormally low exercise ability due to illness or injury might be good customers for this treatment if it ever becomes one. Let's hope they continue this interesting research.

The rest of us will just have to keep on exercising. When you exercise your car hard, it just wears out a bit quicker. When you exercise the human body hard, it responds with better and better performance. Besides, isn't it fun?

Simple exercises make a difference

2008-08-02T13:34:00.004Z

I've been pleased recently with my dedication to my exercise regime. Starting exercise is easy but maintaining it over the long term is very hard. And the long term is where the benefits come in. Being a physiotherapist exercise advice is important professionally as well as personally.

Since I have a chest condition and am 53 years old, I have age and a (relatively minor) health problem to encourage me to keep going. I exercise every other day, alternating running with going to the gym.

Running 40 minutes near where I live is great, there's a large expanse of countryside with a river running through it. Lots of soft ground, short grass and great scenery. When I run past older people out walking, I think why am I doing this? Well, I'm trying to get to their age!

The weight training is different. I love the gym, all the clanking, creative exercising, posturing and mirrors! Most people don't exercise very well and bad technique is all around. I have changed my way of weight training recently and the results are very interesting. It's also taking me much less time to do my training and is kinder to my somewhat older structures.

I'll cover what's new in the gym in my next post. For the meantime, keep going with the exercise. You don't have to go mad or work at a high level, you just need to do it again and again. It 's the old practice makes perfect cracked record.

For suggestions for simple exercises go to The Simple Exercise Series. Seeing a physiotherapist may be your best bet to kickstart your exercise regime and progress it correctly.

Your golf swing could harm your knee replacement

2008-04-16T20:58:00.003Z

It's been hard to know exactly how to advise people after knee replacement exactly which exercise activities they could safely pursue. Even though you can hear stories of people doing all sorts of things with their replacements, what is the sensible course?

Our usual line is "Contact sports, squash, skiing, tennis, jogging and jumping are a bad idea. Good sports are walking, bowls, golf and swimming."

Recent research in the US has thrown this consensus into disarray. Researchers have used specially designed knee replacements which can measure the forces put upon them from the inside. This has shown up that golf, usually thought to be a low impact activity, may put much larger forces on an artificial knee joint that previously suspected.

For further information please go to The Physiotherapy Site.

Why use hip abductor and adductor muscle gym machines?

2008-04-13T17:08:00.007Z

I'm in the gym at least twice a week for an hour, doing a whole-body routine to keep up my muscle power and mass as time goes by. At 53 I want to make sure I don't lose muscle every year as I inevitably would if I didn't train at all.

I do a mixture of exercises, using machines, free weights and the gym balls.

However, as a physiotherapist I really can't see the point of the hip adductor and abductor training machines. You know, the ones the girls make a beeline for and spend some time on, imagining it's going to do good things for their buttock profiles.

Somebody looked at the movements of the hips and said "Hey, we can make machines to exercise the hip in-and-out movements!". So the hip abductor and hip adductor muscle training machines were born.

The hip muscles are very powerful and have to cope with stabilising the pelvis in weight bearing and with propulsion of our high body weight every day. This is called walking! Or running or jumping. The forces involved are very high as the muscles are either stabilising or contributing directly to the movement of our whole bodies.

On the machine we can't approach the forces that we do day to day in walking and moving about generally. If you want train your buttocks then there are lots of exercises which might even be effective! Examples could be lunging, jumping, sprinting, leg press, squat. And many others.

So my tip for today is, do something else rather than spend useless time on these machines. But I'd be interested to hear if any of you have different opinions.

Stretching Muscles After Your Workout

2008-04-10T20:30:00.004Z

I love to workout in the gym, always have. It's the clanking of metal, the rubber flooring, the smell, it all means muscles and effort.

At the end of my workout I'm always keen to head for the shower. Yes, I try and leave out my stretches if I can. Even though I know they should help me become more flexible and allow me to exert more effort to build muscle.

Stretching is easy to build in to your workout, best at the end. There's lots of guidance around about how you should do them. I've found out a few tips over time.

Choose a stretch for each major muscle group
Go to the discomfort point and hold.
Don't bounce or move about. Relax into the stretch and breathe steadily.
Hold it for 30 seconds. This is much longer than you think. If you guess you'll always stop too soon. Stretch so you can see a clock with a second hand.
Go have a shower. Well done!

I've found a lot of interesting information and a great software product which I have bought at The Stretching Institute which I'm sure will be of help to you. The software allows you to generate good quality pictures of the stretches you or your customer need to do, giving accurate guidance as to the technique.

Achilles tendon rupture and age

2008-04-10T19:06:00.007Z

Our bodies change with time. If we are lucky this is a slow process and we may not notice it much. Until something pulls us up sharp, that is.

Our ligaments and tendons are very strong to cope with the large loads we put them in sport and recreation. This is fine when we are young. As time goes on however, the loads we put on our tissues get closer and closer to the maximum stresses they will tolerate. You may have several attendances to your physiotherapist before the big one hits.

The achilles tendon is a large structure in the calf with a poor blood supply. It transmits all the forces of our bodyweight as we move about in life. These forces are sometimes very high.

Football (soccer), squash and sprinting in your mid-40s may just not be a good idea. An achilles tendon rupture is a risk and it's a disabling leg injury. If you get operated on it'll be six weeks in plaster and being careful for three months or more. If not, you're in plaster for much longer and it'll be six months or more before you're back to action.

That's a big chunk out of your normal life. And you'll need to spend some time with the physiotherapists to rehab your ankle.

A rupture of achilles tendon is a signal that you are putting stresses on your body that may be excessive. It is possible to be sportingly active over 45 but you need to be more careful with warm up and training if you haven't done it for a while.

If you have a pain problem then a steady and planned approach to activity is vital. Pacing is the important skill here, the ability to make logical measurements of your activity and increase by pre-chosen increments.

Actually, pacing applies to us all at any age. Athletes use the technique to get ready for the Olympic Games, pain patients to control their chronic pain.

Go to Pacing for Pain for a load of information about this important pain management technique.

Sciatica Is Not A Good Term

2008-02-14T16:08:00.005Z

5-10% of low back pain sufferers develop severe leg pain at some stage in their lives. This is usually termed "sciatica" from the greek meaning 'hip pain'. Physiotherapists are often consulted and can be part of the symptomatic treatment of this distressing condition.

Leg pain is difficult to understand. The pain of sciatica is best referred to as nerve root pain or radicular pain. This implies the nerve root (near the disc) is compromised in some way and giving pain in a particular pattern down the leg. The commonest cause is a disc prolapse.

However, disc prolapses are very common and mostly don't give any trouble so it's hard to know if the one you are looking at on the MRI scan is causing the patient's problem.

Low back pain often generates referred pain which can be felt right down the leg, although it is usually aching and non-localised in nature in contrast to the severe, surging pain which every nerve root pain sufferer knows all too well. They can mostly tell you very accurately where the pain is.

Studies have shown that operation can make the leg pain settle down faster than conservative measures (medic speak for waiting) but that there is no difference to how people are two years after the onset of the leg pain.

Most people recover well from nerve root pain episodes but some go on to have longer term problems with their leg pain.

Whatever the outcome it is better to use the term nerve root pain and diagnose this problem accurately if there going to be better understanding of this unpleasant pain syndrome.

Lifting Training Doesn't Help Low Back Pain

2008-02-14T14:38:00.004Z

All of us who work in NHS hospitals have a lot of mandatory training to do every year. It's part of our contracts and includes cardiopulmonary resuscitation, fire, child protection and manual handling.

There has been a big push to get manual handling training a higher profile and in our department no physiotherapist should touch a patient before they have this. Mainly this is for insurance liability reasons so the organisation can discharge its legal duties to the staff.

I've never been sure whether manual handling training prevents physiotherapists, or other staff, from developing low back pain. Yet it's always seen as "a good thing".

Now the British Medical Journal has published a paper by Martimo et al in the January 2008 issue which reviews research evidence whether training or advice reduces the incidence of low back pain conditions.

They conclude there is no evidence that advice, training and using lifting aids prevents low back pain or the disability from it.

It looks like there may be reasons for manual handling advice and care but preventing back pain may not be helped by this. We don't know enough about what stresses physiotherapists and nurses physically and how this translates into low back pain problems.

There's more about back pain at The Physiotherapy Site.

Exercise is good for you. And Bad.

2007-10-16T19:10:00.000Z

There's so much encouragement to exercise. Everywhere. And it's always positive press, there's never any negative. But watch England's rugby scrum collide with the French scrum and you wonder can it be good for the body.

Many people with diseases and disabilities have been advised not to exercise when they could benefit greatly from it. Increasing your strength and functional ability can lead to good improvements in independence.

Exercising properly is a matter of getting it right, of balancing the intensity of exercise with the ability of the body tissues to cope with the stress. All the skill and benefit of exercise depends on this balance.

Pacing is one of the important, basic skills of getting this balance right. Pacing For Pain gives you the inside information on this technique, and the ebook "Secrets of Pacing".

Total Knee Replacement - Which Therapy?

2007-10-03T19:12:00.000Z

How much and what type of therapy should patients have after total knee replacement? Recent research has shed some light on this difficult question.

Researchers in the UK at the University of Birmingham searched the medical literature for evidence of which kind of exercise was most helpful post-operatively. The results are provisional at best but give some pointers.

The management of knee replacement has changed greatly over the last 10 years. The length of stay in hospital has rapidly and greatly decreased, with a common stay of 4 to 5 days. This has transferred much of the rehabilitation effort to outside hospital units.

The researchers found there was some evidence to support the performance of functional exercises (e.g. balance, coordination, stair climbing, cycling) over just performing static strengthening and range of motion exercises.

At 3 to 4 months after surgery there was a small but useful advantage in doing the functional exercises, but at a year this advantage had disappeared.

I think this means that performing functional exercises may get you back towards normal function a little quicker than not doing them, but that in the long term it does not matter much.

The bigger question remains. Should there be much extensive and intensive therapy after knee replacement to address the obvious limitations in strength, range and abilities after this major orthopaedic surgery?

Reference: Lowe CJ et al. Effectiveness of physiotherapy exercise after knee arthroplasty for osteoarthritis: systematic review and meta-analysis of randomised controlled trials. BMJ (British Medical Journal) 2007, September 20.

Concepts Without Explanation (CWE) 2

2006-11-07T22:20:00.000Z

It's easy to disable people with a word. We can all do it if we deal with patients with health problems of various kinds. They are vulnerable and looking for explanations and understanding. When you give your opinion, they take the idea and convert it into their understanding, often in a visual form, as an image of what is going on.

CWE word of the moment: ARTHRITIS

This is a very powerful word with important meanings for lay people. It conjures up images of destroyed joints, disability and pain. Since arthritis is technically one of the most common conditions in the world this may not be the best way of thinking about it.

As physios or other health workers we are in a great position to do this well. Or badly!

One of the things I have learned in many years working in a hospital is that you should never underestimate the depth of someone's ignorance about their body. That doesn't mean you think they are stupid or patronise them, but don't be surprised when their view of what's going on makes no sense at all. It's our business to find out what these views are and help people towards what we would think of as more realistic interpretations.

Most people have no idea at all what arthritis means. It is usually interpreted as being very negative, as spreading round the body and as being the end of normal function. As such it generates a lot of anxiety.

So using this word comes with a lot of anxiety and we have to be aware of that and offer explanations to clarify the true meaning of the concept as it applies to the patient in front of us. Saying "wear and tear" or " joint damage" may well add up to the same thing so needs the same care.

Over time you develop a "politically correct" dictionary of terms to help you patients understand what their condition means and with the least chance of misinterpretation. That takes some care and the ability to question, listen and respond. So how do you explain? Yes, I'll get onto that another time, along with more danger words from the CWE dictionary.

Avoid Concepts Without Explanations

2006-11-02T22:33:00.000Z

Since I have been working with orthopaedic patients and with people in pain, I have developed some rules by which I practise. We all do this in our various occupations. I get fixated with one guideline or another at times, hopefully moving the idea forward.

My latest thing you should NOT do with patients is give them concepts without explanations. When they come to us there is usually a diagnosis involved, an inference about the possible underlying pathology. It's a concept and that's dangerous.

When we provide information and educational input to patients, we are transferring part of our concepts to them. Unfortunately these ideas do not pass smoothly from one person to another, nor does the recipient of the information interpret the concept in the same way as the giver.

Giving someone a concept, or part of a concept, and letting them get on with it is bad. That's it. Bad. Who knows how they will interpret this and what images they will conjure up?

We HAVE to give explanations with our concepts, we have to find out what the patients are thinking when we give them a concept. Then we need to correct the interpretation if we feel it is inaccurate. And check again later. It's that important.

Be wary of giving Concepts Without Explanation.

The Ottoman Empire

2006-09-22T20:15:00.000Z

I've just spent a week in Istanbul. Turkey is a real culture shock for someone used to western European and American societies. They have a long and illustrious history of their own, with our societies having little relevance in their development.

Walking through a huge, bustling middle-eastern city of 15 million people, I was struck by all the signs and billboards. Big letters, exclamation marks and colourful pictures proclaimed their messages, but I could not make out one clue as to what they all meant. In most western European countries you could work out at least some of the communications. Not in Turkey.

The Turks are friendly and you feel quite safe. They either ignore you or are interested in where you are from. The have little need to speak English as they have their own self-contained language and culture. Turkic type languages are spoken by many millions of people right across Asia, with whom they have a natural racial affinity.

The main reason for going to Istanbul was to attend a European pain conference. It was very well organised. The audiovisual presentations NEVER failed, they all worked perfectly, and that's rare. Congratulations to Lutfi Kirdar Centre.

I started reading about the Ottoman Empire, about the great deeds, the battles, the cruelties, the riches and the great architecture. It was a huge empire and it lasted a long time, much longer than the British or American Empires.

All those battles are described in heroic terms but the suffering must have been enormous. You get no sense of the pain, the injuries and the long-term disability which resulted. So many thousands of men, damaged so badly, with no record of their lives after the event. Lots of work for a physiotherapist there, but I don't know if there was anyone who worked in rehab. I should look that up.

Looking at the magnificent monuments built through the ages, apart from reverence and respect, I am always amused by what the tourist guidebooks say. "Agia Sofia, the greatest church in eastern Christendom, was built by Justinian in...". Built by Justinian? Built by Mehmet the Conqueror? Built by Suleiman the Magnificent? Well, they gave the orders.

It was thousands of ordinary people who actually toiled for years to build the monuments we now enjoy. They slugged away, suffering back pain and who knows what else, falling from heights, having things fall on them, having short lives.

Am I depressed by all this? No, not at all, but it's good to remember all the people who worked their lives, died or suffered in battle, behind the grand history.

People need time

2006-07-17T17:27:00.000Z

Time is important. Giving people the time to express what they want and explore their issues is the key to developing that important therapeutic relationship. This in turn is the key to finding out what their issues really are and avoid applying your solution too quickly.

There is no substitute for sitting down and listening to a story. Humans love stories. We all do. A patient always comes with their story. Sometimes they are well formed, pouring out in clear patterns, other times they are confused and chaotic, jumping from subject to subject and from time to time. Still more difficult is the story which won't come out even with prompting.

But you've gotta get that story, however you do it. You may just need to say hello and then you get the whole thing, just like that. Wow, it's amazing when that happens. You may need to prise every answer out, explaining everything twice. That's hard work. Mostly you pick your way through a mass of facts, looking for patterns which fit.

It doesn't always do to lead the interview too closely. Apparently, a patient will feel he or she has been heard if you let them talk for two minutes initially. I like to ask, after a very short preamble, "Tell me about your pain problem". That usually does it.

As people talk it is important to clarify the things they say, as misunderstanding is very unhelpful to the overall view of what is going on. You can pick up on small facts mentioned in passing which may be important in the picture. You have to chase those small threads, they can lead to interesting places.

Typical refrains from patients with spinal and pain problems are "Nobody listened. Nobody believed. Nobody understood". If you avoid those traps and really listen you will be rewarded with interesting stories, clearer views, devoted patients and improved outcomes.

Next I think I'll move on to the importance of always believing. Yep, always.

The Straight and Narrow

2006-06-17T20:53:00.000Z

There are just so many Straights and Narrows. Not just the moral ones, the religious do's and don'ts, but all sorts which apply to all aspects of our lives. Even to pain, which as you may gather is one of my main interests.

When it comes to the capabilities of our bodily tissues, the Straight and Narrow varies steadily over time. When we are young, the Straight is quite bendy and the Narrow is quite wide. What I mean by this is that we can subject our tissues, our muscles and joints, to a lot of stress when we are young and get away with it.

We can stray from the path of tissue protection quite strongly and do it more often, a bit like staying up for parties for a few nights in succession and still managing to function afterwards. When we are older we can't do this!

If we stray from the path there are consequences. Sometimes they are not too severe. So the path here has nice surroundings, a bit like short rough just off the fairway in golf. We don't suffer too badly and can quickly return to what we did again.

As we get trained in an activity, the path gets very wide indeed and we find it harder and harder to get off it. If you've trained for sport or in the gym, you may have got to the point where you had to make extreme efforts to push yourself to feel muscle soreness or tiredness. You were just so damn fit.

As we get older the path gets straighter and it gets narrower. This means it's easier and easier to fall off, to make our body suffer, if we push ourselves to overdo things. But that's not all. I haven't finished with the path metaphor yet!

When we move into the realm of pain conditions, the path becomes a scary place, a hard place to keep to. And the consequences when we stray can be severe.

That's because the path "develops" a drop on each side. It can be a small drop, causing a problem and some difficulty climbing back up, an additional delay before we regain normality. Or it can be a huge drop, a catastrophic loss of bodily abilities and a long, hard climb to get back to the path. If we can at all.

Every human being alive today is constrained by the resistance of their bodily tissues to physical stress. To some, who are young and strong, it really doesn't show itself. It's still there however. For others the sensitivity of their body to activity is so acute that it dominates their lives.

This is a favourite subject of mine and I do go on about it. But I believe it has something really useful to teach us, a way of coping with our difficulties. Pacing is the name given to this technique. My ebook on the subject, for people with chronic pain problems, is at
http://www.thephysiotherapysite.co.uk/business/pacing_sales.html .

There's more to go on the Straight and Narrow, and also on the Hare and the Tortoise!

fibromyalgia does exist but what does it mean?

2006-04-06T19:03:00.000Z

Variation occurs in all populations of organisms on earth. It's inevitable given the laws of genetics and evolution.

When it comes to pain and fatigue, a small but significant proportion of the population complain of pain and tiredness, attending their doctors in search of diagnosis and relief. We all feel pain and tiredness at times, but this group have more problems than we would consider normal.

However, at the far end of the pain/tiredness spectrum are people who complain of severe pain and/or tiredness which is way beyond the normal presentation of symptoms. These people are now classified as fibromyalgic or as suffering from chronic fatigue.

Not all doctors believe that fibromyalgia exists. I wonder if that is partly because there are 9 women sufferers to every man and most doctors have been male. As female doctors start to dominate the profession perhaps there will be a change of emphasis.

Fibromyalgia is miserable for the sufferers. Their physical abilities are so limited by the severe pain which results from even a low level of activity. And it's relentless, giving no relief at any time. It's like a fierce disciplinarian, never giving you any leeway, ever.

One of the common impressions which comes up regularly is the frequency of physical abuse being a factor in the history of these people. The repeated exposure of the nervous system to painful input might sensitize it to all incoming stimuli, giving the exaggerated responses to many stimuli which characterise fibromyalgia.

Perhaps the reason that women outnumber men 9 to 1 as sufferers is partly explained by the fact that men are the ones who are physically violent to women. The opposite occurs but is much rarer. Women suffer the physical violence and then suffer the long term and persistent consequences.

Physiotherapy jobs - It's that time of year again.

2006-03-20T21:29:00.000Z

It's the time of year when people coming to the end of their training courses start to try and promote themselves into a job. Physiotherapy in the UK has overshot its required training numbers by an unknown but significant amount.

This leads to a very tight market in new physiotherapy jobs. It's already tight in the NHS jobs market and that's before this year's crop of 2000 or so new graduates hit the streets.

In my medium sized NHS Trust, an acute hospital of 830 beds, we have had over seventy enquiring letters so far, with the majority I suspect still to come. Anxiety about getting a job in your chosen area is a new feeling for physiotherapists.

Approaches by letter vary quite widely in quality and care. Good presentation is important in a competitive environment. A must is to give an email address, often surprisingly omitted. This makes it much easier, and less expensive, for us to reply.

Some people just promote themselves so badly it's hard to see them managing to persuade anyone to give them a job. The prizes will go to the good self promoters, the flexible, the persistent and the achievers. There'll be losers, unfortunately, who may get less responsible and rewarding jobs for the foreseeable future. It's hard to see what will happen next but I don't expect applications for physiotherapy training to take a dive.

Do we think we're normal?

2005-11-30T22:16:00.000Z

Habits have a bit of a bad press. We all tend to concentrate on bad ones, usually when performed by someone else. They must have survival value in the world, be a useful set of behaviours to approach the many situations we have to cope with.

Sometimes we don't see that our habits have moved into another dimension, the dimension where they don't make much sense to other people. We cling to our habits, perhaps because we have so much of ourselves invested in them.

One of my customers was telling me about the communication difficulties he was having with his nearest and dearest. It's always difficult when you get one side of the story and I am very conscious of not giving advice about relationships. But exploring these things can be fascinating, and have impact on the therapy for the person.

On questioning (always a much more powerful technique than telling) he has specific and rather rigid habits. He likes all the dirty crockery and cutlery lined up and in particular containers. He does most of the duties about the house but complains his partner does not do enough.

How does his behaviour look to his partner? To me it looks a little obsessive and is probably irritating. However he has not asked her what she feels about the way he behaves. He laughed somewhat sheepishly when I pointed this out. He likes everything done a certain way and at a certain time (straight away - which tires him out) and very likely is unable to delegate and let someone get on with a job (or not).

Sometimes we are so much in the groove of our habits that we forget there is even the vague possibility of someone doing it differently. And that different way could be as or more valid than our own way.

Now all I need to find it someone to tell (or ask) me about my habits and perhaps I can change and be more effective too.

A buyer's market for physiotherapists

2005-11-30T21:49:00.000Z

The large NHS hospitals were the automatic choice of many newly qualified physiotherapists when they were considering their first job. It seemed the obvious choice with the variety of experience, supervision systems, peer support and on-site expertise.

A small town hospital in East Devon (South West England, UK) recently advertised for a junior physiotherapist. Nobody goes there without a good reason, it's just not on anyone's travel plan. The breadth of experience is restricted, the opportunities relatively few. Did they have any applicants?

You bet! They had over two hundred!

Now some of those can be explained by the fact that India has a surplus of physiotherapists at the moment, with an M.Sc. necessary for them to progress. Many apply to the UK and are now finding they have little chance of success with the large numbers of unemployed UK applicants.

Out-of-work physiotherapists have had to make many hard decisions to go forward somehow. Some work in non-health jobs, others have taken volunteer posts or posts which are usually taken by unqualified people.

One upshot of this is that physiotherapists have been forced to think more flexibly about where they might get their first few years experience. We in the large acute hospitals are unable to magic up a huge number of new posts, although we have done our bit to be creative.

Physiotherapists are now considering getting their first jobs in community posts or in small provincial hospitals. That should be good for the units concerned as it was always hard to attract applicants to what may have been seen as less glamorous areas of work.

This market is putting a huge pressure on the locum agencies, who are finding the number of posts available has been cut dramatically. We are in an intense buyer's market for the moment. As the manager of a department it is good as we get people queueing up to come and work for us and can take our pick of good candidates.

It is hard for those caught up in the process however. Many are finding they cannot be so casual about their choices anymore. Can you go travelling for a year and risk coming back when the next year's cohort is qualifying and looking for jobs?

The quality of applications is one of my little obsessions. Some are so bad I can't think they really want a job. You need to be good even to get considered at the moment, let alone appointed. The market is working it's cold magic.

chronic pain management

2005-08-14T10:29:00.000Z

Chronic pain is very common, afflicting a large percentage of the adult population at some level. We can solve many acute pain problems, such as fractures, hernias and infections, but long term pain conditions are a hidden and continuing burden.

If we can't cure the pain, what can we do? Good question. Pain management teams are common in western societies as the importance of chronic pain has been recognized. They usually consist of anaesthetists, clinical psychologists, physiotherapists, occupational therapists and nurses, in various combinations.

One of the fundamental points is teaching patients pacing. The tissues of our bodies have a tolerance to physical stresses. Try going to the gym and pushing yourself when you haven't been for a while! Then you'll feel what I mean.

Overstepping tissues tolerances may not be a big deal for "normal" people, but for pain sufferers it can be critical.

For any of you with these problems I have written my first ebook -
"Secrets of Pacing. How to control your pain and regain your life".

Pacing is a fundamental skill of pain management and my patients tell me it is overall the most important thing we have taught them.

2005-08-13T21:21:00.000Z

change in the nhs

2005-08-13T20:04:00.000Z

It's a while since I've posted anything. So much change is occurring in the NHS it is occupying a lot of my time. I manage a physiotherapy department of about 75 people, providing respiratory, neurological, orthopaedic and musculoskeletal expertise to a large acute hospital.

The new pay structure for the NHS, called Agenda for Change (AfC), is being introduced. This may not seem like much but think about the size of the organisation. The three biggest employers in the world are the Chinese Army, the Indian Railways and the NHS. So it's a massive job.

The government stated than AfC would be funded but this has proved not to be the case. It is likely they could not predict the outcome of this process once it was released into the wild. In one of the effects of the law of unintended consequences, the jobs in the NHS have been valued by the NHS insiders as higher than expected. No surprise there then.

Even though the NHS funding has increased substantially over the last few years, the unleashed demand has taken up much of it, with salaries the main consumers. Massive strides have been made in NHS efficiency with the new funding, so it's not been wasted, but much may be taken up with rewarding serving staff with higher pay.

This is where the tricky stuff comes in. If we reward our staff with higher pay bands and the budget is not infinitely elastic, something has got to give. Even if the higher paid staff take on very different roles to their present ones as justification for their higher banding, the budget still has to be balanced somehow.

This is where the changes come in, and I think they are going to be very far-reaching. We are finding that much of the work we have been doing all these years no longer needs to be done by qualified professionals such as ourselves. On examination, 25 to 75 percent of the work could be done by unregistered practitioners, ie not physiotherapists as such.

Oops. That's going to change the structure of our department over the next few years. If some of our staff are going to be more expensive then there will need to be fewer of them. Since a lesser or greater proportion of our work does not require a qualified physiotherapist, we will have more and more unregistered practitioners.

Nothing bad about all this necessarily, as we move towards having the work done by an appropriate person rather than someone who has always done it. As with everything, there are consequences...