If I was a lay person I would have bet my house my neck was “out!”

I woke up this morning, stretched yawned and bam a sharp pain just below my right clavicle (collar bone). “Poop”, I thought and a few other choice words. one getting up I had what could best be described as a painful pulling under my right collar bone. I went about my morning duties, went down stairs, put the kettle on, fed the cats, cleaned the litter boxes, brewed my tea, grabbed my iPad and headed down to my spin bike in the cave of pleasure & pain, that is my basement. Set up my iPad on the spin bike and cleaned the litter boxes out I the basement.

As I sat spinning and scrawling I noticed my pain was worse when I used my right arm to reach across to my iPad.

Position of my iPad on my spin bike

I tested horizontal adduction (reaching across my chest right to left) and it was sharp and painful with some restriction in range. “Oh poop!” was this my AC joint? (the little joint between your shoulder blade and collar bone) I tried turning my neck and it was restricted to the right and gave me increased pain under mu collar bone.

“MY NECK WAS OUT!!!!!!!!!” well for all intensive purposes that’s what it felt like or even my neck and shoulder were both ”OUT?”

I sat back into cycling position and realised I had much less pain, I tried a few shoulder extensions, using the mills maneuver (look it up ) but emphasised extension of the shoulder. The pain was unaffected, maybe it wasn’t my shoulder, but it still hurt to reach across my body.

Mill’s maneuver

I continued to spin and then decided to fiddle at my neck end to see if I could ”Put it back in?” (i am joking, but maybe not?) I stayed in my cycling position and tried side bending to the right with my head and neck from a semi slouched position (I can hear every Mckenzie therapist on the planet gasping) In the side bent semi slouched position I had relief of my pain. I repeated the movement about 20-30 times and by the end the pain was almost gone. I retested my horizontal adduction and it was much improved. I had put my neck back in, yeh!

I cycled for three hours, occasionally doing a few side bends and testing if my arm movement hurt. when i ended my session I was pain free, well at-least under my collar bone, my butt was another tale.

I wrote this blog in my head whilst out cycling after lunch out in the state park. I relaised I hadn’t felt the pain or restriction since this morning. I did post a thread before going cycling on mechanism versus source of symptoms as I was pondering on my pain event.

The thread can be found on twitter here https://twitter.com/retlouping/status/1538195046452842499?s=21&t=YZv9ADJJSFOIMXNBC1pLSA

So although if I was a lay person I would have bet my house my neck was ”out” as a clinician this is not my thought process. But that said it is easy to understand why people seek out care and treatment from someone to ”put their neck back in.”

The human body is complex and it is hard to explain pain events like the one I had this morning. I believe they are probably more common than we care to accept, and the reason why some people do have ”quick fixes.” Each profession has an explanation of model for these events, chiropractic subluxation, osteopathic lesion, Mulligan facet fixation, McKenzie Derangement, etc etc. In my simple mind and on previous courses I have labelled these event ”re-arrangement” (it’s amazing what a threatened law suit can do for innovative word play)

There are all sorts lay words for these events like a crick in my neck or back, a pulled or a wrenched back, but definitely the most common is the spine being “out.” My simple model of explanation for these sudden onset mechanical pain event, that seem to respond rapidly to manual technique or simple self treatment procedures is the stone in your shoe. You can be happily walking along and get a sharp pain, your heel keep hurting until you take action, which can be, wiggle your foot around, shake your foot, stamp your foot, take your shoe off and tap the shoe, all of them can seem to perform the quick fix and allow you to go back to pain free function. I also use the bend finger model as described in the thread.

Bodies are complex, strange stuff happens and ”quick fixes” do sometimes occur, but they are not putting stuff back in that was out, well maybe not.

As always thanks for reading.

Why I’m not a fan of the term “clearing XYZ” and ”ruling out red flags”

A mini blog

For a long time I have had concerns about the loose terms we use in MSK examination such as ”I cleared the spine” or ”first I would rule out red flags”, these terms seem to suggest that a) this is actually possible & b) once done the clinician is confident and will rarely. if ever return to these things as possible contributors or concerns in the persons current presentation.

I propose this is an error in clinical reasoning, we should replace these terms with ”lowering the probability of XYZ” and in the case of red flags switch to trying to identify them rather than ”ruling them out” ,which is a nonsense term, adapted from utilizing sensitive tests to ”rule out condition”.

It can be seen that ”ruling out red flags” is not a great term when the sensitivity of most ”red flag indicators have awful sensitivity (even though this is not the intent of the term). ref link here https://cor-kinetic.com/wp-content/uploads/2018/07/red-flags-for-low-back-pain-are-not-always-really-red.pdf

Reference here https://bjsm.bmj.com/content/bjsports/52/8/493.full.pdf

I propose that clinicians should reverse their paradigm and be trying to identify relevant red flags that increase the suspicion of a serious condition, rather than “ruling out” anything.

As for the term “I cleared XYZ” I propose we again utilize the same reasoning and propose, ”we lowered the probability of involvement” ie “after a thorough history and exam it was apparent that the probability of the shoulder pain originating from the neck was minimal” as opposed to ”I cleared the neck from the picture”

As always, thanks for reading this mini blog.

The view from the other side.

A personal journey through a foreign health care system (during a pandemic) as an advocate for my mum.

My mum, brother and me circa 1961

This is a blog that I have pondered on writing numerous times over the last year. It seems pertinent that it is the anniversary of the events I’m going to describe. I think this is partly a blog written to get things of may chest and move on from my anger, somewhat. It’s a story that began just over a year ago and describes what it’s like as a seasoned medical professional to become embroiled in an advocacy role for a relative in a foreign countries health care system.

In April of 2021 (in the midst of the global COVID pandemic) I received a message from my brother in Portugal that my elderly 83 year old mum had fallen at home and fracture her femur. He went on to say she had been admitted to the hospital and was going to have surgery next day. so not the best of news, but made worse by the fact I live in Minnesota, USA and my mum in Malta some 5250 miles away as the crow flies.

I contacted the hospital in Malta to try to find out what was going on an was informed my mum had undergone surgery and a nail and plate placed in he femur to stabilize the fracture, an was resting comfortably on the orthopedic ward.

What ensued next was the bureaucratic wrangling and red tape involved in getting permission to travel from the USA to Malta which had the USA on the COVID red list, which meant no US residents could enter Malta due to the pandemic. Luckily I have contacts in Malta who helped me navigate some of this, I got in touch with the Health Minister and applied for an entry permit on compassionate grounds. This process took 3 weeks to sort out, but finally got permission to travel to Malta, with some rules. I had to have two negative PCR COVID test and an Antigen test negative a week and 25 hours before flying. then on arrival I would have to be in quarantine isolation for 14 days and test negative on day 10 for my quarantine.

Great, so I booked my ticket via Amsterdam and headed to the airport. luckily my COVID tests were negative and I had all the paper work in order to enter Malta. BUT, I was refused boarding in Minneapolis because I didn’t have permission to transit in Amsterdam, which required different COVID documentation. I returned home with my tail between my legs.

So on returning home from the airport and after calming down, I received kind help from a Dutch twitter follower who gave me details of the government department in Amsterdam that could assist me in my transit application. I had to rebook all my flights and schedule a return flight via Rome as I was not allowed to transit back though Amsterdam as there were no connecting flights and Holland was also closed to US travelers other than transit.

One week later I returned to the airport after repeating my three COVID test routine. I had a slight hiccup solved by only having carry one luggage.

I landed in Malta after transiting through Amsterdam on May 15th, all my paper work and testing was in order and was health screened at Luqa Airport Malta and told to go immediately to my quarantine address and stay there for 14 days until contacted by the health authorities. I was also given a number to call to schedule a COVID test on day 10. this all seemed a bit bizarre as I was not instructed on how to get to my mum’s apartment to quarantine. Luckily a friend of my mother’s came to pick me up, I double masked, he had also done some shopping for me.

I arrived at my mothers apartment and had arranged with a friend to have a spin bike delivered so I could workout and maintain my sanity. It turned out to be a life saver. I ended up spending up to 8 hours a day spinning and watching the Giro D’Italia on TV.

Fourteen days is a long time to spend in a third story apartment, but I did have the internet and a great view

I passed my isolation time emailing and calling the hospital to try and find out details about how my mother was progressing and enquiring bout the rehab plan and future plans for assistance. Prior to her fall my mother lived alone in a third story apartment, with 30 steps and no lift (elevator). a small back story, in the November prior she had contracted COVID and was bed bound for several weeks, she became very frail and my brother had to fly in and take her to his home in Portugal to get care and recuperate. She had fully recovered and returned to Malta, at her request, in mid March.

I facetimed my mother to discuss with her how she was doing whilst I quarantined. She did not seem to be her normal self and found it difficult to answer my questions. She was adamant though she didn’t feel she wanted to return to her apartment as she was frightened of falling again.

Apart from the frustration and isolation, I was getting more and more distressed with the mixed communication from her care team, I talked to nurses, social workers and Physios, who all had different plans and messages for me, I was led to believe my mum would transition to the rehab hospital so she could be able to negotiate her stairs before being sent home. This plan seemed to change on a daily basis. Six days into my stay I received a call from the lead ward physio saying my mum was ready for discharge home? I asked if he had assessed her ability to climb stairs and informed him she had 30 up and down and no lift. He relied ”no, but he would try her on stairs the next time he saw her.” It was a bizarre discussion even after I informed him that i was an experienced ortho physio as well as a son? I would later come to realize that my mum was on the acute orthopeadic ward and that they wanted the bed for other acute surgical admissions.

After taking with the Physio I called the social worker and ward sister and informed them that my mother could not come home for several reasons, 1. I was in isolation and quarantined in her apartment, 2. She needed to be abe to negotiate 30 steps, up and down and 3. She would need nursing care and a full time support as on Facetiming her it was apparent she was catheterised. They agreed she would be kept on the ward until i could visit in person.

I started to realize that there was going to be a ot of work to do to make sure my mother was safe to come home and that she got the appropriate care and rehab.

Let me tell you 14 days is a long time to be o your own with minimal food, I did order some takeaways and got them left outside for me to pick up once the delivery guy had gone.

On day 10 I was allowed to drive myself to the government COVID tests center , luckily my test was negative but I still had to quarantine for the full 14 days

There were some moments of beauty during my isolation

On May 29th 2021 at noon I officially ended my quarantine. I took a long walk on the beach and enjoyed a burger at the local restaurant.

May 30th would be my first visit to see my mum. She was in the acute orthopedic ward of the National Mater Dei hospital, due to COVID regulations visiting was restricted to one person and for one hour a day. OMG I arrived early and spent the next 30 minutes looking for a parking spot in the underground parking garage, it appeared every man and his dog were visiting, this would be a daily occurrence as everyone had to visit in the restricted time window due to COVID.

Mater Dei hospital was absolutely enormous, it is the biggest general hospital in Malta. I had flashbacks to my days working in UK hospitals as I navigated my way through the corridors to find my mothers ward on the third floor, the smell always brings back memories of my time in North Tees general hospital during my residency year.

I eventually found my mum and had a tearful first reunion. It only took my a brief interaction with her to realize she was not her self, she seemed vague and somewhat confused. She had a walker by her chair and she was sat with her now surgically repaired eg straight on a stool for support. I asked if she was doing exercises and walking, she replied ”only walking, no exercises” She was catheterized and in an adult diaper as she reported she wasn’t allowed to walk to the toilet on her own. My formerly healthy, active , independent 83 year old mum was now a frail, immobile, diapered, catheterized “old woman?”

After a chat we went for a walk using her frame, she had an extremely stiff knee with approximately 30 degrees of flexion, her leg was oedematous, and she shuffled rather than walked. I tried to hide my distress with the whole situation. The hour passed quickly and before leaving the ward I went to the nurses station, to find 6 or 7 nurses all sat on their phones scrolling. I explained who i was and asked for a meeting with my mums care team. The staff nurse said she would talk to the sister and I should come back tomorrow to see what was happening.

I wandered my way back to the car, where I sat and cried for a good 10 minutes.

Little did I know that over the next few days I would cry a lot an have many bizarre encounters with my mother’s health care team and fellow health care professionals .

Next day I arrived early to play find the parking spot with the rest of the population of Malta, or so it seemed. it didn’t help that the hospital was also the national COVID vaccination center.

10am and I entered the ward, as I was passing the desk the nurse waved at me an said that my mother’s care team would be rounding tomorrow at 9am and could i join them to discuss my mum’s care plan. I felt a little easier and went to see my mum and walk with her. Note I said ”walk with her” I am not a fan of PTs saying to patients ”i’ve come to take you for a walk” these are people not pets, as health care providers we walk with a person not take them for a walk.

Anyway, a much less stressful visit and I left after the allotted hour to shop for food and enjoy an afternoon of freedom in the Malteses sun.

For anyone who hasn’t been to Malta it’s a tiny island in the Mediterranean, problem is the population is 514,564 (I just googled it) and there are over 400,000 cars (I googled that too) the roads are narrow and poor quality and everyman and his dog (I think I’ve used that already) seems to be out and about during morning rush hour , lunch time and early evening. Let’s just say that driving in Malta is an experience to behold and made worse by driving on the left hand side of the road, when I predominantly drive on the right at home in the US (I did learn to drive in the UK so I am familiar with the process)

Next day I arrived early at the hospital for the ward round. My mum’s Maltese male friend (86 year old boyfriend) also join us, at my request. The clinical team consisted of two Doctors from the surgical ”firm” two OTs, two PTs, one nurse and a hospital social worker assigned to my mother. The rounds reminded me of my early days in the UK when I would do morning rounds with the surgeons, on the medical and surgical wards. The lead doctor discussed my mums surgery and her progress and the team each told us their thoughts. I then got a chance to talk after listening to them all. I explained I was only there from the US for a few weeks to get my mum safe and settled, I explained her situation prior to falling and also explained that she was frightened of going home to 30 steps and feared falling again. the discussion seemed productive and it appeared that the plan would be to send my mum to the rehab hospital to get her fit to go home with social care and a daily nurse. after the rounds ended the social worker gave me a list of private companies that specialized in live in care assistants, it apparently I was now in charge of organizing this?

I chatted with my mum and her friend and it seemed we had a plan.

I left after visiting time feeling more optimistic, by the time I got home to the apartment I had received an email from the lead doctor stating that the team had met and decided my mum would be discharged home at the end of the week. WTF, I had just met with them and decided on a plan which apparently had changed during my drive home. I contacted the social worker and asked to meet with her. She arranged for me to meet at 9am next day and had arranged another meeting with the care team. By that evening I was spitting feathers I was that angry. Spin David Spin.

Next morning I met with the social worker who apparently was as shocked as I was at the change in plan, she relayed that she had not been consulted either. I discussed with social worker my concerns that my mother appeared to be having cognitive difficulties and appeared to be in the early stages of dementia, the social worker said that none of the medical team had noted this. I explained that I thought she was not fit to make her own care decisions and that she was terrified at being sent home. after our meeting we walked to the ward, where we were met, at the nurses station, by yesterdays care team plus a new lead male PT and the ward sister. We stood in the ward corridor and the sister began by saying that my mum was doing well and was ready for discharge? I asked how they though she would navigate 30 stairs on a walker shuffling ?The male PT piped up ”she did stairs with me this morning” I asked “how many?” he replied 15, I ask how he thought 15 was 30 and that this was unacceptable. The PT then became passive aggressive and told me she could sit on a chair half way up and rest. Let’s just say the next few minutes of interaction where not my proudest moments, but I feel where necessary, I informed one and all gathered that this meeting was totally inappropriate being held in a ward corridor in public view, with no privacy with basically 12 care staff trying to tell a patients son that he was wrong and that his mother was just going to be discharged. I also informed them that i was uncomfortable with their attitude and that they agreed on a plan the day before and changed it without discussing why with me. The tipping point for me was when the PT asked if my mum was “even”Maltese. (luckily she is she was naturalized on her 80th birthday)

I relayed to the care team that I also felt my mother was having cognitive issues and requested an assessment be done to evaluate her decision making abilities. after everyone calmed down the ward sister agreed and decided that after the assessment we would decide my mother fate next day. What became apparent after the meeting was that the goal of the acute ortho team was to free up the wards beds for other surgical cases. my mother had become a victim of the system and of COVID as the doctor kept saying the longer she stays here the higher the risk of infection. I later discovered that the rehab hospital plan was also off the table due to the COVID pandemic.

I left the hospital feeling drained and I am not ashamed to say I drove to a local tourist spot and had a giant piece of chocolate cake to clam my nerves.

Little did I know that the next three days would be a roller coaster ride of emotions. I returned to the hospital next day and on arriving on the ward was informed they hadn’t assessed my mum’s cognitive abilities yet, but at the end of visiting time the doctor and the social woke wanted to discuss a discharge plan with my mum and I? yep a new plan an new day, bizarre. My mu and I went for a walk and did some exercises for her knee. at the end of visiting as previously announced the doctor and social worker arrived. they sat with my mum, her friend and I to review our options, discharge home with support organized by me and the social worker. My mum listened and then told them she wouldn’t go back to her apartment under any circumstances, her boy friend then chimed in and said she could live with him? OMG the fly in the proverbial ointment. I had to step in and explain that he lived with his son and daughter-in-law and that there was no spare bedroom, plus I would need to chat with them first. Another day another cluster F^*k. it became apparent they just wanted my mum off the ward.

That evening I visited my mum’s friend and his son at their house. long story short my mum was not relocating to their house. I don’t drink alcohol, but if i did this would have been a few whiskies evening. Spin David spin 🚴🏻

Next day was ground hog day, another meeting with my mum, the doctor and social worker. I explained that my mum moving to her friend’s house was a no go, they replayed my mum had been cognitively assessed and was fine to make decisions. (I protested and suggested their test was wrong, they didn’t listen, I tried to insist that I have a background in cognitive assessment and as her son was aware she had mental issues, no ne would listen.) The doctor tried to explain to my mum that she was to be discharged home, my mum just kept saying no and crying. Another day, and no decision or solution.

On returning home i wrote a long email to the social worker outlining my concerns regarding my mums care and long term plan, I asked for solutions other than returning home. She replied later that day informing me my mother was eligible for state nursing home care as she was a Maltese citizen. that evening I formulated a new plan to put to my mum.

After playing the parking lottery next morning, I returned to the ward and chatted to my mum whilst we walked. Remarkably she was starting to walk quite well despite her still stiff knee. I discussed going to a nursing home and she just listened. once again the doctor and the social worker appeared at the end of visiting. Today was D day, the doctor sat on the edge of the bed and asked me if i had discussed the options with my mum, I nodded in the affirmative.

The doctor asked my mum if she wanted to be discharged home, she teared up and said ”no”, the doctor said “great then the nursing home it is.” That was it that was how my mum was sent to a nursing home. That afternoon she was discharged from the ortho ward to a long term elderly medical ward to await a place at a state nursing home. Ortho ward team mission accomplished.

I drove home dismayed.

Over the next few days my mum became more and more confused, i discussed this with the new ward staff, they suggested it just part of being moved and her surgery, I knew it wasn’t.

It took four days and I received a phone call that a place had been found in a nursing facility and my mum would be transferred directly from the hospital. The nursing home was a lengthy drive away close to the airport. That afternoon I went to buy some toiletries and new nighties for my mum. I arrived at the new nursing home for the hour visiting time only to be told my US vaccination certificate wasn’t acceptable and i needed a Euro COVID pass, luckily I showed them all my government clearance paper work and they let me in.

My mum was sat in reception waiting for the facility doctor to assess her. The facility was clean and the staff seemed friendly and caring. My mum was extremely confused and thought that she was at my house in the US. (once again a sign of her declining mental status) she was assessed by the doctor and placed on some new meds. I met with the facility coordinator to discuss finances and such. the hour passed quickly.

Next day I returned to the new home feeling happy that my mum was now in a caring environment. OMG it was the day from hell, my mum was agitated, confused and didn’t want to stay in the home, she was verbally abusive to me and told me i had put her in a home so i could go home to the US. I calmed her down and walked with her. she seemed confused, but I put this down to the new facility and her mental status.

That lunch time I had arranged to meet a friend for lunch, it never happened.

I had a front wheel blow out in my mum’s old car, then of course the spare would not come out of the boot (trunk) and when it did it was flat. I had no phone and limped the car to the nearest garage. the man at the garage was lovely and fixed everything and gave me a place to wash up. I cried again.

Next day I visited mum she was more settled but very confused, she was walking around without her walker, she had forgotten she had had surgery. this was my last day, I spent my time explaining this to her, but she didn’t seem to register. on my way home I stopped to get another bloody COVID test so I could go home

I left Malta and my mum with a heavy heart, but knowing she was safe and being cared for, little did I know what the next dew months would bring.

A week after arriving home I received a message that my mum had fallen in the home and was back in hospital. She had another surgery that week as according to the doctor her femur fixation had failed. she stayed in the hospital a week and returned to the home to rehab (they had on site physio). I facetimed her regularly, she was becoming more confused.

At the end of July I got another message she was back in hospital after another fall, she had this time fractured her same femur at the knee. Another surgery, more rehab and a return a new nursing home. This home was the national dementia care home. My mum had developed obvious dementia, so obvious even the ortho staff were now aware of it.

My mum has been bed ridden since returning to the new home. I visited Malta again this year and she is safe, well cared for and doesn’t know who I am. She has developed expressive aphasia which is distressing to those that interact with her.

If you have made it this for, bless you. I don’t think i intended anyone to read this, but writing it all down has been healing.

I miss my mum, I weep for our medical systems and health care professionals who are caring but focus on the wrong things. I am an advocate for person focused care, not discharge drive care, I want people to be cared about not just cared for. As health care professional we can all do better.

If you did read this far, thanks for caring.

Remember Children are not Little Adults. “In the young Beware”

This is micro blog an a reminder that children are not little adults when it comes to Musculoskeletal (MSK) injuries and Sports related injuries.

I have long had the motto ”In the young beware” it is a reminder to think beyond simple sprains and strains in children presenting to your clinic with sports injuries and MSK pain related presentations.

I often recommend a quick health screen of all presenting children by asking if they are ”eating, sleeping, drinking, peeing, pooping normally?” plus are they running a temperature or had a recent sore throat? this is a quick general systems screen.

it is important to remember, unlike adults, children do not suffer multiple sports injuries, even when playing and training at high levels. This paper https://www.jospt.org/doi/pdf/10.2519/jospt.1998.27.2.167?download=true is always a reminder of this.

When considering the type of acute MSK or sports injuries children will likely present with, it is important to remember that their connective tissues are a lot more elastic than adults and their tendons are able to withstand and absorb greater tensile stresses. The weak link in the MSK chain are the attachments of tendons to the bone where the apophyses are not yet fused. So when thinking of injury the Rule of Toos still apply but think ”anchor (apophysis) rather than rope (tendon) injuries.

It is important to remember,as Dr James Noake points out (follow him on twitter here @DrJN_sportsmed) think ANCHORS Adolescent, Not progressing, Cleared hip joint, High impact MOI, Origin pain and tenderness, Rope (tendon) intact clinically , Screen with x-ray in adolescent pelvic pain presentations.

I have also suggested similar in the past (and yep I realise that’s not Yoda ) In the case of young athletes this is enough evidence in the literature to suggest apophyseal traction injuries are common in young athletes.

This paper highlights the issue in young soccer players https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8796099/pdf/10.1177_23259671211065063.pdf

You can also access further reading on the subject here https://www.researchgate.net/publication/315511010_Lower_Extremity_Avulsion_Fractures_in_the_Pediatric_and_Adolescent_Athlete

As always thanks for reading and remember ”in the young beware”

The skill of Listening (It’s always active)

I haven’t written a blog for a while but I thought I would turn one of my twitter threads into a blog due to it’s importance clinically, plus I get fed up with seeing the term ”active listening” on twitter. LISTENING is always active, it requires you to pay attention and use your brain, whilst hearing is passive and is a function of the ears.

Hearing is reception
Listening is action of the brain

To listen you have to be a receptive participant, listening takes part whist you are SILENT (not surprisingly LISTEN is made up of the same six letters) and another speaks. It is important not to feign listening, whist simply preparing to ask your next question. Listen with the intent to seek to understand (PATHOS).

I have recently proposed that changing our paradigm from ”taking” a person’s history to ”receiving” a person’s history will allow clinicians to listen to the persons narrative without frequent interjection.

I have proposed the simple INTENT/RELEVANCE cycle as an exercise clinicians can practice to allow receptive listening. Basically as a clinician you must ask a question with INTENT (knowing WHY you are asking) the questions should more than likely be open ended. The listen to the person and their answer. Your next question can only be asked about the persons response. it’s a fun game to play with colleagues, and I use it on my courses.

Another useful clinical tool to utilize with listening to a persons narrative is the process of paraphrasing. After listening clinicians should be able to reflect back to the person, in a brief summary, what they think they have listened to, using their own words paraphrase back to the person, the essence their story.

Utilising phrases such as ”Have I understood you correctly? It appears that you are saying that……..”

Narrative medicine , listening and trusting the (patient) persons narrative is part of the essence of good patient (person) focused care. Listening is an essential skill i narrative medicine. https://pmj.bmj.com/content/postgradmedj/85/1001/167.full.pdf

Listening is an essential clinical skill, are you a good listener?

As always thanks for reading and good luck with listening, in silence, actively receiving, not preparing to ask another question, but willing to formulate your next question based on what you just received, or even paraphrase back.

Your patients and clients with thank you for listening.

Am I a Bully?

Poulter’s Pondering

Am I a bully?

After a disturbing weekend on twitter I have been doing some self reflection and reflection in general on the topic of bullying. Plus  the accusation posed at me by some, that I am in fact a bully for calling out what I perceived as bullying. 

I have previously posted on twitter that I abhor bullies and bullying. I have been subjected to bullying since I was a small child. I was bullied by my brother, who was 4 years older than me, the worst incident was when he stabbed me in the face with a penknife. I know can you imagine that happening today? I hid the wound from my parents and when it was spotted said I had fallen playing outside. I still have the scar visible on my chin to remind me.

As a child I had a huge mop of curly hair which made me stand out, I was also tall and extremely gangly for my age. Throughout school I was bullied for my hair and height. Children are the worst, but I survived and according to my dad, it apparently builds character. By the time I was 15, the school bullying stopped, why? I was 6 foot 2 inches and had filled out, was doing weight training and swimming 2x day and playing multiple team sports. The bullying stopped when one day after school a kid who enjoyed taunting and bullying me got the shock of his life. I had had enough and just turned and punched him on the nose. This was one of the  two times in my 62 years I have actually punched someone in anger. So apart from the usual bullying by teachers in a boys grammar school I remained relatively free from bullying until I started work as PT.

Through my PT career I have been exposed to the usual bully bosses, thankfully not too many, but enough for me to speak up and suffer the consequences. I worked for an extreme passive aggressive bully boss for 10 years until I eventually quit my job and happily moved on.

So looking at SoMe and reflecting on what I perceive as bullying and others seem to perceive as me bullying.

It seems a normal practice on twitter for people to be overly rude and aggressive in their responses, and then play the victim when challenged. It also seems that the group pile on and mocking spree is an acceptable behavior on twitter and other SoMe platforms. What disturbs me the most is the DM bully. This is the person who DMs you with messages which are derogatory or snide requests to remove a tweets they didn’t like. Often guised  as a polite requests, because their followers have negatively commented about the tweets. The passive aggressive behavior that ensues, if you block said person, like a tweet exclaiming “look he blocked me, who knows why?” 

So in the spirit of two wrongs don’t make a right I have been accused of “subtweeting” so I immediately apologized and deleted, only to be subtweeted with derision. 

If I am a bully for standing up to group mocking and thus blocking, or a bully for calling out bullying, or a bully for commenting and supporting others who are also being bullied, or calling out ageism or vulgar language. Then yes I am a bully. But I think YOU need to look in the mirror and reflect.

My experience with bullies is that how they treat one person is how they will eventually treat you. So good luck and if you are an enabler, it’s only a matter of time before the bully turns on you.

Am I a bully?

The fragility of life.

I watched a man die today who I didn’t know


I watched a man die today who I didn’t know. I watched as he lay there grey and ashen with a volunteer MD, on my flight, pounding on his chest. I watched the life extinguish and drain from a fellow human. I watched a man die today, he died alone on the floor of a plane. I watched a man die and I wept.

10 minutes earlier he had arrived on the plane sweating and complaining that he had had to run to catch this flight, he was loud and angry. He put his bag in the overhead bin and went straight to the restroom. He never returned.

I watched a man die today, who’s name I will never know.

Our life’s are so fragile that they can be extinguished in the blink of an eye. Hug your loved ones, hold them tight, tell them you love them. 


I watched a man die today who I didn’t know.


Online clinical mentoring. A mentee focused approach

Learn from someone who wants you to grow”.

Our mentoring site has moved to it’s new home at ”physios online” see here:

Coaching and mentoring

Our new online home for mentoring and coaching

The aim of the site is to offer clinicians a variety of mentorship opportunities, across a broad spectrum of clinical practice.

I am currently offering mentee focused clinical mentoring. The mentoring session are done online via Zoom and focus on the mentees specific needs. Sessions usually last for 60-90 minutes. Frequency is solely determined by the mentee and their specific needs.

The charge for each session is on average £100 in the UK and 100 Euro in Europe. Region specific charges are negotiable and I am cognisant of different financial constraints around the world.

I also offer clinical consults on Musculoskeletal issue, and I am happy to consult on specific cases with clinicians or see specific patients with clinicians if mutually agreed by the patient.

I also offer bespoke short courses for interested small groups on various topics surrounding patient self treatment and clinical reasoning.

For those interested here is a recent one hour webinar I did for a group in India. Link here

I have also done a recent blog and podcast on “Discs Don’t slip” you can access the podcast here

And the guest blog on all things Intervertebral Disc here “Intervertebral Discs are they jelly Donuts? ”

So if you are interested in mentoring, clinical consultation, or bespoke courses , don’t hesitate to contact me via the “physios Online web site https://physiosonline.co.uk/coaching-mentoring/ or you can find me on twitter @retlouping or email me at Dcpoult@yahoo.com

As always thanks for reading

Also for those interested in online consultations with a UK based Physiotherapist check out PhysiosOnline link here

Long-COVID and graded exercise, why it’s hard for some to grasp the message of harm?

In my last blog post I highlighted that exercise is definitely not medicine in any shape or form for sufferers of Long-COVID (aka COVID Long Haulers), in fact for some long-COVID sufferers pushing through leads to complete breakdown and profound exhaustion.

Over the weekend I began to reflect on ponder, as the feedback and discussions around my blog developed on SoMe. It became apparent that long time advocates of exercise where finding it difficult to accept that graded exercise wasn’t the answer for long-COVID and played mental gymnastics with definitions of exercise, down to suggesting any activity of any sort was exercise and should be utilised to defend their stance.

Let me just place this in perspective, long-COVID sufferers commonly and almost universally are not suffering from a deficit of exercise, they are not exercise avoiders, they are not deconditioned. Their presentations do mimic deconditioning ie post exertion fatigue, general malaise, tachycardia, breathlessness. BUT, these are not due to deconditioned status they are symptoms of the effects of the the virus and it’s long term effects on cellular activity, chronic inflammation and organ damage, including heart, lungs, kidneys, liver and brain. Watch this video from 60 minute if you are still not convinced here

So why is it hard for clinicians to change their paradigm and accept that exercise is not the answer?

The answer lies in our difficulty to unlearn and relearn new information. I have labeled this “first in best dressed syndrome” meaning what we learn first and believe to be true, is much longer lasting , ingrained and harder to change, than new and conflicting information.

As a young educator I had to learn this the hard way, when I excitedly presented some new, controversial and conflicting ideas at a conference. I was overwhelmed by the negative response of the audience and the almost vitriolic attack on my newly presented knowledge. After the presentation someone gave me this paper as a message of support👇


The paper describes the way we handle conflicting information and highlights the seven different strategies that people adopt. All seven can be seen on SoMe discussing the role of graded exercise in the treatment of Long-COVID, as you will see if you read the paper six ways are used to discount the idea that exercise is not indicated and used to protect their original understanding of “exercise is medicine”

One of the hardest things to do is “unlearn” and then replace the old idea with new learning.

Most of use will try to use the six strategies highlighted in the paper above to maintain or previous notions and in some case appear to have adopted the new information.

in fact in some cases the more information that is provided for in support of the new idea, the greater the push back, which creates a back fire effect.

Unlearning is tough. But I would encourage clinicians to ponder on whose interest they serve, their own, or their patients? Believing that your ideas are sound and should be followed, rather than seeking to understand a new perspective from a patient focused point of view, seems futile.

I am striving for change and understanding, receive your patients narrative, listen to the sufferers of long-COVID, there are links to their stories here These narratives are not only sufferers of long-COVID they are your clinical peers.

There is so much we do not know or understand about the cause, and course of long-COVID, BUT making a change in your understanding and beliefs, doing some unlearning and releasing, listening to the narratives of long-COVID sufferers, may improve their care and journey.

Be part of the solution, not the problem.

As always I suggest Ethos (Gain Trust), Pathos (First seek to understand), Logos (the to be understood)

As always, thanks for reading.

Long-COVID is exercise really medicine? Do we need a paradigm shift?

(source google)

Exercise is medicine has become a common mantra across Social Media and in several medical journals. It is well know that exercise has far reaching health benefits and is utilised in rehabilitation to strengthen, condition, also to  improve endurance, aerobic capacity and overall reduce several metabolic health risks from diabetes to heart disease. ( references links: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3004757/pdf/cptj0021-0004.pdf https://bjsm.bmj.com/content/43/1/3 )

BUT, is exercise really medicine and should it be recommended for all that troubles us?

First lets define what we mean by exercise. Simply put formal exercise is aimed at challenging bodily structures and systems to a point of controlled overload causing fatigue and or micro failure with the intent of stimulating adaptation of the structure or bodily system. Common types of exercises aim to strengthen muscles, improving flexibility, stimulate cardiovascular changes, improve general bodily endurance. Everyone is familiar with lifting a weigh to muscular fatigue, running until your pant and sweat, doing aerobic classes that make you pant and sweat, long runs and cycling that improve your endurance, climbing steep hill either by running or walking that challenge your heart rate and breathing. All are designed to push you to challenge the muscle or system followed by a period of rest to allow adaptation. Often the periods of effort/challenge followed by rest lead to increasing abilities in strength, power, improved cardiovascular responses and endurance. It is also recognised that these changes take several weeks and require regular challenging exercise and progression of load and intensity.

Yep exercise sounds great and yes it sounds like a great way to be healthy, almost a medicine in it’s self.

We are one year into the global pandemic caused by the SARS-Corona virus-2 commonly referred to as COVID-19. Many people have contracted the virus world wide and have recovered from the acute presentation, but many are still left suffering from the long term effect which present in multiple ways. This has lead to the term Long-COVID to describe the ongoing , often debilitating signs and symptoms, of post COVID infection.

Common Long-COVID presentations 

  • Overwhelming fatigue
  • Bradycardia
  • Tachycardia
  • Palpitations
  • Dysautonomia
  • Heat intolerance
  • Flu-like feeling
  • Headache
  • Altered appetite
  • Diarrhea
  • Sore throat
  • Dyspnea
  • Breathing-pattern disorders
  • Swollen glands
  • Muscle and joint pain
  • Chest wall and mediastinal pain
  • “Brain fog”
  • Executive functioning challenges
  • Short-term memory loss

(Source )

Source google on fatigue

One of the most common reported presentations with Long-COVID is post activity malaise and or extreme bodily fatigue which is immediate but often delayed by 24 hours. It can be unpredictable in nature. Also commonly reported are fluctuations in heart rate including tachycardia, and breathlessness, with minimal to no physical exertion.

The symptoms of Long-COVID seem to mirror those of Chronic Fatigue Syndrome (CFS) although no direct link has yet been shown. 

So the question arises if exercise or even normal daily physical function causes irregular heart and breathing issues, followed by general malaise and or profound fatigue, how can exercise be the solution to long-COVID?

It may be time to adopt some of the strategies developed for the treatment of CFS such as activity pacing, rather than formalised “graded exercise”. It has been suggested that graded activities of daily living are exercise if they cause increased heart rate and fatigue, I would suggest this is not true in te case of long-COVID sufferers or CFS as the changes in heart rate and fatigue and often O2 saturation, are not due to deconditioning, but are unpredictable responses due to the the long post viral infection process, which at this point in time we do not  fully understand. (Ref ) More on CFS and exercise here

So I propose that for long-COVID exercise per se or even graded activity may not be indicated as a therapy and in the case of long-COVID “exercise is NOT medicine.”

If you want to read more and understand the lived experience of many health professionals with long-COVID check out this blog (here)

And this website here

At the current time we need to seek to understand the individual with long-COVID, there individual and unique presentation and give support and advice on management and perhaps pacing based on their own current understanding  of their activity tolerance, triggers and long-COVID crashes. Employers, spouses, partners and society at large may need to be more understanding and accommodating, as people with long-COVID try to recover and restore their pre COVID health and lifestyles.  There is a nice article/blog on pacing with long-COVID “Long covid and self-help pacing groups—getting by with a little help from our friends” found in the BMJ here

In conclusion it may be more important than ever to be a person focused therapist when managing people suffering from long-COVID. Exercise is NOT medicine, self directed activity pacing may be the best initial intervention, support and understanding are essential. Surgeries will have “crashes” we all need to be supportive and understanding. 

As always thanks for reading I hope this was helpful.