Pinoy Entrep

Guidelines are everywhere these days, we have guidelines on most imaginable subjects and some not. We are advised how to manage low back pain, whiplash and many other conditions by learned groups of eminent persons getting together and reviewing all the evidence. There is a minor business of its own going in the publication of such guidelines, driven by the complexity of many conditions and the costs associated with managing them. The United Kingdom has many bodies engaged in this work including NICE, the National Institute for Clinical Excellence, which engages in-depth assessment of treatments and interventions and decides on their usefulness and cost-effectiveness.

With NICE guidelines, Chartered Society of Physiotherapy (CSP) guidelines and all the others, those of us in the business of managing clinical caseloads on a day to day basis have a lot of reading to do! And it could be important. Recently a spinal treatment and rehabilitation clinic in the UK was successfully prosecuted by the Health Care Commission (HCC), soon to become the Care Quality Commission (CQC), for not offering spinal physiotherapy to its patients. This contravenes the CSP recommendations for the rehabilitation of spinal patients and the clinic was found guilty of transgression and ordered to comply.

The implication of this case is that we all have an obligation to be aware of the recent analysis and recommendations for the conditions that we manage and show that we are applying them to patient care. We are expected to follow the pathways laid down to some extent and could be asked some very uncomfortable questions about why we chose the treatment approach we did should there be a complaint or legal case involved. We also have to ask ourselves why we would not follow the recommendations of an established body that have produced a serious document. Just not doing so is not good enough.

I want to use my clinical judgment is often the cry that goes up when the idea of having to follow external guidelines for assessing and treating our patients comes up. We want to have the control of what we do and make appropriate decisions based on our clinical experience. The different professions are a little like mysterious clubs who dispense knowledge to their initiates so that the special healing techniques can be deployed. We are all resistant to change in varying degrees and there is a degree of closed shop protectionism about some of our attitudes. Criticism is met very quickly with rejection as we strive to protect our core professionalism which we interpret as under attack.

The limits of our knowledge and effectiveness are now important things to establish if we are to stand up to scrutiny. The physiotherapy paradigm, in which I was educated, thinks about the function and dysfunction of the body in a specific way. This colours our view of what to do when we treat patients and some of my views are therefore:

Most individuals do not need routine adjustment or other treatment to function normally, a wide variation in structure and function is seen.

Self limiting conditions will tend to be that and there is a questionable need for intervention in many cases.

Most conditions are self limiting and much of our effectiveness is due to nature and time.

Validated measures of outcome have not been used across much of our work, making our effectiveness hard to ascertain.

We may be wrong in assuming the credit for improvement in many patients.

Much of our self worth about making a difference to particular conditions may be built on sand.

Technical treatments are seductive and often suggested rather than the less concrete work needing to be done to help an individual change.

None of this is to have a negative view of our professions, which I am sure will continue to contribute greatly to the comfort and health of many people in our communities. We need to have faith in our clinical judgments and our training paradigms but also to scrutinize them for errors and ways to improve our therapeutic approaches.

We all have a certain degree of joint mobility, the ability to move our joints through particular distances, even though sometimes if might not be far. We all vary, for genetic reasons, in the amount of mobility shown by our joints and this is likely to be related to the joint mobility of our parents. There are many terms used to describe hypermobility, including joint laxity, loose jointed, double jointed and ligamentous laxity but the term hypermobility is now generally accepted.

The assessment of hypermobility is typically clinical in terms of the doctor or therapist examining and testing the patient. Various testing systems have been proposed over the years, with the Beighton test being a typical measure involving:

It is possible to pull the fifth finger up and beyond 90 degrees to the back of the hand. If this is possible then a score of one is given for that, with two if both fingers show the mobility.

Pressing the thumb back against the underneath of the forearm with a bent wrist gives a score of one again, with two for both.

The elbows go back beyond straight by more than 10 degrees.

Knee extension continues more than ten degrees beyond straight.

The ability to lean forward with the knees fully straight and place the palms flat on the floor. One point for this.

The maximum score possible is nine if all the first four are exhibited in both sides of the body and the person can perform the last. To have a diagnosis of hypermobility the general opinion is that a score of six out of nine is needed.

Hypermobility occurs in approximately 4 to 7 percent of the population although if you look at athletic groups such as gymnasts or dancers there will be a higher likelihood of finding hypermobiles. Joint mobility is affected by several things which include tendon and ligament connective tissue laxity, muscle tone and the structural anatomy of joints. Our genetic heritage, hormonal regimes, gender and sporting or other training are all important in contributing to joint mobility.

Joint laxity is determined primarily by the connective tissues, the mechanical behaviour of which seems to be the pivotal features of whether joints are mobile or not. The structure and function of collagenous tissues varies with genetic differences between people and explains a lot of the variability that people exhibit in their joint mobility. Longer and weaker collagen can result from differences in its synthesis.

Hypermobility is very variable amongst individuals and the consequences can vary themselves, from nothing or very minor problems to chronic pain and disabling symptoms. Typical symptoms which may occur in people with hypermobility are joint pain, loss of accurate joint position sense, increased risk of trauma to joints, increased risk of dislocations, joint swelling and osteoarthritis. Simple activities such as maintaining posture, walking, dancing or taking exercise can be challenging.

Initial medical assessment by a specialist doctor and physical assessment by a physiotherapist is important in the management of hypermobility since the condition can vary so greatly. This leads to a wide range of treatment possibilities which need to be chosen carefully. Patients benefit from a careful explanation of the condition and its benign nature, with education about the consequences of the syndrome being especially important. Activities which stress the joints with painful consequences should be identified and altered.

Some sports and occupations may be unsuitable such as contact sports or jobs which involve strenuous work, momentum or joint stresses. Joint protection principles should be taught and encouragement of an appropriate exercise regime. Moderate exercise can be useful to control weight, encourage good posture and train good muscular joint support. Manual therapy techniques can be used, along with hydrotherapy, acupuncture, TENS (transcutaneous electrical nerve stimulation) and other techniques.

Drugs need to be carefully considered by a doctor due to the potential side effects with long term use and the complexity of some pain medications. Severe joint damage or arthritis can be managed by surgical care such as fusion or replacement of the damaged joints. There are a number of medical conditions which have hypermobility as part of their symptom presentation. Ehlers-Danloss Syndrome type three is thought to be synonymous with joint hypermobility of benign cause.

Flexibility, its restrictions and promotion, is an important concern of a series of para-medical professions which include chiropractic, osteopathy and physiotherapy. Eastern, exercise based traditions such as yoga have used specialised techniques known as asanas over thousands of years, although they were not designed to increase flexibility. The martial art systems from the Far East all concentrate on developing the flexibility needed to perform the movements required for proficiency. The definition of flexibility is not well defined but many people accept it is the ability of joints to go through their anatomical ranges.

Ballistic versus Static Stretching

Many aspects of stretching are controversial and one aspect is the discussion about the relative merits of ballistic and static stretching. There may be some benefit in performing ballistic stretches in terms of maintaining interest as static regimes can be a bit….static, ballistic stretching can be rhythmical and add dynamism to a performance. Most sporting and hobby activities are dynamic in nature and ballistic training permits the practice of manoeuvres specific to the activity. Static stretches may not relate very closely to the active nature of some sports.

Ballistic stretching does have severe possible negative characteristics which can limit their usefulness. Rapid elongation of a muscle and the accompanying connective tissues means the tissues do not have the time they need to adapt by more permanent lengthening as using longer periods of low force stretching has been shown to be more effective. Muscles which are stretched quickly can react by reflexly contracting to prevent injury, limiting elongation. If the movement develops much momentum this can cause forces which overwhelm the tissues’ tolerances.

Stretching Statically

Static stretching occurs when a stretch position is held for a defined period of time at least once, but it could be more times. The stretch should be performed in a controlled manner, without any movement or speed of movement. Static stretching has been researched and shown to be effective in changing the ranges of movement of joints. Static stretches are easier and more convenient to perform, require less energy and may result in less muscle soreness, but many of these things have not been proven.

Whilst effective, static stretching is often used alone without thinking about any requirements for ballistic performance in an activity or sport. There have been many supposed benefits and these include:

Stretching helps to warm up. There is no evidence for this and stretching does not increase muscle temperatures.

Cool down is enhanced by stretching. The mechanism of cooling down is to facilitate the diversion of blood from the exercising muscles back into the circulation. Passive stretches cannot achieve this.

Delayed onset muscle soreness (DOMS) is relieved by stretching. This idea has not been supported by any evidence.

Performance in athletics and sport is improved by stretching. Dynamic flexibility is more closely allied to athletic ability and static stretching has little evidence to support this idea.

Stretching reduces the likelihood of injury. A restriction in the ability to be flexible can make injury more likely but increasing flexibility has not been associated with injury reduction. Evidence has come forward linking stretching to an increased likelihood of injury in exercise.

Physiotherapists use a different way of defining and recording stretching and movements. In active movement the person moves their joint themselves using the muscles of the limb. In passive movement the same joint ranges may be performed but this time the physiotherapist might do the movement for them. Stretching may be passive or active or be a combination of the two.

A patient can actively stretch their joint by lifting their arm up with their own power, stretching the opposite set of muscles and structures. The normal joint movement is termed physiological and if there is a restriction in the joint the physiotherapist will want to know if this is due to weakness, stiffness or pain to decide the treatment. The passive physiological range will give important clues as to which of these problems is the culprit. If the physiotherapist finds that passive stretches allow the full joint movement without pain then they will deduce that joint weakness is the problem to be treated. Accessory movements are also used by physiotherapists, encouraging the gliding and sliding movements which happen during normal actions.

Soft Tissues of the Foot

The soft tissues of the foot consist of ligaments, tendons and muscles. Ligaments are fibrous bands or sheets with limited elasticity which connect bones together. Ligaments both provide stability for the joint complexes and also allow movements to occur within their controlling restrictions. All the multiple joints of the foot have ligamentous capsules surrounding them, giving them stability and a base for the synovial membrane which secretes lubricating fluid. The largest ligament in the foot is the plantar ligament which connects the ball of the foot bones to the heel.

The longitudinal foot arch is partly supported by the plantar ligament which holds some of the energy generated in walking and releases it later in the gait cycle to contribute to the spring in our step. Plantar ligament strain gives very painful and sharp symptoms under the foot arch and injuries here can interfere with the supporting functions of the arch. The heel bone carries the attachment of the Achilles tendon, the big and powerful fibrous structure which carries the forces exerted by the soleus and gastrocnemius, the big and powerful calf muscles. The calf exerts the propulsion force we need to run, walk and jump.

Walking is a complex movement and often referred to as controlled falling. The gait cycle is the cycle we go through repeatedly with the same series of anatomical actions. The foot bears weight evenly on the front and rear on standing. In gait the foot hits the ground typically at the rear and outer border of the heel, the weight then passing forwards and towards the ball of the foot and the great toe. The plantar ligament stretches to some degree and absorbs some of the load. As the foot rolls inwards and the arch flattens to some amount, the foot moves into what is called pronation.

Supination is the next posture the foot moves towards as the midfoot hits the ground and starts to bear weight, the foot rotating outwards until the walker starts to push off on their toes so they can take their foot off the surface. In gait problems these postural movements can become exaggerated. Overpronation occurs when the foot turns in excessively and throws exaggerated forces across to the great toe which typically suffers sixty percent of the load in gait. If the person tends to bear weight along the outer, lateral border of the foot as they walk forwards the foot is said to be underpronated.

Problems with Gait

As the body acts as a unit one area can have affects on another. An abnormal gait can be an antalgic gait which describes a walking pattern which is aimed at avoiding pain. There’s a man who lives nearby who walks about just using his hips and knees, his trunk gliding as if he’s on rails. I suspect he has quite severe back pain as he is employing an antalgic gait to avoid too much lumbar stress. Other people who have foot problems may walk abnormally, leading to knock on problems in other areas of the body as they struggle to reduce forces through one particular area.

Babies’ feet are cute and chubby and very mobile, being made up significantly of cartilage rather than bone initially, and it takes almost twenty years for the feet to become fully bony and growth completed. The foot arch is not obvious in the very young due to the thick pad of fat which fills up this area. As the child learns to walk the fatty cushion reduces and the arch reveals itself. Typically young children are often knock kneed to some degree up to the age of six with this process changing slowly with time until they have the normal knock knee of about seven degrees.

It’s not until we are around twenty years of age until our feet are fully mature and fully ossified. Looking at the feet of young babies it is clear they are fat and bendy, with much of the internal skeleton being made up at this age of cartilage. We can’t see any foot arch due to the fat deposits occupying this area and have to wait until walking commences before the fat reduces in size and we can observe the typical foot arch. Young children commonly also have knock knees but this tends to settle gradually by the time they are 6 years of age. The level of knock knee reduces gradually towards the adult level of seven degrees.

The elastic nature of our tissues, the tendons, muscles and ligaments, decreases with time and even in our thirties this occurs, making the feet more easily stressed and damaged. Exercise is now typically prescribed for many of our ageing population’s ills and this exposes the feet to significant stresses which can lead to painful changes and abnormalities. As we strive to maintain levels of physical activity and sport with time we need to allow longer recuperation periods for our tissues as well as plan our training increases.

Many problems occur when people in their thirties decide that they want to regain the fitness they once knew as a person in their twenties, forgetting that their soft tissues’ capacity to endure stresses has reduced significantly in the meantime. Some of this problem relates to the amount of weight we have typically gained in the meantime as weight gain can be very important in foot pathologies. Warming up and stretching before activities or athletic performance becomes more and more important as we get older.

In our forties we lose more of the fatty padding from the undersides of our feet, with typical pains occurring in the ball, arch or heel of the foot. The foot tissues are both looser in terms of resisting stress and tighter in terms of being less easily flexible and extensible. Our feet may spread to some degree and by our fifties we may be wearing a bigger size than we did when we were young adults. Now we need to adjust our shoe sizes and comfort and add in strengthening and stretching exercises to maintain foot health.

The family tendencies of our feet may well show themselves in our fifties by arthritic changes, bunion growth and flat feet which are painful. The fifties continues with the change processes ongoing in our feet, the fatty padding under the feet suffering an continual thinning, elevating the likelihood of injury occurring during sports or activities. It is during this period that we need to take care not to overstep the tissue tolerances of our feet if we are to have comfortable activity.

The ability to absorb shocks becomes less as the fatty material padding out our soles continues to thin, with the superficial skin and other tissues losing hydration and losing thickness. Heel fissures and cracks can develop with pain and infection possible as consequences, but simple creams can moisturise the skin effectively and make the appearance of the feet improve. Fifty year old and older people have an increased risk of developing osteoporosis and this has been diagnosed more successfully in recent years. March fractures may develop in the foot bones in these cases.

The body has a reduced ability to resist and recuperate from the stresses of exercises and activity, making it harder to design and undertake an exercise programme which promotes effective fitness in our fifties. Co-existing medical conditions are often present such as obesity, cardiac disease and diabetes and exercise can be a useful treatment addition. Unfit people like this may find that their feet are not ready for the day they start their new exercise programme.

Sixty and older means something different now than it did years ago. People are living longer, feeling younger and expecting to be physically active at greater levels and for longer periods than in previous generations. The upsurge in physical activity such as jogging makes increased demands on the feet of many people in society, with some negative consequences. If a successful fitness regime has been set in the fifties there is every likelihood that it can be maintained into the sixties and beyond.

With many years of walking and multiple physical activities behind them, surgery is most common for people in their sixties as foot problems interfere not only with sport and other vigorous options but starts to get in the way of walking and day to day life. Surgery may be advisable at this stage before the pathologies advance and become more difficult to manage surgically and tissues become less successful at recuperating when we are older.

The warm weather has come round again and the garden is out there, wordlessly calling you to action. If not much has happened out there yet it soon will as the warmth and light take effect. There’s so much to be done as we try and prepare the plot for growing that perfect lawn, vegetables and flowers.

The sudden increase in digging the garden is rapidly followed by a burst of injuries such as back and neck pain and other joint pains. Much of this pain and suffering could be avoided with some preparation and planning.

Winter is typically a time of much reduced physical activity and exercise for most people, turning us into less fit physical beings. The warm weather then calls us to action outside at the very time we are worst prepared to face significant physical demands on our bodies.

Typical advice includes warming up and while this may have some value I feel it does not go sufficiently far. If you do far too many hours digging or put forces on your bodily structures which overstep their tolerances, you are going to get a bad reaction no matter how well you have warmed up. The amount you decide to do also has to be correctly set.

Preparation by warming up may well be essential but if you omit to keep activity levels under control, you may not be able to manage useful levels of work. Winter means we have all done less physical activity, particularly exercise, and our tissues will have a reduced tolerance to physical stresses. Athletes do not go out and perform their event at full tilt when they start training but gradually increase the intensity of training and performance.

Most people fall into the mistake of overdoing things significantly when they start out a new activity, usually because the body does not tell us that we have overdone things until its too late. This makes the decision about the level of activity we should do very difficult to judge. If we get out there in the garden, grab a spade and start digging we are highly at risk of doing too much.

All the major therapy professions such as physiotherapy, osteopathy and chiropractic experience a rapid increase in injuries and pain conditions relating to gardening and other outdoor activities at this time of year. Low back pain is the commonest, with other joint and ligamentous strains also typically occurring. Many people aggravate a pre-existing condition.

11 Tips for Avoiding Injury and Getting Fit for the Garden

1. Keep up activity and exercise during the winter so you are not totally unprepared.

2. Do gentle stretches each time before you get going.

3. When you are doing a lot of ground level work such as weeding, kneel down either with a kneeler or knee pads.

4. Decide how long you will work and when your breaks will be before you start.

5. Start with very short defined times of activity initially and keep the task down to two hours or less in the first few days if you are fit. If you have problems this will need to be lower.

6. Plan a graded increase in activity, using pacing technique, sticking to times you have decided.

7. The trap is when you feel good, so limit the increases in activity to the times you decided even if you feel you could do more.

8. Lift well and get someone else to help you if the load is heavy.

9. Avoid mowing by swinging the mower from side to side; walk up and down with it instead.

10. Give yourself a planned change in task, avoiding doing consecutive activities and postures which have similar physical requirements. Do some greenhouse work or pruning in between bouts of digging for example.

11. Stop the job if you feel any significant pain or soreness and re-evaluate the next day. If it’s just soreness in the muscles then you can resume the task at a lower level.

Pacing is the key skill and the ability to decide how much to do before you start. And to stick to your decisions.

After the operation

Will there be any stitches? Some surgeons place all the stitches under the skin so that they do not need to be removed. Others use clips and stitches in the skin which do need to be removed after about a week. Some of the small incisions may in fact be closed with adhesive strips that will peel off in the shower. You should be told clearly about this before you leave hospital.

What about recovery?

Returning home When the patient returns home depends on their level of fitness, whether there is an adult at home to help them and how much discomfort they have. After laparoscopic cholecystectomy most patients will be able to be discharged one or two days after the operation. Open operations mean that most patients stay a day or so longer before discharge, but overall they can return home when they feel ready.

Painkillers and pain The level of pain suffered by patients varies greatly as most suffer some pain symptoms in the first three or four days but others feel very little pain or discomfort. The typical area for pain is around the incision sites but some pain can be experienced in the shoulder region, likely due to the diaphragm becoming irritated during the operation. As carbon dioxide is absorbed into the bloodstream the discomfort will settle. It is advisable to use painkillers over the first days so that patients can sleep comfortably and start to become active again. The pain should resolve by five to ten days from the operation. A slower recovery after an open procedure is to be expected.

Having a bath and shower Soap and water can be applied to the wound area either by showering or having a bath after around two days. A transparent wound dressing is used by some surgeons, left in place for a while and washing or bathing can continue with it on. Patients will usually be advised about this. Swimming is best avoided for about ten days or so until wound healing is well advanced.

Walking Patients can start to walk about as soon and as much as they want although they will be a little stiff at first and will not feel like walking long distances during the first week after the operation.

Car driving Typically driving a car can be resumed when patients feel confident and able to control the vehicle in an emergency, after a few days from the procedure.

Sport, heavy lifting and work Return to work can be accomplished as soon as a patient feels comfortable enough to cope with the job demands. Home or part-time workers can usually resume work very soon after the event. Driving to work or spending a lot of the day on the feet delays work return for about two weeks. Full time work is usually achievable for most people after laparoscopic operation by ten days from the procedure but if they have had an open operation this will be a few days more.

Physical activities and sports can be resumed as soon as he patient’s discomfort allows but a graded return to these pursuits would be advised as fitness is regained. A month or more may be needed before resumption of contact or violent sports.

Side effects which might occur The sites where the telescopes have been inserted or the wound site in an open operation usually suffer some swelling, bruising and hardness. Fluid and blood collection under the wound causes the hardness and swelling initially, added to by the drawing together of the stitches and then by scar tissue formation.

Post operative problems after gall bladder removal

Bleeding and bruising Bleeding has already been mentioned but at times there can be a lot of bleeding. A small blood vessel near the incision site or under the skin can release a large amount of blood which is seen as a tense lump under the wound. Typically this settles on its own.

Wound infection A wound infection is possible but not common. Wound redness developing may necessitate the use of antibiotics. If the wound should drain pus then it may need reoperation to let out the infection.

Bile duct injury The major risk during gallbladder surgery is injury to the main bile duct. This is rare (1 in every 300 operations) but does require a major operation to repair the problem. All surgeons are aware of this risk and work very hard to avoid the problem.

Other abdominal problems The other post operative difficulties which can occur inside the abdomen, such as bile leakage, do not usually present themselves until after patients have been discharged. The development of increasing pain in the abdomen or the occurrence of jaundice with its typical yellowy skin colour mean the patient should consult a doctor immediately.

Loose bowels Cholecystectomy may cause some patients to suffer a degree of diarrhoea and this is typically a minor problem. At times medication may be prescribed to help control the problem.

DVTs ” deep vein thromboses It is possible to get a DVT after cholecystectomy but the risk is low and they are uncommon. If there is an increased risk such as a person on the contraceptive pill or who has had a thrombosis previously then the surgeon should be made aware of this and will then take steps to reduce the risk. To further stop thromboses occurring patients are encouraged to keep their feet and legs moving as soon after the operation as possible and to get up to walk.

General anaesthetics ” the risks A general anaesthetic comes with some risks which are usually low but may be more likely in people with other medical diseases:

Common but short term effects (risk of 1 in 10 to 1 in 100) are a feeling of sickness and blurring of vision (which can be treated and usually resolve quickly) and injection site discomfort and bruising.

Less frequent complications (one in a hundred to one in ten thousand) are temporary difficulties with speaking and breathing, headaches, muscular pains, damage to lips, tongue and teeth and sore throat.

Very rare and very serious side effects (less than one in ten thousand risk) are long-term damage to nerves or blood vessels, liver and kidney failure, damage to the brain, voice box or lungs, eye injury, severe allergy reactions and death. These occur very rarely and may be related to the other medical conditions the patient is suffering from.

What is the benefit of laparoscopic cholecystectomy? Surgeons have changed from traditional open cholecystectomy to laparoscopic cholecystectomy because it has several benefits. The main ones are minimal scarring, less pain after the operation, a reduced risk of infection and a faster recovery time. Most patients are now able to be up and about and home within 24 hours of the operation and should be able to return to work within 7 days. Laparoscopic surgery is no longer new and the consultant will have performed many of these operations.

How to deal with problems A fever or infection discharging from a wound is an acute problem which sometimes presents and patients should initially contact their general practitioner for advice. Referral to the hospital surgeons may be necessary and the doctor will make the necessary calls should this be required. If local urgent medical consultation is not available from their general practitioner then attendance at the local Emergency Department should be sought.

Post cholecystectomy syndrome (PCS)

PCS or postcholecystectomy syndrome includes a series of symptoms such as ongoing symptoms after the operation which were thought to be due to the gallbladder or new symptoms typically classed as related to that organ. There are also symptoms caused by the removal of the organ itself. Changes in bile flow once the gallbladder, normally the bile reservoir, has been removed are thought to cause the difficulties. The upper digestive tract can suffer inflammation of stomach and oesophagus due to increased flow of bile, with the lower tract suffering from colic-like abdominal pains and diarrhoea.

About 10-15% of cholecystectomy patients may complain of such symptoms and careful discussion of potential post-operative complications is necessary for PCS problems to be identified. The most secure way of reducing the risk of PCS developing is to get a clear diagnosis that the gallbladder is the organ causing the patients symptoms.