Have You Been Getting the Right Treatment? 11 Recommended Steps for High Quality Care

At the Consortium Physiotherapy Clinic Hull we see regularly see a large volume of patients complaining of back pain, neck pain, shoulder problems and knee issues.

Published in the British Journal of Sports medicine this year was a systematic review (source) of 44 best clinical practice guidelines. They highlighted huge gaps between what the growing body of research and evidence says we should do and what is actually provided in many clinics.

11 recommended key points

1.      Care should always focus around YOU the patient

2.      Your clinician should always screen you and try to rule out serious and sinister conditions

3.      You should also be assessed for a variety of cognitive, social, lifestyle and emotional factors that are likely to influence your care

4.      Imaging should not be routinely used unless you are suspecting serious pathology, have failed treatment and/or your symptoms are progressing and are hard to explain

5.      You should be physically examined which may include neurological screening tests, functional tasks, flexibility and/or muscle strength

6.      Your progress should be measured using tools called outcome measures which are often questionnaires that assess your musculoskeletal health

7.      Education about your condition and the options open to you to help manage it is essential

8.      Participation in physical activity and/or exercise should form a key part of your management plan

9.      Passive treatments where you are mobilised, massaged or manipulated should only be used alongside other evidence-based treatments, this type of treatment should not make up the majority of your care

10.    You should always be offered evidence based conservative management before being referred for a surgical opinion or considering surgery

11.    Where possible we should help your either continue to work or assist you in getting you back to work

PART ONE - Managing load to avoid injury: Is it right to wrap yourself up in cotton wool?

Welcome to the latest instalment of our CONSORTIUM CHARTERED PHYSIOTHERAPISTS educational blog. This article is guest written by one of our colleagues Chris John. He is a very talented physio who we feel has a very promising future ahead of him.    

Hello! Let me introduce myself...

I'm Chris John, a senior MSK physiotherapist working within the NHS and also in the sporting setting with Hull City AFC Academy. In the past I have worked with Hull Kingston Rovers, Yorkshire Carnegie Academy, Northampton Saints Community and Dewsbury Rams so it’s fair to say I have an interest in keeping elite sportspeople injury free! My passion lies in exercise led therapy, this has motivated me to write this.... my first ever blog! This blog will highlight the importance of using an evidence based approach to understanding load management as an injured patient or simply as someone that exercises/trains. It should provide you with a basic understanding of how to monitor your loads as well as the actual importance of monitoring loads in order to make you fitter and stronger! Reading this will also guide you through the process of recovering from injuries and more importantly reduce your risk of getting injured in the first place!

So...... what does load actually mean?

LOAD is an umbrella term that in this case refers to the stresses (training or competition) that you subject yourself to during exercise... this can include all types of exercise and their intensities and volumes...

As a general rule of thumb... if you take on more load than you are capable of handling then you are more likely to get injured. However... if you do the opposite and take on less load than you are capable of you will end up doing the same, as this will only result in deconditioning, leaving you in a position where again you are more likely to get injured!

So... ideally you need to find the happy medium. You need enough load to get you fitter and stronger but… not too much as to risk injury. Conversely… do too little and you run the risk of getting injured when you do compete! This fine balance is not necessarily guess work as many people often resort to! Instead…I suggest you use a science based approach and learn about the multiple factors that influence load and try to sensibly control as many of them as you can. These factors are often completely individual to you. The main advantage to controlling them is to

 - Reduce the likelihood of you ending up injured!  

-  Get fitter, stronger, faster and more efficient whilst avoiding injury set backs

-  Prevent injuries re occurring

So… does load actually relate to injury then?

YES….of course! As a physiotherapist that is relatively new in my senior position, I have quickly realised that we cannot eradicate all possibilities of anyone getting injured. However..... decreasing your risk of injury is absolutely achievable!

So with this in mind... I want to educate you on the factors that are out there that both increase or decrease your risk of injury?

FACTORS THAT INFLUENCE YOUR LOAD & INJURY RISK

Risk factors obviously make you more susceptible to injury. These can be intrinsic or extrinsic (source).

 INTRINSIC FACTORS

An intrinsic risk factor can be biological or physiological (Brukner 2012) source. This means it is often personal to you, some internal factors you can control e.g. how much training you choose to do, how hard you go and how long you go for. Other factors can include the type of training you choose to do and in what environmental conditions you choose to train in. Some internal factors are still personal to you while you cannot control them e.g. your age, weight, medical history and previous history of injuries. None of these factors are dictated to you.

EXTRINSIC FACTORS

An extrinsic risk factor is defined as something you CANNOT BE IN CONTROL OF. Extrinsic factors may for that reason increase your chance of injury Brukner 2012 (source).

For example.... if you perform at a high level then how you train or how hard you go may be dictated to you by a coach. You also have very minimal control over the loads that you subject yourself to during competition. During competition you will also have no choice over the environment you often compete in e.g. the type of surface you are, the weather conditions or even the instructions given to you dictating how you should compete by a coach/manager.

So in order to try to stay injury free you ideally need to be as sensible as possible when it comes to the things WITHIN your control. This can often include modifying your training appropriately in order to make sure it sensibly suits you. Alongside this you need to ensure that you only subject yourself to external factors (i.e. competition) if you are fit enough or adequately prepared for them in the first place.

Is there a link between internal and external factors?

Yes…. there is a very important link! This needs careful consideration. For example.....if you are a novice runner that ends up heading out on a training run with another runner that is more conditioned than you then the external loads you are subject too will be exactly the same for both of you e.g. you both run 10k at the same pace and in the same conditions. However the internal loads accumulated will be far higher for the previously injured, older and more novice runner. This leaves him in a position where he is far more likely to get injured.

All the factors mentioned previously will also have an important influence on how you will potentially recover from injury and whether you will successful return to competing.

What are the effects of loading?

The optimal amount of load is described as an 'envelope of function' by Scott Dye (Dye, 2005) source. This optimal amount of load is the capacity in which a person can safely load and maintain BENEFICIAL tissue homeostasis. If you underload or overload you create DETRIMENTAL homeostatic changes and are therefore more likely to cause an injury. This is demonstrated clearly in the diagram below....(John 2017)

How do I know if I have loaded too much?

Am I running the risk of getting injured?

Often if you have over loaded yourself you will become injured and experience symptoms, this may not be immediate as often we see a delayed ‘post traumatic cytokine flare’ production that can occur 6 to 24 hours after your loading. Therefore you may not know if you have done too much and become injured until after the event. This is an important factor to monitor when you are returning from injury and will guide your progress during this time.

What are the signs that I am doing too much?

Obviously the most common way in which people realise they are doing too much is when they find themselves injured. Sometimes we do end up pushing ourselves more than we sensibly should and there can be early warning signs… if this is the case you may start to notice changes in mood, higher stress levels, lower energy levels, poor sleeping and worse stiffness than you would usually expect following exercise.

What if I am doing too little training?

Research now suggests that training hard will actually leave you less likely to become injured during competition (Gabbett, 2016) source. If you find training too easy and find that it doesn't challenge your body enough you may find that you are not adequately prepared for exercise and therefore you are more likely to get injured when you do actually compete.

OK so… obviously I should monitor my loading to try and stay fit?

Absolutely, monitoring load as a tactic to help avoid over use and injury is becoming increasingly popular.

How can you monitor load?

You probably all already use simple methods to monitor loads…for example

You may calculate how many miles you run per week and progress it by a certain percentage each week, usually this is quoted as a maximum of 10% per week to avoid injury. However, this has limitations, mainly as it only takes into account the previous one weeks’ worth of running.

Another option is proposed by Gabbett (2016) source.

Not so long back I had the pleasure of attending a course ran by Dr Tim Gabbett. Tim holds a PhD and has had more than 20 years of experience working as a sports scientist with a number of high performance athletes and various elite teams around the world. He has written a lot of research looking at load progression and has proposed the acute to chronic workload ratio (acute:chronic) (Gabbett, 2016) source.

This is basically the ratio you need to work out in order to achieve the optimal 'happy medium' we discussed.

ACUTE : CHRONIC as a more advanced method

To work out your acute to chronic workload ratio you need to find a way to quantify the loads you undertake.

To demonstrate this using a simple example we could use a runner’s average weekly mileage

This provides you with a more accurate figure over a 4 week period rather than just one or two weeks.

WHAT RATIO DO YOU WANT?

0.8 - 1.3  is ideal

*** More than 1.5 danger zone ***
(Please consider that 1.5 is only a general guide as some people can respond differently to load) source

So, how is monitoring your load going to help you !?!?!

Gabbetts evidence suggests that….

Your acute load should not be 10% higher than your chronic load or you are at increased risk of injury. He suggests the zone in which you should function or train in as the ‘safe zone’ – using the acute:chronic workload ratio this equates to (1.0)

Most injuries were sustained a week after the actual spike in loads (source). Therefore… if you have a spiked week then this should be a warning sign to remind you to re manage your load and make sure you get the next weeks training load right! Rule: Don’t spike on a spike or you are more likely to get injured! This suggests using a model that takes into account training over a 4 week period as suggested above is a far more sensible method than just simply progressing mileage based upon the previous week.

If you are to have a period of time off training (for example it’s the end of season or you are going on holiday), if you can maintain some training load during this time off you are less likely to get injured on your return.  Again showing the importance of not then underloading.

Gabbett describes a person that gets injured frequently as a “chronic rehabber”. As a physio we want you to get back to normal activities injury free; however… if you already have a history of continually getting injured then you are at a much higher injury risk! Unfortunately I feel that sometimes as physios we can be very guilty of wrapping up our patients in cotton wool and often end up doing very little with types of people in fear of causing re injury! The chronic rehabber may also be frightened to do much after having been injured because they are then more scared of re-injury. Gabbetts data shows a low amount of loading (as often happens in scenarios such as this) puts you at an increased risk of injury instead! Therefore… high chronic loads that are built up gradually and safely are the key to staying symptom free!

train hard to stay injury free 

Basically, the fitter you are, the less likely you are to be injured. So don’t be scared to load and train hard! Just do it properly and sensibly and consider using the acute to chronic workload ratio.

I hope you all haven’t under loaded yourselves prior to the New Year and now ended up over loading and becoming injured! Please monitor things sensibly…OR…seek advice from my specialist physiotherapy colleagues at the CONSORTIUM CHARTERED PHYSIOSTHERAPISTS clinic in Hull who will be more than happy to discuss the subtle details of load management with you.

As this is my first blog any feedback can be directly messaged via my LinkedIn and would be hugely appreciated.

If you enjoyed reading this blog then please look out for the second part that is due to be published in combination with my consortium physio colleagues. This will provide you with more advanced methods of load management in order to keep you injury free.

Thank you for reading,

Chris