Peter O'Sullivan

“What should we say and do when confronted with complex pain?”

Integration of anatomy and mind –> relationship between pathology and pain is not clear. Pathological processes may be asymptomatic.

Incidence of LBP is up, despite improvements in treating structures. Evidence for treating LBP = non-conclusive

Therefore; it doesn't matter what you do if you're not addressing the underlying mechanism. Adopt a different approach.

You need an understanding of causes (multi-factorial)

Pain prevents effortless movement –> pain impairs function but not activity.

People adopt provocative behaviours that increase pain and are activating muscles throughout movement/rest. Unable to “switch off” muscle activation in the presence of pain.

Bending is not the risk, sustaining the movement / position is the risk.

Lack of mindfulness is associated with CLBP and catastrophising → back pain is relative to fear of movement.

The majority of causes of CLBP are not structural. They may be physical, influenced by lifestyle/ social environment. Also, neuro-physiology.

Studies comparing specific studies don't make sense, because they don't take cognicence of the other factors that contribute and which are all different.

Don't train muscles, train function/ behaviour /movement /patterns. You can't change beliefs until you change behaviour. You can't change behaviour if you don't know what you're doing.

Dr. Michael Voight

The hip is often not recognised as the initial source of symptoms –> managed for seven months before looking at the hip. Usually look at muscle strains, LBP and arthritis.

Intra-articular hip pathology almost always follows the L3 dermatome

Localisation of symptoms are important for diagnosis; lat. = ITB, bursitis, post = Lx spine

Atraumatic hip pathology is usually symptomatic of underlying impairment. Muscle imbalances –> usually crossed pelvic syndrome

Tests:

• “log rolling” rot of the femoral head in acetabulum in mid-range to reproduce the symptoms (minimum stress on the surrounding structures). Should produce ant. groin pain
• Impingement (forced flexion / int. rot.)
• Comparison is usually to the contralateral side, because there are so many variations to “normal”

Adductors are often accused, but clinically doesn't make sense (resisted isometric contraction should be indicative of muscle pathology)

Loose bodies are the closest indication for arthroscopy, but surgery is often more damaging than leaving the loose body. However, it could be a significant cause of pain.

Labral tears –> caused by extreme rotation (e.g. tennis). Not disabling but athlete then can't compete at high levels. Removal affects microinstability –> sets patient up for degenerative changes. Therefore, repair and use bone anchors rather than remove.

Femoro-acetubular impingement – abnormal relationship between the proximal femur and acetubulum –> reduced joint space. Limited int. rotation with hard end feel.

Rehabilitation / Management (dependent on the requirements of bio healing)

• Gait with protected WB
• Early ROM
• Strengthening (isometric –> open chain –> closed chain)
• Function

Immediately post op:

• Distraction in straight plane
• Mobility (int. and lat. glide to stretch capsule)
• Stationary cycle (avoid recumbent cycling → excessive hip flexion)

Intermediate rehab:

• Glut. med. most affected by reflex inhibition following arthroscopy
• “Clam shells” and “reverse” in resting, abduction and extension
• Different walking patterns with theraband

Advanced rehab: Function

5 and 10 year follow-up after hip anthropscopy = good outcomes with hip function

Ruth Jones

Best long term follow up for stress urinary incontinence is surgery.

Muscle strengthening is the goal in the short term

Role of the pelvic floor:

• Organ support
• Continence
• Sexual function
• Spinal stability

The movement of the pelvic floor during a contraction isn't as important as the direction and distance of the movement

Strengthening isn't as important as technique. Having a strong pelvic floor doesn't always stop incontinence

Urethra is supported by pelvic floor muscles during cough to prevent urethra from dropping / moving inappropriately. When support is not there = stress urinary contractions.

There is more to pelvic floor management than strengthening

Johan Lambeck

30% of people over 65 fall 1/year and this increases with age, as do hospital admissions as a result of falls

Loss of balance = failure to meet intrinsic / extrinsic demands of mobility in a specific environment

Intrinsic:

• Strength, ROM (e.g. lumbar spine), walking balance, single leg stance, STS, reaching outside BOS
• Medication that affects function
• Vision, BP, blood sugar, cognitive ability
• Low BMI
• Disease e.g. CVA, PD

Predictors of falls:

• PD (previous falls, lack of arm swing, dementia, progression of disease)
• CVA (low score on Berg balance scale)
• Rheumatology

Fall risk predictors (practical):

• Fall history
• 5 minutes walking without aid
• Still able to cut toenails themselves
• STS without a problem
• Dressing alone
• Frail and older than 80

Balance strategies:

• Balance is task specific and context specific
• Predictive strategies: counterweight, static
• Reactive strategies: ankle/hip, stumble, arm, fall strategies

Negotiating and avoiding obstacles –> short and long step strategies:

• Reaction speed is hardly influenced
• Elderly choose long step (hamstrings don't have enough force to rely on short step) but “long step” is still too short

People who walk slowly are more likely to fall sideways. Why?

Prevention programmes:

• unsteady posture, dasd, voluntary immobility, asda movement errors, sdsd skill loss – circle of influence
• Interventions that include balance retraining significantly reduce falls, also important to raise awareness of the limits of stability
• Single leg stance activities
• Muscle strengthening around the hip, knee, ankle
• Tai Chi (modified to bare essentials that affect balance)
• Obstacle course
• Flexibility

Falls precautions programmes are paid in full by medical aid in Netherlands because it is evidence based.

Problems with land-based falls prevention – could lead to slipping, stumbling when person has to change gait variables

Variables of balance exercise:

• Highly challenging exercises
  • Movement around the centre of gravity (centre of mass)
  • Narrow BOS
  • Min. UL support
• High total dose
• Avoid “walking exercises” during therapy time
• Add multiple tasks

Can all these strategies be used in a hydrotherapy programme? Yes, showed improvement in balance with multiple outcome measures

Henning Langeburg

Different components of tendon = different properties. Type III collagen = more elastic (scarred)

During loading – blood flow increased, metabolism increased

Strength of tendon is increased with training

Micro-tearing of tendon fibres during loading → strengthening. Too much tearing → degeneration

Don't use NSAIDs in tendon pathology because there is no inflammation present. Rather use eccentric loading of the tendon (increasing load). Bent / straight knee with Achilles tendonopathy (pain acceptable during training)

Eccentric training:

• VAS
• Pain should be present during loading (up to 5 on VAS)
• Pain unchanged 3-4 weeks –> patience
• Training pain gone before next exercise
• Progress by increasing the load (e.g. backpack)

No elastic component in patellar tendon (functions more like a ligament, connects bone to bone). Pain is dissimilar to Achilles tendon. Therefore training regime must be different (should use declined board rather than a flat surface, because load is increased in that position)

Why eccentric exercises?

Pain is important in tendon strengthening!

Dr. Louise Rutz-LaPitz

We need more tools → too little time for severely impaired patients, and high costs

Is there a way to motivate patients (and students) to do / learn more?

Control is our tasks / behaviour, not muscle or movement patterns

Motor learning is not a treatment concept, it's a skill acquisition associated with practice (→ relatively permanent change) and carry over to other tasks. It develops out of a need to solve problems in the environment. There is a search for a solution. You can't give them the answer, they must work it out through lots of practice and active participation with guidance from the physio. Must have a meaningful goal.

Plasticity is the foundation for recovery / foundational change, which requires attention.

Technology:

• Non / immersive virtual reality (pilots are trained with this…it works)
• Gravity supported exoskeleton (No robot actuators, therefore the movement is initiated by the patient)
• “Robot gloves” - active, passive and interactive, 2 degrees of freedom… and other robotic devices that facilitate active movement

Evidence is conclusive for some devices and not for others.

Shamila Marie

Physio research focussed on conditions and management (in the past) e.g. sputum and details (is it just about sputum?)

Physio is generally indicated in “at risk” patients. We need to be humble and take a step back to ask “Are we really necessary?”

EBP:

• Incentive spirometry
• DBE
• PEP
• Mobility
• CPAP

Target patients:

• ICU
• Abdominal surgery
• Cardio-thoracic surgery

Guidelines:

• South African CPRG guidelines (2006)
• AARC guidelines

Moving away from condition / pathology –> quality of life

PCP? In relation to HIV

“Empower people with TB and communities” “Enable and promote research” What are the steps to achieve the above? How do we convey the message to everyone on the ground?

Professor Jennifer Jelsma

Romy Parker

Pain is the second or third most commonly reported symptom (fatigue is #1)

There is a shift from the terminal to chronic –> transition in mx approach (biopsychosocial approach)

Pain = significant psychological distress. If it is so common, why is it so poorly mx?

Clinical barriers:

• Lack of awareness of the issue
• Lack of knowledge about pain mx / appropriate analgesia
• Fear of addiction
• Lack of time in consultations

Symptoms are wide ranging (30% early stages, 90% late stage), more than one type at more than one location

HIV has a preference for neural tissue:

• Pain because of nerve damage (eg. Headaches)
• Idiopathic causes
• Pain as a result of ARV's

Mx of pain is dependant on cultural context and “what pain means”

Exercise has an immediate impact on pain reduction and is safe, raises levels of self-efficacy and HRQoL

TENS is useful for peripheral neuropathies. Beware of sensation deficits, as neuropathies are often undiagnosed.

Professor Dele Amosun

Identity is not what you do or what you have. It's who you are and everything that that includes.

More than 1000 complaints of misconduct raised over past few years (2004/2005). Has the number risen or has reporting improved (with patient empowerment)? Content for reports of misconduct can be obtained from the SASP website.

Why such a high number? Whose fault is it? Unethical behaviour should be identified earlier and if the behaviour develops later, we didn't lay a good foundation.

“Medical recond…”: study on the quality of physiotherapist enties. Phillips, Stiller (2005)

“Should enties be authorised by qualified physios”? What happens when it's the role model that changes student behaviour? What is the role of modelling in UG education and behaviour? Who is accountable?

Informed consent is a process of communication that offers choices to patients, not just about giving information.

What are the legal requirements for informed consent in SA?

Need an informal consent form for UWC students? What happens when they didn't have a form, do they leave out consent?

What can we do to get people with disabilities giving input to the curriculum? People can come to campus and give a presentation. Students can go to facilities / homes and interview. How about subscribing to blogs of people with disabilities?

Dr. Brenda Morrow

Physiotherapy is relevant to remove secretions and manage associated problems (short term) but there is a poor evidence base.

Best study:

• 30% decrease in respiratory function
• No standardisation, can't identify appropriate patients
• May do more harm than good
• Many complications

Neonates and COT:

• Increased incidence of haemorrhage in RDS
• Arrhythmia
• Raised intracranial pressure
• Fractures

Percussion has been shown to cause atelectasis and paed patients are more prone to atelectasis.

CPT is recommended for clearing mucous

Primary pneumonia → CPT has a role according to evidence. Anecdotal evidence suggests that CPT can help clear secretions in neonatal stages

HMD: latest studies suggest risks of rib #'s. Min. handling for neonatal patients in ICU and CPT is appropriate

Asthma: at best, severe asthma has no role for physio. Reduced role in the acute phase, maybe a role in the sub-acute / chronic phase. No routine CPT in any child.

Head injury: CPT / suctioning → increased intracranial pressure therefore no CPT in the acute phase until increased pressure has stabilised

Neuromuscular disease: physio's have a role in education on positional changes. CPT is of probable benefit with atelectasis / mucous plugging and neuromuscular disease

Most studies show little to no benefit of CPT with most common ICU patients.

Indications: increased or retained secretions (only when impacting on lung mechanics or impaired gaseous exchange, not merely the presence of mucous)

No hyperinflation in babies –> danger of pneumothorax

“Use gravity” to drain secretions, not “postural drainage” → misconception of “upside down position”

Potential benefits for specific patients. Determine risk for every patient. Needs very careful assessment. Use a creative approach. Research is essential.

Saline before suctioning → hypoxia and has no effect on liquefying secretions, so don't do it.

Susan Hanekom

What is EBP: buzzword, abused concept?

Sackitt's definition… Does it work? What's the harm, costs? What about clinical experience, preference, context?

Formulate best practice guidelines. Develop protocols / algorithms

Developing an algorithm:

• What is the contextual framework?
• What is the synthesis of the evidence? (sys. rev.)
• formulate best practice recommendations (GRADE sys.)

Validate context using Delphi study, 3 rounds → development of an instrument

Helene van Asuregen

60% of all trauma (gunshot / stabs) cases in South Africa → “The hidden epidemic”

Survivors:

• Poor function
• Reduced QoL
• Reduced return to work
• Increased burden on carers

No rehab programmes for these patients post D/C

Helene van Asuregen

Increased incidence in SA as a result of smoking, TB, industrial mining dust, domestic use of biomass fuels. Also, HIV may contribute to the level of COPD

Guidelines serve as a basis for medical aid reimbursement

BODE index = multidimensional tool to evaluate COPD and prognosis

Proposed outcome measures also included:

• Borg scale – perceived level of exertion
• 6 MWT – assess exertion capacity
• MRC and VAS for dyspnoea
• QoL questionnaires

Bear in mind that these guidelines are only based on evidence sourced from PubMed and Cochrane. Also, only used COPD, not COAD as keywords.