Authors: Catherine Moore & Pete Rumble

Life can be tough.

Just when all your ducks are in a row and the sun is shining on your parade, the rain comes along. This is the risk of undertaking a worthwhile activity. Everything in life carries risk: getting in the car to drive to an appointment, setting up a business, finding love, crossing the road to get to an exercise venue, or falling whilst in an exercise class.

In therapy terms, the risk of harm to a patient is ever present and should be at the forefront of every clinician’s mind (BMJ Best Practice 2020). However, there are times when the risks seem to outweigh the benefits, and this has the potential to stifle your clinical brain to the point of paralysis. I was discussing this with a patient recently, lamenting that I might go and work in Tesco (other supermarkets are available) as that just seemed so much easier, less wounding.

I thought I would share their response with you;

As Chartered Physiotherapists, we consistently push people to the limit of their abilities because this is where the therapy happens. We push people to the limits of their strength, their endurance, their balance. Anyone who has done this alone in the gym or at home will know that occasionally this doesn’t work out. Occasionally you will push your tissues beyond what they can cope with and strain a muscle, push your balance beyond what you can cope with and topple over. Because we have experience in classes and clinics, we risk-assess the activities patients undertake and we explain to them the benefits, risks, harms and uncertainties of what we intend to do. This duty of candour (HCPC Standards), enshrined in our code of conduct, allows both patient and therapist to make informed choices about what they undertake. However, in spite of all the risk assessments and disclaimers in the world, accidents do still happen, and it worries clinicians.

So, what is the alternative? Stop people moving? You can’t injure yourself if you never move… or can you? Immobility and not exposing the human movement system to physical stress has profound detrimental effects. Astronauts return from space with weaker bones due to a lack of gravitational loading. The human body is engineered for movement – how else would we have obtained food when we were in the wild? Our skin, the largest organ of the body, needs regular pressure relief in order to remain healthy. Skeletal and cardiac muscles need activation to maintain their strength and most joints need movement to prevent them getting stiff (Atlay 2001, Wu, Li, Cao et al 2018). It is possible (and very likely, probable) that the consequences of not moving are more likely to make you fall than if you keep moving (Salgado, Lord, Packer et al 1994; Sherrington and Tiedemann 2015).

If you, the individual, have the capacity to decide on taking the risk to push yourself to new limits of ability, then you have also taken responsibility to retain and use information given therein and communicate any concerns. It could reasonably be asserted that we are doing more harm by not engaging in physical activity than an occasional harm that occurs during exercise.

Take Home message:
We strongly believe the benefits of exercise far outweigh the risks.

I have deleted my application to Tesco (sorry Tesco, I actually would have been a great employee – punctual, reliable and honest). I have recoated myself with Teflon, licked my wounds and readjusted my risk benefit analysis. Right then… everyone on your feet.

References:

Atlay, A. (2001) Systemic and local effects of immobility, Journal of Rheumatology and Medical Rehabilitation 12(4):271 – 276.

BMJ best practice guidance (2020), Weighing up risks and benefits. Available online at https://bestpractice.bmj.com/info/toolkit/practise-ebm/weighing-up-risks-and-benefits/(accessed 19/02/2020)

Health & Care Professions Council : Standards of conduct, performance and ethics
https://www.hcpc-uk.org/standards/standards-of-conduct-performance-and-ethics/
(accessed 19/02/2020)

Salgado, R., Lord, S., Packer, J., and Ehrlich, F. (1994) Factors associated with falling in elderly hospital patients; Gerontology. 40 96), 325-331.

Sherrington, C. and Teidemann, A. (2015) Physiotherapy in the prevention of falls in the older person, Journal of Physiotherapy, 61 (2) 54-60.

Wu, X., li, Z., Cao, J., Wang, Y., Liu, G., Liu, Y., Fangfang, L., Song, B., Jin, J., Liu, Y., Cheng, S. and Wan, X. (2018) The association between major complications of immobility during hospitalisation and quality of life among bedridden patients: A 3 month prospective multi-center study. PLoS ONE 13(10): e0205729 

Feature image credit:: https://jamanetwork.com/journals/jama/article-abstract/2679279

Catherine Moore updated 6th Feb 2020

Physiotherapy has become a very confused profession. When I first qualified over two decades ago, life was very simple. Poor posture caused back pain and reduced core stability contributed. Agreed maybe it was a little too simplistic but lots of patients benefited from this wisdom. However, as the profession ‘grew up’ it wanted to be more accepted in the medical community for having an evidence base, so we went about proving that what we did was effective. We embarked on a journey towards truth that involved applying effectiveness research to everything we did. Because we wanted acceptance, we pursued the gold standard of evidence, the randomised control trial (RCT).  

Funny fact about RCTs; they were designed to show the effectiveness of drugs.  

Drug treatments can be blinded (so you can be given a bottle that might contain a drug or it might just contain a dummy tablet, no way to know hence the term blinding) and drugs can be dosed (the same volume of the drug can be delivered each time). In the Physio world the ‘drug’ is the treatment we offer. In order to decide upon that treatment there is a complex social interaction that goes on between the therapist and patient. An alliance is formed based on what the patient perceives will have benefit and the evidence/ experience brought by the therapist. The problem with this interaction is that it can neither be blinded or dosed.

The good Physio will take the time to explore the finer nuances of the patients’ problem. What aggravates the problem, what eases it, what functional limitations does the patient report. In many ways, patients are very similar but also very different. Take for example two back pain patients (please excuse the extreme stereotypes here). Mrs Jones is a nurse who stands or walks for 12 hours whilst Mr Smith is a brick layer who will bend forward most of the day. They both have back pain but their genetic make-up, body morphology, eating habits, exercise habits and other lifestyle factors mean that their tissues are under extremely different stresses. This brings me to the next issue with RCTs; in an RCT, both patients would be labelled “non-specific low back pain” (NSLBP) and given the same treatment. Currently the majority of low back patients (94-95%), regardless of the differences in stresses, will be labelled low back pain and researched in the same homogenous group.

The other thing the RCT requires is a control group or placebo. Control is really important in drug trials as the control group of the trial can be given a ‘placebo’ which is the dummy drug but patients won’t know they are receiving it. In physiotherapy trials the control is usually no intervention (patient remains on a waiting list) or usual care (GP and meds). Does the patient assigned to the control group then go and sit in a dark room for the whole time the other group are receiving the treatment in the trial? No of course not! They have access to friends, books, the internet, this blog. They will attempt to find answers and may even follow advice, so can they really be classed as a control in this instance? I do not believe so. These confounding variables can influence recovery.

Compare the two groups six months later and guess what? There is no discernible difference between the treatment group and the control. The conclusion is that the intervention is dismissed as ineffective. However, the problem here is that statistics have been used to show the difference between the groups. Statistics will tend to use the mean improvement scores from both groups and compare them against each other. Mean is the average improvement, average means average. Some people will have improved a lot, some people will have had a moderate improvement and some people will have worsened. When we average this out, we get a small or minimal change based on the intervention. What we don’t know is which patient improved and why or indeed which patients got worse and why? Maybe the intervention does work for the right person at the right time but due to the homogeneity of the researched group we can’t answer that question.  

As a consequence of this over-reliance on the RCT, we have therapists who will tell you that the there is no evidence that how you sit makes a difference to your low back pain (it does but don’t tell anyone I told you), there is no evidence one exercise programme is better than another for low back pain (there are better ones but again please don’t tell anyone I told you this), there is no evidence that tape is useful (it is when used at the right time for the right purpose, but if you tell anyone I said that I might have to kill you). Where does this leave us as a profession and where does this leave the patient. If nothing works….do nothing? Sit how you like for as long as you like? Do whatever exercise you like or no exercise? The pain is all in your head and you just need to sort your head out? It has become so confusing.

Therapists have become dependent on the published evidence and have lost sight of the original tenets of the evidence-based triad. It is a balance of the best of the published evidence (I am inclined to argue that the RCT is not the best for Physiotherapy but that is my personal opinion), the evidence the patient brings and the evidence the therapist brings based on their expertise and experience. What the evidence from RCTs tell me is that what they show does not match my daily evidence gained through patient encounters. Does this mean I am wrong and the RCTs are right? My patients tell me otherwise. They tell me they feel better, move more, get back to their functions. Why is this so different to what the published ‘evidence’ says. Could it be the methodology of the research is wrong?

I am undosable

I am unblindable

I do not treat you all the same

I am not wanting to give an ‘average’ treatment

Here at Moore Associates every patient is an individual. We will look at the unique needs of all individuals. If you have to sit for work, then how you sit and how long you sit is important. If you need to walk, how you walk is important. If you must bend a lot, how you bend is important. We assess what will help your low back pain in relation to your genetics, your morphology, your lifestyle habits and tailor your rehab to the stresses your body needs to cope with. We will use tape if we think it is warranted, we will use massage, mobilisations and core stability when it is required to help you move and cope with your day to day activities. We will not give you a generic exercise sheet that will have as much chance of making you worse as helping you improve. We will teach you how to manage YOUR back – its yours so YOU need to manage it.

Owen Moore - Update 2nd Feb 2020
If this was a drug, we would all be on it 3 times a day!
If you can walk, you can jump rope. Train the way you want to perform. Believe in your ability to be better. Take ownership of your fitness - at home, today and forever.
Create a new habit - 3 sets of 3mins 20secs (10mins of jump rope) - as easy as brushing your teeth.

I had the pleasure yesterday of hosting the Buddy Lee Jump Rope System (JRS) to a select few at the UFC Gym, Nottingham, England.
My interest in jumping rope started a few years back when the General Manager of UFC Gym Nottingham, Mr. Rikki Jeffrey helped me achieve double unders in a single morning (despite months of CrossFit training).  When I managed to secure Buddy Lee's attendance, Rikki was the first person I wanted to ask about hosting the seminar. Huge thank you for yesterday AND your help back then sir!

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Fast forward now to 2019. I was asked to help plan and deliver a boxing class for Parkinson's Disease patients and I was looking for a jump rope methodology that was progressive, safe and effective for at-risk patients. Amongst the fog of videos, opinions and impossible somersault tricks, I discovered the methodology that has since changed my fitness, health and that of my patients. Imagine making falls and fraility a thing of the past? Can you ask an 80-year old who is osteoporotic to jump rope? Absolutely - if you coach them correctly.
Obesity, ACL injury,  cardiac rehabilitation, chronic pain syndromes ~ these are all conditions receptive to a functional loading approach that jumping rope allows. We should be prescribing jump ropes NOT drugs; opiods and NSAID's convey more risk than benefit. The time for change is imminent and I intend to champion self-efficacy and fitness with a JRS.
There's the 3 Phase approach (Base, Conditioning & Sports/HIIT), low impact, challenging skillsets and fun cognitive tasks - all this and more from a cost-effective, space-efficient treatment. I am now writing an exercise prescription program for common musculoskeletal conditions with the research to support the JRS.

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I have been reviewing the literature about skeletal muscle injuries, tendon adaptions to physical stress and also the emerging clinical utility of jumping rope.
I was very interested to learn that jumping rope (regular & weight ropes) increased sit-up and press-up ability significantly over a 12-week schedule,  as well as reduced body fat and improved grip & throwing function!  
Full researcgh paper (.pdf) ::
https://pdfs.semanticscholar.org/96e7/f38a4864aba2aaa4850b1fb04ae25df36ba6.pdf?_ga=2.5571568.276023919.1579971608-2005536517.1579971608

Bias, Chance or Truth?
In their book Clinical Epidemiology - The Essentials, Fletcher & Fletcher [1] make note of how our clinical observations can be subject to bias and chance; when these have been controlled or minimised, truth should emerge. I learned very early on that the tendency towards bias and chance during the post-graduate education period left me vulnerable to being swayed by people rather than the movement science. Ever since the CSAG review in 1994 [2] I have wondered how useful a medical/disease model for lower back pain [LBP] was to the patients I assessed and treated.
Now let's be clear right from the outset; I am biased. My view of how to treat LBP is an amalgamation of research I have read, applied and found useful. As a physical therapist, I have not been adequately trained in medicine, psychiatry or other allied disciplines to be deemed competent to treat my patients for depression, anxiety, mindfulness etc. etc. It is however, abundantly clear that the way people think and view the world can influence their recovery from musculoskeletal [MSK] pain syndromes. But does the way you think actually change your ability to manage the symptoms in your lower back? I do not believe this paradigm.

A weekend course does NOT constitute a qualification; it represents an awareness/taster of an idea or belief. I suspect that there would be outrage and shock if our military special forces, airline pilots or emergency services were "qualified" after a Saturday/Sunday training session.
Movement Impairments - Cause or Source?
Treatment by physical means, and a focus upon the movement system, is my unique focus [3]. I make no apologies for distancing myself from the shift in physical therapy practice towards telephone calls masquerading as treatment or handing out leaflets and hoping patients figure it out for themselves. Two events in 1998 changed my direction of thought and practice pattern forever ::
* 2 days with Professor Shirley Sahrmann in the Gleeson Lecture Theatre [Mar 1998, Chelsea & Westminster Hospital] & subsequent Mary McMillan lecture [4].
* A secondment to work in the Ergonomics Department at Nottingham City Hospital [1998-1999 with Professor Sue Hignett] & subsequent post-grad study/cert in Occupational Health [5].

So why was this such a shift for me?
Independently of each other, both Prof. Sahrmann & Prof. Hignett pronounced their focus upon the causes of pain problems rather than trying to ameliorate the symptoms or sources of pain. Put bluntly, the body tissue that hurts [::defn ::source:: ligament, muscle, tendon] can be cooked, frozen or electrocuted by a therapist, but what discussion is taking place with the patient about the cause [::defn - cause:: sustained or repetitive movement that is physical stressor]. I have rarely found passive treatments rewarding for either the patient or physiotherapist.

That said, we cannot deny that at the right time [6] in an injury continuum, modalities like taping, acupuncture, manual therapy etc can help people recover. Indeed, my own sporadic injuries [e.g. calf strain 6 days before Army selection] benefitted tremendously from taping [7]. Shame Rocktape couldn't improve my eyesight on the Snellen test otherwise I would have used it on my eyes too!

What I truly believe is that over a lifespan, making people autonomous should be a key goal. You wouldn't dream of having your teeth brushed for you, by the dentist, morning and evening for the rest of your life?

References ::
1. https://www.amazon.co.uk/Clinical-Epidemiology-Essentials-Robert-Fletcher/dp/0781752159/ref=cm_cr_ar...

2. http://bjgp.org/content/bjgp/47/421/501.full.pdf

3. http://www.apta.org/uploadedFiles/APTAorg/Practice_and_Patient_Care/Movement_System/MovementSystemSu...

4. https://watermark.silverchair.com/ptj1208.pdf?token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485y...

5. http://www.lboro.ac.uk/departments/design-school/staff/sue-hignett/

6. http://bjsm.bmj.com/content/bjsports/46/4/220.full.pdf

7. https://www.researchgate.net/profile/Catherine_Moore11

New site written & published yesterday and the new focus upon upper body strength - (the muscle up [https://youtu.be/rtF51pQB6Wc] has led to a fierce challenge in the gym. Watch this space for more info and instructions as I improve.