Clinical Guidelines. Who are they guiding?

There are a plethora of clinical guidelines published around the world on various clinical presentations from low back pain to managing multiple medical conditions. The intent of a guideline is to offer clinicians evidence based information on the most effective way to diagnose, manage and implement treatment for the target condition. They are simply put, evidence summations and sign posts for the best current care. Ref: https://en.m.wikipedia.org/wiki/Medical_guideline

There have been many papers written on the lack of adoption or “adherence” to the published clinical guidelines amongst clinicians. Some of the lack of adoption is based on lack of awareness of the existence of the guidelines, but a lot of clinicians fail to follow them because they patients they see do not fit the inclusion criteria for the evidence base used to write the guidelines. It is common for RCT to exclude people with multiple co-morbidities, law suits, workers compensation claims, those undergoing current therapy, previous surgery etc. The average patient seen in daily practice, often has one or more of these exclusion criteria.

Useful reference: https://bmjopen.bmj.com/content/bmjopen/9/10/e032329.full.pdf

I have consistently suggested that clinical guidelines reflect a “perfect” world situation using the average outcomes from RTCs and Systematic reviews, where in everyday clinical practice patients come with complex issues, often with co-morbidities and related complex social determinants of health. It is obvious to most clinicians that no one necessarily needs what the average of all of us might need.

So what use are the guidelines if clinicians are not following them and the do not reflect the real world situation of everyday clinical practice?

A recent review by Lin et al looked at the best advice across the board from multiple guidelines and came up with 11 common recommendations. These recommendations are reasonable and can be applied across multiple clinical disciplines and seem to apply to most if not all patients. 👇

Source: https://bjsm.bmj.com/content/bjsports/54/2/79.full.pdf

As a clinician the paper is an important read, the recommendations are easy to apply in everyday practice.

It appears that a lot of clinicians don’t follow the guidelines because they are unaware, feel their patients aren’t represented, stuck in a treatment belief that they believe in but lacks evidential support, or (dare I say it), they believe they know better.

I have to admit, I’m not a guideline follower, but I do believe I am pretty close to the 11 recommendations from the Lin et al paper.

As always thanks for reading.

Clinical tests a numpties guide. (And I’m king of the numpties)

Over the last few days I’ve been having several discussions on twitter, about clinical tests including the reliability, validity and accuracy of said tests. During the discussions, with some very clever clinicians, it became evident that clinicians may not have a good grasp on what constitutes a valid test, or how to test with intent using a Bayesian Conditional Probability approach, for testing a clinical hypothesis.

So I decided to write a numpties (that’s me) guide to clinical testing. So strap in and enjoy the journey.

When I originally trained and on continuing education courses, early in my career, I remember learning clinical tests on a simple level. Instructors would say “here is a test for shoulder impingement (ie Hawkins Kennedy or Neer’s test), if it’s positive your patient has a shoulder impingement.” Despite evidence against this being correct, you can still find this information with a simple Google search on “shoulder impingement tests” 👇

Source: https://www.physio-pedia.com/Hawkins_/_Kennedy_Impingement_Test_of_the_Shoulder

Clinical tests should not be used to prove a hypothesis or diagnosis, they should be used with the sound clinical intent of assessing the shift in probability of your clinical hypothesis.

It is important to choose the best tests, that will improve the probability of your clinical hypothesis being correct. It is also important to remember that your clinical hypotheses should be based on sound clinical reasoning and on receiving the patient historical narrative. Here is a link to a webinar I did on clinical reasoning in low back pain which give examples of this https://youtu.be/8KZvRbmQu7s

So what do we need to be aware of when choosing a clinical tests?

For most clinical tests we need them to have good clinical utility, based on good reliability and validity. Sounds complicated and technical. Simply put reliability is the ability for agreement, validity is the ability of the test to do what it says on the tin, ie how good is is at finding the target pathology (the tests sensitivity) and how good is it at detecting when you don’t have the target condition (the tests specificity)

Here is a link to an old blog post I wrote showing how sensitivity and specificity are calculated http://retlouping.blogspot.com/2009/04/truth-in-diagnosis-simple-guide-to.html?m=1

Sensitivity of a test is basically a description of the true positive rate.

Specificity of a test is basically a description of the true negative rate.

Source unknown?

The aim of a good test is to have both high Sensitivity (Sn) and high Specificity (Sp)

An old pneumonic was used to indicate that Sn and Sp could be used to rule conditions in an out, SnNout and SpPin. In simple terms if a test has a high Sn it will be very goo at detecting the target, so counter intuitively it could be used to rule a target out if the test result was negative. Conversely Sp when high would be good at saying you don’t have the target hence when a test with high Sp was positive it could thus be used to rule in the target. I would propose that this simple view of testing doe snot improve your ability to test your Clinical hypothesis. A combination of Sn & SP can be used to calculate a ratio known as the likelihood ratio, which can then be used to calculate the change in probability when you perform your test when it is both positive and negative.

(Some further reading here. https://en.m.wikipedia.org/wiki/Sensitivity_and_specificity#Medical_examples

Likelihood ratios are useful as they are a combination of the true positive and true negative rates of the test. Once calculated they can be used with a Bayesian nomogram or online calculator to calculate the post test probability of your clinical hypothesis give you know the pre test probability, which is generally available looking at population data or the occurrence in your clinical population of the target condition.

Calculation likelihood ratios: 👇

Once you have calculated the likelihood ratios of you test (here is a link to an online calculator http://getthediagnosis.org/calculator.htm ) you can use them as a rough guestimate of how a positive or negative test may alter the post test probability of your clinical hypothesis. See the table below 👇

if you know the pre test probability of the target hypothesis you can also get an accurate post test probability using a Fagan or Bayesian nomogram. I speak to this in the blog I posted earlier.

The nomogram is easy to use (but you can use the free online calculator posted above) find the pre test probability on the right, find the Likelihood ration in the middle and dram a line from one through the other extending to the post test probability on the right.

It is important to note that due to Bayesian conditional probability the post test result of your test now becomes the new pre test probability of you next test. Hence be aware that if you use a test that has a positive likelihood ratio below 1 you are lowering your new pre test odds. See the example below.

Conditional probability is also why a cluster of average test can produces a better post test odds than a single test average test. Each test shifts the pre test probability for the next test.

I hope this all makes sense? It highlights that in the old way of thinking when a test came up negative you may just have chosen a new tests or several new tests until several, until one came up positive “confirming” your hypothesis. It is important to remember that every test has an effect on the starting point of the next test.

Look at the data set below, it can bee seen that in the case of testing for SI joint pain we should be aware that many of the listed tests have poor clinical utility.

Any test with a +LHR below one is basically a useless test as it lowers the post test probability and thus the new pre test probability for the next test.

It is also important to remember that if you have a very high pre test probability of a target condition, based on the history findings received from the patient, it is important to be cognizant that a poor clinical test may not shift the probability post test enough for you to reject the diagnosis. An example of this is with COVID-19 and testing. 👇 this is why we should seek to understand the basics of clinical tests and their application to clinical scenarios.

I have tried to simplify testing to allow understanding of the complexity and affect testing can have on probability. I propose that we should use clinical tests sparingly and that all clinical tests should be seen as ‘special”. Ask your self “well the test I am about to perform shift the probability of my clinical hypothesis significantly in a positive direction?” If the answer is “No” then why perform the test?

As usual thanks for reading.

“Always test with intent.”

Ethos, Pathos, Logos and developing a patient centered alliance

I have been talking about patient empowerment for over half of my career. Terms like “Patient Centered Care” and “Therapeutic Alliance” have become more more common place than they were 20 years ago.

But has much changed on a day to day basis in the practice of Physical Therapy(Physiotherapy) or do we just pay lip service to the terms?

On the average day in a busy clinic, with a packed schedule, several new evals, one or two re-evals, several patients turning up late, how do your “motivational interviewing” and relationship building skills fare?

If you have a consistent patient interaction skill set, then even on the busiest day, with all the hiccups that may ensue, you will still be able to give each and every patient the understanding and empathy they deserve.

One simple and consistent method of patient interaction is to practice Ethos, Pathos, Logos. The original concept developed by Aristotle to win people over to his arguments during debate. This was later expanded on by Stephen Covey (of Seven Habits fame).

Ethos, is the root word for Ethics and Covey explains it is the essence of developing a good relationship, simply put it means “gain trust.”

During the initial encounter with a patient everything matters, patients are assessing your clinic, the staff, and you, as much as you are assessing them. It is important they feel safe and listened to. Gaining their trust is key to a good therapeutic alliance. Without trust as a foundation everything else may start to fail.

Pathos, is the root word for empathy, Covey suggests that this implies “seeking to understand”, without judgement, truly listening to another, seeing things from their point of view. The emphasis is on empathetic listening, where one listens not with the intent to prepare to answer, but to understand the patient’s narrative. (This synergies with Ethos, as it is a powerful tool for building trust)

Logos, is the root word for logic, here Covey suggests that after truly listening then one can “seek to be understood” again this synergies with Pathos and Logos, seeking to be understood requires one to utilize the patient’s narrative, to form an individualized assessment and treatment plan, based on shared decision making with the patient. Education is not simply an add on to the end of a treatment session it is part of the fabric of the whole patient encounter. Allowing patients to reflect during the clinical encounter leads to a more patient centered learning experience.

Ethos, Pathos, Logos is a simple framework which can be utilized to make each clinical, encounter meaningful for both the clinician and the patient. 

@retlouping 2020

Be better than placebo. Another train journey micro blog

On social media recently there are numerous discussions on placebo, placebo effect contextual effects, non specific effects and specific effects. Some are proposing as clinicians we should #bebetterthanplacebo, or suggesting we should be more than the sum of the contextual effect, often created around a therapeutic alliance.

So are we better than placebo? Well true placebos are inert substances with no known  active effect, so hopefully our treatments are truly better than “nothing”.  The problem arises when we ask are we better than the sum of the contextual effects created during the therapeutic encounter? (See the milk bottle model)

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What are the differences between “nonspecific” treatment effects or so called “placebo responses” and specific effects? If you are just reducing pain with your intervention is this a specific or a non specific effect?

Kory Zimmer  Ref has suggested that to understand the specific effects of an intervention you should replace the word “specific” with “unique” ie what responses are unique to the intervention?

With this in mind I would ask you to ponder, what effects are unique to your interventions, that are not attributable to contextual effects?

What’s in a word? It’s all Biopsychosocial (Micro blog)

There is still a lot of confusion regarding the word “biopsychosocial”. Yes it’s a compound word made up of three other words “biological (physical) , Psychological (of the mind) and Social (of the environment)

The trouble is that just like the word biopsychosocial is all one, so are humans. Clinicians constantly talk about the three elements as separate drivers of pain and health, whilst forgetting that they all apply and are often intimately connected in a causal relationship that can not be found by separating  them.

Humans experience distress, often manifested as “yellow flags, this can be in response to multiple drivers. We talk about self efficacy (the belief you can do something) and locus of control ( the belief you have control in yourself, internal locus, or that external factor control your situation an external locus.

These measures are part of the human experience and are a reflection of human suffering. It is normal to be distressed when experiencing ill health or pain. Everyone, bar non, will display some degree of psychological manifestation during  times of suffering.

The hard part for clinicians is to realise distress responses are normal and are all part of the human condition.

I have proposed the analogy that trying to separate biopsychosocial into it’s composite part to find causation is like trying to separate water in to hydrogen and oxygen to find out the properties of water.

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As clinicians it may be time to utilize a “whole-istic” approach to understanding patient who present for treatment of painful conditions. Considering their social determinants of health, their coping strategies, their level of distress, including kinesiophobia, catastrophizing, self efficacy and locus of control, their physical and functional impairments, is all part of the big picture contributors of the clinical condition.

We can not understand the whole by dissecting it into it’s constituent parts, just like we can’t uncook a pancake.

 

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Resurfacing or still drowning in despair?

Resurfacing or still drowning in despair?

 A brief commentary on Andy Murrays new documentary “Resurfacing”

https://www.imdb.com/title/tt11243364/

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I initially watched Andy Murray’s “Resurfacing” documentary out of curiosity due to some twitter comments and recommendations to watch it . I didn’t expect it to be so engrossed and at some points emotionally involved in Murray’s journey. I also found myself questioning some of the wisdom of the medical interventions, rehab and medical advice he received. That said, I accept that it’s easy to be critical and that hindsight is often 20/20.

After tweeting a few comments it was suggested maybe I should write a blog review. So I did.

Problem is I started the blog several times then deleted it.  Below is my fourth effort, enjoy.

I re-watched “Resurfacing” wrote some notes during the documentary and still don’t quite know what to make of Murray’s whole journey.

I recommend that readers watch the documentary (if they have access) and make up their own minds. One good thing to come out of watching the documentary twice and reflecting on my thoughts about what occurred over two years, was I had to read some new evidence based papers on corticosteroid injections in to the hip (which fueled a great discussion on twitter here https://twitter.com/retlouping/status/1213466336426369036?s=21 ), and MRI findings in the hips of high level athletes, and one on findings in asymptomatic individuals compared to age and sex matched symptomatic patients, which I reviewed on twitter here https://twitter.com/retlouping/status/1213524327125135360?s=21 and here https://twitter.com/retlouping/status/1213794544648704000?s=21

The documentary starts with Murray preparing for surgery on his right hip. He has a long history of right hip issues but in January 2018 he made the decision to have arthroscopic surgery to “fix” his hip issues that have not “healed” with conservative care.

On January 9th 2018 Murray undergoes arthroscopic hip surgery, reports post surgery by Murray indicate he had a torn ligamentum  Teres which was trimmed, a repair of a torn labrum, cleaning up of “inflamed tissue” and the surgeon noted excessive articular cartilage damage. (Remember this as it is important later)

Post op Murray and his medical/ rehab team, which compromised two Physiotherapists, a conditioning trainer, a Pilates instructor, and his tennis coach, did lots of passive stretching, pool work, strength and conditioning including bike work, reformer and climber.

Jamie Delgado, Murray’s coach, states a few weeks after the surgery “Surgery went well, it got rid of the issues.”

Murray’s team were focusing on a quick return to function and improved range of motion. The biggest issue was Murray’s function was apparently progressing well, the only thing that wasn’t progressing was his PAIN.

In Murray’s own words his hip felt “sore and weak.” Despite lots and lots of hard work and strength training.

A comment that made the  hairs stand up on the back of my neck was “We didn’t know how long it would take to recover from the surgery.”

How could this be possible?

My observation was that Murray was doing too much too soon in his post op rehab and was not respecting the repair and healing process. Too much passive stretching, not considering post op movement restrictions such as external hip rotation in the early phase of labral repair surgery.

Of course Murray was painful, his body was still recovering from what is major surgery. I think he and his team made the mistake of thinking minimally invasive arthroscopic surgery means minor surgery due to small wounds. They also seemed to be under the impression that Murray’s hip  was ‘fixed” and it was just a matter of getting his conditioning back. I think they did not respect his post op pain enough.

In April 2018 Murray was still having a lot of pain in his right hip, so they consulted a new MD who advised them to have a repeat MRI and consider pain management strategies including oral medication, cortisone injections and nerve ablation to “numb down” the hip to allow Murray to push harder on returning to play.

Quote “once you get rid of the pain and improve the range of motion, then it’s down to the rehab team”

Over the next few months Murray had two intra-articular cortisone injections and two nerve ablation procedures. As expected he had some improvement in his pain and he started to ramp up his training, conditioning and tennis practice. He continued to “push through the pain” but continued to have ongoing hip pain when he tried to practice tennis at full steam.

My thought at this point were why would you numb the area that is obviously causing problems under high mechanical load, so that you could go ahead and expose that area to more high mechanical load?

This is akin to having a sore forehead from repeatedly smashing your head against a wall, the solution isn’t numb your forehead to allow you to keep smashing your head against the wall?

Plus what is the risk on of accelerating the articular cartilage defects noted at Murray’s arthroscopic surgery? I refer back to the twitter thread on this https://twitter.com/retlouping/status/1213466336426369036?s=21

Was it wise to have the corticosteroid injects?

Was it wise to have the nerve ablations?

(Remember hindsight  is 20/20 but did his medical team consider the risks, rewards and the evidence?)

In August 2018 Murray decides to return to tennis to test out his hip out. He plays and wins two extremely long matches. In his third match he is visibly struggling with hip pain, he is limping and struggling to go for shots that require high loads through the right hip. Murray is visibly despondent and crying after the match.

Murray comments post match “my body doesn’t want to do it, my mind doesn’t want to push through the pain barrier.” He is visibly distressed. “My body is telling me NO, it hurts.”

August 2018 Murray appears physically and mentally spent. His wife Kim discusses trying to continue and commit to carrying on until the end of the year.

It’s at this point you realize that Murray is not just a Tennis player, he is a brand and an Industry, he employs a host of people and has responsibilities to sponsors. Retiring has big personal and financial repercussions.

Murray decides to try something with different energy?

After watching the documentary twice I realized that Murray is obviously bombarded with solicited and unsolicited advice from many sources. He receives mail on a daily basis offering him advice and “medical fixes” for his problem.

He also echos that every time he engages with a new practitioner he gets new hope, which is dashed when the new approach doesn’t work. I pondered that no where in the documentary did we see Murray receive any professional psychological support?

In August 2018 Murray travels to Philadelphia to try a new rehab approach with Bill Knowles at YSC sports. At YSC Murray undergoes a series of new rehab exercises including break dancing, playing like a child, forward rolling, leap frogging. The idea seems to be to return to simple play patterns to distract Murray and move his hip in unfamiliar patterns. The approach also involves manual therapy and “alignment” of his spine and hip. At the end of the therapy Murray seems somewhat frustrated that he is still in pain.

“Every single brings hope and a flicker that this is it.”

“None of the therapy is done in bad faith.”

December 2018 Murray is practicing on court in Miami. Murray seems to be reaching his psychological low.

Quote:

“There is nothing I can do.”

“I want someone to say stop.”

“I feel like I don’t deserve this. I literally have done everything I have been told.”

“I feel like I deserve a better outcome.”

It appears at this stage that Murray has lost his internal locus of control.

Murray discusses that he will perhaps play in the 2019 Australians open and retire at the 2019 Wimbledon tournament if he can stay match fit through the pain.

We see Murray play and loose his first round singles match at the Australian open, where in an emotional interview he appears bid farewell to tennis

There is a light hearted  moment at this stage of the documentary where Marry is seen collecting the days mail and limping visibly jokes about the unsolicited letters he receives from people offering to “fix” his hip.

Ah! this one is asking if I have considered the homeopathic remedy.” (Chuckles out loud)

Murray decides to retire than decides not to, he is tracking, with interest, the the return to tennis of Bob Bryan who has undergone a hip resurfacing surgery and returned to high level doubles tennis. We see Murray reviewing videos of hip resurfacing and discussing a possible early surgery and a return to tennis at Wimbledon.

He is seen working out on his climber and receiving news that his resurfacing surgery will be on January 28th. He verbalizes that he has no doubts about the surgery but wants it ASAP as he may second guess his decision and he keeps getting messages from other surgeons, saying go with them.

On January 29th 2019 Murray undergoes a hip resurfacing procedure of his right hip.

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Side note on the perils of SoMe:

Murray posts pictures of him in bed, post surgery and X-rays of his hip resurfacing on instagram. Both pictures cause heated discussion and some humor on SoMe.

The X-ray has numerous comments because Murray’s genitals are visible on the X-ray.

The picture of him in his bed starts a heated debate and arguments amongst doctors in the USA and UK due to the drip, cannula and blood pressure cuff placement on Murray’s arm. (He is a right handed tennis player)

https://www.avainfo.org/page/AndyMurray

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Despite the SoMe controversy the recovery from his hip resurfacing went well.

Murray asks his surgeon if he can return to tennis without damaging his new hip, his surgeon says he has a 15% chance of destroying the resurfacing over seven years if he does. Apparently Murray was comfortable with the risk.

My observation was that post hip resurfacing Murray’s rehab was much more measured an appropriate. He didn’t over do things, he followed a graded loading program with less passive stretching a more self directed activities from pool therapy to land exercises. His rehab was also much more prolonged and he didn’t return to tennis drills until 4 months post surgery, in contrast after his initial labral repair surgery he had been pushing his rehab and tennis hard in the hope of a quick return.

Murray also appeared to be much more comfortable in his own skin and was enjoying being pain free for the first time in several months. He even questioned whether he wanted to commit to the work required to return to first class tennis, he appeared to be enjoying family life and just being able to go about his day without hip pain.

In May 2019 he returned to active on court tennis practice and did some measured sprints which looked free and easy and were at a speed far above his previous levels for the past 12 months. He is seen discussing returning to high level tennis with his surgeon, who jokingly asks if she needs to buy a hat to come watch him at Wimbledon?

Carry on” remarks his surgeon.

The documentary ends on an extremely high note with Murray returning to Doubles at queens with Lopez and they win the tournament. Murray’s return to tennis is complete????

As I write Murray has played several singles matches in 2019 everything seemed on track for him to play singles in the Australian open in 2020.

Sadly Murray has announced that he has withdrawn from the Australian open due to a “pelvic injury” it has been reported he has a bone bruise of his pelvis on the side of his hip resurfacing.

Andy Murray Out Of Australian Open Because Of Pelvic Injury

https://www.forbes.com/sites/daniellerossingh/2019/12/28/andy-murray-out-of-australian-open-because-of-pelvic-injury/

Is this an early sign of overload and a warning sign for Murray’s future? Only time will tell.

Overall the documentary is an emotional rollercoaster ride for both Murray and the watcher. As a medical practitioner it is sometimes hard to watch without screaming “WHY” at the TV screen.

My thoughts questions and reflections:

  1. Pain should be respected, sometimes it is due to damage and you can’t out exercise it.
  2. You can’t cut out pain and just because you see things on MRI, fixing them may not solve the PAIN problem.
  3. Is passive stretching into pain in early post op care indicated?
  4. Did the rehab team understand post op labral repair ROM restrictions and recovery timelines?
  5. You can do too much loading to soon post operatively.
  6. You can’t cut, burn or inject away pain.
  7. should you inject corticosteroids into a hip with severe articular cartilage changes? (See twitter discussion in article)
  8. You can’t accelerate healing by exercising excessively.
  9. Each new health care provider offers hope, which can be quickly dashed when pain and function don’t improve as promised.
  10. You can be too close to a patient to give them advice.
  11. Twitter pundits advice is sometimes the wrong advice in certain situations. ie hurt doesn’t mean harm, you can’t go wrong getting strong, you can exercise with pain, your scan isn’t your destiny, exercise is the answer………etc, etc, etc
  12. Rest is sometimes indicated.
  13. Your rehab team should not be your friends?

 

My early comments from twitter:

“Just finished watching, have to admit it brought some Tears to my eyes. A powerful, powerful lived experience narrative.

My only comment is that his medical support team need to watch & do some self reflection. 

You can not keep smashing your head against a wall and expect no pain”

 

 

“Watching Andy Murray Resurfacing whilst I spin. 🚴🏻

It is so hard to watch. Easy to second guess in hindsight.

 Current thoughts.

  1. You can’t cut out pain.
  2. You can’t ignore some pains, they do mean damage.
  3. Why do PTs stick their elbow in people’s butt cheeks?”

 

Below is a general review of the documentary

The Gist: For the uninitiated, Murray is one of the greatest male tennis stars ever (a surefire Top 20 player ever), and has a list of accomplishments from here to the moon. But by 2017, a dozen years into his pro career, early retirement was looking like a serious possibility. He suffered a hip injury requiring rehabilitation. And then, surgery. And eventually, surgery again. That last surgery looked like it might be just-so-he-can-walk-normally surgery, not play-gruelingly-intense-tennis-matches surgery. He was 30 years old at the time, which is getting-up-there for a pro tennis player, but it’s not a decrepit age where he’d be better off shuffling to the park to play chess with the geezers.

Amidst all this was incredible indecision — and who can blame him, considering the blooms of uncertainty burst with vivacious color as we grow older? As many sports stars tend to be, Murray is a guarded individual, which makes director Olivia Cappuccini’s access here notable. She hangs with him during countless rehab and workout sessions, scenes that don’t seem quite so tedious when we realize Murray endured 1,000 more that weren’t caught on camera. We get glimpses of him in his mansion with his wife, Kim — a frequent talking-head commentator — and their toddler children; we see him weep during a press conference before a match that might be his last; we’re all-too-present for the gory details of the second surgery, where he had the ball of his hip replaced with metal.

Why does Murray so desperately need to continue? Tennis is all he knows: Cue the old snapshot of him as a grade-schooler, holding a racket and grinning. There’s also the therapeutic component. For his most psychologically raw and intensely human moment, he’s not on camera, but audio only, sharing how his mother used to give rides to a man that eventually shot up his school while he took cover in a classroom; how his parents divorced soon after; how his older brother, with whom he was very close, moved away. Tennis helped relieve him of his anxiety. So maybe now we know why he’s so animated and passionate on the court, and so reluctant to give up the thing that gave him not only great joy and great pain, but also escape and catharsis.

https://decider.com/2019/12/04/andy-murray-resurfacing-on-amazon-prime-stream-it-or-skip-it

 

The pain was literally all in my head. (Well face, which technically is my head)

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I like to think I keep up with the current evidence and trends in the “science of pain” (see what I did there) and I am definitely against anything that suggest the old chestnut “it’s all in your head” (subtext for your crazy and imagining your pain). I am also aware even with our best intent sometimes the “pain is a brain construct” also leads patients to think this is still the old “it’s all in your head” suggestion.

For the last month I have been suffering (my personal choice of words) from a severe face pain, which I have experienced in the past, but not this bad. The pain is deep in my face, beneath my left eye and into my front teeth and jaw. I am a frequent allergy and sinus sufferer (still my choice of words). Let me tell you, I understand pain, I know the current construct of nociceptive input being interpreted and the brain deciding, “yep!,here have some pain, you are in danger”.

My pain has taken several personalities over the last month, the dull ache, the sharp twinges in to my teeth (I went to the dentist, as I have in the past, it’s not my teeth), a gnawing sensation like a hamster having a good chew in my sinus, and pressure, lots of uncomfortable pressure. My symptoms have waxed and wained over the four weeks. After a serious session of two days of water boarding (aka salt sinus washes using a sinus was kit) I thought that the worse was over as I could sleep and not wake up all night (did I mention the pain was disturbing my sleep?)

Remember I’m a man, so going to a doctor in the first three weeks was never on my mind, I wasn’t at the about to die stage, so no doctor yet.

I have to confess the things that I tried and the things which gave me the most relief.

1. Water boarding, or the closest I ever wish to come to water boarding, two hourly sinus washing. I am amazed what lives up there.
2. Pressure to my sinus externally. Yes manual therapy, acupressure, what ever you want to call it. It feels great with the pressure on and a bit of deep rubbing, but once you stop the pain comes back in seconds. My wife just gives me knowing looks, as I sit with my index finger poked into my face.
3. Hot pack. I made a rice bag for the microwave. I am loathed to admit, number one best relief, the hotter the better ( I managed to avoid burning myself) the relief lasted up to an hour afterwards, enough time for me to get to sleep.( I think sleeping helped me cope with the daily pain.)
4. I started taking my Claritin (loratadine 10mg) and got some relief from the pressure. Blowing my nose frequently helped, but only temporarily.

5. Hanging my head over the end of the bed or lying on the couch with my head dangled upside down watching TV. (Our brains are amazing, because after 10 minutes you don’t realize the TV is upside down.) I got relief whilst in this position, I figured all the gunk stuck up there flowed somewhere away from what every was irritated up there in my head. Of course half an hour after getting up the pain came back.
6. NSAIDs, I overdosed myself at bed time, which allowed me to sleep, I tried to avoid during the day, as I am not a fan of medication.

 

Three and a half weeks in I spent a few hours outside walking in the cold, my pain got worse, the pressure increased and I felt back to square one. I also had some increase in life stresses, this seemed to be the straw that broke my tolerance for the pain. My wife was away traveling and I found myself on my own with my pain feeling sorry for myself. ( I truly think my mental state changed and hence my ability to cope changed.)

Yesterday I called an made an appointment to see and MD. I am not a fan of visiting the doctors, but off I went. Let me tell you I had a great experience and I am glad I went. (I know I hear a few voices shouting, you should have gone earlier.) I consulted with a float MD, who I had never met before. He was a 67 year old extremely pleasant MD who immediately asked me what my reason for coming was and how could he assist me. We had the usual chat about my accent (ETHOS) and he looked quickly at my electronic chart, smiling and saying “wow! We better listen to you, you don’t seem to need our help often.” At that point I knew I had met a skilled caring MD who understood that when patients like myself arrive for a consult we do so because we have a problem that is concerning us. He listened to my story and my expectations.

He did a quick exam of my ears throat and nose and listened to my chest. He didn’t press on my sinuses, be trusted that my accurate report of my own palpation.

He explained that he thought I had a severe inflammation of my sinuses, and that some antibiotics and a steroid would be the best initial treatment. I nodded and said that was my main reason for coming.

I have taken two doses of the steroids and one and a half days of antibiotics. The steroids seem to be working as my pain is already 90% improved, I know it will take a few days for the antibiotics to do their job. Today I feel a bit of pressure and sensitivity in my face, but have a positive sense that this is the correct treatment.

As usual the lessons I have learnt from the experience.

1. Maybe I should go to the doctors quicker, but I like to let my body try to work on getting better on it’s own.
2. Pain can be tolerable one day, but the same pain can be intolerable on a different day.
3. Sleep is important when you are in pain and feeling sick.
4. You do strange things to try to get pain relief.
5. Our emotional state affects how we cope with pain.
6. I DO NOT HAVE A HIGH PAIN TOLERANCE. I am totally intolerant to pain, I would prefer not to be in pain. I do have the ability to be tolerant if necessary in the knowledge that this is short duration and has a visible end point. I reached my tipping point at four weeks.
I closing the other driving force or me to go to the doctor was my wife sent me a Viber message saying “isn’t it time you went to the doctors?” I always ask my patients if this is the reason they have come for a consult. “My wife told me to come.”

Thanks for reading.

 

 

 

When is a contraction not a shortening? Let’s talk about muscle contractions.

When is a contraction not a shortening? Let’s talk about muscle contractions.

1. The definition of a contraction is

• the process of becoming smaller.
“the general contraction of the industry did further damage to morale”
synonyms: • shrinking, shrinkage, decline, decrease, diminution, dwindling
• “the contraction of the industry”
• the process in which a muscle becomes or is made shorter and tighter.
“neurons control the contraction of muscles”
synonyms: • tightening, tensing, flexing
• “the contraction of muscles”
• a shortening of the uterine muscles occurring at intervals before and during childbirth.
synonyms: • labor pains, labor;
• cramps
• “my contractions started at midnight”       (Source: Google “definition of contraction)
But when it comes to muscle we have three distinct types of “contractions” concentric, isometric and eccentric. Only concentric contractions would fit the definition above of shortening. Isometric contractions keep a constant muscle length, whilst eccentric contractions are “oxymoronic” and actually have muscle lengthening, not shortening.

This issue was discussed in a paper by Faulkner “Terminology for contractions of muscles during shortening, while isometric, and during lengthening” he points out the contraction when pertaining to muscle does not indicate shortening but instead proposes the following definitions: The verb “to contract” and the nouns “contraction” and “contractility” need to be defined correctly in terms appropriate with long-term usage as “specifically for muscle, to undergo activation and generate force. Ref

So simply put a muscle contraction is when a muscle undergoes activation and generates force.

He goes on to propose that the terms concentric isometric and eccentric are also confusing and should be perhaps be replaced with the adjectives that provide the greatest clarity “shortening,” “isometric,” and “lengthening”.

It seems that these definitions have not been universally adopted and muscle contractions are still commonly referred to by concentric, isometric and eccentric.

The molecular magic of a muscle contraction.

Concentric and isometric muscle contractions can easily be explained by the sliding filament hypothesis which will be familiar to many who have studied muscle physiology. It was put forward by Huxley in the late 1950s and the involves the now well recognized, Z bands, sarcomeres, H bands,I zones, actin and myosin filaments. Ref (See diagram below) Ref

Interesting Tidbit: It is possible to have a concentric contraction of muscle even when you are dead and the sliding filament hypothesis still applies. This is of course known as rigor mortis, which develops several hours after death. It is interesting to note that once a muscle has undergone a shortening contraction, energy is required in the form of ATP to allow relaxation (normally created aerobically) obviously after death this is not possible and hence rigor mortis contractions can last for several days. the term “a stiff” indicating a dead body has it’s origin in rigor mortis. Ref

The big problem though is that the sliding filament hypothesis can not explain eccentric contraction and many of the features that they possess such as high force generation with low energy expenditure or the ability to generate a force whilst lengthening against a load. In recent year a large protein molecule Titin which connects myosin to the Z band and to actin has been shown to be highly elastic and have the capability of bonding to actin during the presence of calcium release during eccentric contraction. Work by Herzog has shown that Titin has both elastic and visor elastic properties when muscle is stretched passively, but when stretched actively as in the case of eccentric contractions Titin binds at the Z band end with Actin and acts like a rigid sprain creating high resistant forces in the muscle. This is a proposed mechanism for the high force generation and low energy expenditure of eccentric contractions.Ref
Ref2
Ref3

For those who have further interest in this hypothesis and the action of Titin during eccentric contraction, there is an interesting lecture by Herzog here “A new paradigm of muscle contraction.” Thanks to @sportstherapy56 Ian Brown PT, for pointing me to this great reference.  Video link 

Interesting tidbit number two: “Titin is the short name for an extremely massive protein molecule. The full-length scientific name of this protein molecule contains 189,819 characters and is considered (by some) as the longest word in not just English, but any language.” Ref
Click here for a link to Titin in it’s full glory. Ref

Interesting tidbit number three: a sarcomere is on average 3 microns (micrometers long) that is 3 millionths of a meter. The average human hair is 90 microns hence a sarcomere is 30 times smaller than a human hair. These are “magic” molecular force generating machines. (Authors comment)

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What have I learnt and why do we still teach and learn muscle actions?

So what have I learnt in my four day journey of trying to understand eccentric contractions? I learnt there is still much to be discovered about what happens at the molecular level during muscle contractions, especially where eccentric contractions are concerned.

Muscle contractions are fascinating, I wonder why we learn the “action” of muscles as though this reflects some sort of essential function. We seem to focus on concentric muscle contractions which reflect muscle action, yet muscle function involves all three types of contraction. I would propose that we would be better suited to learn the function of muscles and their synergy and role with other muscles. Eccentric contractions are just as common as concentric contractions, we call certain muscles extensors or flexors when they are able to control the opposite movement via an eccentric contraction. A prime example would be the quadriceps muscles during squatting or the hamstrings during walking and running.

There is far more to muscle than shortening.

Ancora Imparo (yet I am still learning) Michelangelo

 

To be continued…………………………. Thanks for reading. 👍