tag:blogger.com,1999:blog-65603983052094261172024-02-02T10:12:01.524-08:00Altered HaemodynamicsClinical Reasoning Sessionshttp://www.blogger.com/profile/09852524904111114134noreply@blogger.comBlogger24125tag:blogger.com,1999:blog-6560398305209426117.post-68090464734128680502021-01-14T09:44:00.011-08:002021-01-16T04:40:48.730-08:00Making Sense of the Cranial Nerves: 3 SHORT FILMS<p style="text-align: left;"><span face="Roboto, Arial, sans-serif" style="background-color: #f9f9f9; color: #030303; font-size: 14px; white-space: pre-wrap;">Cranial nerve testing should be within the skill set of ALL clinicians </span><span face="Roboto, Arial, sans-serif" style="background-color: #f9f9f9; color: #030303; font-size: 14px; white-space: pre-wrap;">who treat neck, head and orofacial presentations.</span></p><p style="text-align: left;"><span face="Roboto, Arial, sans-serif" style="background-color: #f9f9f9; color: #030303; font-size: 14px; white-space: pre-wrap;">Most clinicians are well versed and confident with neurological testing of the upper and lower limbs as well as upper motor neuron tests. However, when it comes to what is arguably the riskiest of anatomical regions, the head and neck ... t</span><span face="Roboto, Arial, sans-serif" style="background-color: #f9f9f9; color: #030303; font-size: 14px; white-space: pre-wrap;">here appears to be a strong suggestion that history and education have not prepared physiotherapists well for this.</span></p><p style="text-align: left;"><span class="style-scope yt-formatted-string" dir="auto" face="Roboto, Arial, sans-serif" style="background: rgb(249, 249, 249); border: 0px; color: #030303; font-size: 14px; margin: 0px; padding: 0px; white-space: pre-wrap;">The harsh reality is that many </span><a class="yt-simple-endpoint style-scope yt-formatted-string" dir="auto" href="https://www.youtube.com/hashtag/physios" spellcheck="false" style="background-color: #f9f9f9; cursor: pointer; display: var(--yt-endpoint-display, inline-block); font-family: Roboto, Arial, sans-serif; font-size: 14px; text-decoration: var(--yt-endpoint-text-regular-decoration, none); white-space: pre-wrap;">#Physios</a><span class="style-scope yt-formatted-string" dir="auto" face="Roboto, Arial, sans-serif" style="background: rgb(249, 249, 249); border: 0px; color: #030303; font-size: 14px; margin: 0px; padding: 0px; white-space: pre-wrap;"> report that:</span></p><p style="text-align: left;"><span class="style-scope yt-formatted-string" dir="auto" face="Roboto, Arial, sans-serif" style="background: rgb(249, 249, 249); border: 0px; color: #030303; font-size: 14px; margin: 0px; padding: 0px; white-space: pre-wrap;">1. They were not taught CN’s at University</span></p><p style="text-align: left;"><span class="style-scope yt-formatted-string" dir="auto" face="Roboto, Arial, sans-serif" style="background: rgb(249, 249, 249); border: 0px; color: #030303; font-size: 14px; margin: 0px; padding: 0px; white-space: pre-wrap;">2. If they were, they are a little rusty with application and interpretation</span></p><p style="text-align: left;"><span class="style-scope yt-formatted-string" dir="auto" face="Roboto, Arial, sans-serif" style="background: rgb(249, 249, 249); border: 0px; color: #030303; font-size: 14px; margin: 0px; padding: 0px; white-space: pre-wrap;">3. It’s not something they do very often, and the tests are really hard to recall</span></p><p style="text-align: left;"><span class="style-scope yt-formatted-string" dir="auto" face="Roboto, Arial, sans-serif" style="background: rgb(249, 249, 249); border: 0px; color: #030303; font-size: 14px; margin: 0px; padding: 0px; white-space: pre-wrap;">Indeed a recent Twitter poll revealed that 53% of respondents suggested that they had not been taught these skills at University. Of those that had, over 50% suggested that they were not comfortable with applying them and interpreting the tests in clinical practice.</span></p><div><span class="style-scope yt-formatted-string" dir="auto" face="Roboto, Arial, sans-serif" style="background: rgb(249, 249, 249); border: 0px; color: #030303; font-size: 14px; margin: 0px; padding: 0px; white-space: pre-wrap;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiyZKfWyS3GwZbHDnQMIsYU8MnQh-3w2wIwyA06b5CY_67KQq3vETyPUgT2Jz4HVpjomNrNcFZb33cHrsZlRKHJZV5a1E92DlVE7ulz2uCuC46CFkNOhUrrPBgdVBkw-9e-Jn4_7HarxKI/s2048/Screenshot+2021-01-14+at+17.17.22.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1126" data-original-width="2048" height="354" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiyZKfWyS3GwZbHDnQMIsYU8MnQh-3w2wIwyA06b5CY_67KQq3vETyPUgT2Jz4HVpjomNrNcFZb33cHrsZlRKHJZV5a1E92DlVE7ulz2uCuC46CFkNOhUrrPBgdVBkw-9e-Jn4_7HarxKI/w644-h354/Screenshot+2021-01-14+at+17.17.22.png" width="644" /></a></div>
This is perhaps a little alarming for a profession which is championing the concepts of FCP and ACP roles within healthcare.
There is a mismatch here, and a clear need to improve understanding, education and competencies.
But it is not just FCP’s & ACP’s who need these skills. They are easily attainable for any clinician, and can easily be understood and applied from UG level.
BUT DON'T FEEL BAD ... I think perhaps the educational system in some places (not all), has let us all down, and </span><span style="background-color: #f9f9f9; color: #030303; font-size: 14px; white-space: pre-wrap;">I agree entirely, the CN's are a bit complex and do at first provide a challenge to learn.</span></div><div><span class="style-scope yt-formatted-string" dir="auto" face="Roboto, Arial, sans-serif" style="background: rgb(249, 249, 249); border: 0px; color: #030303; font-size: 14px; margin: 0px; padding: 0px; white-space: pre-wrap;"><br /></span></div><div><span class="style-scope yt-formatted-string" dir="auto" face="Roboto, Arial, sans-serif" style="background: rgb(249, 249, 249); border: 0px; color: #030303; font-size: 14px; margin: 0px; padding: 0px; white-space: pre-wrap;">The missing links are often context, understanding, working knowledge and the application of clinical reasoning.</span></div><div><span class="style-scope yt-formatted-string" dir="auto" face="Roboto, Arial, sans-serif" style="background: rgb(249, 249, 249); border: 0px; color: #030303; font-size: 14px; margin: 0px; padding: 0px; white-space: pre-wrap;"><br /></span></div><div><span class="style-scope yt-formatted-string" dir="auto" face="Roboto, Arial, sans-serif" style="background: rgb(249, 249, 249); border: 0px; color: #030303; font-size: 14px; margin: 0px; padding: 0px; white-space: pre-wrap;">That is why I've put together 3 short films in the 'Fireside CPD Sessions' series, to help make sense of the cranial nerves, their functions + when and how we might test them.</span></div><div><span class="style-scope yt-formatted-string" dir="auto" face="Roboto, Arial, sans-serif" style="background: rgb(249, 249, 249); border: 0px; font-size: 14px; margin: 0px; padding: 0px; white-space: pre-wrap;"><span style="color: #0b5394;"><br /></span></span></div><div><span class="style-scope yt-formatted-string" dir="auto" face="Roboto, Arial, sans-serif" style="background: rgb(249, 249, 249); border: 0px; margin: 0px; padding: 0px; white-space: pre-wrap;"><span style="color: #0b5394; font-size: medium;"><a href="https://youtu.be/vS8IDpVFmEg" target="_blank">FILM 1. <span face="Roboto, Noto, sans-serif">Cranial Nerves: A Clinical Reasoning Guide</span></a></span></span></div><div><span class="style-scope yt-formatted-string" dir="auto" face="Roboto, Arial, sans-serif" style="background: rgb(249, 249, 249); border: 0px; color: #030303; font-size: 14px; margin: 0px; padding: 0px; white-space: pre-wrap;"><span color="rgba(0, 0, 0, 0.87)" face="Roboto, Noto, sans-serif" style="font-size: 15px;">An opportunity to get to know the cranial nerves and their functions from a clinical reasoning perspective.</span></span></div><div><span class="style-scope yt-formatted-string" dir="auto" face="Roboto, Arial, sans-serif" style="background: rgb(249, 249, 249); border: 0px; color: #030303; font-size: 14px; margin: 0px; padding: 0px; white-space: pre-wrap;"><span color="rgba(0, 0, 0, 0.87)" face="Roboto, Noto, sans-serif" style="font-size: 15px;"><br /></span></span></div><div><span class="style-scope yt-formatted-string" dir="auto" face="Roboto, Arial, sans-serif" style="background: rgb(249, 249, 249); border: 0px; color: #030303; font-size: 14px; margin: 0px; padding: 0px; white-space: pre-wrap;"><div class="separator" style="clear: both; text-align: center;"><iframe allowfullscreen="" class="BLOG_video_class" height="266" src="https://www.youtube.com/embed/vS8IDpVFmEg" width="320" youtube-src-id="vS8IDpVFmEg"></iframe></div><br /><span color="rgba(0, 0, 0, 0.87)" face="Roboto, Noto, sans-serif" style="font-size: 15px;"><br /></span></span></div><div><span class="style-scope yt-formatted-string" dir="auto" face="Roboto, Arial, sans-serif" style="background: rgb(249, 249, 249); border: 0px; color: #030303; font-size: 14px; margin: 0px; padding: 0px; white-space: pre-wrap;"><span color="rgba(0, 0, 0, 0.87)" face="Roboto, Noto, sans-serif" style="font-size: 15px;"><br /></span></span></div><div><span class="style-scope yt-formatted-string" dir="auto" face="Roboto, Arial, sans-serif" style="background: rgb(249, 249, 249); border: 0px; margin: 0px; padding: 0px; white-space: pre-wrap;"><span style="color: #0b5394; font-size: medium;"><a href="https://youtu.be/Eur27pTwN1o" target="_blank"><span face="Roboto, Noto, sans-serif">FILM 2. </span><span face="Roboto, Noto, sans-serif">Cranial Nerves: Subjective questioning - A SHORT FILM</span></a></span></span></div><div><span class="style-scope yt-formatted-string" dir="auto" face="Roboto, Arial, sans-serif" style="background: rgb(249, 249, 249); border: 0px; color: #030303; font-size: 14px; margin: 0px; padding: 0px; white-space: pre-wrap;"><span color="rgba(0, 0, 0, 0.87)" face="Roboto, Noto, sans-serif" style="font-size: 15px;">This short film is designed to introduce the cranial nerves and consider the subjective questions (that we often don't ask) that might lead us to test them in the clinical situation.</span></span></div><div><span class="style-scope yt-formatted-string" dir="auto" face="Roboto, Arial, sans-serif" style="background: rgb(249, 249, 249); border: 0px; color: #030303; font-size: 14px; margin: 0px; padding: 0px; white-space: pre-wrap;"><span color="rgba(0, 0, 0, 0.87)" face="Roboto, Noto, sans-serif" style="font-size: 15px;"><br /></span></span></div><div><span class="style-scope yt-formatted-string" dir="auto" face="Roboto, Arial, sans-serif" style="background: rgb(249, 249, 249); border: 0px; color: #030303; font-size: 14px; margin: 0px; padding: 0px; white-space: pre-wrap;"><div class="separator" style="clear: both; text-align: center;"><iframe allowfullscreen="" class="BLOG_video_class" height="266" src="https://www.youtube.com/embed/Eur27pTwN1o" width="320" youtube-src-id="Eur27pTwN1o"></iframe></div><br /><span color="rgba(0, 0, 0, 0.87)" face="Roboto, Noto, sans-serif" style="font-size: 15px;"><br /></span></span></div><div><span style="color: #0b5394; font-size: medium;"><span class="style-scope yt-formatted-string" dir="auto" face="Roboto, Arial, sans-serif" style="background: rgb(249, 249, 249); border: 0px; margin: 0px; padding: 0px; white-space: pre-wrap;"><span face="Roboto, Noto, sans-serif"><a href="https://youtu.be/UDBWmd9gbbw" target="_blank">FILM 3. </a></span></span><span face="Roboto, Noto, sans-serif" style="white-space: pre-wrap;"><a href="https://youtu.be/UDBWmd9gbbw" target="_blank">How to remember the Cranial Nerves: A Function Based Approach - A SHORT FILM</a> </span></span><span color="rgba(0, 0, 0, 0.87)" face="Roboto, Noto, sans-serif" style="background-color: #f9f9f9; font-size: 15px; white-space: pre-wrap;">This short, tongue in cheek, ‘Fireside CPD’ film, draws upon story telling, and offers an inventive and fun method of recalling the FUNCTIONS of the cranial nerves. </span><span color="rgba(0, 0, 0, 0.87)" face="Roboto, Noto, sans-serif" style="background-color: #f9f9f9; font-size: 15px; white-space: pre-wrap;">Pull up a chair, open a bottle, or make a nice cuppa and enjoy a fun and inventive way to remember the cranial nerves based on FUNCTION.</span></div><div><span color="rgba(0, 0, 0, 0.87)" face="Roboto, Noto, sans-serif" style="background-color: #f9f9f9; font-size: 15px; white-space: pre-wrap;"><br /></span></div><div><div class="separator" style="clear: both; text-align: center;"><iframe allowfullscreen="" class="BLOG_video_class" height="266" src="https://www.youtube.com/embed/UDBWmd9gbbw" width="320" youtube-src-id="UDBWmd9gbbw"></iframe></div><br /><span color="rgba(0, 0, 0, 0.87)" face="Roboto, Noto, sans-serif" style="background-color: #f9f9f9; font-size: 15px; white-space: pre-wrap;"><br /></span></div><div><span class="style-scope yt-formatted-string" dir="auto" face="Roboto, Arial, sans-serif" style="background: rgb(249, 249, 249); border: 0px; color: #030303; font-size: 14px; margin: 0px; padding: 0px; white-space: pre-wrap;"><span color="rgba(0, 0, 0, 0.87)" face="Roboto, Noto, sans-serif" style="font-size: 15px;">These films should provide a solid base for all clinicians who wish to familiarise themselves with the cranial nerves, gain a basic understanding of their function, AND develop an easy method for recalling the tests.</span></span></div><div><span class="style-scope yt-formatted-string" dir="auto" face="Roboto, Arial, sans-serif" style="background: rgb(249, 249, 249); border: 0px; color: #030303; font-size: 14px; margin: 0px; padding: 0px; white-space: pre-wrap;"><span color="rgba(0, 0, 0, 0.87)" face="Roboto, Noto, sans-serif" style="font-size: 15px;"><br /></span></span></div><div><span class="style-scope yt-formatted-string" dir="auto" face="Roboto, Arial, sans-serif" style="background: rgb(249, 249, 249); border: 0px; color: #030303; font-size: 14px; margin: 0px; padding: 0px; white-space: pre-wrap;"><span color="rgba(0, 0, 0, 0.87)" face="Roboto, Noto, sans-serif" style="font-size: 15px;">ENJOY!
</span>
For more on the Cranial Nerves, go to: </span><a class="yt-simple-endpoint style-scope yt-formatted-string" dir="auto" href="https://www.youtube.com/redirect?q=http%3A%2F%2Falteredhaemodynamics.blogspot.com%2F2013%2F10%2Fcranial-nerve-testing-cervical-spine.html&redir_token=QUFFLUhqbHM3RmhEZzdXR1NucHV4cEFwUTQ2eTdOaTh1Z3xBQ3Jtc0tuVC02c0JabXVEZ2V5MXRfTjZsYWVWeEJTQ1R1ZDhOcVBYcXUtbm1BNGpwNFZtRUZSSlJVay1oZVVmMVJEMHhUeEhNYmxnN2xHazVUcnRpaHV5MHNXdG9kNmwwVjdraVhQeFZkdDFUM1dHQzR2blU4OA%3D%3D&v=vS8IDpVFmEg&event=video_description" rel="nofollow" spellcheck="false" style="background-color: #f9f9f9; cursor: pointer; display: var(--yt-endpoint-display, inline-block); font-family: Roboto, Arial, sans-serif; font-size: 14px; text-decoration: var(--yt-endpoint-text-regular-decoration, none); white-space: pre-wrap;" target="_blank">http://alteredhaemodynamics.blogspot....</a><span class="style-scope yt-formatted-string" dir="auto" face="Roboto, Arial, sans-serif" style="background: rgb(249, 249, 249); border: 0px; color: #030303; font-size: 14px; margin: 0px; padding: 0px; white-space: pre-wrap;">
For a 'Cranial Nerves Country Song' ... go to: </span><a class="yt-simple-endpoint style-scope yt-formatted-string" dir="auto" href="https://www.youtube.com/watch?v=WgjyE3T4wyk" spellcheck="false" style="background-color: #f9f9f9; cursor: pointer; display: var(--yt-endpoint-display, inline-block); font-family: Roboto, Arial, sans-serif; font-size: 14px; text-decoration: var(--yt-endpoint-text-regular-decoration, none); white-space: pre-wrap;">https://www.youtube.com/watch?v=WgjyE...</a><span class="style-scope yt-formatted-string" dir="auto" face="Roboto, Arial, sans-serif" style="background: rgb(249, 249, 249); border: 0px; color: #030303; font-size: 14px; margin: 0px; padding: 0px; white-space: pre-wrap;">
Look out for 'Cervical Spine: Risk & Rehabilitation for Clinicians' ONLINE COURSE (2021)
</span><div><span class="style-scope yt-formatted-string" dir="auto" face="Roboto, Arial, sans-serif" style="background: rgb(249, 249, 249); border: 0px; color: #030303; font-size: 14px; margin: 0px; padding: 0px; white-space: pre-wrap;"><br /></span></div></div>Clinical Reasoning Sessionshttp://www.blogger.com/profile/09852524904111114134noreply@blogger.com0tag:blogger.com,1999:blog-6560398305209426117.post-29638094913986656122020-09-11T02:47:00.017-07:002020-09-26T00:21:40.444-07:00Risk Assessment of the Cervical Spine: A visit to the graveyard & directions for the future<p><span style="font-family: arial; font-size: medium;">That old chestnut the 'vertebral artery test' has been with us in Physiotherapy for nearly 4 decades, and yet still the arguments rage on about its clinical use. </span></p><p><span style="font-family: arial; font-size: medium;">Confusion is never helpful in a clinical (or any) situation, so I've tried to make sense of the background, the logic and ongoing discussion regarding the use of 'the test that refused to die'.</span></p><p><span style="font-family: arial; font-size: medium;">Inspired by the recent debates within the literature, I've put together 3 SHORT FILMS.</span></p><p><span style="font-family: arial; font-size: medium;">Film I, discusses the history of the development and early use of the test. Film II uses some case studies to test the test, and then Film III, takes to the graveyard of old worn out tests, and attempts to offer some logical directions for the future for ALL clinicians working with neck pain, headache, dizziness and visual disturbances.</span></p><h4 style="text-align: left;"><span style="color: #0b5394; font-family: arial; font-size: medium;">The key message, is that risk assessment of the cervical spine is relevant for ALL clinicians and NOT (as previously suggested) just for those who practice manual therapy. </span></h4><p><span style="font-family: arial; font-size: medium;">What we know from medico-legal cases is that delays to diagnosis and appropriate management can occur for a range of reasons. It may focus the mind to know that some medico-legal cases I've worked on, have involved <u>assessment of the cervical spine (without intervention).</u></span></p><p><span style="font-family: arial; font-size: medium;">Hopefully, these films and the case studies contained within them will help to guide clinicians with their problem solving and clinical reasoning, in the quest for safe and efficient practice.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh7msn0lb24-6jiLYkAdLBgBlWscmwBDJ0NJaZJLp13ZlsqcOKp35KNydWmQfL1rROnFnFeGIxIIOxaVasrWu1QQgtsNhcOfh_fcg3IC5VVdnJtfpSIIv5MJF9AmgZuXVVwGArhCPY77kk/s1920/Cervical+RISK+Part+III.003.jpeg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1080" data-original-width="1920" height="351" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh7msn0lb24-6jiLYkAdLBgBlWscmwBDJ0NJaZJLp13ZlsqcOKp35KNydWmQfL1rROnFnFeGIxIIOxaVasrWu1QQgtsNhcOfh_fcg3IC5VVdnJtfpSIIv5MJF9AmgZuXVVwGArhCPY77kk/w625-h351/Cervical+RISK+Part+III.003.jpeg" width="625" /></a></div><p></p><h2 style="text-align: left;"><span style="color: #0b5394; font-family: arial; font-size: medium;"><span><br /></span></span></h2><h2 style="text-align: left;"><span style="color: #0b5394; font-family: arial; font-size: medium;"><a href="https://www.youtube.com/watch?reload=9&v=4DFMAZds1QI" target="_blank"><span>I. </span><span color="var(--ytd-video-primary-info-renderer-title-color, var(--yt-spec-text-primary))" face="Roboto, Arial, sans-serif" style="background-color: #f9f9f9;">The Vertebral Artery Test - A SHORT FILM (Part I)</span></a></span></h2><p><span style="font-size: medium;"><span color="var(--ytd-video-primary-info-renderer-title-color, var(--yt-spec-text-primary))" style="background-color: #f9f9f9; font-family: arial;"><span style="color: #030303; white-space: pre-wrap;">A short educational film about the long and tortuous history of the 'vertebral artery test', of interest to any clinician who manages patients with cervical spine issues.
</span></span></span></p><p><span style="font-size: medium;"><span color="var(--ytd-video-primary-info-renderer-title-color, var(--yt-spec-text-primary))" style="background-color: #f9f9f9; font-family: arial;"><span style="color: #030303; white-space: pre-wrap;"><br /></span></span></span></p><div><span style="font-size: medium;"><span color="var(--ytd-video-primary-info-renderer-title-color, var(--yt-spec-text-primary))" face="Roboto, Arial, sans-serif" style="background-color: #f9f9f9;"><span face="Roboto, Arial, sans-serif" style="color: #030303; font-size: 14px; white-space: pre-wrap;"><br /></span></span></span></div><p></p><div class="separator" style="clear: both; text-align: center;"><iframe allowfullscreen="" class="BLOG_video_class" height="266" src="https://www.youtube.com/embed/4DFMAZds1QI" width="320" youtube-src-id="4DFMAZds1QI"></iframe></div><span style="font-family: arial;"><p><span style="font-family: arial;"><br /></span></p></span><h2 style="text-align: left;"><span style="color: #0b5394;"><a href="https://www.youtube.com/watch?v=Ne8c0Snc-WY"><span style="font-family: arial;"><span style="font-size: medium;">II. </span></span><span color="var(--ytd-video-primary-info-renderer-title-color, var(--yt-spec-text-primary))" face="Roboto, Arial, sans-serif" style="background-color: #f9f9f9;"><span style="font-family: arial; font-size: medium;">The Vertebral Artery Test Part II: Risk assessment of the cervical spine</span></span></a></span></h2><div><span style="font-family: arial; font-size: medium;"><br /></span></div><div><span style="background-color: #f9f9f9; color: #030303; white-space: pre-wrap;"><span style="font-family: arial; font-size: medium;">Part II of III, taking a look at the vertebral artery test from the perspective of NON manual therapists. Putting things into context using 4 case scenarios, with regard to risk assessment of the cervical spine.
The video covers the umbrella concept of 'cervical arterial dysfunction'.</span></span><span face="Roboto, Arial, sans-serif" style="background-color: #f9f9f9; color: #030303; font-size: 14px; white-space: pre-wrap;">
</span><p></p><p></p><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><iframe allowfullscreen="" class="BLOG_video_class" height="266" src="https://www.youtube.com/embed/Ne8c0Snc-WY" width="320" youtube-src-id="Ne8c0Snc-WY"></iframe></span></div><p><span style="font-family: arial; font-size: large;"><br /></span></p><h2 style="text-align: left;"><span style="color: #0b5394;"><a href="https://www.youtube.com/watch?v=TrWg6wX9z14"><span style="font-family: arial; font-size: large;">III. </span><span color="var(--ytd-video-primary-info-renderer-title-color, var(--yt-spec-text-primary))" style="background-color: #f9f9f9; font-family: arial; font-size: large;">Cervical Spine Risk Assessment: Directions For The Future </span></a></span></h2><div><span style="font-family: arial; font-size: medium;"><span color="var(--ytd-video-primary-info-renderer-title-color, var(--yt-spec-text-primary))" face="Roboto, Arial, sans-serif" style="background-color: #f9f9f9;"><a href="https://www.youtube.com/watch?v=TrWg6wX9z14"> A SHORT FILM (Part III)</a></span></span><div><span style="font-size: medium;"><br /></span></div><div><span style="font-family: arial; font-size: medium;"><span class="style-scope yt-formatted-string" dir="auto" style="background: rgb(249, 249, 249); border: 0px; color: #030303; margin: 0px; padding: 0px; white-space: pre-wrap;">Part III of the vertebral artery videos, takes us to the graveyard of tired old clinical tests, and moves on to offer some directions for the future for risk assessment of the cervical spine.
A consideration of blood pressure, cranial nerve examination and sensorimotor testing is incorporated into the clinical case studies that provide background for the video/vlog.</span></span></div><div><span style="font-family: arial; font-size: medium;"><span class="style-scope yt-formatted-string" dir="auto" style="background: rgb(249, 249, 249); border: 0px; color: #030303; margin: 0px; padding: 0px; white-space: pre-wrap;"><br /></span></span></div><div><span style="font-family: arial; font-size: medium;"><span class="style-scope yt-formatted-string" dir="auto" style="background: rgb(249, 249, 249); border: 0px; color: #030303; margin: 0px; padding: 0px; white-space: pre-wrap;"><div class="separator" style="clear: both; text-align: center;"><iframe allowfullscreen="" class="BLOG_video_class" height="266" src="https://www.youtube.com/embed/TrWg6wX9z14" width="320" youtube-src-id="TrWg6wX9z14"></iframe></div><br />
<br /></span><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjE9BrjRFqKgYcpwxN4Drcx0acDm4Fy5N8DnAzfxoaMX9ePxj6s64y9A_pf_glZ6OsL7Be9EVxJNf9Zui-RLBslayZFrm0EznM0PTy65UpXxi9QJ28ndgbTP1xVLEFaZ5oAorcbffwzEfw/s1920/Cervical+RISK+Part+III.028.jpeg" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="1080" data-original-width="1920" height="351" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjE9BrjRFqKgYcpwxN4Drcx0acDm4Fy5N8DnAzfxoaMX9ePxj6s64y9A_pf_glZ6OsL7Be9EVxJNf9Zui-RLBslayZFrm0EznM0PTy65UpXxi9QJ28ndgbTP1xVLEFaZ5oAorcbffwzEfw/w625-h351/Cervical+RISK+Part+III.028.jpeg" width="625" /></a></div><br /></span></div><div><span style="font-family: arial; font-size: medium;"><span class="style-scope yt-formatted-string" dir="auto" style="background: rgb(249, 249, 249); border: 0px; color: #030303; margin: 0px; padding: 0px; white-space: pre-wrap;"><br /></span></span></div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh2DboLvbmy5G-8T3TuDXoBzqL8uamudtv7I0D-dzzurl_yNUpC9dOAxZhlVob0J3Jc6aP4TdrUwEVlQmvIOUZtoS66amfGvQr9PfbQXkIadhMMo-31hw-Hr-y_t9Dh-ogcqi0zbrxguWo/s1920/Cervical+RISK+Part+III.029.jpeg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1080" data-original-width="1920" height="351" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh2DboLvbmy5G-8T3TuDXoBzqL8uamudtv7I0D-dzzurl_yNUpC9dOAxZhlVob0J3Jc6aP4TdrUwEVlQmvIOUZtoS66amfGvQr9PfbQXkIadhMMo-31hw-Hr-y_t9Dh-ogcqi0zbrxguWo/w625-h351/Cervical+RISK+Part+III.029.jpeg" width="625" /></a></div><br /><div><span class="style-scope yt-formatted-string" dir="auto" style="background: rgb(249, 249, 249); border: 0px; color: #030303; font-family: arial; font-size: large; margin: 0px; padding: 0px; white-space: pre-wrap;"><br /></span></div><div><span class="style-scope yt-formatted-string" dir="auto" style="background: rgb(249, 249, 249); border: 0px; color: #030303; font-family: arial; font-size: large; margin: 0px; padding: 0px; white-space: pre-wrap;">Find more detail at: <a href="https://www.trustme-ed.com/lectures/cervical-arterial-dysfunction-moving-forward-with-alan-taylor/alan-taylor-part-3" target="_blank">https://www.trustme-ed.com/lectures/cervical-arterial-dysfunction-moving-forward-with-alan-taylor/alan-taylor-part-3</a></span><span class="style-scope yt-formatted-string" dir="auto" style="background: rgb(249, 249, 249); border: 0px; color: #030303; font-family: arial; font-size: large; margin: 0px; padding: 0px; white-space: pre-wrap;">
Look out for the 'Cervical Spine: Risk & Rehabilitation online resources from Alan Taylor & Roger Kerry ... coming soon.</span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-family: arial; font-size: x-small;"><span face=""verdana" , sans-serif" style="color: #333333;"><span style="mso-fareast-font-family: "Times New Roman";"><span><i><b>Author:</b> Alan J Taylor is a writer and critic who tries to think about stuff . He works as a Physiotherapist<span>, </span>University <span>Assistant Professor</span> and Medico-Legal expert witness whilst maintaining a small clinical work load. The views contained in this blog are his own and are not linked to any organisation or institution. </i></span><span><i> He once rode the Tour of Britain and worked as a cycling soigneur. He still enjoys riding a b<span face=""verdana" , sans-serif">i</span>cylce through the leafy lanes of Nottinghamshi<span face=""verdana" , sans-serif">re and Derbyshire. In a World full of conflict and division ... l</span></i></span></span></span><i style="color: #333333;">ike Bukowski, he 'writes to stay sane'.</i></span><span style="font-size: medium;"><br /></span><p></p><p><span color="var(--ytd-video-primary-info-renderer-title-color, var(--yt-spec-text-primary))" face="Roboto, Arial, sans-serif" style="background-color: #f9f9f9;"><span style="font-size: medium;"><br /></span></span></p><div class="style-scope ytd-video-primary-info-renderer" id="info" style="align-items: center; background: rgb(249, 249, 249); border: 0px; display: flex; flex-direction: row; font-family: roboto, arial, sans-serif; margin: 0px; padding: 0px;"></div><p><span color="var(--ytd-video-primary-info-renderer-title-color, var(--yt-spec-text-primary))" face="Roboto, Arial, sans-serif" style="background-color: #f9f9f9;"><span style="font-size: medium;"><br /></span></span></p><div class="style-scope ytd-video-primary-info-renderer" id="info" style="align-items: center; background: rgb(249, 249, 249); border: 0px; display: flex; flex-direction: row; font-family: roboto, arial, sans-serif; margin: 0px; padding: 0px;"></div><p><span color="var(--ytd-video-primary-info-renderer-title-color, var(--yt-spec-text-primary))" face="Roboto, Arial, sans-serif" style="background-color: #f9f9f9; font-size: var(--ytd-video-primary-info-renderer-title-font-size, var(--yt-navbar-title-font-size, inherit));"><br /></span></p><p><br /></p></div></div></div></div>Clinical Reasoning Sessionshttp://www.blogger.com/profile/09852524904111114134noreply@blogger.com0tag:blogger.com,1999:blog-6560398305209426117.post-16642400755847762022018-11-08T07:10:00.001-08:002021-01-18T11:50:54.614-08:00Who's harming who?: Was Roger Kerry right ... will Physiotherapy eat itself?<span style="font-family: "verdana" , sans-serif; font-size: 12pt;">Following
directly on from </span><span style="font-family: "verdana" , sans-serif; font-size: 12pt;"><i><b><a href="https://alteredhaemodynamics.blogspot.com/2018/05/the-case-of-sprained-ankle-reflection.html" target="_blank">Blog I</a></b>. The case of the 'sprained ankle': A reflection on the narrative of ‘harm’.</i></span><span style="font-family: "verdana" , sans-serif; font-size: 12pt;"> </span><br />
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<span style="font-family: "verdana" , sans-serif; font-size: 12pt;"><i><b>Blog
II:</b> </i></span><br />
<span style="font-family: "verdana" , sans-serif; font-size: 12pt;"><i><br /></i></span>
<span style="font-family: "verdana" , sans-serif; font-size: 12pt;"><i>Who's harming who?: Was Roger Kerry right ... will Physiotherapy eat itself?</i></span><span style="font-family: "verdana" , sans-serif; font-size: 12pt;"> ... looks at the implications
of the the ongoing discussion around 'harm' for the physiotherapy
profession and considers how the profession can and needs to move forward.</span><br />
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<span style="font-family: "verdana" , sans-serif; font-size: 12pt;">When I perused again, Roger Kerry's must read <a href="https://rogerkerry.wordpress.com/2017/04/24/physio-will-eat-itself/" target="_blank">'Physio will eat itself'</a> I was struck once again by this erudite paragraph ...</span><br />
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<span style="color: black; font-size: 12.0pt;"><span style="font-family: "verdana" , sans-serif;">The recent lively debate surrounding the current narrative of 'harm' has perhaps made Roger's words echo louder in some quarters. 'Harm' has a range of definitions and thus, may be interpreted in a number of ways. <o:p></o:p></span></span></div>
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The definition below, is one that I am often sent and it is perhaps a helpful
starting point.<o:p></o:p></span></span></div>
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<span style="color: black; font-size: 12.0pt;"><o:p><span style="font-family: "verdana" , sans-serif;"><img height="556" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh4kqOVKx0Jq8gYSvx6v75pL6h_ooHYvn3HmKlNAxqYaeok23PgVBX94cDz_vGg6SCUyhI6CBKJlipDYCBag821qwVyy4Ba8exrQXbBri5sPQJ53LH_wVA8ocgKXlDLk99kXIEI0azKhe4/s640/Screen+shot+2018-05-02+at+16.29.56.png" width="640" /></span></o:p></span><br />
<span style="color: black; font-size: 12.0pt;"><o:p><span style="font-family: "verdana" , sans-serif;"><br /></span></o:p></span></div>
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<table border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="mso-cellspacing: 0cm; mso-padding-alt: 4.5pt 4.5pt 4.5pt 4.5pt; mso-yfti-tbllook: 1184;"><tbody>
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<span style="font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><span style="font-family: "verdana" , sans-serif;">If we are to maintain our stance as a science based profession then data, the interpretation of data and the public messages we convey are important. When I asked Australian physiotherapists and 'leading authorities on back
pain' Chris Maher and James McAuley, for their 'harm' definition and supportive data for the recent <a href="https://www.smh.com.au/lifestyle/health-and-wellness/a-difficult-position-experts-question-whether-ergonomics-holds-up-20180910-p502w5.html" target="_blank"><span style="color: blue;">Sydney Morning Herald</span></a><span style="color: blue;"><a href="https://www.smh.com.au/lifestyle/health-and-wellness/a-difficult-position-experts-question-whether-ergonomics-holds-up-20180910-p502w5.html"><span style="color: blue;"> article</span></a> t</span><span style="color: blue;">hey seemed unable to supply it</span><span style="color: blue;">.</span> That article not only suggested
that ergonomic interventions (which I have no intellectual or other
investment in) were harmful, but also 'dangerous'. All of this was suggested without ANY supportive
data and was a clear example of the manipulation of
language. It seems perhaps, that the article in question may have strayed into murky waters of <b>'opinion based medicine'</b>. Either way, lets be absolutely transparent ... if ergonomic interventions are ACTUALLY 'harmful ' or 'dangerous', surely there should be an immediate call for them to be risk
assessed and controlled? 'Harm' is after all, something we should take VERY seriously and that is precisely why we need data. <o:p></o:p></span></span></div>
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<span style="font-family: "verdana" , sans-serif;"><b><span style="font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">Bold statements require bold data, and leading experts should be able
to provide that ... OR expect their statements to be questioned.</span></b></span><br />
<span style="font-family: "verdana" , sans-serif;"><b><span style="font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><br /></span></b></span>
<span style="color: blue;"><span style="font-family: "verdana" , sans-serif;"><span style="font-size: 12pt;">Interestingly ...<b> </b></span></span><span style="font-family: "verdana" , sans-serif; font-size: 16px;">Maher blocked me on Twitter for asking for his harm data. That can of course, be interpreted that any way you wish.</span><b style="font-family: verdana, sans-serif;"><span style="font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"> </span></b></span></div>
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<span style="font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><span style="font-family: "verdana" , sans-serif;">It is worth reflecting that the opposite of harmed is (some would
argue) helped. Imagine for a moment, if someone, a therapist or a
representative of the the ergonomics industry, had presented a series of
patient narratives to say that (say) ergonomics had 'helped' them. No one
would be able to deny those patient narratives, after all, they are what the
patient thinks, believes and reports ... But now tell me that there wouldn't
be a <b>rush to the science</b> and the RCT data to suggest that despite what those
patients' believe, there is no strong scientific support for what they
described or said, and that all they had to support their statements were
associative argument and belief. Indeed, if that was a company trying to sell
a product, then they would quite likely be accused of at best, </span></span><span style="font-family: "verdana" , sans-serif; font-size: 16px;"><b>'opinion based medicine'</b> or at worst ... </span><span style="font-family: "verdana" , sans-serif; font-size: 12pt;">snake oil salesmanship.</span></div>
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<span style="font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><span style="font-family: "verdana" , sans-serif;"><br />
<b>A sociological perspective</b><o:p></o:p></span></span></div>
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<span style="font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><span style="font-family: "verdana" , sans-serif;">The manipulation of language (<a href="https://www.youtube.com/watch?v=M-iwVXr-mJ8" target="_blank">Unspeak</a>) is a
common psychosociological phenomenon and a tactic commonly used by
politicians who wish, by creating fear and silencing opposing
views, to push through specific agendas. The uncertainty and misinformation which surrounds 'Brexit' springs to mind, and Donald
Trump's demonisation of <a href="https://www.seattletimes.com/nation-world/nation-politics/video-of-cop-killer-becomes-trump-campaign-push/" target="_blank"><span style="color: blue;">immigrants</span></a> as rapists, drug runners and (more recently) cop-killers is a further example. This constant media stream affects the
macrocosm of everyone's life, and is perhaps one of the factors which wears down an
individuals resistance to language manipulation, when it enters the microcosm of their everyday
work in physiotherapy.</span></span></div>
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<span style="font-family: "verdana" , sans-serif; font-size: 16px;">So if we get back on track and consider physiotherapy treatments or management options.</span></div>
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<span style="color: blue; font-family: "verdana" , sans-serif;"><span style="font-size: 12.0pt;">If a treatment or advice is <b>not efficacious</b> … say
so (use RCT evidence). </span><span style="font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><o:p></o:p></span></span></div>
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<span style="color: blue; font-family: "verdana" , sans-serif;"><span style="font-size: 12.0pt;">If it is <b>uneconomical or costly</b> … say
so (use health economics evidence).</span><span style="font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><o:p></o:p></span></span></div>
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<span style="color: blue; font-family: "verdana" , sans-serif;"><span style="font-size: 12.0pt;">If it is 'harmful' ... provide <b>definition a
measure and some data</b>, any data. </span><span style="font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><o:p></o:p></span></span></div>
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<span style="color: blue; font-family: "verdana" , sans-serif;"><span style="font-size: 12.0pt;">If it is 'dangerous' ... provide <b>data and a
proposed risk assessment strategy, root cause analysis or both. </b></span><span style="font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><o:p></o:p></span></span></div>
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<span style="font-family: "verdana" , sans-serif;"><span style="color: blue; font-size: 12pt;">Above all<b> </b>... use<b> plain English, with clear and
agreed definitions.</b></span><span style="font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><o:p></o:p></span></span></div>
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<span style="font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><span style="font-family: "verdana" , sans-serif;">Consider for a moment the commonly used Physiotherapy mantra
<i>'Hurt does not always equal harm'</i> ... then ponder that, in virtually
the same breath, we hear the promotion of the idea that X, Y or Z treatment
or advice is 'harmful' to the patient, on the back of associative
argument only, or in other words, without any supportive data. <o:p></o:p></span></span></div>
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<span style="font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><span style="font-family: "verdana" , sans-serif;">Take heavy school bags and LBP as another example. Contemporary science has
suggested that carrying heavy school bags does not appear to be associated
with LBP in school children. So with that knowledge, we can now de-threaten
the 'heavy school bag' as non-harmful, and re-assure children and parents that they are less likely to be factor contributing to to their present or future LBP. <o:p></o:p></span></span></div>
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<span style="font-family: "verdana" , sans-serif;"><b><span style="font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">But here is the key question ...</span></b><span style="font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"> is the next stage of this process, to go on
to say that any practitioner or therapist or newspaper article that offers a
contrary option (to the currently fashionable or in vogue ones), is causing 'harm' to patients? As things stand, it could be
suggested perhaps ... that they have not kept up do date with the science, that they
are offering advice which is contrary to current thinking, that they
may be instrumental to a delay to appropriate management ... but 'harm' or
'harmers'? That would be more much challenging to effectively demonstrate. </span></span><br />
<span style="font-family: "verdana" , sans-serif;"><span style="font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><br /></span></span>
<span style="font-family: "verdana" , sans-serif;"><span style="font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">The <a href="https://jamanetwork.com/journals/jamaneurology/fullarticle/2712902" target="_blank">recently published LBP study</a> suggesting that pain neuroscience education (PNE) appears to be no more effective than placebo, raises some interesting questions with regard to the time, energy and belief invested into that particular modality. Would the next step be to suggest that PNE was harmful? I personally don't think so. BUT ... that is precisely why we need to be more consistent with our word usage as a profession
in EVERY respect, and that means with our patients, with each other and with our press releases and SoMe statements. <o:p></o:p></span></span></div>
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<span style="font-family: "verdana" , sans-serif;"><a href="https://www.blogger.com/null" name="_GoBack"></a><span style="font-size: 12pt;">These BLOGS, and my Twitter commentary
are NOT a defence of passive treatments, inappropriate or outdated advice or
anything else really, <b>who would want to defend those things?</b> It
is a request for transparency, scientific consistency and an honest dialogue.
The recent BJSM (peer reviewed) editorial entitled, <a href="https://bjsm.bmj.com/content/early/2018/10/27/bjsports-2018-099749" target="_blank">'Evidence based physiotherapy needs evidence based marketing'</a> ... is a salient example of where that scientific
consistency has gone sadly astray. We have <a href="https://bjsm.bmj.com/content/early/2018/10/27/bjsports-2018-099749.responses" target="_blank">publicly challenged the authors</a>
of this editorial, to provide the harm data on the specific physiotherapy
interventions named, <b>OR withdraw their claim on the basis that it is
not supported by their Utopian ideal of ‘rock solid research data’. </b></span></span></div>
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<span style="color: blue;"><span style="font-family: "verdana" , sans-serif;"><span style="font-size: 12pt;">Their lack of tangible and credible response (to date) from the authors to that challenge, has been disappointing to say the least. Once again, the reader can make their own judgement on that. </span></span><span style="font-size: 12pt;"><o:p></o:p></span></span></div>
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<span style="font-family: "verdana" , sans-serif; font-size: 16px;"><br /></span><span style="font-family: "verdana" , sans-serif; font-size: 16px;">Amongst and perhaps despite all of this, there is an increasing awareness of the need for a move toward self management options for MSK conditions. </span><span style="font-family: verdana, sans-serif; font-size: 16px;">It is apparent that we DO have some qualitative data to support the contention that ideas and beliefs (which may be influenced by practitioners choice of words/descriptions) may lead to confusion and uncertainty (amongst patients), leading to negative impacts on activity participation, health behaviours and self-management decisions in knee </span><a href="https://bmcrheumatol.biomedcentral.com/articles/10.1186/s41927-018-0023-x" style="font-family: verdana, sans-serif; font-size: 16px;" target="_blank">osteoarthritis.</a><br />
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<span style="font-family: "verdana" , sans-serif; font-size: 12pt;">It would be hopeful to imagine that the best, the most
efficacious treatments and communication methods would eventually make their way to the top of the
pile without a war of words and obfuscation. The caveat to that though, is
that there will always be innovators, early, late adopters and laggards ...
that links directly to the </span><a href="https://www.youtube.com/watch?v=9QnfWhtujPA" style="font-family: verdana, sans-serif; font-size: 12pt;" target="_blank"><span style="color: blue;">diffusion of innovations</span></a><span style="font-family: "verdana" , sans-serif; font-size: 12pt;">. Perhaps this is a source of ongoing frustration
amongst innovators and early adopters who wish to push for rapid change, but
is that a strong rationale for open ridicule? Is that a sound tactic that
will facilitate or hasten change? I suspect that they are also difficult questions
to answer with any accuracy.</span><br />
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<span style="font-family: "verdana" , sans-serif;"><b><span style="font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">The real world implications of the narrative of 'harm'</span></b><span style="font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><o:p></o:p></span></span></div>
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<span style="font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><span style="font-family: "verdana" , sans-serif;">There is an important and logical corollary of the ongoing 'harm'
narrative to consider and think carefully through. That is, IF the profession
collectively buys into the narrative of harm ... and harm ACTUALLY is taking
place, then two things may follow logically from there.<o:p></o:p></span></span></div>
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<span style="font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><span style="font-family: "verdana" , sans-serif;">1. If it truly IS the case, that some physiotherapists are somehow, 'harming'
patients. </span></span><span style="font-family: verdana, sans-serif; font-size: 12pt;">Then that is a serious allegation with serious implications for the
profession.</span></div>
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<span style="font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><span style="color: blue; font-family: "verdana" , sans-serif;">Questions are immediately raised.</span></span><br />
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<span style="font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><span style="color: blue; font-family: "verdana" , sans-serif;">What is the harm? </span></span><br />
<span style="font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><span style="color: blue; font-family: "verdana" , sans-serif;">How is this harm taking place? </span></span><br />
<span style="font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><span style="color: blue; font-family: "verdana" , sans-serif;">Where is the line
drawn? </span></span><br />
<span style="font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><span style="color: blue; font-family: "verdana" , sans-serif;">Who are the harmers? </span></span><br />
<span style="color: blue;"><span style="font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><span style="font-family: "verdana" , sans-serif;">... and how should the harm be risk assessed, with a view to harm </span></span><span style="font-family: "verdana" , sans-serif; font-size: 16px;">limitation</span><span style="font-family: "verdana" , sans-serif; font-size: 12pt;">? </span></span><br />
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<span style="font-family: "verdana" , sans-serif; font-size: 12pt;">Those questions would have massive implications for the governing
bodies of Physiotherapy the World over. It would require clear definitions,
it would require the collection of accurate data followed by root cause
analysis (which has its </span><a href="https://qualitysafety.bmj.com/content/26/5/417" style="font-family: verdana, sans-serif; font-size: 12pt;" target="_blank"><span style="color: blue;">limitations</span></a><span style="font-family: "verdana" , sans-serif; font-size: 12pt;"> too), risk assessment and action plans put
in place to limit or reduce further risk to patients (if that risk REALLY
exists). </span></div>
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<span style="font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><span style="font-family: "verdana" , sans-serif;">2. If there is TRULY is data to to support the narrative of harm, then
it is likely that law suits would follow. </span></span><br />
<span style="font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><span style="font-family: "verdana" , sans-serif;"><br /></span></span>
<span style="font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><span style="font-family: "verdana" , sans-serif;">Law suits often develop from a
patient or their relatives interpretation of what they see/hear in the news
or on social media. So if a patient were able to claim that they were harmed
by the mismanagement of their case AND could evidence that, AND were inclined
towards blame, then it is quite feasible that a law suit could follow. If
that happened then medico-legal expert witnesses would be called in on either
side, to look at the evidence pertaining to the individual case and the
profession. That of course, would require the measures applied to the 'harm',
which would be considered with the science around the efficacy (or otherwise)
of and <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2038981" target="_blank"><span style="color: blue;">risk of treatments</span></a>. These things happen in
other <a href="https://www.health.org.uk/sites/health/files/LevelsOfHarm_0.pdf" target="_blank"><span style="color: blue;">professions </span></a>and are clearly documented.<o:p></o:p></span></span></div>
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<span style="font-family: "verdana" , sans-serif;"><span style="color: blue; font-size: 12pt;">So the questions remain ... </span><span style="font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><o:p></o:p></span></span></div>
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<span style="font-family: "verdana" , sans-serif;"><span style="color: blue; font-size: 12.0pt;">Are some physiotherapy treatments (or how they
are delivered) <u>REALLY</u> 'harming' patients?</span><span style="font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><o:p></o:p></span></span></div>
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<span style="font-family: "verdana" , sans-serif;"><span style="color: blue; font-size: 12pt;">If so ... how are we capturing that data, and what
are we doing to risk assess and prevent future 'harm'?</span><span style="font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><o:p></o:p></span></span></div>
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<span style="font-family: "verdana" , sans-serif;"><b><span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">OK,
so "how can we move forward?". I hear you ask. </span></b><span style="font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><o:p></o:p></span></span></div>
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<span style="font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><span style="font-family: "verdana" , sans-serif;">Recently I watched a <a href="https://www.youtube.com/watch?v=LjfiQKsgrsE&t=0s&index=2&list=PLkeoBd4A272NvTlC5lxdws55q2aTv0GT2" target="_blank"><span style="color: blue;">video</span></a> of how things can be done
effectively without the need to demonise, shout down opposing views or appear to leave just one solution to a problem ... if you've not seen it you should. Irish
Physiotherapist Kieran O' Sullivan calmly discusses LBP, strategies for recovery
and the state of the knowledge (to date) in the area, in a most convincing
performance. By re-conceptualising what we consider as 'safe' or 'dangerous'
physical activities,<span style="background: white; color: #111111;"> </span>Kieran
says in 45 minutes, far more than months of convoluted 'discussion' on Twitter
has achieved on the topic of evidence and word usage in the last year. He
does so in a calm, reassuring and humble tone, exposing his own fallibility
... which to me is far more convincing than any shouting match, and a great
example of how things can be done in a more constructive way. There are
countless more examples out there too ... of skilled evidence based
therapists who are doing the very best to navigate an increasingly hostile
environment with care, empathy, positivity, cohesion and a range of
solutions to the increasingly complex health problems that we
encounter.<o:p></o:p></span></span></div>
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<span style="font-family: "verdana" , sans-serif; font-size: 12pt;">We can also take a tip from the discipline of psychology, who appear
able to both define and measure harm very effectively and very
scientifically. </span><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4152561/pdf/13063_2014_Article_2207.pdf" style="font-family: verdana, sans-serif; font-size: 12pt;" target="_blank"><span style="color: blue;">The recording of adverse events from psychological treatments in clinical trials: evidence from a review of NIHR-funded trials</span></a><span style="font-family: "verdana" , sans-serif; font-size: 12pt;">.
There are many more examples in dietetics, medicine, drug trials etc.
Physiotherapy needs to step up to the science OR lose the narrative ... until
it (harm) can be effectively defined and measured.</span></div>
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<span style="font-family: "verdana" , sans-serif;"><span style="font-size: x-small;">From: The recording of adverse events from psychological treatments in clinical trials: evidence from a review of NIHR-funded trials</span><span style="font-size: 12pt;"><o:p></o:p></span></span></div>
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I share the obvious frustration of many with the slow pace of change, and I suspect
(without a shred of evidence) that this is why the narrative of harm has
developed. It is worth reflecting that harm, due to its multiple definitions
and interpretations, can range from multiple deaths (war) to taking offence
('I felt harmed by your views') and everything in between. In a world where
we are seeing increasing mental health problems often linked to self-harming
and suicide, it is clear that we are in very emotive territory. No decent
ethical therapist would want to harm or mislead their patients, but as
science and knowledge moves on, if they are clinging on to outdated knowledge
and ineffective methods (as supported by science, rather than opinion) ...
should they be classified, demonised or even mocked as harmers? </span></span><br />
<span style="font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><span style="font-family: "verdana" , sans-serif;"><br /></span></span>
<span style="font-family: "verdana" , sans-serif; font-size: 12pt;">OR ... is there a
different way to approach this? Is there a middle ground? </span><br />
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<b>I truly do not know the answer, but it is a question which we as a
profession, should not shy away from as the profession attempts to nurture and develop 'good clinicians'.</b></span></span><br />
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<span style="font-family: "verdana" , sans-serif; font-size: 12pt;">There IS common ground fortunately, and it is hopeful that many are
agreed that there is a need to change the approach to MSK care. </span><span style="font-family: "verdana" , sans-serif; font-size: 12pt;">This means being more honest with the level and type
of care we can and should currently offer, and the outcomes that may be
achieved, as highlighted by<b style="color: purple;"> </b>(<a href="https://bjsm.bmj.com/content/bjsports/early/2018/06/06/bjsports-2018-099198.full.pdf" target="_blank"><span style="color: blue;">Lewis & O’Sullivan BJSM, 2018</span></a>). It also means being honest with our interpretation of the science and evidence. Scaremongering claims by researchers, academics, clinicians or social media commentators that one treatment or advice or another is harming patients is, in the absence of evidence (of widespread measurable harm), wilfully misleading to patients, therapists and the general public alike and frankly, amounts to 'fake news'.</span></div>
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<span style="font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><span style="font-family: "verdana" , sans-serif;">For the profession to move forward, it requires a radical change of mind set
which aligns with the current challenging health care climate. It is a
global challenge that is well recognised and which Physiotherapists the
World over can rise to … IF and perhaps only if, collectively the profession can bring itself to end the self-perpetuated, conflicts and phoney, self created divisions<b> </b>which evolve from the </span></span><span style="font-family: "verdana" , sans-serif; font-size: 16px;">unnecessary<b> </b></span><b style="font-family: verdana, sans-serif; font-size: 12pt;">narrative of 'harm'.</b><br />
<br />
<span style="font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><span style="font-family: "verdana" , sans-serif;">For anyone with even the slightest interest in the sociology of conflict ... <a href="https://www.icrc.org/eng/assets/files/other/irrc-874-bartal-chernyakhai-schori-gundar.pdf" target="_blank">this article</a> makes a fascinating read and illustrates that in the tiny microcosm of MSK physiotherapy, we really don't need another war. </span></span><br />
<span style="font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><span style="font-family: "verdana" , sans-serif;"><br /></span></span>
<span style="font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><span style="font-family: "verdana" , sans-serif;">Otherwise, Roger Kerry may well prove to be a prophet ... and that really WOULD be a thing. <o:p></o:p></span></span><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEixI9BVDzH9yv7c6JjFQDYAoKSWoAeENBC2HYnEWf_yEI1V5XO6F3iBMZ9woRbTrC6L2X-dRlXjwM3hoX8xV5Ln8e_yG8tJk87lmyMRqDVYiVfJz3AouSd5Z86ncKMfJL61rj0gcr1BIgI/s1600/The-5-Most-Depressing-Songs-Ever3-550x286.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="286" data-original-width="550" height="207" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEixI9BVDzH9yv7c6JjFQDYAoKSWoAeENBC2HYnEWf_yEI1V5XO6F3iBMZ9woRbTrC6L2X-dRlXjwM3hoX8xV5Ln8e_yG8tJk87lmyMRqDVYiVfJz3AouSd5Z86ncKMfJL61rj0gcr1BIgI/s400/The-5-Most-Depressing-Songs-Ever3-550x286.jpg" width="400" /></a></div>
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<span style="font-family: "verdana" , sans-serif;">HT this time, goes to colleague and regular sounding board Roger Kerry, for his regular thought provoking musings on the psycho-sociology of the physiotherapy profession.</span></div>
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<span style="background-color: white; color: #333333; font-family: "verdana" , sans-serif; font-size: 16px;"><span style="font-weight: normal; mso-fareast-font-family: "Times New Roman";"><span style="font-size: xx-small;"><i><b>Author:</b> Alan J Taylor is a writer and critic who tries to think about stuff . He works as a Physiotherapist<span style="font-weight: normal;">, </span>University <span style="font-weight: normal;">Assistant Professor</span> and Medico-Legal expert witness whilst maintaining a small clinical work load. The views contained in this blog are his own and are not linked to any organisation or institution. </i></span><span style="font-size: xx-small; font-weight: normal;"><i> He once rode the Tour of Britain and worked as a cycling soigneur. He still enjoys riding a b<span style="font-family: "verdana" , sans-serif;">i</span>cyle through the leafy lanes of Nottinghamshi<span style="font-family: "verdana" , sans-serif;">re and Derbyshire. In a World full of conflict and division ... l</span></i></span></span></span><i style="background-color: white; color: #333333; font-family: verdana, sans-serif; font-size: x-small;">ike Bukowski, he 'writes to stay sane'.</i></div>
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<br />Clinical Reasoning Sessionshttp://www.blogger.com/profile/09852524904111114134noreply@blogger.com0tag:blogger.com,1999:blog-6560398305209426117.post-72535633496445952252018-07-04T12:27:00.001-07:002018-07-05T05:27:57.675-07:00A sudden rush of blood to the head: Why words really do matter in EVERY domain<style>
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<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">So ... it
seems there has been a proper furore and rush of blood to the heads </span><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;"><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">(sorry ... that was a feeble attempt at a haemodynamics link </span><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">) </span>of some folk</span><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">, over the use/choice of a
word in the <a href="https://twitter.com/thecsp" target="_blank"><s>@</s><b>thecsp</b></a> (UK)
PR campaign ‘<a href="http://www.csp.org.uk/professional-union/practice/public-health-physical-activity/love-activity-hate-exercise" target="_blank">Love Activity, Hate Exercise</a>’. </span><br />
<br />
<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">The whole affair highlights the
incredibly emotive power of words/word choice and how interpretation is entirely
dependent on perspective and context. </span></div>
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjTMIa4c9jjhB5DICklEwYkNlCtwctjWsW8Z6GhbZyXZdwy8QllkYADbcLPpfPmyz8ZZcxK9ZtV129GwSFKRN1QOm8MujlXL5xSPbyyROKazCFeD7r8zF-XEzr-F6K4MI5nqu_6xtfcdg4/s1600/Screen+shot+2018-07-04+at+19.00.17.png" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="370" data-original-width="496" height="238" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjTMIa4c9jjhB5DICklEwYkNlCtwctjWsW8Z6GhbZyXZdwy8QllkYADbcLPpfPmyz8ZZcxK9ZtV129GwSFKRN1QOm8MujlXL5xSPbyyROKazCFeD7r8zF-XEzr-F6K4MI5nqu_6xtfcdg4/s320/Screen+shot+2018-07-04+at+19.00.17.png" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><h1>
<span style="font-family: "arial" , "helvetica" , sans-serif;">Love activity, Hate exercise?</span></h1>
<span style="font-family: "arial" , "helvetica" , sans-serif;">Image: CSP http://www.csp.org.uk/professional-union/practice/public-health-physical-activity/love-activity-hate-exercise </span></td></tr>
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<span style="font-family: "calibri"; font-size: 12.0pt; font-weight: normal;">A similar attempt at influencing opinion was
run by the </span><span style="font-family: "calibri"; font-size: 12.0pt; font-weight: normal;">American Heart Association <a href="https://twitter.com/American_Heart" target="_blank"><s>@</s><span style="mso-bidi-font-weight: normal;">american_heart</span></a> (USA) in 2017,
they called it <a href="http://www.heart.org/HEARTORG/HealthyLiving/PhysicalActivity/GettingActive/5-Steps-to-Loving-Exercise-Or-At-Least-Not-Hating-It_UCM_445812_Article.jsp#.Wzy7voVkLu1" target="_blank">‘5 Steps to Loving Exercise ... Or At Least Not Hating It’</a>. That blog campaign
successfully conveyed the message that not everyone likes <a href="https://twitter.com/hashtag/Exercise?src=hash"><s>#</s><span style="mso-bidi-font-weight: normal;">Exercise</span></a> and gave some practical
tips that were designed to help non-exercisers begin to <a href="https://twitter.com/hashtag/LoveActivity?src=hash"><s>#</s><span style="mso-bidi-font-weight: normal;">LoveActivity</span></a> or even exercise.</span></div>
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<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">As
well as promoting movement and physical activity (and exercise), one of the key
messages of both campaigns seems to be that <a href="https://twitter.com/hashtag/Exercise?src=hash"><s>#</s><b>Exercise</b></a>
adherents and promoters (I would place myself into that category) ... may find
it challenging to see things from a non-exerciser's perspective ... The suggestion
being that anything that helps facilitate a greater understanding of the
patients perspective, and helps start a conversation, can only be helpful,
surely?</span></div>
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<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">That
said, HATE is an incredibly emotive word and I've always encouraged my kids
never to use it ... so I see the antipathy to its use. However, I can see the
value in backing the <a href="https://twitter.com/hashtag/LoveActivity?src=hash" target="_blank"><s>#</s><b>LoveActivity</b></a>
campaign, because if a patient uses the 'hate' word (and they do) as therapists
we have to have the empathy and skills to deal with that ... It is a psychosocial
phenomenon of our times and something we challenge our students to consider the
realities of.<span style="mso-spacerun: yes;"> </span></span><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;"></span></div>
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<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">Seems
like Marmite ... you'll either LOVE it, OR H*** it … AND quite frankly, it is entirely
your choice.</span></div>
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiqJVfVfivpuTkR9zZdGlUaCAJ0iHOpwF7c4-94tIYT4mO5em_0a-ko94I_Ck47szXfo_eLRsQJlhj0d0-xwaxz4t5FzNb7BYeXNQPX4vUTacdXIKzxrRwaJVeoajjlbDWJxz7UmvEp8k0/s1600/Screen+shot+2018-07-04+at+19.05.44.png" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="921" data-original-width="921" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiqJVfVfivpuTkR9zZdGlUaCAJ0iHOpwF7c4-94tIYT4mO5em_0a-ko94I_Ck47szXfo_eLRsQJlhj0d0-xwaxz4t5FzNb7BYeXNQPX4vUTacdXIKzxrRwaJVeoajjlbDWJxz7UmvEp8k0/s320/Screen+shot+2018-07-04+at+19.05.44.png" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: "arial" , "helvetica" , sans-serif;">Image: https://www.flickr.com/photos/dontcallmeikke/3306300654</span></td></tr>
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<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;"></span><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">The
ugly divisions that have ensued within the profession (and are still going on) are
also a psychosocial phenomenon of our times, and times past. The only thing
that has really changed is the platform and the players. There have always been
differences of opinions and schools of thought. Social media has simply opened
up debate and discussion to all. That is probably a good thing in a profession
that is striving to change. However, what is clear is that it becomes very easy
to create divisions, factions/tribes and to polarise opinion. </span>
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<b style="mso-bidi-font-weight: normal;"><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">Q. Is that a good thing?</span></b><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;"> </span></div>
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<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">A.
Maybe, maybe not. It depends on the context, perspective (and perhaps motive).</span></div>
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<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">In Jeremy
Lewis and Peter O’Sullivan’s recent <a href="https://bjsm.bmj.com/content/bjsports/early/2018/06/06/bjsports-2018-099198.full.pdf" target="_blank">BJSM editorial</a> <span style="color: purple;">‘<cite><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">Is it time to reframe how we care
for people with non-traumatic musculoskeletal pain?</span></cite> <span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span></span></span></div>
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<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">They
suggested, “<span style="color: purple;">… Evidence informed self-management is the key. To achieve this,
the efforts of many institutions, including educational, healthcare, political
and professional organisations, health funding bodies and the media, need to be
involved.</span>” In essence what they were saying was that there is a need for a
cohesive and consistent message from ALL invested and concerned with improving
patient care.<span style="color: #ffec00;"> </span>Those cohesive messages
whether they are about assessment/treatment methods/modalities, or exercise/advice
interventions, need to be evidence informed, consistent and convincing. Most folks
are cognisant with the concept that nothing is written in stone, evidence
evolves, and what we seemed quite certain about today, may be proved entirely
wrong tomorrow. </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">Q. So, where does that leave
us? <span style="mso-spacerun: yes;"> </span></span></b></div>
<div class="MsoNormal">
<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">A.
It leaves us all, frantically trying to make sense of an ever shifting
environment, conflicting stories, personal opinion, interpersonal/tribal
battles and #FakeNews.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">Q. OK … so what is the
solution?</span></b><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;"> </span></div>
<div class="MsoNormal">
<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">A.
That is the 64 million dollar question!</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">It
is also a question I been battling with for a while. Unfortunately, I can’t
pretend to know the answers either … and I expect the answers will differ
anyway, depending on a range of factors, not least the psycho-sociological
environment from where you view all of this. It is my guess that regardless of
your environment most folks will feel elements of uncertainty and confusion,
whether they are (Physiotherapy) clinicians, researchers, teachers/academics or
indeed patients … and it is worth reminding ourselves (wherever we may fall on
that spectrum) that everyone his their own ‘coal face’ and everyone contributes
to the landscape highlighted by the BJSM editorial.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<h3>
<span style="color: blue;"><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">Here
are a few tips or considerations on how to survive in a constantly changing
environment.</span></span></h3>
</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoListParagraph" style="mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-bidi-font-family: Calibri; mso-bidi-theme-font: major-latin; mso-fareast-font-family: Calibri; mso-fareast-theme-font: major-latin; mso-hansi-theme-font: major-latin;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><b style="mso-bidi-font-weight: normal;"><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">Evolve or die:</span></b><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;"> Sounds a bit harsh, I
know, BUT it is a fact of life. History reminds us, that emerging research has
challenged much of our previously accepted knowledge. In addition, much of what
we believe to be true today will become obsolete within a decade or so. It may be helpful to recall that one previous profession linked to ours did eventually get 'wound up' ... they were known as <a href="https://api.parliament.uk/historic-hansard/lords/1986/mar/24/professions-supplementary-to-medicine" target="_blank">Remedial Gymnasts</a>. </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoListParagraph" style="mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-bidi-font-family: Calibri; mso-bidi-theme-font: major-latin; mso-fareast-font-family: Calibri; mso-fareast-theme-font: major-latin; mso-hansi-theme-font: major-latin;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><b style="mso-bidi-font-weight: normal;"><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">Be less dogmatic:</span></b><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;"> 1. Above, dictates that
dogmatic thoughts or deeds are unlikely to yield results. No system, method,
school of thought works for all of the people all of the time. There are
(pretty much) always exceptions to any rule.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoListParagraph" style="mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-bidi-font-family: Calibri; mso-bidi-theme-font: major-latin; mso-fareast-font-family: Calibri; mso-fareast-theme-font: major-latin; mso-hansi-theme-font: major-latin;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><b style="mso-bidi-font-weight: normal;"><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">Get comfortable in the
grey:</span></b><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;"> This
is difficult but essential. Most folk prefer black and white answers of
absolute certainty. I’m sorry, but 1 & 2 above dictate that you may have
chosen the wrong profession if you expect or demand that from Physiotherapy.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoListParagraph" style="mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-bidi-font-family: Calibri; mso-bidi-theme-font: major-latin; mso-fareast-font-family: Calibri; mso-fareast-theme-font: major-latin; mso-hansi-theme-font: major-latin;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><b style="mso-bidi-font-weight: normal;"><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">Be less divisive and
collaborate:<span style="mso-spacerun: yes;"> </span></span></b><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">When Lewis & O’Sullivan
(<a href="https://bjsm.bmj.com/content/early/2018/06/06/bjsports-2018-099198.info">BJSM</a>)
said “the efforts of many institutions, including educational, healthcare,
political and professional organisations, health funding bodies and the media,
need to be involved (in change, sic)”… they meant it! Clinicians, and patients,
clearly play a vital part and social media opinionists require a sense of
social responsibility, if they really want to be effective change makers.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoListParagraph" style="mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-bidi-font-family: Calibri; mso-bidi-theme-font: major-latin; mso-fareast-font-family: Calibri; mso-fareast-theme-font: major-latin; mso-hansi-theme-font: major-latin;"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><b style="mso-bidi-font-weight: normal;"><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">Don’t buy into phoney wars:
</span></b><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">Physiotherapists
have always been caught up in hierarchical factions and been led by colourful
gurus, still (unfortunately) are. Why there is a need to create divisions’
remains a mystery, perhaps it is the frailty of humans? Regardless, the created
phoney wars, appear to serve no one (except those who create them) and simply
retard progress. </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoListParagraph" style="mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-bidi-font-family: Calibri; mso-bidi-theme-font: major-latin; mso-fareast-font-family: Calibri; mso-fareast-theme-font: major-latin; mso-hansi-theme-font: major-latin;"><span style="mso-list: Ignore;">6.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><b style="mso-bidi-font-weight: normal;"><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">Recognise how language can be manipulated: </span></b><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">Controversial … not really, just a reality of life in a World of
fake news.<b style="mso-bidi-font-weight: normal;"> </b><a href="https://www.amazon.co.uk/Unspeak-Words-Weapons-Steven-Poole/dp/0349119244" target="_blank"><u>Unspeak </u></a>is a language
style adopted by commentators who wish to make counter arguments untenable. It is a
tactic (weapon) used by those who prefer to perpetuate division or phoney wars. It
relies heavily on opinion (not evidence) and emotion. It is created to make any
alternative viewpoint seem abhorrent or untenable.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoListParagraph" style="mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-bidi-font-family: Calibri; mso-bidi-theme-font: major-latin; mso-fareast-font-family: Calibri; mso-fareast-theme-font: major-latin; mso-hansi-theme-font: major-latin;"><span style="mso-list: Ignore;">7.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><b style="mso-bidi-font-weight: normal;"><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">Be … pro-honesty,
pro-community, pro-evidence and anti-division (if you really have to be anti-anything)</span></b><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">: See 6 above and ‘Unspeak’
below. </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">Q. OK … so what is
‘Unspeak’ and what on earth has it got to do with physiotherapy?</span></b></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">A. Unspeak
is a term that was coined by Journalist Steven Poole in 2007 in his book ‘Words
Are Weapons’. Unspeak has crept imperceptibly into the narrative of
Physiotherapy discussions. It is a tactic to make controversial issues
unspeakable and, therefore, unquestionable. </span><br />
<br />
<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">This<a href="https://www.youtube.com/watch?v=M-iwVXr-mJ8" target="_blank"> VIDEO</a> is an interactive
documentary investigating the manipulative power of language. Watch it! Once
you have recognised it, you will always be able to spot the tactics in ANY
environment. </span></div>
<div class="MsoNormal">
<br /></div>
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEitHR399E3w2vKRiJFNvpXDNRITPpu3iqp6jByWfjXfXpvV4Ia1J-x4n8XFfFJ8RJ836-TrmIZuds1zBK1LkeZYt98HBfDxQZau2CetmhRsRlTp3qGlaXUx9YybCluQiF-Glnbt49egSMo/s1600/Screen+shot+2018-07-04+at+19.09.22.png" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="631" data-original-width="1275" height="197" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEitHR399E3w2vKRiJFNvpXDNRITPpu3iqp6jByWfjXfXpvV4Ia1J-x4n8XFfFJ8RJ836-TrmIZuds1zBK1LkeZYt98HBfDxQZau2CetmhRsRlTp3qGlaXUx9YybCluQiF-Glnbt49egSMo/s400/Screen+shot+2018-07-04+at+19.09.22.png" width="400" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: "arial" , "helvetica" , sans-serif;">https://www.youtube.com/watch?v=M-iwVXr-mJ8 </span></td></tr>
</tbody></table>
<div class="MsoNormal">
<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;"> </span><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;"> </span><br />
<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">There
are many examples; perhaps the easiest to follow is the pro/anti abortion one. Pro
abortion campaigners began to call themselves ‘pro-choice’ … after all everyone
wants CHOICE, don’t they? </span>
</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">But
… in a clever manipulation of language, the anti-abortion lobby quickly
countered their opposition, by referring to themselves as ‘Pro-Life’ … <b><span style="color: purple;">because
who on earth would argue that they were ‘Anti-LIFE’? </span></b></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">Q. Yes, and …?</span></b></div>
<div class="MsoNormal">
<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">A.
Oh sorry. The reason this came up again, is because it has been part of the
narrative of physiotherapy for a little while now, to demonise certain elements
of physiotherapy practice by referring to them (without evidence) as ‘harmful’
… or ‘low value’. It has been highlighted again by the recent and ongoing 'Hategate' controversy.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">Q. So what is the problem
with that … ?</span></b></div>
<div class="MsoNormal">
<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">A.
Well here at last, we get to the point … ‘harm’ is a very emotive word, a
little like ‘hate’, in fact the two may be associated or linked e.g. “the
deaths and horrific injuries (harm) that occurred in the fight, were associated
to the long standing hatred between the two gangs”. An extreme example YES, but
one that illustrates that harm can truly be emotive. </span><br />
<br />
<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">To allocate the ‘harm’ to
a harmless modality (name your own example HERE .................…………..) seems somewhat disingenuous
to say the least. If a modality has been shown to be ineffective or
uneconomical (from a health economics perspective) then say so, that is fine. When
I railed against this on SoMe lots of folk misinterpreted my stance, but since
the ‘hate controversy’ has blown up, we are back full circle to the harsh reality of word
choices.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">Q. Can you give me an
example?</span></b></div>
<div class="MsoNormal">
<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">A.
Sure. At my particular ‘coal face’ (UG and PG Physio/Sports Rehab Teaching), we have to try and make sense of all of the
incoming information (from researchers, clinicians, policy makers, SoMe
commentators etc.) and contextualise and disseminate it for inquisitive minds. With the luxury of both time and resources, we
do our best to keep up to date, and appreciate how busy clinicians must find
that really challenging. We also know a lot more about how the <a href="https://www.journalofphysiotherapy.com/article/S1836-9553(18)30044-4/fulltext" target="_blank">words we use in a clinical environment</a> with patients can affect them adversely (or not, depending on choice). </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">At
the end of the day, very few people WANT to do harm. So when a physiotherapy or
Sports Rehab’ student asks if say, muscle knots or <a href="http://alteredhaemodynamics.blogspot.com/2017/07/massage-confessions-of-ex-pro-cyclist.html" target="_blank">massage</a>
are ‘harmful’ because they heard it said on the Internet. We try to add some
context and perspective, and use that as an <u>opportunity to develop critical
thinking</u>.</span></div>
<div class="MsoNormal">
<br /></div>
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiDY1Nd845g40q-zkRW3FvqN56uf9BCk-o53563Xm2T36RQjz4qF7JTl5ojDg5j9wT4bv8tf-QKr92IYKsNxba6k3xfXq75ZkZU7Kyap3oM5c_fTCWZnXInJisUqShaFRoar5sLZ0GhifY/s1600/Screen+shot+2018-07-04+at+19.36.59.png" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="451" data-original-width="640" height="450" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiDY1Nd845g40q-zkRW3FvqN56uf9BCk-o53563Xm2T36RQjz4qF7JTl5ojDg5j9wT4bv8tf-QKr92IYKsNxba6k3xfXq75ZkZU7Kyap3oM5c_fTCWZnXInJisUqShaFRoar5sLZ0GhifY/s640/Screen+shot+2018-07-04+at+19.36.59.png" width="640" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: "arial" , "helvetica" , sans-serif;">Image: https://www.flickr.com/photos/jeanlouis_zimmermann/3042615083</span></td></tr>
</tbody></table>
<div class="MsoNormal">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">Q. Yes, but you know this
is not about physical harm, it is about adverse psychological effects. So what
is your problem?</span></b></div>
<div class="MsoNormal">
<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">A. <span style="mso-spacerun: yes;"> </span>OK that’s fine, I see that they do occur (in
some cases). So why not refer to them as ‘adverse psychological effects’ or
delays to diagnosis/appropriate care? I just feel uncomfortable (in the same way as those who who perfectly understandably, dislike the use of the word 'hate') with the use of the
language as a tool for demonisation, particularly in the absence of either a
clear definition or any evidence to support the statements that are made. </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">Q. The term ‘harm’ is used
in psychological literature isn’t it?</span></b></div>
<div class="MsoNormal">
<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">A.
Yes, BUT ‘harm’ in this case is clearly defined as adverse events such as
measured deterioration of old symptoms/appearance of new symptoms,
suicidal/homicidal behaviour etc. See, <a href="http://www.diva-portal.org/smash/get/diva2%3A702978/FULLTEXT01.pdf">Reporting
of harms in randomized controlled trials of psychological interventions for
mental and behavioural disorders: A review of current practice</a>. The same
applies to drug trials, where harm e.g. adverse, physical or psychological
events are <a href="http://listverse.com/2017/06/19/top-10-clinical-trials-that-went-horribly-wrong/" target="_blank">defined and clearly quantified</a>. Creating an environment where certain treatments or people who administer them, are seen as 'harmers' in the absence of either definition or evidence, is a disingenuous and divisive narrative. </span></div>
<div class="MsoNormal">
<br /></div>
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<b style="mso-bidi-font-weight: normal;"><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">Q. OK … what about the word
‘Hate’ in the CSP #LoveActivity #HateExercise campaign, it has been suggested
that this has made exercise “unspeakable”?</span></b></div>
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<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">A. Yes,
I saw that, and is an interesting turn of events. Because of my interest in the use/misuse of language I have
thought about it really hard. I think it is important to look at the context in
EVERY situation. First of all what is the intent? If the intent were (for some
reason) to demonise exercise, then you could perhaps make that argument. BUT,
as I understand it the campaign … it’s not trying to do that. Rather, as I said
earlier, the <b><span style="color: purple;">CSP campaign appears to be a well-intentioned strategy to raise the
awareness and importance of physiotherapists prescribing physical activity and exercise</span></b>.
Whilst at the same time, like the American Heart Association information, it
recognises that a large part of the population are not natural exercisers. The
question mark appears to make that explicit, as a number of commentators have
suggested. However, those who are opposed ethically, to the word 'hate' (and many are) will always find it difficult to get behind a campaign no matter how well intentioned, that contains that particular word. </span></div>
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<b style="mso-bidi-font-weight: normal;"><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">Q. So how do we all move
forward from here?</span></b></div>
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<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">A.
Well personally, I'd suggest that it has become abundantly clear that the power of language can unite or divide and perhaps everyone has learnt from that. Going forward, we should all be better equipped to spot the manipulation of language in narratives, wherever we may encounter it. As for the rest, I would hand this back over to the two evolving sages, <a href="https://bjsm.bmj.com/content/early/2018/06/06/bjsports-2018-099198.info" target="_blank">Lewis & O’Sullivan</a> … </span></div>
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<span style="color: blue;"><b style="mso-bidi-font-weight: normal;"><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">They suggested we should:</span></b></span></h3>
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<b><span style="color: purple;"><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">1.
Frame past beliefs against new evidence.</span></span></b></div>
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<b><span style="color: purple;"><br /></span></b></div>
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<b><span style="color: purple;"><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">2. When
in conflict, learn to evolve with the evidence. </span></span></b></div>
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<b><span style="color: purple;"><br /></span></b></div>
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<b><span style="color: purple;"><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">3.
Acknowledge the limitations of current surgical and non-surgical interventions for
persistent and disabling non-traumatic presentations.</span></span></b></div>
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<b><span style="color: purple;"><br /></span></b></div>
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<b><span style="color: purple;"><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">4. Upskill
and reframe of practice, language (in all domains, sic) and expectations. </span></span></b></div>
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<b><span style="color: purple;"><br /></span></b></div>
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<b><span style="color: purple;"><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">5.
Consider aligning current practice with that supporting most chronic healthcare
conditions. </span></span></b></div>
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<b><span style="color: purple;"><br /></span></b></div>
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<b><span style="color: purple;"><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">6.
Better support those members of our societies who seek care.</span></span></b></div>
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<b><br /></b></div>
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<span style="color: purple;"><b><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">7.
Be more honest with the level and type of care we can and should currently offer,
and the outcomes that may be achieved (<a href="https://bjsm.bmj.com/content/bjsports/early/2018/06/06/bjsports-2018-099198.full.pdf">Lewis
& O’Sullivan BJSM, 2018</a>).</span></b></span></div>
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<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">To
do all of those things, will require a radical change of mind set which aligns
with the current challenging health care climate. It is a global challenge that
is well recognised and which Physiotherapists the World over can rise to … IF and perhaps only if, they can bring
themselves to end the self-perpetuated, unnecessary conflicts.</span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgc5zq84OJIIW_Y4ZL2uDRESWTjs_x0dmfVzfgnnn4H9vWvSMaFxqEgpuIsUuMRwl9iNs_nNHY4MCw7TooQc5pBFYtJT5F3-M55_EamJNgK6BgSMWgfNtgIBMSbl_1_wbMRmY3BodHNTks/s1600/Screen+shot+2018-07-04+at+19.33.16.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1101" data-original-width="738" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgc5zq84OJIIW_Y4ZL2uDRESWTjs_x0dmfVzfgnnn4H9vWvSMaFxqEgpuIsUuMRwl9iNs_nNHY4MCw7TooQc5pBFYtJT5F3-M55_EamJNgK6BgSMWgfNtgIBMSbl_1_wbMRmY3BodHNTks/s400/Screen+shot+2018-07-04+at+19.33.16.png" width="267" /></a></div>
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<b style="mso-bidi-font-weight: normal;"><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">Q. Alan … doesn’t that
sound a little Utopian.</span></b></div>
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<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">A.
Maybe… maybe not.</span></div>
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<br />
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">Footnote:</span></b><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;"> There is no guarantee that
this Blog does not contain elements of Unspeak.<span style="mso-spacerun: yes;"> </span></span><br />
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<span style="font-family: "verdana" , sans-serif;"><span style="font-weight: normal; mso-fareast-font-family: "Times New Roman";"><span style="font-size: xx-small;"><i><b>Author:</b> Alan J Taylor is a writer and critic who thinks about stuff and works as a Physiotherapist<span style="font-weight: normal;">, </span>University <span style="font-weight: normal;">Assistant Professor</span>
and Medico-Legal expert witness ... The views contained in this blog
are his own and are not linked to any organisation or institution. </i></span><span style="font-size: xx-small; font-weight: normal;"><i>Like Bukowski, he 'writes to stay sane'. He once rode the Kellogs Tour of Britain and worked as a cycling soigneur.</i></span></span></span></div>
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Clinical Reasoning Sessionshttp://www.blogger.com/profile/09852524904111114134noreply@blogger.com0tag:blogger.com,1999:blog-6560398305209426117.post-30165561371417947452018-05-02T08:32:00.000-07:002018-11-09T00:54:07.525-08:00The case of the ‘sprained ankle’: A reflection on the narrative of ‘harm’ <style>
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</style><span style="font-family: "calibri"; font-size: large; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">Harm, harmed and harmful are words we hear daily in a range of contexts. In the world of MSK Physiotherapy, there has been a lively debate, relating to the ongoing use and abuse of those labels. Indeed, it has even been suggested that we should spend less time talking about the narrative of 'harm' and more time getting on with the task in hand. As uncomfortable and temporarily distracting as it may be, exploring in detail the psychosociology of the development of the 'harm' narrative, will allow us to do <b>exactly that.</b> </span><br />
<span style="font-family: "calibri"; font-size: large; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;"><br /></span>
<span style="font-family: "calibri"; font-size: large; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">It is clear, that everyone has their own frame of reference for their interpretation, context and use of the term 'harm', together with the narrative that goes with it. In any debate or discussion, it is helpful to form a view or even ask, exactly why or how someone formed their own views or perspective on a topic. Here's my own perspective on 'harm' ... a personal story, grounded in </span><span style="font-family: "calibri"; font-size: large;">altered haemodynamics,</span><span style="font-family: "calibri"; font-size: large;"> musculoskeletal trauma, clinical reasoning and decision making. </span><br />
<span style="font-family: "calibri"; font-size: large;"><br /></span>
<span style="font-family: "calibri"; font-size: large;">I’m going to tell you a very personal tale of actual, real measurable material harm, as a direct result of inappropriately applied
health care. It is a story which </span><span style="font-family: "calibri"; font-size: large;"><span style="font-family: "calibri"; font-size: large;">I wrote, but never thought I would publish. I </span>have only ever revealed it to a handful of
people, so as I take you (as a reader) into my confidence, do bear with me, as I
eventually get to my point. It may go some way to explaining why for me, asking for harm data, is not some kind of game, but rather a serious and genuine question, with a potential <b>end goal in mind.</b></span><br />
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<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">I’d not been qualified that long as a
Physiotherapist, when my Mother suffered an injury. It is a story in keeping with the title of this BLOG. My Mother’s name was Jessie … and my wife
always described her as a <a href="https://en.wikipedia.org/wiki/Mrs._Pepperpot" target="_blank">Mrs Pepperpot</a> like character. She was in her early 70’s, a short rotund, jocular lady who always seemed full
of fun. She enjoyed painting, flower arranging, pottering about in her extensive
garden and, as she called it ... “bending her tummy” (going to the Church hall exercise class). She
phoned me on the day she twisted her ankle in the garden, I had a quick look,
but she was in a lot of pain and the ankle was already very swollen. I decided
to take her to the GP. He examined her and confidently explained from his
physical tests that she had ‘sprained’ her ankle. He advised her to rest, ice,
compress and elevate, the management recipe (at the time) for such injuries. I took her
home and we dutifully followed the Doctor’s instructions, but I remember she
was in a lot of pain and she could hardly weight bear. I was a little worried,
but I tried to re-assure her, and left her with an ice pack and her leg propped
on up on pillows, telling her that I would be back the next morning.</span></div>
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<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">The next morning things were not good, she
told me she had had a terribly painful night and could not stand the weight of
the bed clothes on her ankle, I looked at the ankle and a bluey-red bruise was
already apparent and the swelling could only be described as like a balloon. I
called the Doctor; he listened patiently to my description, then re-assured us
that this was a “normal soft tissue response to injury”. He advised some
analgesia and a little gentle movement “as tolerated” and to continue with the
RICE regime. I managed to locate a pair of crutches in the loft (every physio
has crutches in the loft … don’t they?) and proceeded to teach her how to use
them to get around. She seemed a little happier now that she could potter about a
little and the analgesia was taking effect. Two weeks later, she was still
unable to weight bear properly and remained in a lot of pain. Despite the RICE
regime the ankle remained very swollen, very painful and very sensitive to
touch.</span><br />
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<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">Now a little worried, I’d been scanning the
text books (back in the days before Google) and found the section on traumatic
avulsion fractures of the ankle. I asked her if she had felt or heard anything
when the ankle twisted? She paused briefly, and said, “just a popping sound
like a chicken bone”. My eyes widened and I reached for the phone. I explained
the situation and the Doctor agreed to see her at the end of his list. He had
another look and this time tried to palpate the lateral malleolus … Jessie
almost jumped through the ceiling … “It’s terribly tender Doctor, you can’t
really touch it,” she explained, clearly embarrassed. “Mmmmm” he said, “I think
we’d best send you for an X Ray, just to check” he reassured her with a smile.
“Do you think it might be broken Doctor?” she asked, looking a little worried.
“We can’t really tell till you’ve had an X ray,” he explained. “So I think we’d
best be on the safe side”.</span></div>
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<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">Sure enough, the X Ray at the local hospital
revealed a small avulsion fracture of the lateral malleolus and it was decided
to treat it with a back slab immobilisation because of the extensive swelling. She
seemed much happier now that she had a diagnosis and the smile had returned to
her face as she joked with the medical staff and toddled off (non-weight bearing)
with her crutches.</span></div>
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<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">6 weeks later she returned to the fracture
clinic, the back slab was removed, an X Ray taken, and she was given the all
clear to begin to weight bear “as tolerated”. I quietly listened to the
instructions and exercises given by the physios and secretly suspected that my
role would be to provide a little encouragement and guidance. As it happened,
my role was minimal as she got on with the prescribed exercises and steadily began
the process of weight bearing. Two weeks later she had progressed to a stick
and things were going famously, but one thing troubled her, although the pain
was now manageable, it still seemed very swollen. I reassured her that that was
probably normal and that it would go down in time. It did go down… until 4 weeks
later.</span></div>
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<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">“I’m a
bit worried,” she said, when I called round. “I’ve been pottering in the garden
and I think I must have a rash or something, my ankle has gone all swollen
again” and look at it” she said, pointing to the red, swollen ankle resting on
the pillow. I’d never thought to measure the swelling (clinical tip), but it
looked much more swollen to me and it was certainly redness extending up to the
calf. “Can I touch it,” I asked, leaning forward to palpate the ankle “gently,”
she said, “oh and my calf has started to hurt too,” she added. I pressed my
thumb and fingers into the warm, swollen tissue, they left an indentation,
there was obvious pitting oedema. Deep vein thrombosis came flooding back to my mind, I
recalled the lectures, the text books, red, hot swollen, pitting oedema,
history of trauma, immobilisation, Virchow's Triad etc. etc. </span></div>
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<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">We were soon sitting in the Doctors waiting
room. “What seems to be the problem Jessie?” he said smiling. She took of her
shoe and sock and without a word nodded at the swollen, red ankle. “Mmmm …” he
said again, observing the temperature and pitting oedema, it looks like a case
of <a href="https://www.nhs.uk/conditions/Phlebitis/" target="_blank">phlebitis</a> he said confidently. “Oh dear, that sounds bad” exclaimed Jessie,
speaking up for the first time. “Oh … it’s nothing to worry about," said the Doctor
reassuringly, noting her alarm at the undecipherable medical jargon (clinical
tip). “We see it quite commonly after periods of immobilisation, we need to keep
an eye on it, and if things don’t settle down, you may need some
anti-inflammatories or maybe antibiotics for the inflammation. Oh … and I’ll ask
the nurse to get you some compression stockings”. The Doctor seemed very
confident and I was a newly qualified Physiotherapist barely making sense of
all the information I’d acquired, but I couldn’t help myself … “How can you be
sure that it’s not a DVT,” I stuttered unconvincingly, my mind racing. He shot
me a glance, and putting two and two together accurately said, “Aaah … I
remember now, Alan … you’re fresh out of Physiotherapy School aren’t you? Where
are you working these days?” He paused, clearly thinking through his response,
I didn’t answer. “Well we can never be entirely certain with these things, but
I’ve seen lots of similar cases and I think it is phlebitis … BUT (he said with
emphasis) we should keep an eye on it and if things don’t improve we’ll need to
send Jessie back to the hospital for some tests.”<span style="mso-spacerun: yes;"> </span></span></div>
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<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">4 or 5 days later (I don’t recall exactly) Jessie
became feverish and breathless and was rushed into the local hospital. Everything
was a blur, I vaguely remember some discussion and argument among the Doctors
about her diagnosis. Eventually, she was sent for Duplex ultra-sound scans and was
urgently medicated for the DVT that was revealed on the scans. She died in
hospital 2 days later from the complications of a pulmonary embolus. The post
mortem detailed both pathologies very clearly.</span></div>
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<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">The family were naturally shocked, her granddaughters
were too young to understand that they would miss out on hours of fun,
painting, flower arranging and pottering in the garden with their grandmother. The pain of the event was immeasurable and had an impact across generations.
There was talk among Jessie’s brothers and sisters, of misdiagnosis and medical
malpractice; my head was in a spin. I arranged a meeting with the medical
director of the hospital and the GP. We discussed the case and the events that
led to Jessie’s death … they acknowledged that the management perhaps could
have been different … that clinical decisions could have been expedited, the
tests done quicker. I observed the pained look on their faces. They called it a
“tragic case”. I asked them if they had learnt anything, the GP hung his head. Nothing
came of it, no blame was apportioned and the family chose not to pursue a
medico-legal case. I was relieved; it would have been too painful.<span style="mso-spacerun: yes;"> I did make a request though, that they use the root cause analysis of the case as training for medical staff, Doctors, Nurses and Physiotherapists alike.</span></span></div>
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<span style="color: blue; font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;"><b>So … how do you reflect on a case like that,
and what prompted me even to tell the story?</b></span></div>
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<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">Well actually it was and still is, the current
narrative in MSK physiotherapy that re-awakened the memory of this case and
prompted me to want share the story. </span></div>
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<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">I’ve watched with increasing discomfort and dismay, a range of
prominent SoMe commentators from top researchers, bloggers, to every day
Twitterati (including patients), confidently asserting that certain physiotherapy management methods are, in
their words ... “harmful”. When I politely ask for data to support this contention, it becomes clear that (to date) there is no data. There is however, a quite reasonable associative argument, which though clear to see, remains unquantified. A debate has ensued and is still ongoing, about the use and definition of the
word ‘harm’ and it became apparent that there are many. Similarly, </span><span style="font-family: "calibri";">everyone has their own particular frame of reference for their interpretation and context for the use of the term 'harm'.</span><br />
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<span style="color: blue; font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">If we go back to Jessie’s case in the cold light
of day, the raw data = 1 premature death. </span></div>
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<span style="color: blue; font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">Was there measurable harm? .... Yes. </span><br />
<span style="color: blue;"><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;"><br /></span>
<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">Was there immeasurable harm? ... Very likely.</span></span><br />
<span style="color: blue;"><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;"><br /></span>
<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">The unmeasured psychological trauma has not been captured … how could it be (effectively)? </span></span></div>
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<span style="color: blue; font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">Was that down to the treatment/management in this case? </span></div>
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<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">Maybe, … it certainly could be ascribed (in part) to delayed/misdiagnosis.
Above all, it was down to errors in clinical decision making, and that is what clinical encounters will always be down to … doing the right thing, at the right time for the
right patient, or as Greg Lehman would say, '</span><span style="font-family: "calibri";">being a </span><span style="font-family: "calibri";">good clinician'.</span></div>
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<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">A judgement on whether emotional distress is harmful or not, is entirely down to the ideas and beliefs of the individual. The very same thing applies to claims about treatments for MSK conditions. A period of ‘wrong’ management, may well have
delayed the application of the ‘right’ management (an ever shifting phenomenon in most MSK domains). That (in most cases) won’t
result in a measurable adverse event, but it could easily be an adverse or
negative factor (physically, psychologically or socially) affecting ultimately, the recovery of
the patient from whatever ails them. </span></div>
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<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;"><b>Is that harmful? </b></span><br />
<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;"><br /></span><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">... and if it is (?), <b>are we able to successfully identify when it transitions into harm </b></span><span style="font-family: "calibri";"><b>?</b></span><br />
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<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">Clearly, all of THAT remains open to debate. All we
can say is that IF a treatment is deemed ‘harmful’ … then it would be helpful to find a way to
measure that harm. With that knowledge, in order to prevent further harm, action could be planned and taken. To do this we would have to take into account the evidence on efficacy of
treatments, the health economics literature, the (captured) adverse events
data; we have to listen to patient opinions about what they consider to be <a href="https://ifwebuildit.blog/2018/04/30/understanding-harm-value/">value</a> or effective care, or harmful care, in a range of environments and from a range of experiences. It is clearly a very complex multi factorial topic, which has
no easy answers and (currently) appears dominated more by emotion and volume than reason. </span><br />
<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;"><br /></span>
<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">The polarisation of the debate and the ongoing manipulation of language, creates fear and uncertainty, and gives impression that there is only <b>one solution.</b></span></div>
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<span style="font-family: "wingdings"; mso-ascii-font-family: Calibri; mso-ascii-theme-font: major-latin; mso-char-type: symbol; mso-hansi-font-family: Calibri; mso-hansi-theme-font: major-latin; mso-symbol-font-family: Wingdings;"><span style="mso-char-type: symbol; mso-symbol-font-family: Wingdings;"></span></span><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;"><span style="mso-spacerun: yes;"> </span></span></div>
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<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;"><span style="mso-spacerun: yes;">This BLOG post was NOT written or designed (because it contained a personal story) to be impermeable to critique, neither is it to suggest some kind of <a href="https://www.icrc.org/eng/assets/files/other/irrc-874-bartal-chernyakhai-schori-gundar.pdf" target="_blank">victim-hood</a>, that would not have been Jessie's style nor is it mine. A single case study does not create or demolish a narrative. It may just however, explain the context of why I find the current physiotherapy narrative of harm </span></span><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;"><span style="mso-spacerun: yes;"><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;"><span style="mso-spacerun: yes;">uncomfortable, </span></span>difficult, unnecessarily divisive. I wouldn't go as far as to say I'm personally harmed by it, but it is certainly one reason why I speak out against it. None of this makes me right either, and my own (or Jessie's) narrative does not negate anothers, everyone will have their own perspective and frame of reference for analysing the topic. </span></span><br />
<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;"><span style="mso-spacerun: yes;"><br /></span></span>
<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;"><span style="mso-spacerun: yes;">If this story promotes a just a moment of critical thinking in 1 single person ... then it will have achieved its objective. That said, It would be really nice to see a positive outcome of this debate, a lot less conflict and even perhaps, an </span></span><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;"><span style="mso-spacerun: yes;"><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;"><span style="mso-spacerun: yes;">agreement on a </span></span>way forward. I know that Jessie would have been thrilled if she could have been, even a tiny part of that process. </span></span><br />
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<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;"><span style="mso-spacerun: yes;">Thanks for listening and for getting this far ... </span></span><br />
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<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;"><span style="mso-spacerun: yes;">Please feel free to comment or critique in the usual way. </span></span><br />
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<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;"><b>Footnote: </b>Jessie of course, did not die of
a sprained ankle (that would be <a href="https://www.amazon.co.uk/Unspeak-Words-Weapons-Steven-Poole/dp/0349119244" target="_blank">UNSPEAK</a>). Sprained ankles are not really harmful per se, and the doctors, nurses and therapists who deal with them, equally do not routinely deliver 'harmful' care. Jessie died from a pulmonary
embolus due
a complex series of human clinical decisions and events. Something I can
only attempt to square up or put down to <b>‘the frailty of humans’.</b> The
root cause analysis of her case, made for an interesting, yet painful read.</span></div>
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<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">I’m unsure whether it was irony or destiny
that took my physiotherapy career and specific interest, down the route of vascular speciality
and medico-legal work specialising in adverse vascular events and clinical
reasoning errors. I try to see some ‘good’ in that. </span><br />
<br />
<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">I've
seen some very interesting and illuminating cases of real measurable,
material harm and ongoing physical and psychological disability, linked
directly to physiotherapy interventions over the years ... and still the
cases still trickle in. </span></div>
<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;"><span style="mso-spacerun: yes;"><span style="color: blue; font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;"><i> </i></span> </span></span><br />
<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;"><span style="mso-spacerun: yes;">HT to Blaise Doran<span style="font-size: large;">, </span>Carl Davies, Greg Lehman and a few others who in their own ways, have helped me to shape and tell this story. </span></span><br />
<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;"><span style="mso-spacerun: yes;"><br /></span></span>
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<span style="font-family: "verdana" , sans-serif;"><span style="font-weight: normal; mso-fareast-font-family: "Times New Roman";"><span style="font-size: xx-small;"><i><b>Author:</b> Alan J Taylor is a writer and critic who tries to think about stuff . He works as a Physiotherapist<span style="font-weight: normal;">, </span>University <span style="font-weight: normal;">Assistant Professor</span>
and Medico-Legal expert witness whilst maintaining a small clinical work load. The views contained in this blog
are his own and are not linked to any organisation or institution. </i></span><span style="font-size: xx-small; font-weight: normal;"><i> He once rode the Tour of Britain and worked as a cycling soigneur. He still enjoys riding a b<span style="font-family: "verdana" , sans-serif;">i</span>cyle through the leafy lanes of Nottinghamshi<span style="font-family: "verdana" , sans-serif;">re and Derbyshire. In a World full of conflict and division ... l</span></i></span></span></span><i style="font-family: verdana, sans-serif; font-size: x-small;">ike Bukowski, he 'writes to stay sane'.</i></div>
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Clinical Reasoning Sessionshttp://www.blogger.com/profile/09852524904111114134noreply@blogger.com0tag:blogger.com,1999:blog-6560398305209426117.post-59631898341888324072017-11-01T09:36:00.016-07:002021-10-09T07:10:39.917-07:00Massage: Confessions of a cycling soigneur .... (Part II)<span style="font-family: helvetica;"><span style="font-size: medium;"><span face=""verdana" , sans-serif">This year the cycling Tour of Britain went right past my house. The rather eerie coincidence of the 175km Stage from Mansfield to Newark passing so close to home, has not passed me by (I wrote about a similar 175km stage in - <a href="http://alteredhaemodynamics.blogspot.co.uk/2017/07/massage-confessions-of-ex-pro-cyclist.html" target="_blank">‘Massage: Confessions of an ex-pro cyclist – Part 1’</a>).</span><br />
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<span face=""verdana" , sans-serif">In the follow up to <a href="http://alteredhaemodynamics.blogspot.co.uk/2017/07/massage-confessions-of-ex-pro-cyclist.html" target="_blank">Part I</a>, I take a look at the role of the soigneur in professional cycling and consider the <u>science behind the art</u>. For those perhaps unfamiliar with the term, it is French for a caretaker or carer, literally a person who gives massage, and other assistance to a team, during a cycle race. My experience as a soigneur in cycling was short and sweet (I’ll explain why at the end of this blog) with stints on the </span><span face=""verdana" , sans-serif">Tour of Guadeloupe, </span><span face=""verdana" , sans-serif">Rapport Tour in South Africa, and a follow up on the London-Paris Triathlon.</span></span><br />
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgRP5QFg8FNpkQopP4ItbQy1Mv_4HBfTheWYHBIhvL7xTE1wBucLZiJcxflHeea9WFqQKZSL5Lk8blzsQVMFfBP5LLNUUzcFdu6KaNSs4XPREwaGoESVIxssdXlNKRSbdbbUuOTVwbPQCQ/s1600/2012_Tour_of_Britain%252C_Stage_2.jpg" style="margin-left: auto; margin-right: auto;"><span style="font-family: helvetica;"><img border="0" data-original-height="1003" data-original-width="1600" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgRP5QFg8FNpkQopP4ItbQy1Mv_4HBfTheWYHBIhvL7xTE1wBucLZiJcxflHeea9WFqQKZSL5Lk8blzsQVMFfBP5LLNUUzcFdu6KaNSs4XPREwaGoESVIxssdXlNKRSbdbbUuOTVwbPQCQ/w690-h400/2012_Tour_of_Britain%252C_Stage_2.jpg" width="690" /></span></a></td></tr>
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<span style="font-family: helvetica;"><span style="font-size: medium;"><span face=""verdana" , sans-serif"><br /></span></span></span><div><span style="font-family: helvetica;"><span style="font-size: medium;"><span face=""verdana" , sans-serif"><br /></span></span></span></div><div><span style="font-family: helvetica;"><span style="font-size: medium;"><span face=""verdana" , sans-serif"><br /></span></span></span></div><div><span style="font-family: helvetica;"><span style="font-size: medium;"><span face=""verdana" , sans-serif"><br /></span></span></span></div><div><span style="font-family: helvetica;"><span style="font-size: medium;"><span face=""verdana" , sans-serif"><br /></span></span></span></div><div><span style="font-family: helvetica;"><span style="font-size: medium;"><span face=""verdana" , sans-serif">The job is much more challenging than many would appreciate and involves considerably more than massage. In short, the soigneurs are generally the first to rise and last to go to bed, though team mechanics (on rainy days) may dispute this. The key requirements for the role are organisation, stamina and an understanding of the sport. <span style="color: #990000;">John Herety, Team Director at JLT Condor </span>said, “It’s a long day, they work from very early in the morning to last thing at night. It looks glamorous from the outside, but it’s a hard, hard job.” He went on to explain that in the UK, the term ‘Carer’ is used more commonly since the dark days of the Festina drug scandal in 1998 when Willy Voet, the Festina Pro team soigneur was stopped by the police. In his car were the drugs the team needed if they were to have any chance of playing a competitive part in that year’s Tour de France. The story was told in Voet’s subsequent book <a href="https://www.amazon.co.uk/Breaking-Chain-Drugs-Cycling-Story/dp/0224061178" target="_blank">‘Breaking The Chain: Drugs and cycling, the true story.’ </a></span><br />
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<span face=""verdana" , sans-serif">Nowadays, post-Armstrong, the sport appears to have cleaned up its act. <span face=""verdana" , sans-serif">S</span>oigneurs still play a vital part in every team’s preparation, especially in the stage races (races that last more than 1 day) like the Grande Tours of France, Italy and Spain. The role involves everything from, driving to and from airports, shopping for provisions (nutritional needs of the riders), to making up bottles and feed bags, pinning on numbers, pre-race massage, handing up feed bags, through to post-race massage and even in some cases, washing/mending riders clothes … not to mention, acting as the riders confidant … this is no ordinary job. </span><br />
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<span face=""verdana" , sans-serif">So what is the role of the massage I hear you ask? Well, riders will make their way to the massage table in dribs and drabs, depending on the day’s events such as stage wins, crashes, visits to doping control, TV/Radio interviews etc. Then they will spend between 30-45 minutes on the table, receiving a full body massage with a bias towards the legs. Those legs of course, will have been pumping at 90-120 revolutions per minute for anything between 4 and 6+ hours (day after day) in the big Tours. Each team will have 3-4 soigneurs who share the volume of work. Most riders avail themselves to the skills of the soigneur, BUT there are a few notable exceptions. It is said that Chris Boardman former yellow jersey holder and Tour de France stage winner, was not a big fan of massage, but would occasionally take to the massage table to appease the GAN soigneur at the time.</span></span><br />
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjSrVfOg5hqdaPXu_PosmVYkEvQ3m3QZyITbTX_zsNchuAtdD4ux9fzAlgzDzi3JkdoeIRBGW1HoZsWQcTlBAniJy-5CjbeiErLCd7IUIev0OXOKO-ZTugwaJ3gNr5-YGLRATg3YmP_WQM/s1600/cancellara-op-de-massagetafel.png" style="margin-left: auto; margin-right: auto;"><span style="font-family: helvetica;"><img border="0" data-original-height="563" data-original-width="1000" height="360" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjSrVfOg5hqdaPXu_PosmVYkEvQ3m3QZyITbTX_zsNchuAtdD4ux9fzAlgzDzi3JkdoeIRBGW1HoZsWQcTlBAniJy-5CjbeiErLCd7IUIev0OXOKO-ZTugwaJ3gNr5-YGLRATg3YmP_WQM/s640/cancellara-op-de-massagetafel.png" width="640" /></span></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: helvetica;">Massage: A social interaction. Photo via <a href="https://derotsmedia.com/2012/03/22/5-april-holland-sport-special-parijs-roubaix/" target="_blank">https://derotsmedia.com/2012/03/22/5-april-holland-sport-special-parijs-roubaix/</a></span></td></tr>
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<h2><span face=""verdana" , sans-serif"><span style="color: blue; font-family: helvetica;"><br /></span></span></h2><h2><span face=""verdana" , sans-serif"><span style="color: blue; font-family: helvetica;"><br /></span></span></h2><h2>
<span face=""verdana" , sans-serif"><span style="color: blue; font-family: helvetica; font-size: medium;">So what of the science?</span></span></h2>
<span style="font-family: helvetica;"><span face=""verdana" , sans-serif" style="font-size: medium;">Much has been written on the topic and massage as a 'therapy' has its fair share of critics and advocates (<a href="https://www.painscience.com/articles/does-massage-work.php" target="_blank">see here</a>). It is fair to say that the evidence for its use is far from conclusive. In cycling, massage has always been a traditional form of preparation for the big Tours and major events by riders, coaches and team managers alike. So much so, that from a socio-economic perspective, professional teams will happily employ 3 or 4 soigneurs for the duration of the Grand Tours and major events throughout a season. Whi<span face=""verdana" , sans-serif">lst some riders retain personal soi<span face=""verdana" , sans-serif">gneurs.</span></span></span><br /><br />
</span><h3>
<span face=""verdana" , sans-serif"><span style="color: blue; font-family: helvetica;">So let’s consider a few questions:</span></span> </h3>
<span style="font-family: helvetica;"><span style="font-size: medium;"><span face=""verdana" , sans-serif"><i>Is massage always the same?</i></span><br />
<span face=""verdana" , sans-serif"><br /></span>
<span face=""verdana" , sans-serif">No. There are a plethora of different styles and applications, ranging from Swedish massage’ hands on to mechanical methods using foam rollers and devices/tools. This naturally makes reproducibility and research into massage very challenging. The most commonly used types of massage in cycling <span face=""verdana" , sans-serif">are</span> hands on, Swedish style applications, but the exact <span face=""verdana" , sans-serif">method</span> and style may be down to an individual’s preference.</span><br />
<span face=""verdana" , sans-serif"><i><br />Is massage always appropriate?</i></span><br />
<br />
<span face=""verdana" , sans-serif">Short answer ... NO.</span><br />
<span face=""verdana" , sans-serif"><br /></span>
<span face=""verdana" , sans-serif">Pre-event massage immediately before an event, has been shown to <a href="http://www.jssm.org/volume07/iss4/cap/jssm-07-549.pdf" target="_blank">reduce explosive power and speed</a>. Hence most pre-event rubs tend to be more for the superficial application of oils or creams, especially in adverse weather conditions e.g. cold, rain, snow etc.</span></span><br />
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjTlcUobrh6bHbzlU5RYBrWyUJgnG_bHhLWq8pAgHcv73QR1Q6J3bZkjlt00u-Fh7l5_9KIOP3szCycgTDM_gbVAX5BodGNDy9A3NmQ3hj5C3LCRxMfBJP4RC1h0sTPDqNB3gM8jYI8VlE/s1600/tdw_paris_nice_301_670.jpg" style="margin-left: auto; margin-right: auto;"><span style="font-family: helvetica;"><img border="0" data-original-height="446" data-original-width="670" height="424" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjTlcUobrh6bHbzlU5RYBrWyUJgnG_bHhLWq8pAgHcv73QR1Q6J3bZkjlt00u-Fh7l5_9KIOP3szCycgTDM_gbVAX5BodGNDy9A3NmQ3hj5C3LCRxMfBJP4RC1h0sTPDqNB3gM8jYI8VlE/s640/tdw_paris_nice_301_670.jpg" width="640" /></span></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: helvetica;">Image: http://www.cyclingnews.com/news/extreme-weather-protocol-misses-the-mark-in-paris-nice/</span></td></tr>
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<span style="font-family: helvetica;"><br />
<span style="font-size: medium;"><span face=""verdana" , sans-serif"><i>Why is it difficult to conduct research into massage?</i></span><br />
<br />
<span face=""verdana" , sans-serif">The reasons are many and varied. As mentioned previously, each rider is different, their exercise and race protocols are different, techniques vary and their application is differs from practitioner to practitioner. Not to mention, the difficulties of setting up a sham control group. Most studies into the effect of massage have been small, in both numbers and effect sizes (<a href="https://link.springer.com/article/10.1007%2Fs40279-015-0420-x" target="_blank">see here</a>) and compare to other dissimilar interventions. </span><br />
<br />
<i><span face=""verdana" , sans-serif">Physiological effects?</span></i><br />
<br />
<span face=""verdana" , sans-serif">Emerging research (<a href="http://bjsm.bmj.com/content/bjsports/51/19/1386.full.pdf" target="_blank">reported here</a>) into physiological effects, is <span face=""verdana" , sans-serif">partially</span> encouraging. <span face=""verdana" , sans-serif">Some</span> studies have (apparently) shown support for the contention that 'massage attenuates the inflammatory response to exercise, as well as decreases pain, muscle tone and hyperactivity'. This research suggests that reductions in inflammatory cells and proinflammatory cytokines via massage may 'mitigate secondary injury associated with intense exercise, thereby reducing tissue damage and accelerating recovery'. This all sounds <span face=""verdana" , sans-serif">almost too good to be true<span face=""verdana" , sans-serif">, and </span></span>readers <span face=""verdana" , sans-serif">should note that</span> <a href="http://stm.sciencemag.org/content/4/119/119ra13?ijkey=e645ef3396c0c3ae05981a4a93b3de03b453d057&keytype2=tf_ipsecsha" target="_blank">this particular small study</a> has been comprehensively pulled apart by various commentators (<a href="https://www.painscience.com/biblio/massage-therapy-attenuates-inflammatory-signaling-after-exercise-induced-muscle-damage.html" target="_blank">here</a> & <a href="https://respectfulinsolence.com/2012/02/13/a-study-that-oversells-massage-therapy/" target="_blank">here</a>). <span face=""verdana" , sans-serif">Furthermore</span>, a <a href="https://link.springer.com/article/10.1007%2Fs40279-015-0420-x" target="_blank">meta analysis in 2016</a> suggested that the effects on 'performance recovery are rather small and partly unclear'. <span face=""verdana" , sans-serif">However, a</span> later <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5623674/" target="_blank">systematic review with meta analysis in 2017</a> s<span face=""verdana" , sans-serif">tated</span> </span><span face=""verdana" , sans-serif">that 'current evidence suggests that massage therapy after strenuous
exercise could be effective for alleviating DOMS and improving muscle
performance'. </span></span><br />
<span style="font-size: medium;"><br />
<span face=""verdana" , sans-serif"><span style="color: blue;"><b>To summarise, it seems that as things stand ... NO ONE IS QUITE SURE!</b></span></span></span><br />
<br />
<span style="font-size: medium;"><span face=""verdana" , sans-serif">It has been quite rightly <span face=""verdana" , sans-serif">proposed</span> that ‘future studies should attempt to use standardised protocols so that between-study comparisons in which only varied single variables, such as timing and dose of massage, can be examined’. This of course works perfectly well in Science, but is entirely non-contextual for the sport, or the individual involved in that sport.</span><br />
<span face=""verdana" , sans-serif"><br /></span>
<span face=""verdana" , sans-serif"><i>So what about the psychological effects of massage?</i></span><br />
<br />
<span face=""verdana" , sans-serif">Massage (mainly in small underpowered studies) has been reported to have significant psychological benefits, including increased relaxation and decreased expression of stress biomarkers (i.e. cortisol). <span face=""verdana" , sans-serif">Ho<span face=""verdana" , sans-serif">wever, t</span></span>he effects of therapeutic touch are a key area for further research and this comes in the light of recent research (<a href="https://elifesciences.org/articles/28755" target="_blank">here</a>) suggesting that skin is thought to play a key role in the regulation of blood pressure. This may in part, provide a physiological explanation for the commonly reported relaxation and wellbeing commonly reported.</span></span><br /><br />
</span><h3>
<span face=""verdana" , sans-serif"><span style="color: blue; font-family: helvetica;">So what is the bottom line?</span></span></h3>
<span style="font-family: helvetica; font-size: medium;"><span face=""verdana" , sans-serif">Well frankly, the jury remains out from a scientific perspective, especially with regard to the physiological effects of massage. </span><span face=""verdana" , sans-serif">The effects of multiple
bouts of massage, either daily or at regular intervals over the course
of the Grand Tours, has yet to be investigated. Despite this, t</span><span face=""verdana" , sans-serif">he suggestion remains that massage, to quote the <a href="http://bjsm.bmj.com/content/51/19/1386.long" target="_blank">BMJ 2017</a>, remains 'an area worthy of (further) investigation, as we continue to advance the science for these therapies'.</span><span face=""verdana" , sans-serif"><span face=""verdana" , sans-serif"> <span face=""verdana" , sans-serif"> </span></span></span></span><div><span style="font-family: helvetica;"><br /></span></div><div><h3><span face=""verdana" , sans-serif"><span style="color: blue; font-family: helvetica;">2021 Update</span></span></h3><div><span style="font-family: helvetica; font-size: medium;">The publication of a research paper in 2021 causes quite a stir in massage and Physiotherapy circles as the following headline started to do the rounds in prominent newspapers such as <a href="https://www.thetimes.co.uk/article/massage-helps-injuries-heal-faster-study-finds-zw23nl97f?shareToken=037f22a45cc036478e02d0cf0e281e68" target="_blank">The Times</a> and the the <a href="https://news.harvard.edu/gazette/story/2021/10/massage-helps-injured-muscles-heal-faster-and-stronger/" target="_blank">Harvard Gazette</a></span></div><div><span style="font-family: helvetica;"><br /></span></div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEif65xwkQOHfM-tfzFgTkf8zCaZswep63rlGPBEE-6bel3q-Wizo2Saf0a5CkpLHlOZ62CGD0NCUYMzc3K7hMIO_5n0OlD3gYSg9L_nEPtx6e3aIDsY2i5OMeTIx2hTkP4xC-PKkvpHKbI/s2334/Screenshot+2021-10-09+at+08.08.41.png" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="1134" data-original-width="2334" height="328" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEif65xwkQOHfM-tfzFgTkf8zCaZswep63rlGPBEE-6bel3q-Wizo2Saf0a5CkpLHlOZ62CGD0NCUYMzc3K7hMIO_5n0OlD3gYSg9L_nEPtx6e3aIDsY2i5OMeTIx2hTkP4xC-PKkvpHKbI/w677-h328/Screenshot+2021-10-09+at+08.08.41.png" width="677" /></a></div><div><br /></div><br /></div><div><br /></div><div><br /></div><div><br /></div><div><br /></div><div><br /></div><div><br /></div><div><br /></div><div><br /></div><div><br /></div><br /><div><span face=""verdana" , sans-serif"><span style="color: blue; font-family: helvetica;"><br /></span></span></div>
<span style="font-family: helvetica;"><br /><br /></span></div><div><span style="font-family: helvetica; font-size: large;">What lay beneath the headlines was the that the <a href="https://www.science.org/doi/10.1126/scitranslmed.abe8868" target="_blank">study</a> published in Science Translational Medicine was carried out on mice using </span><span style="background-color: white; font-size: large;"><span style="font-family: helvetica;">a custom-designed robotic system to deliver consistent and tunable compressive forces to the mice’s leg muscles. The findings that were reported as suggesting that the "</span></span><span style="background-color: white; font-size: large;"><span style="font-family: helvetica;">mechanical loading (ML) rapidly clears immune cells called neutrophils out of severely injured muscle tissue. This process also removed inflammatory cytokines released by neutrophils from the muscles, enhancing the process of muscle fibre regeneration".</span></span></div><div><span style="font-size: medium;"><span style="background-color: white;"><span style="font-family: helvetica;"><br /></span></span></span></div><div><span style="font-size: medium;"><span style="background-color: white;"><span style="font-family: helvetica;">Unsurprisingly, this development caused quite a stir among the hands off protagonists and opinion shapers, who naturally focused on the fact that the study was carried out on rodents, which is a fair starting point for critique, and one I would use myself. However somewhat curious, I decided to explore if any mice studies had ever translated into anything meaningful for humans ... the findings were perhaps a little eye opening. An article entitled '<a href="https://fbresearch.org/medical-advances/animal-research-achievements/" target="_blank">Animal Testing and Research Achievements</a>' was more revealing than I had anticipated. The article offers a list of conditions from cancer to mental health conditions (with everything in between), a random click on a condition of interest soon reveals that mice studies have been hugely influential on an impressive range of conditions leading to '</span></span><span style="background-color: white;"><span style="font-family: helvetica;">life-saving and life-improving breakthroughs'. I have to say, I'd not realised the actual research impact of animal studies until I was prompted to take a look at the background literature. </span></span></span></div><div><span style="font-size: medium;"><span style="background-color: white;"><span style="font-family: helvetica;"><br /></span></span></span></div><div><span style="font-size: medium;"><span style="background-color: white;"><span style="font-family: helvetica;">That said, the mice massage study has not yet been translated into humans, so whilst the headlines may shout loudly, and massage protagonists, researchers may hail this as a break through, there is still a way to go. Meanwhile ... '<i>t</i></span></span><span style="background-color: white;"><span style="font-family: helvetica;"><i>he team is continuing to investigate this line of research with multiple projects in the lab. They plan to validate this mechanotherpeutic approach in larger animals, with the goal of being able to test its efficacy on humans. They also hope to test it on different types of injuries, age-related muscle loss, and muscle performance enhancement</i>'. </span></span><span style="background-color: white; font-family: helvetica;">All I would personally say, is watch this space for further developments and keep an open mind.</span></span></div><div><span style="font-family: helvetica;"><span style="color: blue;"><b><span face=""verdana" , sans-serif"><span face=""verdana" , sans-serif"><span face=""verdana" , sans-serif"><br /></span></span></span></b></span></span></div><div><span style="font-family: helvetica;"><span style="color: blue;"><b><span face=""verdana" , sans-serif" style="font-size: medium;"><span face=""verdana" , sans-serif"><span face=""verdana" , sans-serif">In the mean time</span>, p</span>ractitioners may be wise to avoid extravagant claims for what they are doing.</span></b></span><br />
<br />
<span style="font-size: medium;"><span face=""verdana" , sans-serif">If however, we consider the psycho-social benefits of massage, there is perhaps <span face=""verdana" , sans-serif"><span face=""verdana" , sans-serif">an argument</span></span> for its continued use. What is particularly interesting, is that whilst many pro cycling teams, have radically altered training programmes, diet and resting regimes for their athletes in response to emerging science, none have so far considered it prudent to remove or alter massage as an active ingredient of rider preparation.Whether this is down to science, tradi<span face=""verdana" , sans-serif">tion or a fear of rider rebellion, <span face=""verdana" , sans-serif">remains</span> another unknown.</span></span><br />
<span face=""verdana" , sans-serif"><br /></span>
<span face=""verdana" , sans-serif">Massage, as suggested in <a href="http://alteredhaemodynamics.blogspot.co.uk/2017/07/massage-confessions-of-ex-pro-cyclist.html" target="_blank">Part 1 of this blog</a>, may indeed be the ultimate biopsychosocial intervention, for there are (some) biological, psychological and social reasons for its continuation in the context of professional sport … and that truly is food for thought in an ever changing world. <span face=""verdana" , sans-serif"><span face=""verdana" , sans-serif"><span face=""verdana" , sans-serif"><span face=""verdana" , sans-serif">Wh<span face=""verdana" , sans-serif">at is clear, is that t</span></span>he<span face=""verdana" , sans-serif">re remains a demand for massage in sport (and other areas of health provision). <span face=""verdana" , sans-serif">Massage will </span>continue to be delivered by those with the <span face=""verdana" , sans-serif">necessary skills<span face=""verdana" , sans-serif">, and whether <span face=""verdana" , sans-serif">ANY </span>therapists <span face=""verdana" , sans-serif">bel<span face=""verdana" , sans-serif">ie</span>ve themselves above and beyond <span face=""verdana" , sans-serif">that ... is frankly, entirely up to them ... and their interpretation the science<span face=""verdana" , sans-serif">, ethics, psychology and so<span face=""verdana" , sans-serif">cio<span face=""verdana" , sans-serif">-economics</span> of the topic.</span></span></span></span></span></span></span></span></span></span></span></span></span><span face=""verdana" , sans-serif" style="font-size: medium;"> </span><br />
<br />
<b><span style="color: blue;"><span face=""verdana" , sans-serif" style="font-size: medium;">That massage as a therapy, has stood the test of time <span face=""verdana" , sans-serif">is <span face=""verdana" , sans-serif">indeed </span>an interesting so<span face=""verdana" , sans-serif">ciological observation<span face=""verdana" , sans-serif"> ... and perhaps nothing more. </span></span></span></span></span></b><br />
<br />
<span face=""verdana" , sans-serif">
</span>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEilgd99YHdbrdxYkuOa_JrVMmCa_8Wl2VFfaJ-mXRonL5lu08rcZ3xbHYudR0G4COKOvOz41MU4c04E7liaYMZXvUsqCdU6llmhyphenhyphen4leA5bOFMhi5C-QUAjRxL0TPqG4a8WDSlaIZCI2SE8/s1600/cycling-massage-e1428668964760.jpg" style="margin-left: auto; margin-right: auto;"><span style="font-family: helvetica;"><img border="0" data-original-height="988" data-original-width="1600" height="393" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEilgd99YHdbrdxYkuOa_JrVMmCa_8Wl2VFfaJ-mXRonL5lu08rcZ3xbHYudR0G4COKOvOz41MU4c04E7liaYMZXvUsqCdU6llmhyphenhyphen4leA5bOFMhi5C-QUAjRxL0TPqG4a8WDSlaIZCI2SE8/s640/cycling-massage-e1428668964760.jpg" width="640" /></span></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: helvetica;">Massage in cycling - perhaps the most biopsychosocial of interventions </span></td><td class="tr-caption" style="text-align: center;"><span style="font-family: helvetica;"><br /></span></td><td class="tr-caption" style="text-align: center;"><span style="font-family: helvetica;"><br /></span></td></tr>
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<span style="font-family: helvetica;"><span face=""verdana" , sans-serif"><br /></span></span></div><div><span style="font-family: helvetica;"><span face=""verdana" , sans-serif"><br /></span></span></div><div><span style="font-family: helvetica;"><span face=""verdana" , sans-serif"><br /></span></span></div><div><span style="font-family: helvetica;"><span face=""verdana" , sans-serif"><br /></span></span></div><div><span style="font-family: helvetica;"><span face=""verdana" , sans-serif"><br /></span></span></div><div><span style="font-family: helvetica;"><span face=""verdana" , sans-serif"><br /></span></span></div><div><span style="font-family: helvetica;"><span face=""verdana" , sans-serif"><br /></span></span></div><div><span style="font-family: helvetica;"><span face=""verdana" , sans-serif"><br /></span></span></div><div><span style="font-family: helvetica;"><span face=""verdana" , sans-serif"><br /></span></span></div><div><span style="font-family: helvetica;"><span face=""verdana" , sans-serif"><br /></span></span></div><div><span style="font-family: helvetica;"><span face=""verdana" , sans-serif"><br /></span></span></div><div><span style="font-family: helvetica;"><span face=""verdana" , sans-serif"><br /></span></span></div><div><span style="font-family: helvetica;"><span face=""verdana" , sans-serif"><br /></span></span></div><div><span style="font-family: helvetica;"><span face=""verdana" , sans-serif"><br /></span></span></div><div><span style="font-family: helvetica;"><span face=""verdana" , sans-serif"><br /></span></span></div><div><span style="font-family: helvetica;"><span face=""verdana" , sans-serif"><br /></span></span></div><div><span style="font-family: helvetica;"><span face=""verdana" , sans-serif"><br /></span></span></div><div><span style="font-family: helvetica;"><span face=""verdana" , sans-serif"><br /></span></span></div><div><span style="font-family: helvetica;"><span face=""verdana" , sans-serif"><br /></span></span></div><div><span style="font-family: helvetica;"><span face=""verdana" , sans-serif"><br /></span></span></div><div><span style="font-family: helvetica;"><span face=""verdana" , sans-serif"><br /></span></span></div><div><span style="font-family: helvetica;"><span face=""verdana" , sans-serif"><br /></span></span></div><div><span style="font-family: helvetica;"><span face=""verdana" , sans-serif"><br /></span></span></div><div><span style="font-family: helvetica;"><span face=""verdana" , sans-serif">Image: <a href="https://semiprocycling.com/everything-a-cyclist-should-know-about-massage" target="_blank">https://semiprocycling.com/everything-a-cyclist-should-know-about-massage</a></span><br />
<br />
<span face=""verdana" , sans-serif" style="font-size: medium;"><b><u><span style="color: blue;">Finally a word of advice.</span></u></b> </span><br />
<br />
<span face=""verdana" , sans-serif" style="font-size: medium;">It is worth reminding yourself that the role of team masseur/soigneur is one of the most demanding of jobs, both physically and psychologically. Having experienced both, first as a pro-cyclist and secondly a team soigneur … I can tell you for sure, personally, I would rather ride the race, and that is why my tenure in the job (as a soigneur) was very short lived. The final straw for me, was actually the 8 hours I spent bobbing up and down in a tiny fishing boat on the English Channel, trailing in the wake of a swimmer in the London-Paris Triathlon. BUT don’t let that put you off, it is also an incredibly rewarding role …but it is no ordinary job AND believe me, you’ll earn every last penny!</span><br />
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</span><div class="MsoNormal" style="background-color: white; color: #333333; margin: 0cm 0cm 0.0001pt;">
<span face=""verdana" , sans-serif"><span style="font-family: helvetica; font-size: x-small; font-weight: normal; mso-fareast-font-family: "Times New Roman";"><span><i><b>Author:</b> Alan J Taylor is a writer and critic who thinks about stuff and works as a Physiotherapist<span style="font-weight: normal;">, </span>University <span style="font-weight: normal;">Assistant Professor</span>
and Medico-Legal expert witness ... The views contained in this blog
are his own and are not linked to any organisation or institution. </i></span><span style="font-weight: normal;"><i>Like Bukowski, he 'writes to stay sane'. He once rode the Tour of Britain and worked as a cycling soigneur.</i></span></span></span></div>
<span style="font-family: helvetica;"><div><span style="font-family: helvetica;"><br /></span></div><span style="background-color: #647b91; color: white; font-family: Montserrat, sans-serif; font-size: 14px; text-align: center;">Copyright Altered Haemodynamics © 2017 All Rights Reserved</span><br />
<br /></span>
<br /></div></div>Clinical Reasoning Sessionshttp://www.blogger.com/profile/09852524904111114134noreply@blogger.com0tag:blogger.com,1999:blog-6560398305209426117.post-84041600712616032532017-07-13T04:08:00.002-07:002017-07-17T01:06:26.130-07:00Massage: Confessions of an ex-pro cyclist (Part I)<style>
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<tr><td class="tr-caption" style="text-align: center;"></td></tr>
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<div style="text-align: justify;">
</div>
<div style="text-align: justify;">
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left; margin-right: 1em; text-align: left;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjXTcb1nmue3njjYh3qSb3yR96WTLqFG9Tza19N6QPlkQiV3fxN50n50WSZiE_DXaClQj7d7JqEAqlJ0jBhiYNwiAUrkc20vDpUiW8sHNqnlxh5dUjuJTfoTSZUKevPu5Z51yglDki3WNk/s1600/soigneurs_massage.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="675" data-original-width="1013" height="426" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjXTcb1nmue3njjYh3qSb3yR96WTLqFG9Tza19N6QPlkQiV3fxN50n50WSZiE_DXaClQj7d7JqEAqlJ0jBhiYNwiAUrkc20vDpUiW8sHNqnlxh5dUjuJTfoTSZUKevPu5Z51yglDki3WNk/s640/soigneurs_massage.jpg" width="640" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-size: xx-small;"><span style="font-family: "verdana" , sans-serif;">Photo: Soigneur http://www.cyclist.co.uk/in-depth/683/soigneur-diaries</span></span></td></tr>
</tbody></table>
<br />
<span style="font-family: "verdana" , sans-serif;"><span style="font-size: small;"><span style="font-family: "verdana" , sans-serif;"><span style="font-size: small;">With the 2017 Tour De France in full swing, it may come as a surprise to many, that every team will employ 4 or more masseurs (known in France as <a href="http://www.cyclingweekly.com/news/racing/secret-life-soigneur-230187" target="_blank">Soigneurs</a>) and virtually every rider in the race will take sports massage as part of their daily routine. I’ve seen a great deal written on the topic of massage over
the years (<a href="https://criticalphysio.net/2015/05/19/no-sex-please-were-physiotherapists/" target="_blank">here</a>, <a href="https://www.painscience.com/articles/does-massage-work.php" target="_blank">here</a>),
not all of it complimentary (forgive the unintended pun). So, rather than
discuss the topic from the perspective of a physiotherapist, I’m going to make
my observations on the topic from the recipient or service user,
in this case, the rider. I’ll try to explain what compels Tour de France riders’
to take sports massage at the end of each stage, despite what the science may
suggest.</span></span> </span></span></div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<span style="font-family: "verdana" , sans-serif;"><span style="font-size: small;">Why? I hear you ask … well partly, because (in what seems now, like another lifetime) I spent a number
of years as both an amateur and professional cyclist and have more than a few tales to
tell. I rode and survived 2 Tours of Ireland, 1 Tour of Flanders, 1
Professional Tour of Britain, and a host of other single day and stage races,
during a long and occasionally successful career in the UK and on the continent.
So, in essence, I have felt the pain and suffering of elite level sport, and spent
more than my fair share of ‘time on the table’ under the hands of some of the
finest masseurs/masseuses in the business. </span></span></div>
<div style="text-align: justify;">
<br /></div>
</div>
<div class="MsoNormal">
<span style="font-family: "verdana" , sans-serif;"><span style="font-size: small;">By way of illustration, allow me tell you a story that
remains most vivid in my mind, relating to massage … it was the 243km 5<sup>th</sup>
Stage of the 1988 Kellogg’s Tour of Britain, from Birmingham to Bristol.
Unusually for a long stage, the race started from the gun and the <a href="http://www.cyclingnews.com/features/tour-de-france-glossary/" target="_blank"><i>peloton</i></a> (big group of cyclists) was
soon strung out in a line as the pace shot up to 28 mph +. We were in for a
long day of toil, because not only was the pace high (and we had 4 days in our
legs already), but then the rains came down, and the hills around Cheddar Gorge
loomed ominously ahead. </span></span><br />
<br />
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; text-align: left;"><tbody>
<tr><td style="text-align: center;"><span style="font-family: "verdana" , sans-serif;"><span style="font-size: small;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhZFHkjDemG4dIU9MghhlCmu1PwZdM6W_ueQcVbgO_unLCipWZ8Nnt3lmKxUvvKbRpfDPRiERew5UA_vo5qgkOwuycgSjW-0JPRSgUNZ3J_uBh9ssSzi900zCDxNxGk_pACwaGGguR9A4M/s1600/Quotefancy-1646086-3840x2160.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="900" data-original-width="1600" height="360" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhZFHkjDemG4dIU9MghhlCmu1PwZdM6W_ueQcVbgO_unLCipWZ8Nnt3lmKxUvvKbRpfDPRiERew5UA_vo5qgkOwuycgSjW-0JPRSgUNZ3J_uBh9ssSzi900zCDxNxGk_pACwaGGguR9A4M/s640/Quotefancy-1646086-3840x2160.jpg" width="640" /></a></span></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: "verdana" , sans-serif; font-size: xx-small;"><span style="font-size: x-small;">Photo:https://quotefancy.com/quote/1640043/Fausto-Coppi-Cycling-is-suffering</span></span></td></tr>
</tbody></table>
<span style="font-family: "verdana" , sans-serif;"><span style="font-size: small;">As the race splintered, I soon found myself in a group of non-climbers
and we clubbed together to form what is commonly known in the sport as the ‘Laughing
Group’ or <a href="http://www.cyclingnews.com/features/tour-de-france-glossary/" target="_blank"><i>autobus</i></a>. That is, a collection of riders who ride together to make it
to the finish inside the time limit for the race (a rider has to finish within
a set percentage of the time of the stage winner, and the limit is pre-set by
the race directors). The laughing group has a leader who calculates the timings
and ensures the group tries hard enough to get to the finish just in time so
that riders do not get eliminated (thrown off) the race. To do that, we all had
to take our turn at the front, chain gang style, and I still recall today the
pain in my legs as the cold rain drenched us, the grit blackened our faces, and
the hills sapped at our strength and morale. The captain had done his job well and
we limped in with 3 minutes to spare. I rode straight to the team hotel where I
dropped my filthy bike with the mechanic. <span style="font-family: "verdana" , sans-serif;">I </span>wearily made my way to my room,
where I quickly showered and lay on the bed in a fitful sleep, still shivering
from the cold and the effort.</span></span></div>
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><span style="font-family: "verdana" , sans-serif;"><span style="font-size: small;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhDlyyHDZGB4aPFsDPYP5A6zlN3kdYR_weVylYdynrabQiFWHDUUu2J7BM7BwebulEj8N-z31LIJKvnAcneGci_UGB7sO4G4GAzVAnoXF_Y_HGoPXi4tG0Ez0VLwx6s_GNA0wmEicIl8J8/s1600/kelloggs-tour-cycling-logo.png" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="915" data-original-width="1000" height="292" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhDlyyHDZGB4aPFsDPYP5A6zlN3kdYR_weVylYdynrabQiFWHDUUu2J7BM7BwebulEj8N-z31LIJKvnAcneGci_UGB7sO4G4GAzVAnoXF_Y_HGoPXi4tG0Ez0VLwx6s_GNA0wmEicIl8J8/s320/kelloggs-tour-cycling-logo.png" width="320" /></a></span></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: "verdana" , sans-serif; font-size: xx-small;"><span style="font-size: x-small;">Photo: http://www.sportfortelevision.com/tour-of-britain-prutour/</span></span></td></tr>
</tbody></table>
<span style="font-family: "verdana" , sans-serif;"><span style="font-size: small;">I don’t recall how much time had passed, but I was awoken
from my fitful slumber by the room telephone, it was the team masseur. “Hey Al,
you’re next on the table” he announced, with his usual enthusiasm. All my body
wanted to do was sleep, I could think of nothing else. “Erm, I think I’ll give
it a miss today, I think I’m just gonna sleep this off”, I said, rubbing the grit
from my eyes. “No no … you’d better come down, the guys said you looked a bit
pale when you came into the hotel, we’d best take a look at you, come on down
now, I’m just two floors below”. “OK” I said weakly, unable to fight my corner,
“Ok, I’ll be down in 5 minutes”. As I rose from the bed, I felt like I’d left
my body and soul somewhere on the road between Birmingham and Bristol and my
legs by this time, were aching more than I’d previously recalled, ever before in
my career, I felt broken and drained. Despite this, I called on <span style="font-family: "verdana" , sans-serif;">my</span> last ounce
of resilience and took the stairs down to the masseur’s room. It was a
peculiar masochistic tendency of mine, just to see how good or bad my legs felt
… they felt BAD, and I limped onto the massage table, already dreading the next
day. </span></span><br />
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><span style="font-family: "verdana" , sans-serif;"><span style="font-size: small;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj-Z6BqNMgQ6iixDMlLVlTIPpesoRvQDpbMIajbLgRVusfORDdROo20oY7uiVTOXU_AEfobqpkKq-KcvcQo2bfttywcmiES8uANk5bonoWrCZfrM0g6a-wOtWcuPWGSMzgK87no0atccOU/s1600/1988-Tour_Of_Britain-_Holme_Moss_climb.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="1194" data-original-width="1600" height="476" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj-Z6BqNMgQ6iixDMlLVlTIPpesoRvQDpbMIajbLgRVusfORDdROo20oY7uiVTOXU_AEfobqpkKq-KcvcQo2bfttywcmiES8uANk5bonoWrCZfrM0g6a-wOtWcuPWGSMzgK87no0atccOU/s640/1988-Tour_Of_Britain-_Holme_Moss_climb.jpg" width="640" /></a></span></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: "verdana" , sans-serif; font-size: xx-small;"><span style="font-size: x-small;">Photo: Kelly and Roche back in the old days. https://www.mamnick.com/blogs/journal/8823043-homeroads</span></span></td><td class="tr-caption" style="text-align: center;"><span style="font-family: "verdana" , sans-serif;"><span style="font-size: small;"><br /></span></span></td></tr>
</tbody></table>
<div class="MsoNormal">
<span style="font-family: "verdana" , sans-serif;"><span style="font-size: small;">Without batting an eyelid, the masseur said, “Tough day Al?”
I settled onto the table and wearily began to purge myself of the story of my terrible day. I
explained nervously, that he’d need to take it easy, because my legs were
caning me from the efforts of the last 4 days, the rain, the cold, not to
mention the distance. “I know … I can feel it”, he said confidently. Already a
qualified physiotherapist by this time, I guessed knowingly, that he couldn’t
really … he was just saying that, to make me feel better. However, I sensed
that he’d started his work with a much lighter touch, and gradually he worked
away at the thighs and calves, focusing on the sore spots that he found, with
his skilled hands and fingers. </span></span><br />
<br /></div>
<div class="MsoNormal">
<span style="font-family: "verdana" , sans-serif;"><span style="font-size: small;">After a short while he broke the silence, once
he knew that I had relaxed into the session, “Big day tomorrow Al?” he said.
“What do you mean” I asked, suddenly jolted back into reality. “Westminster
circuit race”, he announced with a jaunty grin. “Oh” I said, suddenly recalling
that we had a 100km race in the City of London barely 15 hours away. “It’s your
big day isn’t it? Your chance to get up there with the big boys?” he announced
confidently. Referring to the fact that flat circuit races like that were meant
to be my specialty. “Oh” I said doubtfully. “Not with these legs”. “We’ll soon
have you ship shape” he replied confidently, as the kidology continued and he
kneaded and wrung my aching muscles. I sensed that he spent a little extra time
on my legs that evening, as he worked hard to return the <i>‘souplesse’</i> (French
word for flexibility and suppleness) into those tired muscles, and I could feel the pain ebbing away. As he worked, he talked, and we discussed how the
next day would go, how I would find the strength and ability to play my part in
the race with some of the World’s greatest riders (Sean Kelly, Stephen Roche
etc.). Finally he said “Were all done, Al” … “Go and get some food, now the
colour has returned to your face”. I rose gingerly from the massage table after
30+ minutes, truly feeling like another man. </span></span></div>
<h4 class="MsoNormal">
<span style="font-family: "verdana" , sans-serif;"><span style="font-size: small;"><i><span style="color: blue;"><span style="font-family: "verdana" , sans-serif;"><span style="font-size: small;">'The pain in my legs had ebbed
away, I was no longer broken … in fact I was looking forward to tomorrow, the
finale in London, I was going to the capital city to finish my first Tour of
Britain, and I was going to make it count.'</span></span></span></i></span></span></h4>
<h4 class="MsoNormal">
</h4>
<div class="MsoNormal">
<br />
<span style="font-family: "verdana" , sans-serif;"><span style="font-size: small;">The physio within me was not to be fooled though, I did the ‘stair
test’ on the way down to dinner, and sure enough, I could go down the steps two
at a time, in fact I literally skipped the last two (bravado, I know). As I did
so, I spied Sean Kelly sitting (looking a little perplexed, at my little leap),
at a nearby table, quietly finishing his dinner with his team mates. I gave him
a little wink as a strolled confidently past his table … I said (secretly to
myself) “see you tomorrow big fella”. </span></span></div>
<br />
<div class="MsoNormal">
<span style="font-family: "verdana" , sans-serif;"><span style="font-size: small;">The next day went like a dream, we took the coach transfer
to London, and I felt like I was floating on air, yesterday’s ‘laughing group’ legs
were gone, and I took my place on the start line feeling strong and confident.
I truly did ‘mix it with the big boys’ that day. The 100km Westminster stage was won
by the classy Dutchman Jacques Hanegraaf, and Mr Kelly, well he came second,
perhaps because I’d made his legs hurt with my hard turns on the front of the
race (ha, ha … that’s my story and I’m sticking to it). I finished that stage
in the top 20 (my only top 20 placing in the whole race), for me it was a minor
victory. As we sailed over the finish line I was close enough to Kelly to give
him a little ‘<i>frotter</i>’ (French, to rub or chafe … riders use this technique to
move through the peloton), he laughed this time, and gave me a friendly pat on
the back as we coasted along on the momentum of the final sprint, our day’s
work done. </span></span></div>
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><span style="font-family: "verdana" , sans-serif;"><span style="font-size: small;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgxQnECYn6kKJ4oAA200DxGnQ-q2KiXi26FLY-k40weL8XXsJg0hpvRuOdOn5QxS9Xx43F2R5zGQWEzzgjoRuTNLFkkmBbmH0mvdzaUtWgYDnDlb4MmecFDla0Etkg6Dei5rBtyJKqMxow/s1600/Kelly.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="800" data-original-width="586" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgxQnECYn6kKJ4oAA200DxGnQ-q2KiXi26FLY-k40weL8XXsJg0hpvRuOdOn5QxS9Xx43F2R5zGQWEzzgjoRuTNLFkkmBbmH0mvdzaUtWgYDnDlb4MmecFDla0Etkg6Dei5rBtyJKqMxow/s320/Kelly.jpg" width="234" /></a></span></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: "verdana" , sans-serif; font-size: xx-small;"><span style="font-size: x-small;">Photo: Sean Kelly http://www.seankellyclassic.com/</span></span></td></tr>
</tbody></table>
<br />
<div class="MsoNormal">
<span style="font-family: "verdana" , sans-serif;"><span style="font-size: small;">The masseur was the first to come over and congratulate me,
“You rode like the wind Al” he said with a massive grin. I was high on the adrenaline
of finishing my first big pro Tour in such exalted company. I said simply,
“Well, if it wasn’t for you … I would never have made the start line today …
end of!” He laughed out loud, saying nothing at all. I shook his hand as hard
as I could, knowing what his eyes were saying … he was just doing his job.</span></span></div>
<span style="font-family: "verdana" , sans-serif;"><span style="font-size: small;">So what does this story tell us, I hear you ask? Well it’s a
simple story of a lived experience of massage from the perspective of a
sports<span style="font-family: "verdana" , sans-serif;">person</span>, which I felt worth sharing. I wanted to share it because it
illustrates what an incredibly powerful tool, massage and <b>‘time on the table’</b>
is for the competitive athlete. </span></span><br />
<h4 class="MsoNormal">
<span style="font-family: "verdana" , sans-serif;"><span style="font-size: small;"><span style="font-weight: normal;"><span style="color: blue;"><i>The therapeutic alliance between the athlete
and the masseur/masseuse during that 30-40 minutes is thought by many riders to be <a href="http://www.nbcsports.com/video/michael-valgren-explains-important-massages-cyclists">as
valuable as training and sleep</a> in the preparation for competition.</i></span></span> </span></span></h4>
<br />
<div class="MsoNormal">
<span style="font-family: "verdana" , sans-serif;"><span style="font-size: small;">The naysayers and the sceptics will of course insist that my
experience (and those of all of the TDF riders) was/is either a one off or,
entirely down to pre-conceived expectations and/or the theatre of placebo. To
those, I would say that the experience of immediate post race pain relief, together with
improved mood, occurred time and time again under of the hands of good massage
therapists AND if it was placebo … frankly as a sportsperson, truly I didn’t/don’t
care. </span></span><br />
<br />
<h4>
<span style="font-weight: normal;"><i><span style="color: blue;"><span style="font-family: "verdana" , sans-serif;"><span style="font-size: small;">As a <a href="http://www.chrisworsfold.com/how-to-practice-placebo-based-physiotherapy/">therapist
you should milk it</a>, because if it means the difference between your
athlete being able to compete at their best the next day (or not), then <a href="http://muse.jhu.edu/article/195993">get comfortable</a> with that. </span></span></span></i></span></h4>
</div>
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhQE6EiXK4FPJVwUGof0RarWRyfmQ4yFybNV59w1E6AgejWR7PUo89tDLsf73ro9AMv2FFP4yFDGZEsQjMy1QA3hZe-jLQIFH20yeXEswx3DsCMFQhH6XgOAGctOSupbhF1S1XUZ65P988/s1600/Jerseys+Cycling.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="759" data-original-width="1600" height="302" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhQE6EiXK4FPJVwUGof0RarWRyfmQ4yFybNV59w1E6AgejWR7PUo89tDLsf73ro9AMv2FFP4yFDGZEsQjMy1QA3hZe-jLQIFH20yeXEswx3DsCMFQhH6XgOAGctOSupbhF1S1XUZ65P988/s640/Jerseys+Cycling.jpg" width="640" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: "verdana" , sans-serif;">Retro Jerseys FOR SALE!</span></td></tr>
</tbody></table>
<span style="font-family: "verdana" , sans-serif;"><span style="font-size: small;">For those who suggest that as an athlete, I should have
built my <a href="https://www.ncbi.nlm.nih.gov/pubmed/24716648">resilience</a>
and not be reliant on passive modalities (such as massage), I would politely
explain, that the half hour on the massage table is where I was able to cast
off my demons, talk trough the tough times, plan my tactics for the next day,
work on my kidology and actually develop my focus, my social support and
therefore DEVELOP my resilience. Massage uniquely combines the <a href="https://www.psychologytoday.com/articles/201303/the-power-touch">power of
touch</a> with individualised sports psychology, there is no time during a
competition where the athlete feel so at peace, yet strangely empowered and
motivated, than on that massage table. </span></span><br />
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<br />
<b><span style="font-family: "verdana" , sans-serif;"><span style="font-size: small;">My advice to therapists who wish to work in elite sport, is this:</span></span></b><br />
<br />
<h4>
<span style="color: blue;"><i><span style="font-family: "verdana" , sans-serif;"><span style="font-size: small;">Understand that there is a <b>demand for massage within elite sport</b></span></span></i></span></h4>
<h4>
<span style="color: blue;"><i><span style="font-family: "verdana" , sans-serif;"><span style="font-size: small;">Learn and understand the power of <b>'time on the table'</b> </span></span></i></span></h4>
<h4>
<span style="color: blue;"><i><span style="font-family: "verdana" , sans-serif;"><span style="font-size: small;">Learn and practice the skills of soft tissue massage</span></span></i></span></h4>
<h4>
<span style="color: blue;"><i><span style="font-family: "verdana" , sans-serif;"><span style="font-size: small;">Decide for<b> <u>yourself</u> </b>whether knots and sore spots exist in athletes muscles</span></span></i></span></h4>
<h4>
<span style="color: blue;"><i><span style="font-family: "verdana" , sans-serif;"><span style="font-size: small;">Know your athletes inside out</span></span></i></span></h4>
<h4>
<span style="color: blue;"><i><span style="font-family: "verdana" , sans-serif;"><span style="font-size: small;">Know the sport inside out (including the tactics and kidology involved)</span></span></i></span></h4>
<h4>
<span style="color: blue;"><i><span style="font-family: "verdana" , sans-serif;"><span style="font-size: small;">Understand and accept that your <b>'time on the table'</b> intervention may have a strong element of <b>placebo</b></span></span></i></span></h4>
<h4>
<span style="color: blue;"><i><span style="font-family: "verdana" , sans-serif;"><span style="font-size: small;">Combine all those skills and knowledge and <b>APPLY</b> judiciously</span></span></i></span></h4>
<div class="MsoListParagraphCxSpFirst" style="mso-list: l0 level1 lfo1; text-indent: -36.0pt;">
<br /></div>
</div>
<span style="font-family: "verdana" , sans-serif;"><span style="font-size: small;">Put simply, there remains a strong demand for sports massage at the
top level of sport. It is an intervention that just might make the difference
between the starters and the non-starters, the winners and the losers.</span></span><i><span style="font-family: "verdana" , sans-serif;"><span style="font-size: small;"> </span></span></i><br />
<div class="MsoListParagraphCxSpFirst" style="mso-list: l0 level1 lfo1; text-indent: -36.0pt;">
<span style="color: blue;"><span style="font-family: "verdana" , sans-serif;"><span style="font-size: small;"><span style="mso-bidi-font-weight: normal;"><span style="font-family: "verdana" , sans-serif; mso-bidi-font-family: Verdana; mso-fareast-font-family: Verdana;"><span style="mso-list: Ignore;"><span style="font-family: "times new roman"; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; line-height: normal;"><i> </i><span style="font-size: x-small;"> </span></span></span></span></span><span style="font-size: x-small;"><span style="font-family: "verdana" , sans-serif;"></span></span></span></span></span></div>
<h4 class="MsoNormal">
<span style="font-weight: normal;"><i><span style="color: blue;"><span style="font-family: "verdana" , sans-serif;"><span style="font-size: small;">BUT
it is worth remembering … <b>this therapeutic intervention is as much about what you say, as what
you do.</b> Think of it not JUST as massage but rather <b>‘time on the table’</b>, a vital
blend of therapeutic touch and sport psychology<span style="font-family: "verdana" , sans-serif;">, </span>dare I say it … <b>a truly biopsychosocial
intervention ... where the physical, the psychological and the emotional are all considered equally in a holistic ritual. </b></span></span></span></i></span></h4>
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgi3e145C4jYIkzyvc7Hd1dfsvUSlYYEVmZeDMJru7U3saOfbPbGiYqlzfs2rstPP2lTEvKUPuEP3citNvs8ClKHvefaX4V2U6aPN1rb_7EMlBg3w-PXJwGAtUlEE0AeQiwwS2NtVXGfxk/s1600/quote-doubters-do-not-achieve-skeptics-do-not-contribute-cynics-do-not-create-calvin-coolidge-106-24-62.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="400" data-original-width="850" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgi3e145C4jYIkzyvc7Hd1dfsvUSlYYEVmZeDMJru7U3saOfbPbGiYqlzfs2rstPP2lTEvKUPuEP3citNvs8ClKHvefaX4V2U6aPN1rb_7EMlBg3w-PXJwGAtUlEE0AeQiwwS2NtVXGfxk/s640/quote-doubters-do-not-achieve-skeptics-do-not-contribute-cynics-do-not-create-calvin-coolidge-106-24-62.jpg" width="640" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-size: xx-small;"><span style="font-family: "verdana" , sans-serif;">Photo: http://www.azquotes.com/quote/1062462</span></span></td></tr>
</tbody></table>
<div class="MsoNormal">
<span style="font-family: "verdana" , sans-serif;"><span style="font-size: small;">Finally, I’ll just remind those sniffy cynics and <a href="http://www.skepticalaboutskeptics.org/" target="_blank">sceptics</a>
out there, that this article was written anecdotally from the perspective of the service
user (in this case, the rider) and is simply a description of one single experience (of many),
which attempts to explain why elite athletes have such a<span style="font-family: "verdana" , sans-serif;"> long standing</span> and passionate affinity with sports
massage, and as such, <b>it is not a scientific treatise.</b></span></span></div>
<div class="MsoNormal">
<span style="font-family: "verdana" , sans-serif;"><span style="font-size: small;"><span style="font-weight: normal;">Racing in France taught me a great deal, not least an admiration of the beauty of the French language<span style="font-family: "verdana" , sans-serif;">. S</span>o, as this article has been peppered throughout, with French cycling terminology, allow me to take this opportunity to regale <span style="font-family: "verdana" , sans-serif;">you of </span>my
favourite French expression of all … </span></span></span></div>
<div class="MsoNormal">
<h4>
<span style="font-weight: normal;"><span style="font-family: "verdana" , sans-serif;"><span style="font-size: small;"><span style="color: blue;"><i>“Jamais, péter plus haut que son cul.” </i></span></span></span></span></h4>
<span style="font-family: "verdana" , sans-serif;"><span style="font-size: small;"><span style="color: blue;"><span style="color: black;">I'll leave the translation, this time ... to you! </span></span> </span></span><br />
<br />
<span style="font-family: "verdana" , sans-serif;"><span style="font-size: small;">Sound advice for anyone, methinks. </span></span></div>
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<div class="separator" style="clear: both; text-align: center;">
</div>
<br />
<span style="font-family: "verdana" , sans-serif;"><span style="font-size: small;"><b>Part II of this blog</b>,
will discuss massage from the perspective of the race Soigneur/Therapist and will
consider the science behind the intervention … and THAT may reveal a different story
completely?</span></span><br />
<br />
<div class="MsoNormal" style="background-color: white; color: #333333; font-size: 12pt; margin: 0cm 0cm 0.0001pt;">
<span style="font-weight: normal; mso-fareast-font-family: "Times New Roman";"><span style="font-size: xx-small;"><span style="font-family: "verdana" , sans-serif;"><i><b>Author:</b> Alan J Taylor is a writer and critic who thinks about stuff and works as a Physiotherapist<span style="font-family: "verdana" , sans-serif; font-weight: normal;">, </span>University <span style="font-family: "verdana" , sans-serif; font-weight: normal;">Assistant <span style="font-family: "verdana" , sans-serif;">P</span>rofessor</span>
and Medico-Legal expert witness ... The views contained in this blog
are his own and are not linked to any organisation or institution. </i></span></span><span style="font-size: xx-small; font-weight: normal;"><span style="font-family: "verdana" , sans-serif;"><i>Like Bukowski, he 'writes to stay sane'.</i></span></span></span></div>
</div>
Clinical Reasoning Sessionshttp://www.blogger.com/profile/09852524904111114134noreply@blogger.com0tag:blogger.com,1999:blog-6560398305209426117.post-12751771028090910452016-12-03T03:10:00.006-08:002018-01-15T06:15:50.751-08:00How to create your very own evidence base … in a post truth World<style>
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<h3>
<i>"At one time we had truth and lies. Now we have truth, lies, and
statements that may not be true but we consider too benign to call
false." Ralph Keys</i></h3>
<h3>
<i> </i></h3>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiCXPO3KApBrht7V0IOZOTYWzE3YY8TZwJE9cAThP9ujyAHd0rIPXkbuMhBw_uLiBfctRVJptM2tvgpCUp9KWxBBbhQnNk28b7dNqp1VIUQ-Ys22hH_MU4n-C_tuDOOZcfMJXHmejOHmao/s1600/Screenshot+2016-12-03+11.01.54.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="260" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiCXPO3KApBrht7V0IOZOTYWzE3YY8TZwJE9cAThP9ujyAHd0rIPXkbuMhBw_uLiBfctRVJptM2tvgpCUp9KWxBBbhQnNk28b7dNqp1VIUQ-Ys22hH_MU4n-C_tuDOOZcfMJXHmejOHmao/s400/Screenshot+2016-12-03+11.01.54.png" width="400" /></a><i> </i></div>
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<i> </i> </div>
Hurrah! I hear you say (unless you are a member of the AACP
that is … <span style="mso-fareast-font-family: "Times New Roman";">acupuncture
is not recommended as a treatment for back pain</span>) the new <a href="https://www.nice.org.uk/guidance/NG59/chapter/Recommendations#assessment-of-low-back-pain-and-sciatica">NICE
Guideline - <span style="mso-fareast-font-family: "Times New Roman";">Low back
pain and sciatica in over 16s: assessment and management</span></a><span style="mso-fareast-font-family: "Times New Roman";"> </span>has just been
published. That means a group of experts have successfully completed
months/years of hard labour, poring through evidence to produce a thorough <i style="mso-bidi-font-style: normal;">carefully worded </i>(italics for emphasis)<i style="mso-bidi-font-style: normal;"> </i>analysis and clear guidance.</div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjf_eJogycYwl718CaASbZBrb8kDDD2sVKv7cP_AYd6T2pULXSQbkujm3VxTGPN-ll5SJ-GrGcjF_-J5BsB3Fo5KLFOVIcX2WmcSm_w_Jg3CKJ8We2uBiijp7jSuLY8W1Luo0Ufsf1fyac/s1600/Screenshot+2016-12-03+10.21.01.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="95" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjf_eJogycYwl718CaASbZBrb8kDDD2sVKv7cP_AYd6T2pULXSQbkujm3VxTGPN-ll5SJ-GrGcjF_-J5BsB3Fo5KLFOVIcX2WmcSm_w_Jg3CKJ8We2uBiijp7jSuLY8W1Luo0Ufsf1fyac/s400/Screenshot+2016-12-03+10.21.01.png" width="400" /></a></div>
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<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Of course, it doesn’t stop there! Then we get commentary and
analysis via bloggers. Here’s an <a href="http://www.csp.org.uk/frontline/article/clinical-update-low-back-pain-sciatica" target="_blank">example</a>
of a nice balanced piece by Neil O’ Connell who was a member of the guideline
committee. <a href="http://www.csp.org.uk/blog/2016/12/02/nice-low-back-pain-guideline-marks-important-moment-profession" target="_blank">KarenMiddleton</a> added her view on how <span style="mso-fareast-font-family: "Times New Roman";">the
guideline marks an important moment for the physiotherapy profession,
emphasising the ‘opportunity to evolve and look again at practice and
re-evaluate what is best for patients.’ … the guideline gives <i style="mso-bidi-font-style: normal;">clear wording</i> (italics for emphasis) on
that, and naturally is disappointing for some, yet welcome to others.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="mso-fareast-font-family: "Times New Roman";">Naturally,
as is the way of the World, we get the bloggers, sceptics and Twitterati who
also helpfully summarise the guideline, and it is here where things begin to get
a little messy. What is clear, to us all in the ‘modern World’ is that there is
little time to read long documents, and it is human nature to look for short
cuts (so far so good). So in many fields such as medicine, pharmacy and
physiotherapy we have the rise of the ‘infographic’ … </span><br />
<br />
<span style="mso-fareast-font-family: "Times New Roman";">Now, don't get me wrong here, infographics are
brilliant, because they are short snappy and summarise long papers in one
interesting and attractive figure. I you’ve never seen the work of <a href="http://ylmsportscience.blogspot.co.uk/">Yann Le Meur</a> … then you
should. The artistry, accuracy and attention to detail, is both impressive and
incredibly useful to visual learners. </span><br />
<br />
<h3>
<span style="mso-fareast-font-family: "Times New Roman";">HOWEVER</span></h3>
<h3>
<span style="mso-fareast-font-family: "Times New Roman";">not all infographics … <i>how shall
I say</i> … meet this exacting standard.</span></h3>
</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="mso-fareast-font-family: "Times New Roman";">It
became apparently obvious to me, that writing an infographic allows the writer
to interpret something like a guideline, pretty much any way they want (just as
Bloggers and internet commentators do), Herein, lies the rub …</span><br />
<br />
<b><span style="mso-fareast-font-family: "Times New Roman";">IF the
infographic writer, for one reason or another, chooses to alter the emphasis or
wording, miss bit out, or get bits wrong … then the reader or recipient can be
easily mislead. </span></b><br />
<br />
<span style="mso-fareast-font-family: "Times New Roman";">So, you end up with a snap-shot that can misrepresent the
original document. Which of course, means that ANYONE can create their own
version of the evidence base via the medium of the infographic. </span></div>
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<span style="mso-fareast-font-family: "Times New Roman";">HERE
the fun begins!</span></div>
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<span style="mso-fareast-font-family: "Times New Roman";">Below
I’ve written a short infographic (well ... some text and a picture) to help anyone create their own evidence base.
If you follow the simple instructions, you can make any, paper review,
guideline or article say exactly what YOU LIKE … it is a miracle! </span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEheU5i7DgaKLJgJa0ufj3HrZ-spGwxVXDZc7wsdTog5b1nRYkc5Ezt6whM30O4jQsamF4LQskQKBQeM2XMb0JY-BjnW5WGyW9dQZrZcRdVFqGzpFBok5k1UCWkMDErJ1UJTkZv9cLgy2l8/s1600/Screenshot+2016-12-03+10.18.28.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="396" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEheU5i7DgaKLJgJa0ufj3HrZ-spGwxVXDZc7wsdTog5b1nRYkc5Ezt6whM30O4jQsamF4LQskQKBQeM2XMb0JY-BjnW5WGyW9dQZrZcRdVFqGzpFBok5k1UCWkMDErJ1UJTkZv9cLgy2l8/s640/Screenshot+2016-12-03+10.18.28.png" width="640" /></a></div>
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<span style="mso-fareast-font-family: "Times New Roman";">Try it
yourself, adjust your favourite intervention, be it CBT, exercise, massage into
a slightly bigger font or place on the positive side of the table/graph/pie
chart in a slightly bolder colour etc. alter a word here and there (for
emphasis/de-emphasis) and before you know it, you’ve changed the message of the
original. You can even miss stuff out if you like, say radio frequency
denervation or manual therapy (it is entirely your choice), if that’s is
something you don’t particularly subscribe to. </span></div>
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<span style="mso-fareast-font-family: "Times New Roman";">Indeed
... if someone from the AACP had thought of it <b>they could have re-inserted acupuncture
into the LBP guidelines</b> and lots of folk would never have noticed (cos’ they
don’t have time to read the source document). That would of course, be
disingenuous, but hey ... politicians do it daily, and we wouldn’t have had Iraq,
<a href="http://criticalphysio.net/2016/11/18/trump-brexit-and-physiotherapy/" target="_blank">Brexit or Donald Trump</a> without a little (or more) distortion of the truth.</span></div>
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<span style="mso-fareast-font-family: "Times New Roman";">Where
does this leave us? And why did I even bother to put pen to paper?</span></div>
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Well it requires us to have a realisation that we are in the
‘post-truth era’ as detailed so well by Ralph Keyes in his book <a href="http://www.ralphkeyes.com/the-post-truth-era/" target="_blank">The Post-Truth Era:Dishonesty and Deception in Contemporary Life</a>. Keyes states:</div>
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<i style="mso-bidi-font-style: normal;"><span style="mso-fareast-font-family: "Times New Roman";">‘At one time we had truth and
lies. Now we have truth, lies, and statements that may not be true but we
consider too benign to call false. Euphemisms abound. We’re “economical with
the truth,” we “sweeten it,” or tell “the truth improved.” The term</span></i><i><span style="font-style: normal; mso-bidi-font-style: italic; mso-fareast-font-family: "Times New Roman";"> deceive</span></i><i style="mso-bidi-font-style: normal;"><span style="mso-fareast-font-family: "Times New Roman";"> gives way to </span></i><i><span style="font-style: normal; mso-bidi-font-style: italic; mso-fareast-font-family: "Times New Roman";">spin</span></i><i style="mso-bidi-font-style: normal;"><span style="mso-fareast-font-family: "Times New Roman";">. At worst we admit to
“<a href="http://unspeak.net/" target="_blank">misspeaking</a>,” or “exercising poor judgment.” Nor do we want to accuse
others of lying. We say they’re in denial. A liar is “ethically
challenged,” someone for whom “the truth is temporarily unavailable.”’ Ralph
Keyes</span></i></div>
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<span style="mso-fareast-font-family: "Times New Roman";">Furthermore
he states …</span></div>
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<i style="mso-bidi-font-style: normal;"><span style="mso-fareast-font-family: "Times New Roman";">‘We can only understand the
motives of such dissemblers by <b>examining the sea in which they swim</b>. Trends
ranging from the postmodern disdain for “truth” to therapeutic non-judgment
encourage deception. There is much incentive and little penalty for improving
the “narrative” of one’s life. The increasing influence of <b style="mso-bidi-font-weight: normal;">therapists</b>, entertainers, politicians, academics, and lawyers, with
their flexible code of ethics, contribute to the post-truth era. So do ethical
relativism, Boomer narcissism, the decline of community, and rise of the
Internet.’</span></i></div>
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<span style="mso-fareast-font-family: "Times New Roman";">So
there you have it folks … we have to adjust our radars, improve our awareness,
be on our guard, <b>even occasionally take the time to read a source document</b>.
Because, sometimes those nice folks who wrote that <a href="http://alteredhaemodynamics.blogspot.co.uk/2015/02/forget-gurus-cult-of-evidence-based.html?m=1" target="_blank">blog</a> may just have written it to fit their own biases, or particular agendas, and in the same way, the handy
visual snapshot of reality ... the infographic ... has sadly fallen foul of exactly the same
concept. </span><br />
<b><br /></b>
<b><span style="mso-fareast-font-family: "Times New Roman";">The dissemblers are amongst us, and I truly don't know why they behave that way.</span></b><br />
<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgP1Vj0kiy2ZWEVJWMy-9Ez3Tco-pQ_gcdUq7RCrdSbhc9-01GonK2yue-mAggX3feZXXo6TlpEOXcg06WEoQnFTDZNoBJ2sl8Ris7M2MDVLa8EvPA4yRehFgcboq5LEyirvkxqF2q-SCY/s1600/pseudoskeptic-1038x390.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgP1Vj0kiy2ZWEVJWMy-9Ez3Tco-pQ_gcdUq7RCrdSbhc9-01GonK2yue-mAggX3feZXXo6TlpEOXcg06WEoQnFTDZNoBJ2sl8Ris7M2MDVLa8EvPA4yRehFgcboq5LEyirvkxqF2q-SCY/s640/pseudoskeptic-1038x390.jpg" width="640" /></a></div>
<b><span style="mso-fareast-font-family: "Times New Roman";">(</span></b><span style="mso-fareast-font-family: "Times New Roman";">Source:</span><b><span style="mso-fareast-font-family: "Times New Roman";"> </span></b><a href="http://www.skepticalaboutskeptics.org/"><span style="mso-fareast-font-family: "Times New Roman";">http://www.skepticalaboutskeptics.org/</span></a><b>)</b><br />
<br />
<b><span style="mso-fareast-font-family: "Times New Roman";">Now ... just a brief word on sceptics ... AND pseudo sceptics</span></b><br />
<br />
<span style="mso-fareast-font-family: "Times New Roman";">The medical World has its fair share of sceptics or skeptics (as they are known in the USA)</span><b><span style="mso-fareast-font-family: "Times New Roman";">, </span></b><span style="mso-fareast-font-family: "Times New Roman";"><a href="http://www.badscience.net/about-dr-ben-goldacre/" target="_blank">Ben Goldacre of <i>Bad Science</i></a>, is perhaps one of the most well known examples, <a href="http://edzardernst.com/" target="_blank">Edzard Ernst</a> is another.</span><b><span style="mso-fareast-font-family: "Times New Roman";"> </span></b><span style="mso-fareast-font-family: "Times New Roman";">These </span><span style="mso-fareast-font-family: "Times New Roman";">brave souls, speak out on any issues from, basic bad science, global warming, Government policy, Prince Charles and his promotion of homeopathy, through to the risks of spinal manipulation etc. </span><br />
<br />
<span style="mso-fareast-font-family: "Times New Roman";"><b>Good sceptics</b> adopt an open minded approach and use science, debate, exposure (of bad practice) and apply critical examination and inquiry to all sides (including their own). </span><br />
<br />
<span style="mso-fareast-font-family: "Times New Roman";">Here's an example; Ernst has been a long time critic of alternative medicine (AM), and frequently adverse events (e.g. death after SMT) and general poor scientific practice relating to all sorts of disciplines within AM. These range from the more unconventional stuff like 'energy healing', and 'spiritual healing', through to say <a href="http://edzardernst.com/2016/12/slapping-therapy-no-thanks/" target="_blank">'slapping therapy'</a>, and perhaps the more conventional, such as acupuncture.</span><b><span style="mso-fareast-font-family: "Times New Roman";"> </span></b><span style="mso-fareast-font-family: "Times New Roman";">As such, he is commonly aggresively vilified and challenged by proponents of such therapies. His response is kindly, gentlemanly debate (often in the face of virtual abuse), use of science, critique, statistics etc. BUT when evidence comes along to challenge his World view on a topic, he has the good grace and conduct, to </span><span style="mso-fareast-font-family: "Times New Roman";">modify his view according to the developing and changing evidence base, or at the very least, air that evidence. </span><br />
<br />
<span style="mso-fareast-font-family: "Times New Roman";">Of interest to some physiotherapists (either historically or practically), MASSAGE had been a target of his for a number of years, until a new paper caught his eye and he wrote <a href="http://edzardernst.com/2013/02/massage-therapy-finally-some-positive-evidence/" target="_blank">this</a></span><b><span style="mso-fareast-font-family: "Times New Roman";"> </span></b><span style="mso-fareast-font-family: "Times New Roman";">and then later, <a href="http://edzardernst.com/2015/08/four-new-papers-on-a-promising-alternative-therapy-massage/" target="_blank">this</a></span><span style="mso-fareast-font-family: "Times New Roman";">. </span><span style="mso-fareast-font-family: "Times New Roman";">Ernst is an example of how a GOOD honest sceptic is</span><b><span style="mso-fareast-font-family: "Times New Roman";"> </span></b><span style="color: black;">able to adapt their paradigm to new evidence and update their hypotheses to fit the data. In physiotherapy, SOME of our emerging breed of <a href="http://alteredhaemodynamics.blogspot.co.uk/2015/02/forget-gurus-cult-of-evidence-based.html?m=1" target="_blank">bloggers</a>, podcasters and self-proclaimed sceptics are able to do that, and do it very well. SOME appear to default to the habits of pseudo-sceptics.</span><br />
<br />
<span style="color: black;">Pseudo-sceptics ... tend to:</span><br />
<ul>
<li><span style="color: black;">Persistantly judge as false, and debunk anything that contradicts <b>their</b> paradigm.</span></li>
<li><span style="color: black;">Are partially interested in truth, evidence and facts, but MORE interested in defending <b>their own views/stance</b>.</span></li>
<li><span style="color: black;">May fail to update their paradigm to incorporate new evidence, and deny or <b>bury data</b> which doesn't fit <b>their</b> view. </span></li>
</ul>
<span style="mso-fareast-font-family: "Times New Roman";">(Source <a href="http://www.debunkingskeptics.com/characteristics.php" target="_blank">http://www.debunkingskeptics.com/characteristics.php</a>)</span><br />
<br />
<b><span style="mso-fareast-font-family: "Times New Roman";">Sceptic or denier?</span></b><br />
<br />
'A<span style="mso-fareast-font-family: "Times New Roman";"> sceptic will question claims, then embrace the evidence. </span><br />
<br />
<span style="mso-fareast-font-family: "Times New Roman";">A<b> denier </b>will question claims, then reject (or bury) the evidence....' </span><br />
<br />
<span style="mso-fareast-font-family: "Times New Roman";">and for a brilliant commentary on pseudo-skepticism by </span><span style="mso-fareast-font-family: "Times New Roman";">Marcello Truzzi go <a href="http://www.anomalist.com/commentaries/pseudo.html" target="_blank">here</a>. </span><br />
<br />
<span style="mso-fareast-font-family: "Times New Roman";">So
be on your guard people … it's a tough environment out there, and distinguishing truth from fiction in a post-truth World ain't easy ... <a href="http://www.skepticalaboutskeptics.org/resources/videos-of-interest/sharyl-attkisson-astroturf-and-manipulation-of-media-messages/" target="_blank">false news</a>, pervades every aspect of the internet, even those sources, you thought you could trust, AND relies entirely on a passive (non-thinking) click of a button. Those who use it to their advantage know that, and you should too ... if you don't already! </span><br />
<br />
<span style="mso-fareast-font-family: "Times New Roman";">After all, that is what brought us Donald Trump. Good luck folks. </span><br />
<br />
<span style="mso-fareast-font-family: "Times New Roman";">I’ll leave you with the wise words of Ralph Keyes who vocalises this much better than I ever could …</span></div>
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<i style="mso-bidi-font-style: normal;"><span style="mso-fareast-font-family: "Times New Roman";">‘Post-truthfulness builds a
fragile social edifice based on wariness. It erodes the foundation of trust
that underlies any healthy civilization. When enough of us peddle fantasy as
fact, society loses its grounding in reality. Society would crumble altogether
if we assumed others were as likely to dissemble as tell the truth. We are
perilously close to that point.’ <a href="http://www.ralphkeyes.com/the-post-truth-era/" target="_blank">Ralph Keyes</a> </span></i></div>
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<span style="mso-fareast-font-family: "Times New Roman";">Be
careful out there folks …<span style="mso-spacerun: yes;"> words matter, and semantics are important AND that is the TRUTH </span></span><br />
<br />
<span style="mso-fareast-font-family: "Times New Roman";"><span style="mso-spacerun: yes;"><span style="color: blue;"><span style="font-family: "calibri"; font-size: 16px;">HT to Woody Guthrie for being an inspiration - "It's a </span><strike style="font-family: calibri; font-size: 16px;">folk singers</strike><span style="font-family: "calibri"; font-size: 16px;"> critical thinkers job to comfort disturbed people and to disturb comfortable people" ... see what I did?</span></span></span></span><br />
<span style="mso-fareast-font-family: "Times New Roman";"><span style="mso-spacerun: yes;"><span style="color: blue;"><span style="font-family: "calibri"; font-size: 16px;"> </span></span><br />
<span style="font-family: "calibri"; font-size: 16px;"></span></span></span><br />
<span style="mso-fareast-font-family: "Times New Roman";"><span style="mso-spacerun: yes;"><span style="font-family: "calibri"; font-size: 16px;"></span></span></span><br />
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgZHbZRCDbza2SJnNI1X1Rj5oz88MqNd6XsUQIQjJmeEd5Z3BvqtxHi4HRx3VRajAeTHn7d_xHlXDwwCmPd79aWqlG5BIerlHU7vy39WQKjl1Eoy0FbEDrxJTOEJyBZrwuXbyJy5bM4T6w/s1600/611px-Woody_Guthrie_NYWTS.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgZHbZRCDbza2SJnNI1X1Rj5oz88MqNd6XsUQIQjJmeEd5Z3BvqtxHi4HRx3VRajAeTHn7d_xHlXDwwCmPd79aWqlG5BIerlHU7vy39WQKjl1Eoy0FbEDrxJTOEJyBZrwuXbyJy5bM4T6w/s320/611px-Woody_Guthrie_NYWTS.jpg" width="254" /></a><span style="mso-fareast-font-family: "Times New Roman";"><span style="mso-spacerun: yes;"><span style="font-family: "calibri"; font-size: 16px;"><br /></span>
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<span style="font-weight: normal; mso-fareast-font-family: "Times New Roman";"><span style="font-size: xx-small;"><span style="font-family: "verdana" , sans-serif;"><i><b>Author:</b> Alan J Taylor is a writer and critic who thinks about stuff and works as a Physiotherapist<span style="font-family: "verdana" , sans-serif; font-weight: normal;">, </span>University <span style="font-family: "verdana" , sans-serif; font-weight: normal;">Assistant <span style="font-family: "verdana" , sans-serif;">P</span>rofessor</span>
and Medico-Legal expert witness ... The views contained in this blog
are his own and are not linked to any organisation or institution. </i></span></span><span style="font-size: xx-small; font-weight: normal;"><span style="font-family: "verdana" , sans-serif;"><i>Like Bukowski, he 'writes to stay sane'.</i></span></span></span></div>
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Clinical Reasoning Sessionshttp://www.blogger.com/profile/09852524904111114134noreply@blogger.com0tag:blogger.com,1999:blog-6560398305209426117.post-13677290848114905062016-02-23T02:12:00.000-08:002016-02-23T10:00:39.426-08:00Death following a neck injury: What can we learn from the case of Katie May?<style>
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<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;"><i>This commentary was originally written as a general interest article for publication on a Web news page. For one reason or another it was not published ... So here it is, in a modified Blog format.</i></span></div>
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<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">Katie May, a 34 year old Playboy model and
entrepreneur, died on February 4th 2016 following a stroke. Whilst the details are sketchy,
<a href="https://cdanews.com/2016/02/playboy-model-katie-may-died-from-a-stroke-after-second-chiropractor-visit/">media
reports</a> of a neck injury during a photo shoot raises questions as to how a
fit healthy 34 year old, could go from an apparent neck strain to a fatal stroke
in a matter of days. This report takes look at the mechanisms of early stroke
and considers what we can learn from the case.</span><br />
<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;"><br /></span>
<span style="font-family: "calibri";">Neck pain is a common complaint that is thought to affect around 10-13% of the population. However, most patients do not have a life threatening condition. That said the cervical blood vessels can be susceptible to injury. This was illustrated graphically by the tragic death of Australian Cricketer Phillip Hughes. Hughes died from a sub arachnoid haemorrhage (bleed to the brain) following a blunt injury to a blood vessel in his neck from a cricket ball.</span><br />
<span style="font-family: "calibri";"><br /></span>
<span style="font-family: "calibri";">The blood flow to the brain is carried by two small vessels at the back of the neck called vertebral arteries, and two larger vessels at the front, called the carotid arteries. The carotids carry around of 80% of the blood flow to the brain. It is well known that any of these blood vessels can be injured by <a href="http://stroke.ahajournals.org/content/34/12/2856.full.pdf+html" target="_blank">trauma or affected by disease</a>. It is well known that the early presenting symptoms of arterial dissection may be <a href="http://stroke.ahajournals.org/content/45/10/3155.long">neck pain or headache</a> and that ischaemic symptoms may not develop until later.</span><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgvEnCMZLck6ptYpW370EI9Als7hpdBqK5KUOzvkLgJYYblpZwxKXW3KJxbsmdThPLA_8Mz1-w0SIm-29qBetXo_czaBQgNF8aUplKvzVN3LAmk6HGC8yNDs_MPKLJOUM7MLwm4BqOPKmU/s1600/Vessels.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgvEnCMZLck6ptYpW370EI9Als7hpdBqK5KUOzvkLgJYYblpZwxKXW3KJxbsmdThPLA_8Mz1-w0SIm-29qBetXo_czaBQgNF8aUplKvzVN3LAmk6HGC8yNDs_MPKLJOUM7MLwm4BqOPKmU/s400/Vessels.jpg" width="292" /></a></div>
<span style="font-size: xx-small;">A complex anatomical region ... <span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;"><a href="https://www.flickr.com/photos/thomasfisherlibrary/12288500023">https://www.flickr.com/photos/thomasfisherlibrary/12288500023</a></span></span><br />
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<span style="font-family: "calibri";"><b>So, how could an apparently fit, healthy
female, suffer a stroke leading to death at the age of 34?</b></span><br />
<br />
<span style="font-family: "calibri";">The complete picture
of exactly what happened in this case remains unknown, but we can learn from
past experience. There are a number of potential scenarios.</span></div>
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<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">One scenario is that like Phillip Hughes,
Katie May had perfectly HEALTHY blood vessels that were injured internally (arterial
dissection) by an ‘awkward’ fall during a photo shoot. What happened thereafter
remains open to speculation. At that point ANY intervention whether it was
advice (to keep moving), pain management/education or manual therapy/manipulation,
may have ended with the same outcome. </span></div>
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<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">It remains unexplained how some dissection
pathologies resolve yet others go on to lead to stroke or death. It is thought that
this may relate to variety of intrinsic conditions linked to connective tissue disorders and clotting
factors. In addition, extrinsic factors may also play their part. A failure
to recognise the signs and symptoms (assuming there were any) of a developing
pathology in accident and emergency, at the GP practice, or under the care of a
musculoskeletal therapist (Physiotherapist, Osteopath, Chiropractor) may be also
be associated with fatal consequences. A common medico-legal scenario, is a delay to
appropriate triage, in order to commence a trial of management or specific
treatment. </span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjE7SoZRfg9zVwfi_lqmBLKlTtlyYJXqiHmxLb-gqoibRLrQHUx4xPlgf8A5_HPU-JzQLB4D_ODWT5jHTtp0hSKF72ca9gWRzHJA6DnHkVku_gm-ECmM7_7qTYHcrpWNwpaWgkaAmY3WNw/s1600/Blausen_0836_Stroke.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjE7SoZRfg9zVwfi_lqmBLKlTtlyYJXqiHmxLb-gqoibRLrQHUx4xPlgf8A5_HPU-JzQLB4D_ODWT5jHTtp0hSKF72ca9gWRzHJA6DnHkVku_gm-ECmM7_7qTYHcrpWNwpaWgkaAmY3WNw/s400/Blausen_0836_Stroke.png" width="275" /></a><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;"></span><br />
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<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;"><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;"> </span></span><br />
<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;"><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;"> <span style="font-size: xx-small;">Thrombotic stroke<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;"> - image </span><span class="_r3" style="font-family: "times new roman";"><a class="_ZR irc_hol i3724" data-noload="" data-ved="0ahUKEwj6sc-Ur4nLAhXKtBQKHb9FBy4QjB0IBg" href="https://en.wikipedia.org/wiki/Stroke"><span class="irc_ho" dir="ltr">en.wikipedia.org</span></a></span><span class="_r3 irc_msc" style="font-family: "times new roman";"><a class="_ZR irc_msl i3591" data-i="1" data-noload="" data-ved="0ahUKEwj6sc-Ur4nLAhXKtBQKHb9FBy4QhxwICA" href="https://www.google.co.uk/search?tbs=simg%3Am00&tbnid=PF94ILDg2iUvuM%3A&docid=f76RoHj0No-hZM&tbm=isch"><span class="irc_idim">550 × 800</span></a></span><span class="_r3 irc_sbc" style="font-family: "times new roman";"><a class="_ZR irc_sbl i3592" data-i="1" data-noload="" data-ved="0ahUKEwj6sc-Ur4nLAhXKtBQKHb9FBy4QiBwICQ" href="https://www.google.co.uk/search?tbs=sbi%3Acs&tbnid=PF94ILDg2iUvuM%3A&docid=f76RoHj0No-hZM">Search by image</a> </span></span></span></span><br />
<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;"><br /></span>
<span style="font-family: "calibri";">A second scenario of many, is where a person develops musculoskeletal neck pain insidiously or via a minor trauma and seeks
the attention of a manipulative therapist, such as a Chiropractor, Osteopath or
Physiotherapist. Katie May <a href="http://www.etonline.com/news/181696_katie_may_playboy_model_queen_of_snapchat_dead_at_34/">Tweeted</a> that she was going to see her Chiropractor, though no detail has been released. However, the wave of </span><span style="font-family: "calibri";">assumption and </span><span style="font-family: "calibri";">speculation implicating Chiropractors, could well be entirely unfounded as </span><a href="http://www.ncbi.nlm.nih.gov/pubmed/26564115" style="font-family: calibri;">this single case</a><span style="font-family: "calibri";"> study clearly illustrates. </span><br />
<br />
<span style="font-family: "calibri";">The status of the blood vessels at the time of ANY consultation, may be either
healthy OR unhealthy. Unfortunately, without sophisticated equipment, there is
no way of knowing whether vessels may be ‘weak’ or suffering from underlying
disease such as <a href="http://www.strokeassociation.org/STROKEORG/StrokeConnectionMagazine/ReadSCNow/Fibromuscular-Dysplasia-FMD_UCM_461419_Article.jsp#.Vss6evmLSUk">fibromuscular dysplasia</a> or atherosclerosis (rare in the younger patient). This is one of the reasons that manipulation in particular, has been called into question. At best the science remains </span><a href="http://www.chiropratiquelasource.com/recherches/safety.pdf" style="font-family: calibri;">equivocal</a><span style="font-family: "calibri";">. A recent systematic review found no association and suggested that, "the relative risk of ICA dissection after cervical spine manipulation compared with other health care interventions for neck pain, back pain, or headache is unknown". </span><span style="font-family: "calibri";">However, <a href="http://edzardernst.com/2012/11/the-risk-of-neck-manipulation/">critics</a> argue
that spinal manipulation to the neck may injure vessels, leading to
stroke. </span></div>
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<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">Neck manipulation has many descriptions, but generally involves a high velocity manoeuvre,
outside the control of the patient, which may produce a click or crack. </span><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">There is </span><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;"><a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004249.pub4/full"><span style="mso-fareast-font-family: "Times New Roman";">evidence</span></a></span><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;"> to suggest that for
acute/subacute neck pain, cervical manipulation provides better pain relief and
functional improvement than medications such as varied combinations of NSAIDs,
analgesics and muscle relaxants. However, the caveat is that this benefit, may
not be entirely </span><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/?term=Ernst+E.+Adverse+effects+of+spinal+manipulation%3A+a+systematic+review.++J+R+Soc+Med+2007%3B100%3A06-0100.1-9."><span style="mso-fareast-font-family: "Times New Roman";">risk free</span></a></span><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">. Furthermore, it is
suggested that the actual number of adverse events (injury, stroke, death) may
be </span><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/22522273"><span style="mso-fareast-font-family: "Times New Roman";">massively under reported</span></a></span><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">. </span></div>
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<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjDa_mZ8eBtANhyphenhyphenrJmwkoXUsf7jndprqVkR2ZdTTzbQzMXDskao25JFzc0gbKoByl0eBrlmC3wY25zJJmQOB5B2GPWde8XaA-qjq7LptjOUhHivejObviLV2l6TzxWmMHR3jZpjvamkXD0/s1600/risk.jpg" imageanchor="1"><img border="0" height="251" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjDa_mZ8eBtANhyphenhyphenrJmwkoXUsf7jndprqVkR2ZdTTzbQzMXDskao25JFzc0gbKoByl0eBrlmC3wY25zJJmQOB5B2GPWde8XaA-qjq7LptjOUhHivejObviLV2l6TzxWmMHR3jZpjvamkXD0/s400/risk.jpg" width="400" /></a> </span></div>
<div class="irc_hd">
<span class="_r3" style="font-size: xx-small;"><a class="_ZR irc_hol i3724" data-noload="" data-ved="0ahUKEwjMqojlrYnLAhXEWBQKHVETB0wQjB0IBg" href="https://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjMqojlrYnLAhXEWBQKHVETB0wQjB0IBg&url=http%3A%2F%2Fthebluediamondgallery.com%2Fr%2Frisk.html&bvm=bv.114733917,d.d24&psig=AFQjCNEUeAiACQFXMVO8sP2GyTNi1s96AA&ust=1456161317641733"><span class="irc_ho" dir="ltr">thebluediamondgallery.com</span></a></span><span class="_r3 irc_msc" style="font-size: xx-small;"><a class="_ZR irc_msl i3591" data-i="1" data-noload="" data-ved="0ahUKEwjMqojlrYnLAhXEWBQKHVETB0wQhxwICA" href="https://www.google.co.uk/search?tbs=simg%3Am00&tbnid=vQJyHrVI6AKTVM%3A&docid=IXpaYac_NWDoRM&tbm=isch"><span class="irc_idim">1200 × 755</span></a></span><span class="_r3 irc_sbc" style="font-size: xx-small;"><a class="_ZR irc_sbl i3592" data-i="1" data-noload="" data-ved="0ahUKEwjMqojlrYnLAhXEWBQKHVETB0wQiBwICQ" href="https://www.google.co.uk/search?tbs=sbi%3Acs&tbnid=vQJyHrVI6AKTVM%3A&docid=IXpaYac_NWDoRM">Search by image</a></span> </div>
<h2>
<span style="font-family: "calibri"; font-size: 12.0pt;">Could the risk be reduced?</span></h2>
<span style="font-family: "calibri"; font-size: 12.0pt;">The debate on the safety of manipulation has
not been helped by the lack of agreement on the risk of blood vessel injury
following treatment. <a href="http://www.sciencedirect.com/science/article/pii/S1356689X15000260">Some
reports suggest</a> ratios between one in 50</span><span style="font-family: "calibri"; font-size: 12.0pt;"> </span><span style="font-family: "calibri"; font-size: 12.0pt;">,000 to one in nearly 6 million manipulations, though as mentioned,
many question the <a href="http://www.ncbi.nlm.nih.gov/pubmed/?term=Ernst+E.+Adverse+effects+of+spinal+manipulation%3A+a+systematic+review.++J+R+Soc+Med+2007%3B100%3A06-0100.1-9">accuracy
of this data</a>, citing up to 100% under-reporting. A <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3360486/">review</a> of 134
case reports, published in 2012, said, “there was potential for a clinician to
prevent 44.8% of adverse events (such as stroke or death) associated with
manipulation”. The authors suggested, “10.4% of the events were unpreventable”.
Interestingly, the patients who died had continued or excessive spinal
manipulation, despite the fact that they were <i>not responding to treatment, or
their symptoms were worsening.</i></span><br />
<br />
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<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">Despite RCT <a href="https://www.researchgate.net/publication/274258226_The_immediate_effect_of_atlanto-axial_high_velocity_thrust_techniques_on_blood_flow_in_the_vertebral_artery_A_randomized_controlled_trial">reports</a>
that </span><span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">in
apparently healthy vessels, manipulation to the atlanto-</span></div>
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<span style="font-family: "calibri"; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">axial
joint does NOT appear to increase mechanical stress on the vertebral artery, it
remains unknown what the affect might be on diseased, weak or already dissecting vessels (vertebral or carotid). </span></div>
<br />
<span style="font-family: "calibri"; font-size: 12.0pt;">As it stands, scientific knowledge can neither
accurately quantify the risk associated with neck manipulation, nor establish
an unequivocal link between manipulation and adverse events. </span><span style="font-family: "calibri"; font-size: 12pt;">A </span><a href="http://www.ncbi.nlm.nih.gov/pubmed/26250600" style="font-family: calibri; font-size: 12pt;">2016 physiotherapy
publication</a><span style="font-family: "calibri"; font-size: 12pt;">, a profession that has been prominent in the field of neck risk
assessment, suggested that, at best, “early recognition of injury to blood
vessels” may reduce the occurrences of </span><a href="http://www.ncbi.nlm.nih.gov/pubmed/26250600" style="font-family: calibri; font-size: 12pt;"><span style="mso-fareast-font-family: "Times New Roman";">inappropriate treatment</span></a><span style="font-family: "calibri"; font-size: 12pt;">. This raises the important question of what exactly is 'inappropriate treatment'? Whilst manipulation may have been demonised by some, it is important to understand that blindly defaulting to ANY favoured intervention in the absence of sound clinical examination and risk assessment ... may lead to adverse outcomes in the presence of arterial injury. </span><br />
<br />
<b><span style="font-family: "calibri"; font-size: 12.0pt;">Could tragic events like this be prevented?</span></b><br />
<br />
<span style="font-family: "calibri"; font-size: 12.0pt;">Disappointingly, the complexity of the human
body and mind, dictates that the answer will vary from case to case and
clinician to clinician. It remains essential for ALL CLINICIANS to retain an index of suspicion for arterial injury in cases of trauma, be cognisant of ‘red flags’ and apply appropriate <a href="http://www.ifompt.org/site/ifompt/IFOMPT%20Examination%20cervical%20spine%20doc%20September%202012%20definitive.pdf">clinical reasoning and examination procedures.</a> A default to, a single school of thought or approach (whatever that may be), may lead to delays to triage, inappropriate management and potential medico-legal consequences. </span><br />
<br />
<span style="font-family: "calibri"; font-size: 12.0pt;">Atypical, worsening presentations, with OR without subtle ischaemic symptoms may alert the clinician to the presence of arterial injury. The diagnosis of <a href="http://stroke.ahajournals.org/content/45/10/3155.long#T3">arterial dissection</a> rests on a careful clinical history, <a href="http://alteredhaemodynamics.blogspot.co.uk/2013/10/cranial-nerve-testing-cervical-spine.html">physical examination</a>, and targeted ancillary investigations. Clinicials should be cognisant that delay may be fatal. </span><br />
<span style="font-family: "calibri";"><br /></span>
<b><span style="color: blue; font-family: "calibri"; font-size: 12pt;">What do we all have to learn from cases like this?</span></b><br />
<span style="font-family: "calibri"; font-size: 12pt;"><br /></span>
<span style="font-family: "calibri"; font-size: 12pt;">1. R</span><span style="font-family: "calibri"; font-size: 16px;">etain an index of suspicion for vascular injury in trauma cases. </span><br />
<br />
<span style="font-family: "calibri"; font-size: 16px;">2.</span><span style="font-family: "calibri"; font-size: 12.0pt; font-weight: normal;"> Know your anatomy and pathophysiology.</span><br />
<br />
<span style="font-family: "calibri"; font-size: 12pt;">3. Hurt does = harm, in <u>some cases</u>. </span><span style="font-family: "calibri"; font-size: 16px;"> </span><br />
<span style="font-family: "calibri"; font-size: 12pt;"><br /></span>
<span style="font-family: "calibri"; font-size: 12pt;">4. </span><span style="font-family: "calibri"; font-size: 16px;">Examine and question the patient in detail.</span><br />
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<span style="font-family: "calibri"; font-size: 12pt;">5. Have, and retain <u>vigilance</u> for ‘Red Flags'.</span><br />
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<span style="font-family: "calibri"; font-size: 12pt; font-weight: normal;">6. A <a href="http://www.csp.org.uk/tagged/cauda-equina-syndrome">DELAY</a> to appropriate management, is a common root cause in many medico-legal cases.</span></h2>
<span style="font-family: "calibri"; font-size: 12.0pt; font-weight: normal;"> ... There is NEVER <a href="http://theskepticalzone.com/wp/the-myth-of-absolute-certainty/">absolute
certainty</a></span><br />
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<span style="font-weight: normal; mso-fareast-font-family: "Times New Roman";"> <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhkxd4eEjuHTpzFa47bEEDe4Ih6xi5LXVPM00yecsPj1Z7nzv2_UHUZ4wq2SlelLYrxy_ENTX7of_p9Gc2jEUsXxyYqVD-lG6gbBIeOe16CElsbi0D5VuwBDdKAnzYOekfBJ542REB3lXo/s1600/Screenshot+2016-02-23+09.29.03.png" imageanchor="1"><img border="0" height="326" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhkxd4eEjuHTpzFa47bEEDe4Ih6xi5LXVPM00yecsPj1Z7nzv2_UHUZ4wq2SlelLYrxy_ENTX7of_p9Gc2jEUsXxyYqVD-lG6gbBIeOe16CElsbi0D5VuwBDdKAnzYOekfBJ542REB3lXo/s400/Screenshot+2016-02-23+09.29.03.png" width="400" /></a></span><span style="mso-fareast-font-family: "Times New Roman";"></span></h2>
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<span style="color: blue;"><span style="font-weight: normal; mso-fareast-font-family: "Times New Roman";"></span><span style="font-family: "calibri"; font-size: 16px;">HT to Woody Guthrie for being an inspiration - "It's a </span><strike style="font-family: calibri; font-size: 16px;">folk singers</strike><span style="font-family: "calibri"; font-size: 16px;"> critical thinkers job to comfort disturbed people and to disturb comfortable people"</span></span><br />
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<span style="font-weight: normal; mso-fareast-font-family: "Times New Roman";"><span style="font-size: x-small;"><span style="font-family: "verdana" , sans-serif;"><i><b>Author:</b> Alan J Taylor is a writer and critic who thinks about stuff and works as a Physiotherapist<span style="font-family: "verdana" , sans-serif; font-weight: normal;">, </span>University <span style="font-family: "verdana" , sans-serif; font-weight: normal;">Assistant <span style="font-family: "verdana" , sans-serif;">P</span>rofessor</span> and Medico-Legal expert witness ... The views contained in this blog are his own and are not linked to any organisation or institution. </i></span></span><span style="font-size: x-small; font-weight: normal;"><span style="font-family: "verdana" , sans-serif;"><i>Like Bukowski, he 'writes to stay sane'.</i></span></span></span></div>
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<span style="font-weight: normal; mso-fareast-font-family: "Times New Roman";"><span style="font-size: x-small;"><span style="font-family: "verdana" , sans-serif;"><i>You'll find him mostly on Twitter <a href="https://twitter.com/TaylorAlanJ" style="color: purple;" target="_blank">https://twitter.com/TaylorAlanJ</a></i></span></span></span></div>
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Clinical Reasoning Sessionshttp://www.blogger.com/profile/09852524904111114134noreply@blogger.com0tag:blogger.com,1999:blog-6560398305209426117.post-3437835774790294142015-10-28T13:06:00.000-07:002016-02-04T08:06:57.775-08:00Forget models, mantras and gurus ... Listen to the patientThe current debate in Physiotherapy about the use and misuse of evidence based medicine (EBM) was well and truly polarised by Roger Kerry's recent <a href="https://rogerkerry.wordpress.com/2014/09/29/evidence-based-physiotherapy-a-crisis-in-movement/" target="_blank">Evidence-Based Physiotherapy: A Crisis in Movement.</a><br />
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In a brilliant no holds barred polemic, the author called made a plea for sanity in a World gone mad. It got me to thinking. I've long been an advocate of big picture thinking, and puzzled for many an hour and longer about why we think the way we do. Why for instance, physiotherapists got fixated with the vertebral artery, back in the day when spinal manipulation was all the rage. It slowly became apparent that there was more to cervical vascularity than just the vertebral arteries. Hence the development of a <a href="http://www.journalofosteopathicmedicine.com/article/S1746-0689%2810%2900053-2/abstract" target="_blank">system based approach</a> to the issue which focused on movement (not JUST manipulation), all of the vascular system (not JUST the vertebral artery) and all of the potential pathologies (not JUST dissection).<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiIwgExR4hGDeaLxPt1j-yNP2-hqFfol59fw2XzS_FdBu2ku0jyxvUgPyfHJOr4yiAqvI79wT-xswToshGNMX74z6GbyyGXjXL2a53oANawiFRiO-UY02NyS4CMS6CSbvQFEleMoGRLX14/s1600/Cad_anatomy.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="280" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiIwgExR4hGDeaLxPt1j-yNP2-hqFfol59fw2XzS_FdBu2ku0jyxvUgPyfHJOr4yiAqvI79wT-xswToshGNMX74z6GbyyGXjXL2a53oANawiFRiO-UY02NyS4CMS6CSbvQFEleMoGRLX14/s320/Cad_anatomy.jpg" width="320" /></a></div>
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The result was a risk assessment framework which offers sound guidance and direction for those offering any movement based interventions (including assessment) for patients with head and neck pain. The <a href="http://www.scribd.com/doc/172373109/IFOMPT-Examination-Cervical-Spine-Doc-September-2012-Definitive#scribd" target="_blank">IFOMPT document</a> is not a guideline, rather a framework for THINKING, for clinical reasoning, and directs clinicians to make decisions based on the big picture. It exhorts clinicians to familiarise themselves with cranial nerve testing, surprisingly, (and perhaps alarmingly) not part of the skill set of many PT's, and to consider blood pressure as an additional risk assessment tool. None of this was rocket science BUT, it was perhaps an example of restricted thinking, dominated by the 'experts' of the time.<br />
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The new 'experts' of our time are the social media commentators, the 'institutes' the 'organisations' who shape our opinion with their interpretation of EBM. Many seem to shout loudly (<a href="http://alteredhaemodynamics.blogspot.co.uk/2014/10/confirmation-bias-physiotherapy-and.html" target="_blank">and with significant bias</a>) from the roof tops about what we should or shouldn't do. It is a fascinating dynamic, which I have observed from both within and afar. When internationally respected pain expert Mick Thacker wrote a guest <a href="http://www.ingentaconnect.com/content/ppa/pr/2015/00002015/00000039/art00002" target="_blank">editorial</a> recently for <a href="http://www.ingentaconnect.com/content/ppa/pr;jsessionid=apd35hsfd3l2h.alice">Pain and Rehabilitation - the Journal of Physiotherapy Pain Association</a>, he upset the apple cart. He challenged the use of 'mantras' and singular thinking with another brilliantly written piece entitled 'is pain in the brain?' His commententary, that he was surprised that such views about pain were "…so widely accepted by physiotherapists considering our backgrounds", caused outrage in some quarters and he was was vilified on social media by disciples of the pain/biopsychosocial model. They argued their case with such tactical vigour, you would have to conclude they could not be wrong …. unless of course, you were thinking.<br />
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It is perhaps the <a href="http://theskepticalzone.com/wp/the-myth-of-absolute-certainty/" target="_blank">absolute certainty</a> of some, that I find most fascinating and perhaps a little dangerous.<br />
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It is time, as my colleague so rightly said, that we all begin to think for ourselves.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgFamJmdVtNi1KegInlkBRpY6j4I8xLVJ_Ul7HfaQlIL5cjF5oD_a7zixAYj48IAarBo-yNZvRisPAHpikofKrN1EZJZlVx5UgDeeEYm8iV5SRvXwybOOrxs4guTHAxe3oBedQSkJLk26U/s1600/THINK.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="293" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgFamJmdVtNi1KegInlkBRpY6j4I8xLVJ_Ul7HfaQlIL5cjF5oD_a7zixAYj48IAarBo-yNZvRisPAHpikofKrN1EZJZlVx5UgDeeEYm8iV5SRvXwybOOrxs4guTHAxe3oBedQSkJLk26U/s400/THINK.jpg" width="400" /></a></div>
Image via <br />
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<a class="owner-name truncate" data-rapid_p="34" data-track="attributionNameClick" href="https://www.flickr.com/photos/johne777/" title="Go to John Eisenschenk's photostream">John Eisenschenk</a>
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<a href="https://www.flickr.com/photos/johne777/9388708662">https://www.flickr.com/photos/johne777/9388708662</a><br />
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There's no doubt that the biopsychosocial model has much to offer and only a fool would deny its role and value. But should you throw yourself at its alter? The biomedical model has many limitations, that are well recognised.<br />
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But when a patient presents with a worsening scenario, it is worth remembering that not everything is a 'flare up' and just as 'hurt does not always equal harm' ... SORRY but, sometimes it does!<br />
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Similarly, whilst modern science suggests most patients with LBP for instance don't require scans or X rays … <a href="http://www.slideshare.net/TaylorAlanJ/aortic-aneurysm-and-low-back-pain" target="_blank">some do.</a><br />
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It remains our job to be able to recognise those cases and manage the others with whatever skills we have left at our disposal. Otherwise, a sheep like adherence to one particular school of thought may prove to be our undoing. We need to know examination skills, we need to know pathologies … we need to know when scans or triage are appropriate, we need to know the limitations of our own thinking, all these things matter. <br />
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I decided to illustrate my point with a cute story ... which nicely illustrates the shortcomings of both 'models' and how we truly have to listen to our patients and put aside our preconceptions.<br />
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<span style="color: blue;"><span style="font-weight: normal;">Mr Xrayspecs (a 52 year old builder and hobby cyclist) walked into my clinic recently, referred from another Physiotherapy colleague. He presented with a description of chronic lower back pain and non specific left leg pain.</span></span></h2>
I introduced myself and asked him why he'd come to see me.<br />
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"Well, I have this pain you see, and I think it's getting worse, so my physio sent me to see you … seems to think you might be able to help" he said, somewhat doubtfully.<br />
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"Tell more about it " I asked.<br />
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"Well it all started 34 years ago". "34 years", I mirrored and sat back in the chair ready for the long haul.<br />
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"They've tried everything" he went on. First, when my leg started aching (aged 18), they said I had a trapped nerve 'sciatica' they called it. They said I'd got an asymmetry. They gave me lots of treatment, you know manipulations and stuff but nothing worked. Then I went to the osteopath and he put all my joints back in … but that didn't work either."<br />
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It was a familiar story ... one I've heard (probably like you) many times before.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgJCnGzvM2rSSkXUvKNzdSZEGb3HbjKUfqiLFpbNIZHEbz8W_RwDeqgv7PASpdnPp4iZCHU6Vw5JWEgRqE9DXaLpUX0le7H1qHVztFp9TeL0i4z9KquvaykzFaGC8kBhypvfxRXw9Z1OCs/s1600/bicycle-497329_640.jpeg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgJCnGzvM2rSSkXUvKNzdSZEGb3HbjKUfqiLFpbNIZHEbz8W_RwDeqgv7PASpdnPp4iZCHU6Vw5JWEgRqE9DXaLpUX0le7H1qHVztFp9TeL0i4z9KquvaykzFaGC8kBhypvfxRXw9Z1OCs/s400/bicycle-497329_640.jpeg" width="400" /></a> He went on "I just tried to ignore it and carry on riding my bike, but the pain came on every time and my leg felt weak."<br />
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Oh, so you felt it whilst you were cycling did you?" I interjected. "YES", he reiterated with some agitation. "Tell me more", I asked, ... "They said I must be trapping a nerve or something, probably because I was bending forward, on the bike". "Oh" I said, thoughtfully. "Then they sent me for a scan, but nothing showed up".<br />
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<a href="https://pixabay.com/en/bicycle-old-bike-cycle-retro-ride-497329/" target="_blank">https://pixabay.com/en/bicycle-old-bike-cycle-retro-ride-497329/ </a><br />
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He continued, "I was getting really fed up I can tell you, and about 3 years had gone by". "OK, I can understand that" I said compassionately. "Then what happened" I asked. "Well, thats when they said it might all be in my head" he said (his words). "They sent me to a pain clinic, gave me some injections and told me I should self manage it, but I knew something was wrong". "Oh" I said, brilliantly … pausing for dramatic effect.<br />
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"What did YOU think was wrong" I asked. "Well I didn't know what exactly ... but I knew my leg wasn't right, it felt weird, weak, strange, but when I started to say that, I think they thought I was a bit mad, so I backed off a bit". "Oh" I said again, somewhat repetitively, but he carried on regardless.<br />
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"I've been to every specialist you can name, orthopaedics, sport, pain, physios, osteopaths, chiropractors, masseurs, you name it, I've been there". "And" I said, probing hopefully. "Well its just getting worse and now I've got back ache too" he continued. "They sent me for more scans recently and I've got wear and tear and disc degeneration now ... and they said that must have been the problem all along".<br />
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"So now I'm labelled with chronic pain and I'm having CBT and all that psychological pain education stuff". "Oh", I said hopefully. "Yeah but that's a waste of time, just like the rest of it was … pacing whats that gonna do? Mindfulness? I'm a bloody builder … I'm getting worse, not better and NOBODY LISTENS", he said, pausing for effect.<br />
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"What do you mean" I said. "NOBODY LISTENS" he said again, somewhat menacingly.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjlof38JrOG8cc9Sxs7SgWgtxB9Mule9QTTK4wEuDcEKBhAocVLf0SVwkjBr7nbbAOv0zxDkY3l_uNXIvlJr6L3Z_OqNjWCIoS1NVZZV3r1LWpw0DCpjLZuw7pTFqA6HL8JM2xmW10DNsE/s1600/Listen_to_me_by_strawberry_lollipops.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="296" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjlof38JrOG8cc9Sxs7SgWgtxB9Mule9QTTK4wEuDcEKBhAocVLf0SVwkjBr7nbbAOv0zxDkY3l_uNXIvlJr6L3Z_OqNjWCIoS1NVZZV3r1LWpw0DCpjLZuw7pTFqA6HL8JM2xmW10DNsE/s320/Listen_to_me_by_strawberry_lollipops.jpg" width="320" /></a></div>
<a href="http://strawberry-lollipops.deviantart.com/art/Listen-to-me-102802029" target="_blank">Image via - http://strawberry-lollipops.deviantart.com/art/Listen-to-me-102802029</a><br />
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I leaned forward, listening intently with wide eyes. "Look when it all began, it always came on when I was exercising, and it still does, like when I ride my bike, or push a wheelbarrow on site or go up the steps to the roof … I might have back ache now but I didn't before and my leg still feels like it's got no blood flowing into it. To be fair I've been saying that for 34 years but everyone glazes over … Its like they only want to fit you into their bag, their particular pet theory".<br />
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At that point I laughed out loud. "It's not funny" he said. "No, no" I apologised, "I'm not laughing at YOU, I'm laughing at me ... US!" I stuttered.<br />
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"What do you mean" he demanded. 'Well" I began, " I think my colleague may have sent you to see me because he thinks I may have a pet theory too" … It went quiet … I took up the cudgels.<br />
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"When you said that your leg felt like it had no blood going to it, did anybody test for that." I asked. "No" he said, "they just kept talking about nerves or discs initially, then chronic pain and CBT and how 'pain is in the brain' and stuff, like I explained." he said. <br />
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I asked a few more probing questions about the nature of his pain and asked him to lay on the couch.<br />
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I took his lower limb pulses - Normal. <br />
I took his brachial blood pressure - Normal. <br />
I took his ankle blood pressures - Normal.<br />
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I asked if he was still riding his bicycle and if his pain still came on with cycling. "Yes" he said, "as regular as clockwork … as soon as I get to 145 bpm on the heart rate monitor." "Oh" I said. "Can we ask you to exercise to that level I asked'?<br />
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"You can bloody well ask me to do what you like if we can get to the bottom of this bugger" he said cracking a smile for the first time. I explained that we may find nothing at all, and asked him again if wished to continue with a simple exercise test. He was already climbing eagerly onto the exercise bike and adjusting his pulse monitor belt. <br />
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The exercise test quickly reproduced his leg pain as predicted, as soon as he reached around the 145 bpm mark. I pushed him a little further… 165 bpm "Yes", he said with some satisfaction. "Now my leg feels funny, weak, like theres no blood going to it".<br />
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He jumped off the bike and we lay him on the couch … we replaced the left and right BP monitors onto the ankles and inflated them, they ran simultaneously. <br />
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At minute 1 (post exercise) the systolic brachial BP was 185 mmhg<br />
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At minute 1 the right ankle systolic BP was 160 mmhg. The left recorded nothing (I waited … I'd seen this before) ... the BP can be lower than the machine can record.<br />
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At minute 2 the systolic brachial was 180<br />
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At minute 2 the RIGHT ankle BP = 155 <br />
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<span style="color: red;">At minute 2 the LEFT ankle BP = 70 mmhg</span> <br />
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<span style="color: red;">Post exercise ankle brachial pressure index (ABPI) was calculated as 70/180 = </span><b><span style="color: red;">0.39</span> </b><br />
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<span style="color: red;">The published cut off point for post exercise ABPI is currently 0.6</span> (<a href="http://www.ejves.com/article/S1078-5884%2811%2900764-7/abstract" target="_blank">Peach et al, 2012</a>) <br />
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I'd turned the BP monitors away from his gaze … He was anxious to know the result.<br />
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I explained that he would no longer need to continue with the mindfulness and CBT.<br />
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He was referred to the vascular surgeon with a full outline of the consultation and test results.<br />
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4 weeks later (after the tests had been repeated the vascular clinic) magnetic resonance imaging of the arteries revealed a significant flow reduction to the left lower limb in the region of the external iliac artery.<br />
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The patient underwent a 5 hour vascular surgery (longer than expected due to the complex intra-operative findings) involving endarterectomy and shortening of a 'significantly tortuous artery'.<br />
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He made a full recovery and 6 months post surgery reports NO LEG PAIN under any conditions, including exercise. He still gets intermittent low back pain, which he considers to be "normal".<br />
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<span style="color: red;">His post exercise ABPI measures have returned to within normal limits (> 0.6)</span><br />
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He has returned to full function work/cycling/running/skiing with NO LEG SYMPTOMS.<br />
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For various reasons linked to clinical reasoning and therapist/physician beliefs ... it took 34 years to get to the bottom of this case.<br />
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For an analysis of quite how that could be ... try a stab at the <a href="http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/identifying_problems_-_root_cause_analysis_using5_whys.html" target="_blank">5 Whys of ROOT CAUSE ANALYSIS</a> <br />
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<span style="color: blue;"><span style="font-weight: normal;">What do we all have to learn from this case.</span></span></h2>
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<span style="font-weight: normal;"><br />1. Listen to the patient</span></h2>
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<span style="font-weight: normal;">2. There are limitations of BIOMEDICAL reasoning </span></h2>
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<span style="font-weight: normal;">3. There are limitations of BIOPSYCHOSOCIAL reasoning</span></h2>
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<span style="font-weight: normal;">4. NEVER have blind faith for 1 paradigm</span></h2>
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<span style="font-weight: normal;">5. Know your pathology</span></h2>
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<span style="font-weight: normal;">6. KEEP LISTENING TO THE PATIENT</span></h2>
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<span style="font-weight: normal;">7. N=1 (it REALLY does) </span></h2>
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<span style="font-weight: normal;">8. It's OK to be discombobulated ... Just say "Oh"</span></h2>
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<span style="font-weight: normal;"> ... and just for the record, there is NEVER <a href="http://theskepticalzone.com/wp/the-myth-of-absolute-certainty/" target="_blank">absolute certainty</a>. </span></h2>
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Image via Steven Shorrock <a href="https://www.flickr.com/photos/highersights/6231641551">https://www.flickr.com/photos/highersights/6231641551</a><br />
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<span style="font-size: small;"><span style="font-family: "verdana" , sans-serif;"><i>Author:
Alan J Taylor is a writer and critic who thinks about stuff and works
as a Physiotherapist and University Assistant Professor ... The views contained in
this blog are his own and are not linked to any organisation or
institution. </i></span></span><span style="font-size: small;"><span style="font-family: "verdana" , sans-serif;"><i>Like Bukowski, he 'writes to stay sane'. </i></span></span></div>
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<span style="font-size: small;"><span style="font-family: "verdana" , sans-serif;"><br /></span></span></div>
<span style="font-size: small;"><span style="font-family: "verdana" , sans-serif;"><i>You'll find him mostly on Twitter <a href="https://twitter.com/TaylorAlanJ" target="_blank">https://twitter.com/TaylorAlanJ</a></i></span></span><br />
<span style="font-size: small;"><span style="font-family: "verdana" , sans-serif;"><i>... that is until, he finally deletes his account, or is 'evidence based blogged' to oblivion. </i></span></span><br />
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<br />Clinical Reasoning Sessionshttp://www.blogger.com/profile/09852524904111114134noreply@blogger.com6tag:blogger.com,1999:blog-6560398305209426117.post-20535024751067007632015-02-23T11:53:00.000-08:002015-02-23T11:53:41.074-08:00Forget gurus, the cult of the evidence-based blogger has taken over ... 'Biased BLOG Bingo'<style>
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<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">WARNING! This blog may contain traces of humour ... </span></span><br />
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<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">If you suffer a sense of humour deficit ... DO NOT READ ON!</span></span><br />
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<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">Some time ago now, I had the pleasure of reading an excellent
article by <a href="http://will-self.com/" target="_blank">Will Self</a> called <a href="http://www.newstatesman.com/culture/2014/09/will-self-awful-cult-talentless-hipster-has-taken-over" target="_blank">‘The awful cult of the talentless hipster has taken over’</a> … </span></span><br />
<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"><br /></span></span>
<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">Whilst I didn’t necessarily agree with his diatribe entirely, I lapped
up the trademark dour humour, empathised with his view and thoroughly enjoyed
the read. Then in a bizarre moment of thought association, my mind turned to my
own area of interest, Health Sciences and evidence based practice (Physiotherapy in particular) … though this undoubtedly pertains to medicine and all other areas of health care ... I began to ponder ‘the cult of the evidenced based blogger’, which now appears to pervade the zeitgeist
of our increasingly <a href="http://www.bmj.com/content/348/bmj.g3725" target="_blank">confused World</a></span></span><br />
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<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjPAxg5cUm6o_LviaOKSNpRM2IPlhZBjR72snrXBrTlqoPLqhYh2BwiCMVa6Gsbs7g1kwNE5zdPmwadfkLHawts_STMiEcIBiqB37YnorCYTo2ML9wTDJqDVYpk35WQkkJH1HiI6HcdSzE/s1600/Stipula_fountain_pen.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjPAxg5cUm6o_LviaOKSNpRM2IPlhZBjR72snrXBrTlqoPLqhYh2BwiCMVa6Gsbs7g1kwNE5zdPmwadfkLHawts_STMiEcIBiqB37YnorCYTo2ML9wTDJqDVYpk35WQkkJH1HiI6HcdSzE/s1600/Stipula_fountain_pen.jpg" height="213" width="320" /></a></span></span></div>
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<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">Don’t get me wrong, our World is important (to
us … and the people we care for, hopefully) as is the evidence. I like and
respect (most) bloggers (cos’ they’re out there), I blog myself … But sometimes
I begin to wonder about the whole process, or perhaps question the motives of
the bloggers (myself included).</span></span></div>
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<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">Bloggers and Twitterati, these days are ubiquitous; everyone seems to be having a go and some appear to be very authoritative. Yet blogging is a strange and
precarious pastime/hobby/profession, which is both time and thought consuming.
So, unless they are getting paid for it (some are … Will Self falls into that
category), one would have to debate what motivates the ardent blogger. Shouldn’t they have just gone out for a run or <a href="https://www.youtube.com/watch?v=xQ_IQS3VKjA" target="_blank">cycle ride</a> or something? </span></span></div>
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<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"><br /></span></span></div>
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<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">What would actually drive someone to spend
valuable time writing and airing their thoughts on any topic? What drives them
to risk an avalanche of comment/critique if their particular diatribe hits the
wrong button, or perhaps, a rising tide of gushing agreement from the
‘Bloggioso’ or the ‘Twitterati’ for their latest fashionable and populist
masterpiece? </span></span></div>
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<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"><br /></span></span></div>
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<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">Some blogs are really helpful (or are they?) because they interpret and decipher some of those peer reviewed papers (which to be fair, </span></span><span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">may be a bit complex/wordy)</span></span>. So blogs may appear really helpful for those busy clinicians who only get limited time for reading/analysing the latest news on a topic. </span></span><span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"> </span></span><br />
<br />
<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">One clear attraction of blogging (for bloggers), unlike the
restricted writing of peer review for instance, which requires writers to declare <a href="http://download.journals.elsevierhealth.com/pdfs/journals/0161-4754/PIIS0161475410000229.pdf" target="_blank">conflicts of interest</a> ... is that you can say what you
like … and it is clear that some bloggers ‘like what they say’.</span></span><br />
<br />
<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">But … is what
they/we say, prone to BIAS or subject to ‘<a href="http://download.journals.elsevierhealth.com/pdfs/journals/0161-4754/PIIS0161475410000229.pdf" target="_blank">conflicts of interest’</a> as a
result? </span></span><br />
<br />
<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">To help my own decision making, I decided to gather a concoction of my own observations on some of the blog sites that may be influencing how we think and view evidence. Some bloggers may see parts themselves or their writing in one or all of the types (I did). That's not really the intention. Rather, it is for readers to see how a topic may, or may not, be spun. </span></span><br />
<br />
<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">I'll leave you to decide </span></span><span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">what you think ... </span></span><span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">Perhaps after a lighthearted game of 'biased BLOG bingo'. </span></span><br />
<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"><br /></span></span>
<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">I wrote about this in my last blog, so if you haven't already, take some time to consider the definition of <a href="http://alteredhaemodynamics.blogspot.co.uk/2014/10/confirmation-bias-physiotherapy-and.html" target="_blank"><b>confirmation bias</b></a> ... <i>'the tendency for people to favour information that confirms their beliefs'.</i> </span></span><br />
<br />
<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">A quick look at this short YouTube clip may help.</span></span><br />
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<iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='320' height='266' src='https://www.youtube.com/embed/6xMaR8au-YU?feature=player_embedded' frameborder='0'></iframe></div>
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<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">Then consider the concept of </span></span><span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"> <a href="http://download.journals.elsevierhealth.com/pdfs/journals/0161-4754/PIIS0161475410000229.pdf" target="_blank">conflict of interest</a> </span></span><span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">which may be easy to identify in medicine for example, with concepts like '<a href="http://en.wikipedia.org/wiki/Big_Pharma" target="_blank">Big Pharma</a>' and '<a href="http://en.wikipedia.org/wiki/Bad_Pharma" target="_blank">Bad Pharma</a>', which even have their own Wiki pages, but perhaps less overt in Health Sciences and related subjects. </span></span><br />
<br />
<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">With those things in mind, here is my tongue in cheek personal
take (from the experience of both reading and <a href="http://www.nodepression.com/article/skiffle-scuffle-%E2%80%A6-billy-bragg-brings-out-pugilist-pokey-lafarge" target="_blank">writing blogs</a>) on a few
of the types of blogger you may encounter out there … and some of the factors that may influence them <i>... </i>Enjoy! </span></span></div>
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<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"><br /></span></span></div>
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<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEisonJbRuwGGZRoo4olmUgKyd5OEKMdNk3RU7GBH_Zvv8uhrq_YknikEe1zTszZvvnXrgV93zDNuWTwLcoa24tM3KOzSNC6gxmy89LTwg_gbauLNEwKwIHEanqdjD8Eh4LCEjWZSn8USsY/s1600/Blogger.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEisonJbRuwGGZRoo4olmUgKyd5OEKMdNk3RU7GBH_Zvv8uhrq_YknikEe1zTszZvvnXrgV93zDNuWTwLcoa24tM3KOzSNC6gxmy89LTwg_gbauLNEwKwIHEanqdjD8Eh4LCEjWZSn8USsY/s1600/Blogger.jpg" height="320" width="250" /></a></span></span></div>
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<span style="font-size: xx-small;"><span style="font-family: Verdana,sans-serif;"><span style="color: black;"><a href="https://www.flickr.com/photos/notionscapital/5379885034/" target="_blank">Via https://www.flickr.com/photos/notionscapital/5379885034/</a></span></span></span></div>
<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"><br /></span></span>
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<span style="color: #666666;"><span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"><b>Meet some of the ‘blogger types’</b></span></span></span></div>
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<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"><b>1.</b><span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span><b>The altruistic/educational/hobby
blogger</b> – Blogs about a variety of topics of interest to potential readership.
Evidence based, educational conduit, who likes to hear the sound of his/her
voice … Keeps up to date and an open mind, avoids extremism and generally goes
out of his/her way to avoid bias, May throw in some controversy for interest, but sticks to honest appraisals of the evidence. Likes
a little devilish humour and for folks to read his/her blog. No commercial
interests, no adverts, no shop. Altruistic, e</span></span><span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">go driven, no nonsense</span></span> profile builder. Moderate use of social media
(SoMe) to promote blogs. Checks blog
metrics occasionally. Likes to be asked to ‘guest blog’. Secretly hopes for a
trip to Hawaii to speak on his/her latest blog topic. <u><a href="http://download.journals.elsevierhealth.com/pdfs/journals/0161-4754/PIIS0161475410000229.pdf">Conflict
</a><a href="http://download.journals.elsevierhealth.com/pdfs/journals/0161-4754/PIIS0161475410000229.pdf" target="_blank">of interest</a></u> - Nil of note. Has had a book 'in the pipeline' for 15 years. </span></span></div>
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<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"><br /></span></span></div>
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<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"><b>2.</b><span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"><b> </b>
</span><b>Student blogger</b> – Students who
(led by their University Professor) have entered the World of blogging, without
actually knowing what they have let themselves in for. Main qualities are
passion for the topic and enthusiasm. Downfall may be inexperience (blogging), naivety
and failure to critique, or cover the topic from a wide and unbiased
perspective. May find themselves, unwittingly at the sharp end of criticism
from outraged readers. Not always prepared for this. Variable use of SoMe use,
that is until they realise blog metrics contribute to their overall assessment
mark. Comments are enabled … until they get thoroughly blasted by someone. Not
entirely sure ‘exactly’ where Hawaii is, but would love to go. Conflict of interest? ... Actually, the main thing is ... to pass the assessment!</span></span></div>
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<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"><br /></span></span></div>
<div class="MsoListParagraph" style="text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"><b>3.</b><span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span><b>The Snake oil seller</b> – So enthusiastic about their particular brand
of ‘snake oil’. They forgot, or chose not … to support any of their claims with
even a shred of evidence. They tend to rely entirely on anecdote and personal
recommendation from users of the product/idea/treatment technique. Tales of miracle cures are commonplace. Comments are
moderated to include more anecdotal claims or gushing personal endorsements.
Commercial interests are generally utmost on their minds and they will ALWAYS
have an advert for their particular type of ‘snake oil’ on their blog. This
blogger, will be targeted mercilessly by bloggers number 5 and 7, generally to
no effect (because they live in their own World, or maybe Hawaii). Heavy use of
SoMe. The course for this is product /idea/service is ‘brilliant’, said a
delegate. <a href="http://download.journals.elsevierhealth.com/pdfs/journals/0161-4754/PIIS0161475410000229.pdf" target="_blank">Conflict of interest</a> – Zero (there
is no conflict, as their sole interest is profit). A modern day ‘medicine
show’. Link directly to the 'shop' <a href="http://en.wikipedia.org/wiki/Medicine_show" target="_blank">here</a>. Entirely and unashamedly biased.</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"><br /></span></span></div>
<div class="MsoListParagraph" style="text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"><b>4.</b><span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span><b>Society or organisation ‘news’
blogs</b> – Generally low-key interest/news articles for members. Designed to
update folks on the latest development in the field of interest/profession.
Tend to report and stick to facts, seldom court controversy and may tend to be
a little bland. Media spokesperson quotes some 'evidence', but may not always be in context or
entirely up to date (this will be spotted and hastily dealt with by <b>blogger number 7</b>). Low to moderate use of SoMe for promotion of
blogs/articles. Comments commonly disabled. Bland content,
seldom gives opportunity for bias. Metrics? Hawaii? Humour? Shop? ... Pardon me!?</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"><br /></span></span></div>
<div class="MsoListParagraphCxSpFirst" style="text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"><b>5.</b><span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span><b>EBM proponent/Targeted attacker</b> –
Wily operator, who picks a specific (often universally disliked target) and
exposes it/them and provides reams of evidence to back up his/her claims. The
best of these will end up on a TV show deliver a <a href="http://www.ted.com/talks/browse">TED talk</a> or get a column in a broadsheet. Heavy use of SoMe to promote blogs. Commercial
interests may include books, newspaper articles, TV show appearances, talks
etc. Sycophants and wannabees will include them in a Tweet in the hope of a
rebound (seldom works). Comments ARE enabled, and this blogger loves to argue
the toss with anyone who cares to have a go and often does so with incisive
humour or complex statistics. Perhaps a little obsessed and in possession of a
large ego. Naturally biased towards own (often populist views) but generally
and genuinely supported by the evidence. This blogger loves notoriety. Metrics
are through the roof (seldom needs to check) Goes to Hawaii regularly via
private jet. <a href="http://download.journals.elsevierhealth.com/pdfs/journals/0161-4754/PIIS0161475410000229.pdf" target="_blank">Conflict of interest</a>? ‘Pah … call my booking agent, I'm busy working on my next book/TV show’.</span></span></div>
<div class="MsoListParagraphCxSpFirst" style="text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"><br /></span></span></div>
<div class="MsoListParagraphCxSpFirst" style="text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"> The rest … <b>(Type
5b)</b>, may end up looking looking like aspiring wannabees with a particular axe to
grind. These yet to be so ‘successful’ wannabee type 5's, are feverishly typing whilst
waiting for ‘the phone call’ and busily fending off ad hominem attacks from
‘outraged of Tunbridge Wells’ or assorted trolls. </span></span></div>
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<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"><br /></span></span></div>
<div class="MsoListParagraphCxSpMiddle" style="text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"><b>6.</b><span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"><b> </b>
</span><b>The evangelical blogger</b> – Combines the friendly bonhomie of <b>blogger type 1</b> with the spin of <b>blogger 3</b> but has a clear underlying mission of promoting a
particular product/method or school of thought. May have a track record in
peer review publication, suggestive of authority, yet r</span></span><span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">outinely cherry
pick evidence, to support a particular view.
</span></span><span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">Entirely convinced by the sanctity of their chosen path/product. Extremist disciples, </span></span><span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">lambast non-believers or other 'churches' as unseeing heretics. </span></span><style>
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<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">Blog
comments are ALWAYS moderated and predominantly populated by devout and
enthusiastic followers.
Humour is not a common feature of their writing. Evidence based, but a stoic adherence to one
doctrine/product/method, leads to blogs that are littered with confirmation bias and supported by cute anecdotal stories. Heavy use of SoMe for promotion.
Strongly motivated by metrics and sales. <a href="http://download.journals.elsevierhealth.com/pdfs/journals/0161-4754/PIIS0161475410000229.pdf" target="_blank">Conflict of interest</a> - You can
join the latest crusade (in Hawaii) next week, which ironically coincides with their latest blog (submit <a href="http://en.wikipedia.org/wiki/Parody" target="_blank">HERE</a> to apply). Merchandise shop? Click <a href="http://skiffleshow.bandcamp.com/merch" target="_blank"><span style="color: blue;"><u>here</u></span></a>.</span></span></div>
<div class="MsoListParagraphCxSpMiddle">
<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"><br /></span></span></div>
<div class="MsoListParagraphCxSpLast" style="text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"><b>7.</b><span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"><b> </b>
</span><b>Frustrated, change agent blogger</b>
– This passionate and profuse blogger is entirely frustrated by the speed at
which his/her profession effects change. Routinely supplies or demands ‘the evidence’,
which calls for the immediate abolition of out-dated ideas, methods and products,
which have been ‘shown to be ineffective’. Such vigour and attention to detail, means they may occasionally therefore, resemble the internet 'evidence police' or media watchdog. </span></span><br />
<br />
<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"> Fierce belief that the only
really valid evidence is the ‘gold-standard’ RCT. Particularly adept at highlighting what doesn't work ... but may omit to offer alternatives to the discarded idea/method/product ... therefore run the risk of leading his/her colleagues
into an ‘evidence based’, but tool less cul-de-sac. Energetic, challenging and authoritative. Couldn’t
make the conference in Hawaii, but hopes to be there next year (recently spoke
in Milton Keynes/Basildon). Busy writing another blog in the mean time. Loves
Twitter. Metrics matter. Big fan of <b>type 5a</b>. Ubiquitous. No time for shops, but c</span></span><span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">urrently working on a few other <a href="http://download.journals.elsevierhealth.com/pdfs/journals/0161-4754/PIIS0161475410000229.pdf" target="_blank">conflicts of interest</a>.</span></span></div>
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<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"><br /></span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"><br /></span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">NOW it’s time brighten up the academic tedium
with a game of <i>‘Biased BLOG Bingo’</i> with
the blog YOU last read … errr NO, not this one, it is ENTIRELY biased to my
point of view!</span></span></div>
<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"><br /></span></span>
<br />
<div class="separator" style="clear: both; text-align: center;">
<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"></span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"><a href="https://www.slideshare.net/secret/5dmfSIEf5CW0tR" target="_blank">You can go to a presentation version of 'Biased BLOG Bingo' here</a> </span></span><br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh25XiTSXxsjbYCVULd8QiZ3ChMecqFBaistHKH11th1FD262WwoDTU72gvSIHuvy59p6fQecidr9jckV3y0NTTmG-mKL4artyrYz8IqQtx9Avvl4AreiBfRnJ6xFDAMzeqmLzrvbkEssU/s1600/Hamlin's_Wizard_Oil_poster.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh25XiTSXxsjbYCVULd8QiZ3ChMecqFBaistHKH11th1FD262WwoDTU72gvSIHuvy59p6fQecidr9jckV3y0NTTmG-mKL4artyrYz8IqQtx9Avvl4AreiBfRnJ6xFDAMzeqmLzrvbkEssU/s1600/Hamlin's_Wizard_Oil_poster.jpg" height="400" width="261" /></a></div>
</div>
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<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"><br /></span></span></div>
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<span style="font-size: xx-small;"><i><span style="font-family: Verdana,sans-serif;">DISCLAIMER: Bloggers take part in ‘Biased BLOG Bingo’ entirely at their
own risk … </span></i></span><br />
<span style="font-size: xx-small;"><i><span style="font-family: Verdana,sans-serif;">This presentation does not pertain to any bloggers called ‘Hamlin’ …or
anyone else, it is merely a parody conglomeration of stereotypes. Anyway ... lighten up! </span></i></span><br />
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjIMioPSv1D1SXPJGpdDy8JGYP9DSdoCnNV025OBha7FYKeOMeEH28YoDs1KgU0IazET6SYejj1crl_6_hnzX2mqgjcmB21qc9RoXGurSZR32eslzFCa6AlOFxhYkzyczUhkkJnjazNLko/s1600/BBLOGB+update+Alan+pdf.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjIMioPSv1D1SXPJGpdDy8JGYP9DSdoCnNV025OBha7FYKeOMeEH28YoDs1KgU0IazET6SYejj1crl_6_hnzX2mqgjcmB21qc9RoXGurSZR32eslzFCa6AlOFxhYkzyczUhkkJnjazNLko/s1600/BBLOGB+update+Alan+pdf.jpg" height="300" width="400" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Grid design MattLowPT</td></tr>
</tbody></table>
<span style="font-size: xx-small;"><i><span style="font-family: Verdana,sans-serif;"> </span></i></span>
</div>
<div class="MsoNormal">
<span style="color: #0b5394;"><span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">10 points = BINGO (start at zero) </span></span></span></div>
<div class="MsoNormal">
<span style="color: #0b5394;"><span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"><br /></span></span></span></div>
<div class="MsoNormal">
<span style="color: #0b5394;"><span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">The higher the score the MORE biased the blog
… GOOD LUCK!</span></span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"><br /></span></span></div>
<div class="MsoListParagraphCxSpFirst" style="text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">1.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Is this blogger a 'snake oil seller'? (Score 6 immediately)</span></span></div>
<br />
<div class="MsoListParagraphCxSpMiddle" style="text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">2.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Does the blog contain ANY
credible evidence? (Deduct 1)</span></span></div>
<br />
<div class="MsoListParagraphCxSpMiddle" style="text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">3.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Is the
blog full of anecdote, personal experience and endorsements from users of said
product/service/doctrine? (Score 3) </span></span></div>
<br />
<div class="MsoListParagraphCxSpMiddle" style="text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">4.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Is the blog balanced and offers
more than one school of thought? (Deduct 2)</span></span></div>
<br />
<div class="MsoListParagraphCxSpMiddle" style="text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">5.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Does the blog direct you to ALL
of its sources? (Deduct 1)</span></span></div>
<br />
<div class="MsoListParagraphCxSpMiddle" style="text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">6.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Does the blog direct you to just
the sources it wants you to read? (Score 2)</span></span></div>
<br />
<div class="MsoListParagraphCxSpMiddle" style="text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">7.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Does the blog promote ONE
specific idea, method product/service? (Score 3)</span></span></div>
<br />
<div class="MsoListParagraphCxSpMiddle" style="text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">8.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Does the blog recognise and
report opposing views objectively? (Deduct 2)</span></span></div>
<br />
<div class="MsoListParagraphCxSpMiddle" style="text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">9.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Does the blog denigrate/mock the
ideas of others? (Score 2)</span></span></div>
<br />
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product/service (Score 2)</span></span></div>
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<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">11.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Are comments allowed? (Deduct 2)</span></span></div>
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<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">13.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Are comments disallowed? (Score 2)</span></span></div>
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<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">14.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Are the moderated comments predominantly congratulations from ardent ‘followers’? (Score 3) </span></span></div>
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<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">15.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Is there
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<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"><span style="color: blue;">Note to BLOG readers:</span> If your favourite blog scored 10 or more (arbitrary unscientific score) ... Just take a moment to reflect on that. There is no suggestion that blogs should not be biased, bloggers write (and sell) what they like ... BUT having a shop for instance, starts them nicely on the road to a pretty impressive BINGO score. However, it is entirely up to the reader to interpret what they see, or to recognise and identify sources of potential bias (if that is, they want to..?) just as they would, if perhaps they chanced upon a copy of the Daily Mail.</span></span><br />
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<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">As one blogger recently said, "We are all biased" ... it is just a case of how much? So, whilst you may heartily agree with what your favourite blogger says, does or sells, it may be worth reflecting upon their potential for bias/conflict of interest AND how that affects your decision making ... and subsequent actions.</span></span><br />
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<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgbB1MFGT_iO0Otsx6T8VSuNKtlBYJ508PZM8QBR0N4KoiB-abXnuj1bh1FMM9s5YaS4UWSQRwahcgWSAGuBKZyVjvXt7xg_PRy-VBXgNq4hxZw6rjIIihn2O_HrviqEhHsBuIwZ5iEbYQ/s1600/Tonic.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgbB1MFGT_iO0Otsx6T8VSuNKtlBYJ508PZM8QBR0N4KoiB-abXnuj1bh1FMM9s5YaS4UWSQRwahcgWSAGuBKZyVjvXt7xg_PRy-VBXgNq4hxZw6rjIIihn2O_HrviqEhHsBuIwZ5iEbYQ/s1600/Tonic.jpg" height="209" width="320" /></a></span></span></div>
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<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">Yes, yes … I know! … I’ll be scoring my own
blog later (BINGO!)</span></span><br />
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<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;"><span style="font-family: Verdana,sans-serif;">Big thanks to <a href="http://will-self.com/" target="_blank">Will Self</a> for his inspiration …
I may include him in a Tweet (secretly hoping for a rebound ‘re-Tweet’) just
before I delete my own <a href="https://twitter.com/TaylorAlanJ" target="_blank">Twitter</a> account or become blogger <b>number 4</b>. </span></span></span></span></div>
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<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"><i>Author: Alan J Taylor is a writer and critic who thinks about stuff and works as a Physiotherapist and University lecturer ... The views contained in this blog are his own and are not linked to any organisation or institution. </i></span></span><span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"><i>Like Bukowski, he 'writes to stay sane'. </i></span></span></div>
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<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"><i>You'll find him mostly on Twitter <a href="https://twitter.com/TaylorAlanJ" target="_blank">https://twitter.com/TaylorAlanJ</a></i></span></span><br />
<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"><i>... that is until, he finally deletes his account, or is 'evidence based blogged' to oblivion. </i></span></span><br />
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<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"><i>Biased blog bingo grid design .... via <a href="https://twitter.com/MattLowPT" target="_blank">@MattLowPT </a></i></span></span>
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Clinical Reasoning Sessionshttp://www.blogger.com/profile/09852524904111114134noreply@blogger.com3tag:blogger.com,1999:blog-6560398305209426117.post-40221399575516540102015-01-15T11:37:00.000-08:002015-01-16T08:25:01.113-08:0010 Good reasons why physiotherapists are perfectly placed to deliver exercise prescription.<span style="font-family: Verdana,sans-serif;">A <a href="https://twitter.com/physiotalk" target="_blank">Physiotalk</a> <a href="http://physiotherapyispublichealth.blogspot.co.uk/2015/01/exercise-at-heart-of-physiotherapy.html" target="_blank">Tweet Chat</a> recently posed the question ... 'Is exercise at the heart of Physiotherapy?' ... and that got me thinking!</span><br />
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<span style="font-family: Verdana,sans-serif;">So here is my take on that ... written in a mini-blog and offered up as a <a href="https://www.slideshare.net/secret/aAa85ZvVP684IX" target="_blank">SlideShare</a> version for those who prefer that sort of thing.</span><br />
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<span style="font-family: Verdana,sans-serif;">Here are 10 good reasons why physiotherapists are perfectly placed to deliver exercise prescription.</span></h3>
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<span style="font-family: Verdana,sans-serif;">1. Specific knowledge of exercise physiology and sports science<br />2. Specific knowledge of neurology<br />3. Specific knowledge of MSK pathology, co-morbidity and disability <br />4. Specific knowledge of the respiratory system<br />5. Specific knowledge of biomechanics<br />6. Specific knowledge of pain science, and the ability to communicate strategies for behavioural change<br />7. Specific knowledge of the psychological, mental health and societal implications of injury/illness/dysfunction<br />8. The ability to progress and modify exercise prescription to meet mutually agreed goals/targets<br />9. The ability to develop exercise prescription to meet agreed functional needs</span><br />
<span style="font-family: Verdana,sans-serif;">10. The ability to modify exercise prescription to meet the need of all age groups and levels of aspiration.<br /> </span><br />
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<span style="color: blue;"><span style="font-family: Verdana,sans-serif;">Question is … Are we using a ‘system based approach' and leading the pack? … or simply too busy sniping from silos?</span></span></h3>
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<span style="font-family: Verdana,sans-serif;">I have some thoughts about that ... but I think we should concentrate on directions for the future ... for physiotherapy and exercise prescription. </span><br />
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<span style="font-family: Verdana,sans-serif;"><br /> </span><br />
<span style="font-family: Verdana,sans-serif;"><b>1. Step outside your silo ... and lay down your guns!</b> Firing at others is a waste of time and energy ... save it ... or your <a href="http://ylmsportscience.blogspot.co.uk/2014/12/psychology-mental-fatigue-sport.html" target="_blank">performance</a> will suffer!</span><br />
<span style="font-family: Verdana,sans-serif;"><br /><b>2. Concentrate on integrating and sharing the knowledge</b></span><br />
<span style="font-family: Verdana,sans-serif;"><b><br />3. Spend more time and energy on what DOES work</b></span><br />
<span style="font-family: Verdana,sans-serif;"><b><br />4. Consider exercise prescription as a powerful TREATMENT MODALITY</b></span><br />
<span style="font-family: Verdana,sans-serif;"><b><br />5. Develop and promote a <span style="color: blue;">‘Systems based approach’</span> to exercise prescription, which incorporates all of the above</b></span><br />
<span style="font-family: Verdana,sans-serif;"><b><br />6. Exercise your minds … Become leaders NOT followers</b></span><br />
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<span style="font-family: Verdana,sans-serif;">See a full 'SlideShare' version of this mini blog <a href="https://www.slideshare.net/secret/aAa85ZvVP684IX" target="_blank">here</a></span><br />
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<span style="font-family: Verdana,sans-serif;">For resources/evidence for exercise and health, together with just a few reasons WHY exercise matters go <a href="http://www.exercise-works.org/" target="_blank">here</a>. </span><br />
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<span style="font-family: Verdana,sans-serif;">Author: </span></h3>
<span style="font-family: Verdana,sans-serif;">Alan J Taylor is a writer and critic who thinks about stuff and works as a Physiotherapist and University lecturer ... The views contained in this blog are his own and are not linked to any organisation or institution. Like Bukowski, he writes to stay sane.<br /><br />You'll find him mostly on Twitter <a href="https://twitter.com/TaylorAlanJ" target="_blank">https://twitter.com/TaylorAlanJ</a> </span>Clinical Reasoning Sessionshttp://www.blogger.com/profile/09852524904111114134noreply@blogger.com3tag:blogger.com,1999:blog-6560398305209426117.post-58778178384560502232014-12-11T14:22:00.000-08:002014-12-14T07:54:20.883-08:00Neuroplasticity, neuroplasticity, neuroplasticity … The new overuse syndrome: Neuro-babble Tourettes<style>
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<span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">Never have I seen a word bandied about with such reckless abandon. 'Neuroplasticity' is simply ubiquitous, try a search on Twitter or Google, it’s a veritable delight of the good the bad and the ugly.<br /> </span></span><br />
<span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">BUT what if I told you that ‘neuroplasticity is considered by some to be a <a href="http://mindhacks.com/2010/06/07/neuroplasticity-is-a-dirty-word/" target="_blank">dirty word</a> … Not my opinion, but rather that of <a href="http://vaughanbell.net/writing-and-media/" target="_blank">Vaughan Bell</a> a London based neuroscientist and clinical psychologist.<br /><br />So why does an eminent neuroscientist have such an aversion to the term?<br /><br />Well my advice is to read the post, he describes far better than I ever could, how phrases like ‘your brain is plastic’, ‘rewire your brain’ and ‘neuroplasticity’ are virtually meaningless.<i><br /><br /><span style="color: blue;">‘Neuroplasticity sounds very technical, but there is no accepted scientific definition for the term and, in its broad sense, it means nothing more than ‘something in the brain has changed’. As your brain is always changing ... the term is empty on its own.’</span></i> </span></span><br />
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<span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">The article has a helpful educational element and puts neuroplasticity into perspective, going on to describe some of the most common processes associated with the term. With the rider that ... <br /><i><br /><span style="color: blue;">‘the next time you hear anyone, scientist or journalist, refer to neuroplasticity, ask yourself what specifically they are talking about. If they don’t specify or can’t tell you, they are blowing hot air.’</span></i></span></span><br />
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<span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">But Bell is not the only one critical of the current trend towards neuro-babble. Tom Stafford a Cognitive Scientist at the University of Sheffield in the UK wrote an equally cutting piece on the emerging trend of <a href="http://mindhacks.com/2006/03/22/neuroessentialism/" target="_blank">neuroessentialism</a>, a classic neurologism if ever I heard one!<i><br /><br /><span style="color: blue;">‘The belief in, or tactic of, invoking evidence, or merely terms, from neuroscience to justify claims at the psychological level...’</span></i> </span></span><br />
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<span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">It goes on … in a delightfully written piece entitled <a href="http://www.newstatesman.com/culture/books/2012/09/your-brain-pseudoscience-rise-popular-neurobollocks" target="_blank">‘Your brain on pseudoscience: the rise of popular neurobollocks’</a> which appeared in the New Statesman. Stephen Poole the British author and journalist dissects ‘the plague of neuroscientism – aka neurobabble, neurobollocks, or neurotrash …’ Poole has written previously on the misuse and abuse of language in the brilliantly acerbic ‘Unspeak: Words are weapons’ and his rhetoric comes as a warning to all with regard to the rise in neuro-vernacular. His incisive observation of how ... <i><span style="color: blue;">'the “neural” explanation has become a gold standard of non-fiction exegesis, adding its own brand of computer-assisted lab-coat bling to a whole new industry of intellectual quackery that affects to elucidate even complex sociocultural phenomena.'</span> takes a couple of reads (whilst I neuroplasticise and conceptualise ...), but is particularly enlightening.<br /> </i></span></span><br />
<span style="font-family: Verdana,sans-serif;"><span style="font-size: small;">Further, he quotes Paul Fletcher, professor of Health Neuroscience at the University of Cambridge, who suggests …<i><br /> </i></span></span><br />
<span style="font-family: Verdana,sans-serif;"><span style="font-size: small;"><i><span style="color: blue;">‘Too often, a popular writer will “opt for some sort of neuro-flapdoodle in which a highly simplistic and questionable point is accompanied by a suitably grand-sounding neural term and thus acquires a weightiness that it really doesn’t deserve. In my view, this is no different to some mountebank selling quacksalve by talking about the physics of water molecules’ memories, or a beautician talking about action liposomes.’</span></i></span></span><br />
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<span style="font-family: Verdana,sans-serif;"><span style="font-size: small;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgqA4Qllyoe9Cbm-9PfuNajCC2tUT_1DbqpAheUfI5zrFuWCj8Tj06bKzkdLq55wKsWGBJjUyTkRtJJIMZe98xNJlgz3Rkm1by1mhOPV6N0q4MQh8myQhu0l654fIszgDE9Q8dIhiVVDas/s1600/PET-image.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgqA4Qllyoe9Cbm-9PfuNajCC2tUT_1DbqpAheUfI5zrFuWCj8Tj06bKzkdLq55wKsWGBJjUyTkRtJJIMZe98xNJlgz3Rkm1by1mhOPV6N0q4MQh8myQhu0l654fIszgDE9Q8dIhiVVDas/s1600/PET-image.jpg" height="320" width="283" /></a></span></span></div>
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<span style="font-family: Verdana,sans-serif;"><span style="font-size: small;"><span style="font-size: xx-small; font-weight: normal; mso-bidi-font-weight: bold; mso-fareast-font-family: "Times New Roman";">As physiotherapists we should both know and care what other professions and key writers are making of the real achievements and developments in neuroscience. Not least, because we need to be able to communicate effectively but also because we need to maintain and develop credibility. To spout forth repetitious neuro-babble, risks making us sound like new age neuroflaneurs and I am pretty sure that’s not a route we should be taking, as the profession steadily weeds out the nonsense.<br /><br /><br />While I’m on the case, just keep a look out for the emergence of neuro linguistic programming (NLP) amongst the maelstrom of information that comes your way. Indeed, I saw a tweeted PPT slide from a recent Physiotherapy conference detailing the key elements of NLP. If you’ve read around the subject, you may have encountered this eloquent deconstruction of that particular branch of ‘neurononsense’ … which you can find <a href="http://neurobollocks.wordpress.com/2013/03/29/neuro-linguistic-programming-the-1970s-neurobollocks-that-just-refuses-to-die/" target="_blank">here</a>. If you are of a scientific persuasion, it would be wise to root out the ‘neuro-flapdoodle’ of NLP before it has chance to take root.<br /><br /><br />Thankfully, there does appear to be some awareness that we need to consider what we say and how we say it … I was alerted to an excellent piece on pain by Lorimer Moseley, entitled<a href="http://www.bodyinmind.org/time-to-embrace-bioplasticity/" target="_blank"> ‘It is not just the brain that changes itself – time to embrace bioplasticity?’</a>, where, somewhat ironically, but honestly, he discusses the concept of ‘bioplasticity’. Moseley, clearly alerted to the linguistic pressures of the topic, makes light of the neurobabble by constructing a few (tongue in cheek) terms of his own. Then adds the following slice of antipodean back pedalling humour:<i><br /><br /><br /><span style="color: blue;">‘Bioplasticity is, from herein, the new black. I repent my neurocentric ways and hold aloft the banner of biocentricity. It seems to me to be a fairer reflection of what we know about ourselves and it is a sensible umbrella term for the changes that occur across multiple systems when, for example, pain persists, or when, for example, we try to change pain. In fact, these tasks that we call neuroplasticity training, do not only induce changes in the nervous system, so perhaps they should be called bioplasticity training. Just a thought. And immune activation. And endocrine response. And motor output. And heart rate fluctuation….’</span></i></span></span></span><br />
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<span style="font-family: Verdana,sans-serif;"><span style="font-size: small;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEinBqb5oMvaia18SR61Mf2hy31zzPk2BguxwJ6WKyoWzY8YHmZhFlP8kEB9e-bZmsW-4CMAiMBuIZTHn_a5DNLZUImdGIEOyi48o3C7M3U_IMZEXkmuje2FpHjj0Gh5PnqnglBxJykF17w/s1600/Uitgelezen-Great-Myths-of-the-Brain_900_450_90_s_c1_smart_scale.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEinBqb5oMvaia18SR61Mf2hy31zzPk2BguxwJ6WKyoWzY8YHmZhFlP8kEB9e-bZmsW-4CMAiMBuIZTHn_a5DNLZUImdGIEOyi48o3C7M3U_IMZEXkmuje2FpHjj0Gh5PnqnglBxJykF17w/s1600/Uitgelezen-Great-Myths-of-the-Brain_900_450_90_s_c1_smart_scale.jpg" height="200" width="400" /></a></span></span></div>
<span style="font-family: Verdana,sans-serif;"><span style="font-size: small;"><br /></span><span style="font-size: small;"><span style="font-size: xx-small; font-weight: normal; mso-bidi-font-weight: bold; mso-fareast-font-family: "Times New Roman";">So there we have it … and it truly is a thought that we should keep. Perhaps we really should consider a ‘<a href="http://www.sciencedirect.com/science/article/pii/S1746068910000532" target="_blank">system based approach</a>’ (I think I have argued this case before…) to our consideration of pain and dysfunction. We should work together to combine the brilliant emerging elements of pain science and brain function with a sound consideration of the amazing system that is the human body, which of course includes the periphery. A brain requires a body, and vice versa … ask any suffer of quadriplegia or Wallenberg syndrome. BUT let us not become the new neuroflaneurs of pseudo pop-psychology, by endless repetition of meaningless neurobabble, because there are folk out there who clearly, can see through it.<br /><br />Our role requires us to work in multidisciplinary teams and it may be prudent for us to be cognisant of the opinions of other professions with regard to the way the emerging knowledge is considered, disseminated and taught. It may be wise to consider our own linguistics and mantras in this field too ... lest we begin to sound like 'beauticians talking about action liposomes'. Therein lies our challenge ...<br /> </span></span></span><br />
<span style="font-family: Verdana,sans-serif;"><span style="font-size: small;"><span style="font-size: xx-small; font-weight: normal; mso-bidi-font-weight: bold; mso-fareast-font-family: "Times New Roman";">Here's a helpful linguistics tip … via the eloquently entitled <a href="http://neurobollocks.wordpress.com/2013/11/14/you-keep-using-this-word-neuroplasticity-i-do-not-think-it-means-what-you-think-it-means/" target="_blank">neurobollocks website</a> … <br /><br /><i><span style="color: blue;">‘when you see (or hear – sic) the word ‘neuroplasticity’ think ‘bollocks’ instead ... 99% of the time you’ll be absolutely dead-on.’ </span></i></span></span></span><br />
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<span style="font-family: Verdana,sans-serif;"><span style="font-size: small;"><span style="font-size: xx-small; font-weight: normal; mso-bidi-font-weight: bold; mso-fareast-font-family: "Times New Roman";">For those who find that perhaps a little harsh ... My own personal strategy hereon in, is to simply substitute 'neuroplasticity' with 'neuro-flapdoodle' every time I encounter it in common parlance ... It just brightens my days up no end. Such is the power of language. <br /><br /><i><br /></i></span></span></span><br />
<span style="font-family: Verdana,sans-serif;"><span style="font-size: small;"><span style="font-size: xx-small; font-weight: normal; mso-bidi-font-weight: bold; mso-fareast-font-family: "Times New Roman";"><i><b>Author:</b> <span style="color: blue;"> </span></i></span></span></span><br />
<span style="font-family: Verdana,sans-serif;"><span style="font-size: small;"><span style="font-size: xx-small; font-weight: normal; mso-bidi-font-weight: bold; mso-fareast-font-family: "Times New Roman";"><i><span style="color: blue;">Alan J Taylor is a writer and critic who thinks about stuff and works as a Physiotherapist and University lecturer ... The views contained in this blog are his own and are not linked to any organisation or institution. Like Bukowski, he writes to stay sane.</span></i></span></span></span><br />
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<span style="color: blue;"><span style="font-family: Verdana,sans-serif;"><span style="font-size: small;"><span style="font-size: xx-small; font-weight: normal; mso-bidi-font-weight: bold; mso-fareast-font-family: "Times New Roman";"><i>You'll find him mostly on Twitter <a href="https://twitter.com/TaylorAlanJ" target="_blank">https://twitter.com/TaylorAlanJ</a></i></span></span></span></span><br />
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Clinical Reasoning Sessionshttp://www.blogger.com/profile/09852524904111114134noreply@blogger.com0tag:blogger.com,1999:blog-6560398305209426117.post-52797749833294917122014-10-29T13:04:00.000-07:002014-10-30T08:24:03.084-07:00Confirmation bias, physiotherapy and the highlighter pen ...<!--[if gte mso 9]><xml>
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<span style="font-family: Verdana,sans-serif;">The recent Body in Mind blog post <a href="http://www.bodyinmind.org/exercise-chronic-whiplash/" target="_blank">‘Exercise for chronic whiplash: does it matter how we do it?’</a> by Zoe Michaleff, was an
unexpected delight and breath of fresh air. Here you can see a top researcher reporting on a study that
found the virtual <a href="http://www.ncbi.nlm.nih.gov/pubmed/24918474" target="_blank">OPPOSITE</a> of what her team found, in an open objective account, without bias
and without trying to tear that study apart from a methodological (or any other)
perspective. She even went on to offer a plausible scientific explanation for the
differences between the studies.</span></div>
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<span style="font-family: Verdana,sans-serif;">Why, you may ask is this so refreshing? Well, because we so
seldom see it!</span></div>
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<span style="font-family: Verdana,sans-serif;">Whilst some commentators have gamely suggested we think carefully before alighting the latest <a href="http://thesportsphysio.wordpress.com/2014/08/02/all-aboard-the-latest-bandwagon/" target="_blank">'bandwagon'</a> (whatever that may be this week) and others have exhorted us to simply <a href="http://rogerkerry.wordpress.com/2014/09/29/evidence-based-physiotherapy-a-crisis-in-movement/" target="_blank">think</a>. More commonly, we see a plethora of blogs/articles/tweets which
support various theories or schools of thought, which are driven consistently by confirmation bias. In fact, it could be argued, some have even gone so far as to patrol the internet, helpfully fulfilling the role of rapid response 'Cyber Evidence Police'... and that's OK ('it's for your own security'), providing they are always right, BUT sadly, no-one is right 100% of the time.</span><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgtJ8WElY8eEOKNmwl4clslGh91HuGqBxzsGgvTe8nkD-Rijjd5jdlBbifuSHQAdF1fwvVKJoqXnUaw2ZsEo26R70nT2zpLtddFUOOl93sD58557jf-DoaBE-aWOiJkcma2IW2vaLarRmE/s1600/EBM.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgtJ8WElY8eEOKNmwl4clslGh91HuGqBxzsGgvTe8nkD-Rijjd5jdlBbifuSHQAdF1fwvVKJoqXnUaw2ZsEo26R70nT2zpLtddFUOOl93sD58557jf-DoaBE-aWOiJkcma2IW2vaLarRmE/s1600/EBM.JPG" height="320" width="251" /></a></div>
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<span style="font-family: Verdana,sans-serif;">Let's first consider the definition of <b><a href="http://youarenotsosmart.com/2010/06/23/confirmation-bias/" target="_blank">confirmation bias</a> </b>or 'my side' bias
... <i>'the tendency for people to favour information that confirms their
beliefs'. </i></span><br />
<br />
<span style="font-family: Verdana,sans-serif;">This YouTube clip is an excellent short resource.</span></div>
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<span style="font-family: Verdana,sans-serif;"><iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='320' height='266' src='https://www.youtube.com/embed/6xMaR8au-YU?feature=player_embedded' frameborder='0'></iframe></span></div>
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<span style="font-family: Verdana,sans-serif;"><span style="mso-bidi-font-style: italic;">Have you ever
picked up a newspaper or magazine article and been drawn to a particular
article and read it voraciously, lapping up the prose and rhetoric as you go?
Conversely, have you picked up an article and discarded it after the first
paragraph or less? Most people have, and the one of the factors that dictates
whether you persist or stop is confirmation bias. In other words we like and
enjoy reading stuff that floats our boat, or that confirms our long held/new
found ideas and beliefs, and tend to avoid or ignore the converse.</span></span></div>
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<span style="font-family: Verdana,sans-serif;"><span style="mso-bidi-font-style: italic;">The result is that
we may become biased towards articles, research literature, books blogs, tweets, <a href="http://www.nature.com/srep/2012/120621/srep00460/full/srep00460.html" target="_blank">people</a>
etc. that confirm our thinking … It is human nature. I often see students
working on critique of research papers for example, using a single marker pen. I
can’t resist asking what they are highlighting … “the interesting stuff”, “the
relevant stuff”, “the bits that support the theory I’m working on” etc. </span></span><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiWZ7IViiwz13AZEPdMH8AI6AvR6yxos3Qti6JB6sGfA9eW73uW1POrer7HdGb4TE0g6LtgpG9RlX9VRysVEfRrx5jvM_2_T62hL8pFcJCLdFcUp2PHuv1czDof6nGthIrvQu7_sD9cS68/s1600/Confirmation+III.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiWZ7IViiwz13AZEPdMH8AI6AvR6yxos3Qti6JB6sGfA9eW73uW1POrer7HdGb4TE0g6LtgpG9RlX9VRysVEfRrx5jvM_2_T62hL8pFcJCLdFcUp2PHuv1czDof6nGthIrvQu7_sD9cS68/s1600/Confirmation+III.JPG" height="220" width="320" /></a></div>
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<span style="font-family: Verdana,sans-serif;"><span style="mso-bidi-font-style: italic;">Only occasionally does anyone have two different coloured marker pens … one for the supporting
evidence and one for the opposite point of view. Try it yourself, concentrate
on what <b>doesn’t</b> support your theory for a moment, concentrate in the holes in
the theory, the method, look at an argument from the opposite side. It is both illuminating
and revealing and naturally, you’ll probably find the second marker pen is used
a lot less than less than the first. Of course, that may be because of what you chose to
critique in the first place.</span></span>
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<span style="font-family: Verdana,sans-serif;"><span style="mso-bidi-font-style: italic;">Believe it or not …
Human nature and confirmation bias may lead you to overlook the methodological,
scientific, statistical or philosophical holes in one paper, whilst using all
of your might to apply those things to another. In other words, there may be a tendency to </span></span><span style="font-family: Verdana,sans-serif;"><span style="mso-bidi-font-style: italic;">ignore or under weigh evidence that could dis-confirm an opposing hypothesis. We see examples of this time
and time again in the interpretation of physiotherapy evidence.</span></span><br />
<br />
<span style="font-family: Verdana,sans-serif;"><span style="mso-bidi-font-style: italic;">It is always worth asking yourself ... </span></span><span style="font-family: Verdana,sans-serif;"><span style="mso-bidi-font-style: italic;"><b>“When is the advocated theory ever wrong?</b>”
Nothing works all the time. An astute person is aware of the limitations
of any idea or practice. Challenge any 'authority' to explain the alternative of their
position, and when they might use another option ... You can see more on that approach <a href="http://scottberkun.com/2009/how-to-call-bullshit-on-a-guru/" target="_blank">here.</a></span></span><br />
<span style="font-family: Verdana,sans-serif;"><span style="mso-bidi-font-style: italic;"> </span></span></div>
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<span style="font-family: Verdana,sans-serif;"><span style="mso-bidi-font-style: italic;">What is even more revealing is when we see ‘conversions’ from one school of thought to another.
Take a moment to look at this <a href="http://m.iowastatedaily.com/opinion/columnists/article_1d916e20-5aff-11e4-875c-e7dac0db1f81.html?mode=jqm" target="_blank">blog article</a> on the 'conversion' of a staunchly religious person to an atheist and
what happened thereafter. Not untypically, the post conversion individual went
on the attack and </span>" … dismissed all others’ beliefs and assumed his
was correct". That frankly, is not a brilliant scientific or philosophical stance to take regardless of the 'evidence', there is always a contrary view and another side to any coin ... and the evidence base, as we know is an ever changing landscape. </span></div>
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<span style="font-family: Verdana,sans-serif;"><b>So that is why </b>Michaleff's article was a breath of fresh air … I
think, as a profession we can all take something from that ... and perhaps 'work together and learn together'. </span><br />
<br />
<span style="font-family: Verdana,sans-serif;">If you want to read a little more on the various types of bias that may permeate our World ... <a href="http://io9.com/5974468/the-most-common-cognitive-biases-that-prevent-you-from-being-rational" target="_blank">this article</a> is not a bad place to start. </span><br />
<br />
<span style="font-family: Verdana,sans-serif;">Personally, I’m just off to the 24h multicoloured highlighter pen shop. </span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhyOr6NXH1y4xyObZgNkUvzARUioX2H1MJsxPCRIQ1GbJTmQtc3z_iq6veaO_VSvrDIZ45csO4WlfzPgcnei_w01OwjK4ttcXozDxyB57BqyW2XK4wPrnF0YqJgp-c2Env2tDnSzaMqL-I/s1600/bright-2796_640.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhyOr6NXH1y4xyObZgNkUvzARUioX2H1MJsxPCRIQ1GbJTmQtc3z_iq6veaO_VSvrDIZ45csO4WlfzPgcnei_w01OwjK4ttcXozDxyB57BqyW2XK4wPrnF0YqJgp-c2Env2tDnSzaMqL-I/s1600/bright-2796_640.jpg" height="213" width="320" /></a></div>
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<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"><i><b>Author:</b>
Alan J Taylor is a writer and critic who thinks about stuff and works
as a Physiotherapist and University lecturer ... The views contained in
this blog are his own and are not linked to any organisation or
institution. </i></span></span></div>
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<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"><br /></span></span></div>
<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"><i>You'll find him mostly on Twitter <a href="https://twitter.com/TaylorAlanJ" target="_blank">https://twitter.com/TaylorAlanJ</a></i></span></span><br />
<span style="font-size: small;"><span style="font-family: Verdana,sans-serif;"><i><br /></i></span></span></div>
Clinical Reasoning Sessionshttp://www.blogger.com/profile/09852524904111114134noreply@blogger.com1tag:blogger.com,1999:blog-6560398305209426117.post-46762821176200460482014-07-02T10:34:00.001-07:002015-03-19T08:47:31.630-07:00What is the difference between cancer & whiplash?... Here's what!<style>
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That was the question ... posed by David Butler on the <a href="http://noijam.com/2014/06/29/what-is-the-difference-between-cancer-and-whiplash/">noijam</a>
BLOG on 29<sup>th</sup> June 2014</div>
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When I first read this post and the reaction on Twitter, I was initially surprised by the fawning sycophantic compliments of self proclaimed skeptics... so I read it again and frankly I was appalled (at many levels).<br />
<br />
Then when I suggested via Twitter that the post was 'bombastic nonsense'
… I was asked quite logically by a PT student, exactly why I thought so?<br />
<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhisz_o9aC44xtWo9lo5s97WaByzIJX-pNv5Z4kpUhR6fMQAL9YVlxgTltBkX5rczqFBgrzGd_mGgFa9b3cRrJCAWyiWMtEOF-roHgk5gWQa4obauItCi5E3j7R3L2MYlpwskh96-LXlMM/s1600/Screenshot+2014-07-02+16.20.04.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhisz_o9aC44xtWo9lo5s97WaByzIJX-pNv5Z4kpUhR6fMQAL9YVlxgTltBkX5rczqFBgrzGd_mGgFa9b3cRrJCAWyiWMtEOF-roHgk5gWQa4obauItCi5E3j7R3L2MYlpwskh96-LXlMM/s1600/Screenshot+2014-07-02+16.20.04.png" height="201" width="320" /></a></div>
</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Twitter with its 140 characters is hardly the best medium
for such discourse, so here is the response in detail.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Well here’s why … </div>
<div class="MsoNormal">
<br /></div>
<h3 class="MsoListParagraph" style="mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<span style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;"> </span></span></h3>
<h3 class="MsoListParagraph" style="mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<span style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;"> </span></span></h3>
<h3 class="MsoListParagraph" style="mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<span style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;"></span></span><span style="color: red;"> </span></h3>
<h3 class="MsoListParagraph" style="mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<span style="color: red;"> <span style="color: black;"> </span></span></h3>
<h3 class="MsoListParagraph" style="mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<span style="color: red;"><span style="color: black;">1. The
analogy 'Cancer-Whiplash' is meaningless and badly chosen . . . </span> </span></h3>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Whilst sympathising entirely with the authors’ stated proximity
to the subject (cancer), this cannot allow us to stray into emotional
territory … lets keep it as factual as possible.<br />
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj5Iueyjs2GpbA6_QlZRKyehjwcgJTXL-IUqdiytVG2euB5KlDqawlYQMqTO2YT0d_TKPjXs8LbTnJJyAQRvBoj3qQ9X2U4eybU1Y4T12WSyvukvM_VaCo70LHT85mGw-xbuko3tNd3x2c/s1600/Cancertoon314.gif" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj5Iueyjs2GpbA6_QlZRKyehjwcgJTXL-IUqdiytVG2euB5KlDqawlYQMqTO2YT0d_TKPjXs8LbTnJJyAQRvBoj3qQ9X2U4eybU1Y4T12WSyvukvM_VaCo70LHT85mGw-xbuko3tNd3x2c/s1600/Cancertoon314.gif" height="246" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><a href="http://www.shannonburns.com/">www.shannonburns.com</a></td></tr>
</tbody></table>
</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Cancer is acquired insidiously – Whiplash associated disorder (WAD) results from trauma.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Cancer may lead to death – WAD rarely (to avoid that unwanted complication <a href="http://alteredhaemodynamics.blogspot.co.uk/search?updated-max=2014-04-23T09:11:00-07:00&max-results=7" target="_blank">see here</a>) </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Cancer is easy to diagnose – WAD diagnosis is in its infancy</div>
<div class="MsoNormal">
<br />
Cancer has clear care pathways and the ‘management process
can be mapped out with confidence’ – WAD is both difficult to diagnose and
little is known about the most effective treatments.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Cancer research is MASSIVELY funded all over the World – WAD
has pockets of minor funding. </div>
<div class="MsoNormal">
<br />
In oncology, clinicians are more often than not, able to be very clear about the diagnosis management and prognosis - In WAD sadly, this is not so. <br />
<br /></div>
<div class="MsoNormal">
<span style="color: blue;">Cancer and WAD are NOTHING like each other … the analogy is meaningless.</span><br />
<br />
To suggest so ... frankly verges on disrespect to the genuine sufferers of either malady .... of course, <span style="color: blue;">REMEMBER only WAD
patients are ever doubted.</span></div>
<div class="MsoNormal">
<br /></div>
<h2 class="MsoNormal">
2. We don’t need another bullshit acronym!</h2>
<h3 class="MsoNormal">
</h3>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgxK9-jw59xYwiiekPoKz30rTd-TjSqlHaHUfN5hfS5xXjvnd32z3pIQ2ojl5OJVyHKgKVVH5HvXXgOnLgA5NvsfsbwyqaWlHt4UME_7v68fKS0X98N1X_VueKh06M85kRpX8iiOftSkLs/s1600/Screenshot+2014-07-02+15.55.13.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgxK9-jw59xYwiiekPoKz30rTd-TjSqlHaHUfN5hfS5xXjvnd32z3pIQ2ojl5OJVyHKgKVVH5HvXXgOnLgA5NvsfsbwyqaWlHt4UME_7v68fKS0X98N1X_VueKh06M85kRpX8iiOftSkLs/s1600/Screenshot+2014-07-02+15.55.13.png" height="191" width="320" /></a></div>
<h3 class="MsoNormal">
This is the bit when I first started to laugh and double-checked
the date …could it actually be April 1<sup>st</sup> ...? </h3>
<div class="MsoNormal">
<br />
<br />
Then I began to laugh again, this
time with tears rolling down my cheeks (see below).</div>
<div class="MsoNormal">
<br />
<br /></div>
<div class="MsoNormal">
Yes, at its basic level WAD
is (‘just’..!) a sprained/strained neck … providing of course, that is ALL the patient complains of!?!</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="color: blue;">BUT … SNSNI = ‘Sprained neck at speed with frequent neural
irritation’ …Help me please … </span></div>
<div class="MsoNormal">
<span style="color: blue;">This HAS to be a joke?? </span></div>
<div class="MsoNormal">
<br />
Physiotherapy as a profession, has been beset with a plethora of
ever changing, confusing acronyms since its inception … ANT changed to AND … Mmmmm!<br />
<br />
ULTT1 (UK) is also BPPT (Aus) ... even better! </div>
<div class="MsoNormal">
<br />
In the perceived wisdom of
the ‘noijam group’ we should be adopting SNSNI … Oh, wait a minute, can’t we
lever in some MORE LETTERS?</div>
<div class="MsoNormal">
<br />
<span style="color: blue;">'SNASWFNI' is surely a lot catchier ... The (Welsh) medics will really take to that??</span><br />
<br />
Maybe NOIgroup (note the acronym) can hype it a little ...?<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh93tq9RoYf0bea3EG8Cc9EWWpGcs8pV-zJviURZZe3-vL8Sg_n9rwwkaHN6aFpwhmZCLoQosMdxrjv_jN3JoQVyuLJwq73YsDU0-yaAuz7WWvb4F66kvouqTR1UxgSny2US7-GpAFGwow/s1600/Screenshot+2014-07-01+10.11.54.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh93tq9RoYf0bea3EG8Cc9EWWpGcs8pV-zJviURZZe3-vL8Sg_n9rwwkaHN6aFpwhmZCLoQosMdxrjv_jN3JoQVyuLJwq73YsDU0-yaAuz7WWvb4F66kvouqTR1UxgSny2US7-GpAFGwow/s1600/Screenshot+2014-07-01+10.11.54.png" height="174" width="320" /></a></div>
</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Wait a minute … Haven't the pain scientists been spending some time
QUITE RIGHTLY suggesting that we should be changing our vernacular (lose the
SCARY language people) when describing conditions to patients. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<h3>
Lets just imagine the patient-therapist discourse for a
moment …</h3>
</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i><span style="color: blue;">Patient … “Hello I have some neck pain following a motor
vehicle collision”</span></i></div>
<i><span style="color: blue;">
</span></i><br />
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i><span style="color: blue;">Therapist – “Oh you are probably suffering from SNSNI” ... (go on try saying it out LOUD!)</span></i></div>
<i><span style="color: blue;">
</span></i><br />
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i><span style="color: blue;">Patient – “Pardon me, … Uh uh, you sound like you have
sinusitis?”</span></i></div>
<i><span style="color: blue;">
</span></i><br />
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i><span style="color: blue;">Therapist – "Let me explain… You have SNSNI … That means you
have a sprained neck" (smiles knowingly)</span></i></div>
<i><span style="color: blue;">
</span></i><br />
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i><span style="color: blue;">Patient – "Is that what they used to call ‘whiplash’"</span></i></div>
<i><span style="color: blue;">
</span></i><br />
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i><span style="color: blue;">Therapist – (Laughs) … “I suppose so”</span></i></div>
<i><span style="color: blue;">
</span></i><br />
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i><span style="color: blue;">Patient – "So what do all those fancy letters mean?" (looks a
little worried)</span></i></div>
<i><span style="color: blue;">
</span></i><br />
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i><span style="color: blue;">Therapist – "Oh, it’s just short for 'Sprained neck at speed
with frequent neural irritation'”</span></i></div>
<i><span style="color: blue;">
</span></i><br />
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i><span style="color: blue;">Patient - … (looking around nervously) “… errr, excuse me, I
think I need to use the bathroom." (gets up and bolts for the nearest door … )</span></i></div>
<i><span style="color: blue;">
</span></i><br />
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Is that just THE SCARIEST description you have ever heard?? </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="color: blue;">Shame on you Noijam … You’re promoting the very thing you
asked us all to STOP! </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
… and anyway, why would any skeptic worth their salt, buy
into the concept that it is JUST neural tissue involvement in WAD ... That is nonsense by any stretch of the imagination. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Oh of course the caveat of the cleverly used word ‘frequent’
allows a brilliant get out clause.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="color: blue;">BUT the suggestion remains. Is this
really sound thinking? </span></div>
<div class="MsoNormal">
<br />
<h2>
<span style="color: blue;">'There's no room for bullshit ...'</span></h2>
</div>
<div class="MsoNormal">
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjxQeon_ehtVM93tfG6rrqC3BYfFjAYpsqvI4iI6LXmoN-nDwOx4NNP4lPgfCcBkHhQGDs2l9Kxj0F0ItmLqrP9FtGIvHiVlPt6Vu7hIldj41fcjVMXZIqGoDRSUL4B9EcfbqaVdpBibgk/s1600/Screenshot+2014-07-02+15.54.43.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjxQeon_ehtVM93tfG6rrqC3BYfFjAYpsqvI4iI6LXmoN-nDwOx4NNP4lPgfCcBkHhQGDs2l9Kxj0F0ItmLqrP9FtGIvHiVlPt6Vu7hIldj41fcjVMXZIqGoDRSUL4B9EcfbqaVdpBibgk/s1600/Screenshot+2014-07-02+15.54.43.png" height="174" width="320" /></a></div>
NOIjam group suggested that there was “no
room for bullshit” in WAD … and then IMMEDIATELY introduced a massive wedge of
nonsensical Guru generated acronym BS straight into the pot??<br />
<br /></div>
<h2 class="MsoNormal">
3. There IS no sectarian war …!</h2>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Or if there is, it is self promulgated, self promoted and
self fueled by nonsense and evangelical hype. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjp_0I2K0bfOssZKaNbg7cXYkgDh3EyS8HztKvcYL516sGPn7XSHzjRqn_Oc5JMO3eXVo0y2aMzBH-wYb0WAiF7mDwcHzAshQSs6lY14tJECFK3X7jTIY_UC7CzaC8mgHghDschf6kqxCU/s1600/religion-war-cartoon-01.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjp_0I2K0bfOssZKaNbg7cXYkgDh3EyS8HztKvcYL516sGPn7XSHzjRqn_Oc5JMO3eXVo0y2aMzBH-wYb0WAiF7mDwcHzAshQSs6lY14tJECFK3X7jTIY_UC7CzaC8mgHghDschf6kqxCU/s1600/religion-war-cartoon-01.jpg" height="224" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><a href="http://www.joeclifford.com/blog/2013/10/14/kate-uptons-erect-nipple/religion-war-cartoon-01/">http://www.joeclifford.com/blog/2013/10/14/kate-uptons-erect-nipple/religion-war-cartoon-01/</a></td></tr>
</tbody></table>
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Yes, there IS an on-going ‘guru’ culture in PT, but any perceived 'war' is of the protagonists own making. What we have in PT, is a young profession (this is not medicine),
struggling gamely to make sense of the ever changing science and the BRILLIANT
work done by folk in many fields ... see <a href="https://fsmweb.northwestern.edu/faculty/viewpub2.cfm?xid=20211" target="_blank">here</a> and <a href="http://uq.edu.au/ccre-spine/michele-sterling" target="_blank">here</a> and <a href="http://www.paininmotion.be/EN/news-whiplash-press-release-VUB-14.html" target="_blank">here</a> for some examples in WAD.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
In WAD … YES at this point in time, confusion reigns, but that is not a time to
scoff, sneer or hype up your own paradigm (you're not the first ... and you won't be the last). </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
YES … Recent RCT’s have shown that many current
methods of management have be called into question … THAT IS BRILLIANT ... <span style="color: blue;">thanks to those researchers.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
…but it is NOT A TIME TO DEMAND APOLOGIES … in some kind of perverted game of 'you were wrong ... BUT we were right' ... that truly would be nonsense of the highest order.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Remember students, clinicians and the PATIENTS sit in the middle of this maelstrom …<br />
<br />
Let’s all
try and help physiotherapy to change together, with a little less of the NONSENSE &
HYPE!</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
It is a time to reflect, a time to change, a balancing act ... and it may be easier to balance on the middle ground ...<br />
<br />
Nothing stays the
same ... and pendulums swing!<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjyzFBft-4tFTjYNMwv9W1_l3ZmEwmTGsyER15QyB2-Ht7YBA8cSYGgFrIwq-9EsHuRs91k0Eq6FuqC-ZbIU6E-HPteMJkBzAGeZmaM4UdA3Mv8-nnxOVp7GYfTeuTkhpvaWcLjxwJA3E8/s1600/Penny_farthing_guitar.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjyzFBft-4tFTjYNMwv9W1_l3ZmEwmTGsyER15QyB2-Ht7YBA8cSYGgFrIwq-9EsHuRs91k0Eq6FuqC-ZbIU6E-HPteMJkBzAGeZmaM4UdA3Mv8-nnxOVp7GYfTeuTkhpvaWcLjxwJA3E8/s1600/Penny_farthing_guitar.jpg" height="400" width="338" /></a></div>
</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b>CANCER & WAD ? Yes, it was just an analogy, of course! </b></div>
<div class="MsoNormal">
<br />
But just like the acronym that arrived on our doorstep uninvited ... it was badly chosen.<br />
<br />
Go on NOIjam …tell me #SNSNI was actually a product of the hayfever season ...<br />
<br />
Sneeze hard enough and the 'war' might be over ... Cheers!<br />
<br /></div>
<div class="MsoNormal">
<br />
<br />
<br />
<div class="MsoNormal" style="mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; mso-outline-level: 3;">
<div class="separator" style="clear: both; text-align: center;">
<span style="color: black;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhVJgyf4SvrBwk0KYg3hNEWOFXcYrgq6ej4dvC5sLGmJhGQ4DRAa5p5G37IeeKu7rK5QOWJGKNVIqXmq5epMLVbotntJtcTJvAoIYWrJDRvSyJ0u6ZS7rWKUIgbJoIgSuZskP6L7qzR-3g/s1600/Glass+full.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhVJgyf4SvrBwk0KYg3hNEWOFXcYrgq6ej4dvC5sLGmJhGQ4DRAa5p5G37IeeKu7rK5QOWJGKNVIqXmq5epMLVbotntJtcTJvAoIYWrJDRvSyJ0u6ZS7rWKUIgbJoIgSuZskP6L7qzR-3g/s1600/Glass+full.jpg" height="216" width="320" /></a></span></div>
<br />
P.S. This post was was submitted to the NOIgroup in response to their BLOG ... Can you see it?<br />
<br />
'the comment is awaiting moderation' ...<br />
<br />
UPDATE (03.07.14) - Deleted .... they said it was the link! <br />
<br />
Just the sycophants (WITH hyperlinks...) remain ... <br />
<br />
UPDATE (11.07.14) Ad hominem attack from NOIgroup (Group V's individual) ... <span style="color: black;"><a href="http://noijam.com/2014/07/11/s-is-for-straw-man-t-is-for-troll/" target="_blank">Here</a> ... Accused of being a 'troll' for daring to disagree ... and prodding the soft underbelly of a Corporate giant. </span><br />
<br />
For those not familiar with this sort of thing ... In argumentation, an 'ad hominem attack' is an attack based on some irrelevant fact about the person NOT the argument ... This sort of thing is not uncommon when someones view or strongly held belief system is challenged <span style="color: black;"><a href="http://edzardernst.com/2014/07/spinal-manipulation-for-herniated-discs-chiropractors-should-start-doing-meaningful-research/" target="_blank">see here.</a> </span><br />
<br />
It is perhaps about as low as argumentation gets ... and in its delivery, often reveals a great deal more about the attacker/s than the target.<br />
<br />
It makes interesting reading, and illustrates what can happen when any individual challenges a Corporate view of the World ... ugly, unnecessary and perhaps not the best of endorsements for the profession. <br />
<br />
What was perhaps most interesting about this vitriolic, attempt at character assassination (apart from the distortion of fact) was the complete lack of insight and humour.<br />
<br />
Humour (or lack thereof) can tell us a lot about how people approach critical thinking ... and as one <span style="color: black;"><a href="http://ptpodcast.com/what-comedy-can-teach-us-about-critical-thinking/" target="_blank">commentator</a> said, "Think about the last time you had your mind blown by a new explanation
backed by some elegantly simple research. My automatic reaction is
always laughter followed by the words, “Son of a bitch. Why didn’t I see
that before?”. </span><br />
<br />
<span style="color: black;">Never be so humourless, as to think yourself above critique. Or, as the French would say, it is always wise never to "</span><i><b>péter plus haut que son cul'.</b></i><br />
<br />
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via <span class="irc_dsh"><a class="irc_hl irc_hol" data-ved="0CAQQjB0" href="http://www.quoteswave.com/picture-quotes/435668"><span class="irc_ho" dir="ltr">www.quoteswave.com</span></a></span><br />
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<br />
UPDATE (12.07.14) Here is the bottom line ...<br />
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If, on the internet, someone (anyone) chooses to write a provocative, emotive blog ... They simply HAVE to expect someone to be provoked by their rhetoric... to raise a debate or challenge ... Unless somehow they think themselves fireproof or above such challenge.<br />
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The kitchen, as we all know ... is HOT. <br />
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... It would be a sad passive World if everyone simply nodded in passive agreement to ANY so called authority or belief system.<br />
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This whole thing goes way beyond this little storm in a TweetCup, it is a much bigger debate about how a profession deals with change, moves forward ... and how it (and the players within it) really should WORK TOGETHER ... Long may it continue :-)<br />
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ACTUALLY ... and for clarity, I think the above paragraph was my KEY POINT<br />
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<i><b><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">Author</span></b></i></div>
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<i><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">Alan J Taylor - is
an ex-professional cyclist, Physiotherapist and writer. Like Bukowski ... "he writes to stay sane". He is a medico-legal expert witness, in the field of clinical negligence related to
manual therapy and stroke or other haemodynamic events.</span></i></div>
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<i><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">He has worked as a
lecturer in Physiotherapy and Sports Rehabilitation & Exercise Science at
the University of Nottingham since 2010.</span></i></div>
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<i><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">He worked full-time
as a physiotherapy clinician until joining the UoN and maintains a clinical case load via his
Consultancy, which regularly takes him to to some of the UK's leading sports
clubs. He deals with a variety of pain and performance related cases, many with
a haemodynamic bias. </span></i></div>
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Clinical Reasoning Sessionshttp://www.blogger.com/profile/09852524904111114134noreply@blogger.com4tag:blogger.com,1999:blog-6560398305209426117.post-36095103699469745162014-07-01T08:46:00.000-07:002014-07-01T12:43:53.853-07:00The Tour de France is coming to town … Time to get on your bike!<h3>
University of Nottingham Physiotherapy Lecturer and ex Tour of Britain rider, Alan Taylor reckons there has never been a better time to get on the cycle path to health and happiness! </h3>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg6kI-mAS4rOT9ovJvlyHTDZ3U_2iVMjr3xcXqkXwSCtw6oN48CUPedm5CS_7O0jBgi0hYpW8iMSLJqUz6Yt-FesFntSKVrYHCgvaq7c5OArvwfZitUS04azrBey8HfaAf7MSwE0tAvLEk/s1600/Tour-de-France-parade.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg6kI-mAS4rOT9ovJvlyHTDZ3U_2iVMjr3xcXqkXwSCtw6oN48CUPedm5CS_7O0jBgi0hYpW8iMSLJqUz6Yt-FesFntSKVrYHCgvaq7c5OArvwfZitUS04azrBey8HfaAf7MSwE0tAvLEk/s1600/Tour-de-France-parade.jpg" height="320" width="317" /></a></div>
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The Tour de France is coming to town LITERALLY, as it visits Yorkshire for the ‘<a href="http://letour.yorkshire.com/" target="_blank">Grand Depart</a>’ on Saturday 5th July. </h3>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjEYEX0q9hQeUJpjHr7NSkl538YimjDRgAz-NNHnbpYOgo7poRQm3BRPiQA-DhdgE4FQdYe-XAoLN5-OaygVWi4zVISi5fraEf5kg7s4G_fGsVr2Ssakua_lojZej85AiumtogydjmFC64/s1600/tour-de-france-2014-route-uk.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjEYEX0q9hQeUJpjHr7NSkl538YimjDRgAz-NNHnbpYOgo7poRQm3BRPiQA-DhdgE4FQdYe-XAoLN5-OaygVWi4zVISi5fraEf5kg7s4G_fGsVr2Ssakua_lojZej85AiumtogydjmFC64/s1600/tour-de-france-2014-route-uk.jpg" height="193" width="200" /></a></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjQ8DcY8_fDEXUWJFM81mYeEx9Gjy1e_TI7S8ijCE1Z8Bw6X5PUudAOmYEsJlQv0KJqYCk4b1r6O_nD2ZBEB8t1OVo5SCbnClcpHJjbIIRO8Jf6ksAO2u7AaPel-7C_CVZ79GxlozctSNk/s1600/grand-depart-yorkshire-2014.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjQ8DcY8_fDEXUWJFM81mYeEx9Gjy1e_TI7S8ijCE1Z8Bw6X5PUudAOmYEsJlQv0KJqYCk4b1r6O_nD2ZBEB8t1OVo5SCbnClcpHJjbIIRO8Jf6ksAO2u7AaPel-7C_CVZ79GxlozctSNk/s1600/grand-depart-yorkshire-2014.jpg" height="141" width="200" /></a>Exciting times … and your chance to soak in the unique atmosphere of the Worlds biggest bike race. Cycling and the Tour de France in particular, has a little bit for everyone. Billed as the Worlds toughest sporting challenge, it has more than its fair share of blood, sweat and tears, with drama and controversy never far away. That’s not to mention the beautiful countryside that serves as a backdrop to those well oiled legs.<br />
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The Worlds top bike riders take on the hills and valleys of Yorkshire as they make their way from Leeds to Harrogate (<a href="http://letour.yorkshire.com/stage-1" target="_blank">Stage 1</a>) and York to Sheffield (<a href="http://letour.yorkshire.com/stage-2" target="_blank">Stage 2</a>) before heading south for leg between Cambridge and London (<a href="http://letour.yorkshire.com/stage-3" target="_blank">Stage 3</a>). It promises to be fun all the way as road becomes lined with LIFE, the bunting goes up, the flags are waved and the <a href="http://festival.yorkshire.com/events/dh-lawrence-and-the-vaudeville-skiffle-show" target="_blank">music plays</a>. All along the route ... it's party time! <br />
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Don't just be a spectator ...</h2>
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But it’s not just about being a spectator there’s a host of events for wannabee Chris Froomes’ – For those of you who may have missed it Chris Froome won last years event for Team Sky, following the success of Sir Bradley Wiggins in 2012 - Team Sky host a series of <a href="http://letour.yorkshire.com/news/get-on-your-bike-this-summer-sky-ride-is-back" target="_blank">rides</a> to keep up the momentum of the Tour visit and encourage cycling for everyone.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhtgKGVkj-jlYD9wFKgh1mU8N1F27qrOnmd3c4ELppbCLhhfumoSiN_iuIejaHvQPepXsp9A5xNmAhg1iy2r6mx-TCkKgwBYv2nn8nf9kmJpfFrZPPXHRqPatQb2Gp1gy0_pEIFJNL-pSI/s1600/bike-190483_640.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhtgKGVkj-jlYD9wFKgh1mU8N1F27qrOnmd3c4ELppbCLhhfumoSiN_iuIejaHvQPepXsp9A5xNmAhg1iy2r6mx-TCkKgwBYv2nn8nf9kmJpfFrZPPXHRqPatQb2Gp1gy0_pEIFJNL-pSI/s1600/bike-190483_640.jpg" height="213" width="320" /></a></div>
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi-_9WwMd3ht7A5b91ziC1Z5C67LX_BP9xNv2aZDeXmjAp1af8bMzzjI_1NaaP915oClIWa78Kbkh6E2OWNrR8kXE3oYZauXTLvf5v0gdbMh-5hucc62VGiCAx0M9EKZJ5FRvq8vRz7Cpc/s1600/Steampunk.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi-_9WwMd3ht7A5b91ziC1Z5C67LX_BP9xNv2aZDeXmjAp1af8bMzzjI_1NaaP915oClIWa78Kbkh6E2OWNrR8kXE3oYZauXTLvf5v0gdbMh-5hucc62VGiCAx0M9EKZJ5FRvq8vRz7Cpc/s1600/Steampunk.jpg" height="240" width="320" /></a>From a health perspective, cycling gets people active, it's gentle on the joints and gives a cardio vascular workout. It’s also a super cheap and quick way to commute in busy cities. As a pastime that can be enjoyed by all age groups, it fits well with Government backed activity schemes like ‘<a href="http://www.nhs.uk/change4life/pages/bike-for-life.aspx" target="_blank">Change4life</a>’. The positive benefits of cycling on <a href="http://www.independent.co.uk/life-style/health-and-families/features/the-cycle-path-to-happiness-8422706.html" target="_blank">happiness and mental health</a> shown by recent research, have far reaching health benefits for everyone.<br />
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Remember, Einstein said of his theory of relativity … "I thought of it while riding my bicycle." If you need any convincing at all, that dusting off that old Claude Butler is the right thing to do, then take a look at this ...!<br />
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You’ll find no less than <a href="http://www.bikeradar.com/road/gear/article/30-reasons-to-take-up-cycling-23965/" target="_blank">30 good reasons</a> for joining in the fun. </h3>
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<a href="http://www.bikeradar.com/road/gear/article/30-reasons-to-take-up-cycling-23965/" target="_blank"><span style="color: blue;">So if you want to look younger, live longer, bolster your brain power and … errr improve your sex life? ... Le Tour is coming!</span></a></h3>
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<span style="color: blue;"> </span></h3>
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<span style="color: blue;">... erm, I'm sure there's a <a href="http://bjsm.bmj.com/content/34/4/310.full" target="_blank">haemodynamics</a> link here somewhere??</span></h3>
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Get the wind in your hair ..! </h4>
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It’s time to get those wheels turning, <a href="http://www.britishcycling.org.uk/" target="_blank">British Cycling</a> is on the threshold of a change in attitudes in the UK, and we can all get the wind in our hair (laughs...).<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgDTFoBwE9TyLgzmFUP420lv64NjLmNtNWdtjjd6AdqF2G8DRRHBJUwLe327JhM5-Q1-WOaxY7KJ9QmvYo06DzesW_RdjSP-dTajpPWoMtQ-EmoPY7RAbAl3KoyM2FWoYZU5-jTJOGQxAk/s1600/v219-TourdeFrance1-Getty.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgDTFoBwE9TyLgzmFUP420lv64NjLmNtNWdtjjd6AdqF2G8DRRHBJUwLe327JhM5-Q1-WOaxY7KJ9QmvYo06DzesW_RdjSP-dTajpPWoMtQ-EmoPY7RAbAl3KoyM2FWoYZU5-jTJOGQxAk/s1600/v219-TourdeFrance1-Getty.jpg" height="240" width="320" /></a><br />
As ex-tour rider Chris Boardman so rightly said "This isn’t just about cycling, it’s about creating accessible, pleasant, healthier places." Read about the Tours projected lasting legacy <a href="http://www.britishcycling.org.uk/campaigning/article/cam20140630-campaigning-news-New-vision-for-Leeds-unveiled-as-possible-legacy-from-hosting--Tour-de-France-0" target="_blank">here</a><br />
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Alan Taylor is a Lecturer in <a href="http://www.nottingham.ac.uk/healthsciences/undergraduate/physiotherapy-rehabilitation-courses/index.aspx" target="_blank">Physiotherapy and Sport Rehabilitation & Exercise Science </a>at the University of Nottingham. He rode the Kellogg's Tour of Britain in 1988 and still rides a bike for pleasure and commuting. Sometimes he plays in a band ...<br />
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(Follow on Twitter <a href="https://twitter.com/TaylorAlanJ" target="_blank">@Tayloralanj</a>)<br />
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<span style="color: blue;">For a full run down on the PARTY that is the Tour de France ... Go <a href="http://festival.yorkshire.com/" target="_blank">here </a></span></h3>
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<span style="color: blue;"> </span></h3>
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<span style="color: blue;">Oh ... and if you happen to be near Hebden Bridge... Go <a href="http://www.skiffleshow.com/" target="_blank">here </a></span></h3>
<br />Clinical Reasoning Sessionshttp://www.blogger.com/profile/09852524904111114134noreply@blogger.com0tag:blogger.com,1999:blog-6560398305209426117.post-34645936195047999842014-04-23T09:11:00.000-07:002014-10-12T11:07:56.831-07:00The art of ‘naysaying’ …evidence based practice and whiplash associated disorder<style>
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<b style="mso-bidi-font-weight: normal;"><span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Cambria; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: minor-latin;">So first of all,
what is a naysayer?</span></b></h3>
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<span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Cambria; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: minor-latin;">Well,
the <a href="http://www.merriam-webster.com/dictionary/naysayer" target="_blank"><span style="mso-bidi-font-family: Cambria;">Merriam-Webster</span></a> gives the
following definition – “a person who says something will not work or is not
possible: a person who denies, refuses, or opposes something”</span></div>
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<span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Cambria; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: minor-latin;">The
<a href="http://www.urbandictionary.com/define.php?term=naysayer" target="_blank"><span style="mso-bidi-font-family: Cambria;">Urban Dictionary</span></a> definition is
somewhat lengthier and perhaps more revealing:</span></div>
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<span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Cambria; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: minor-latin;">“</span><span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Cambria; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB; mso-hansi-theme-font: minor-latin;">One who frequently engages in excessive complaining, negative banter
and/or a genuinely poor and downbeat attitude.” </span></div>
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<span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Cambria; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB; mso-hansi-theme-font: minor-latin;">They continue … “Naysayers are distinguished by
their tendency to consistently view the glass half empty, make frequent one-way
trips to <b>negative town</b>, and constantly <b>emphasize the worst of a situation</b>. They
have the keen ability to spread their pessimistic attitude to a group of
unsuspecting bystanders and <b>encourage others to employ their mind-set</b>.” </span></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiJgrguneNbcIMCZzXYoq6PUjpXOxFntV34CASDWulELBddf58yLvCci_fNPnMitqd4tdJtKVDGfRaDOTx3egIhH8uY06nFiKzeJWzQ2DTnBjz4H25jj6rLz_kiYZi7sQHLbTQ3NZpKbac/s1600/half+full.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiJgrguneNbcIMCZzXYoq6PUjpXOxFntV34CASDWulELBddf58yLvCci_fNPnMitqd4tdJtKVDGfRaDOTx3egIhH8uY06nFiKzeJWzQ2DTnBjz4H25jj6rLz_kiYZi7sQHLbTQ3NZpKbac/s1600/half+full.png" height="196" width="640" /></a></div>
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<br /></div>
<h3>
<span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Cambria; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB; mso-hansi-theme-font: minor-latin;">From a behavioural perspective they suggest that “Naysayers … will stop at
nothing to bring a general sense of negativity to any situation.” </span></h3>
<h3>
<span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Cambria; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB; mso-hansi-theme-font: minor-latin;"> </span>
</h3>
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<b style="mso-bidi-font-weight: normal;"><span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Cambria; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB; mso-hansi-theme-font: minor-latin;">BUT … What has this all got to do with Physiotherapy and evidence based
practice?</span></b></h3>
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<br /></div>
<div class="MsoNormal" style="line-height: 115%; margin-bottom: 10.0pt;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Cambria; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB; mso-hansi-theme-font: minor-latin;"></span></b></div>
<h3>
<b style="mso-bidi-font-weight: normal;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhOIgTPREblZmnPmNj5kNaGM2p44QohZBnbIe25Dbi6c2Zv05NnWOy0uzUCwNSNgQyknG_8Dzg-hgMHH5aOx-GjoUdlsZddgw-zGKmeQ3CApTxdiaFLTtPeTeEMb9DFjwzDLX7z8MiyUno/s1600/Thoma_Loneliness.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhOIgTPREblZmnPmNj5kNaGM2p44QohZBnbIe25Dbi6c2Zv05NnWOy0uzUCwNSNgQyknG_8Dzg-hgMHH5aOx-GjoUdlsZddgw-zGKmeQ3CApTxdiaFLTtPeTeEMb9DFjwzDLX7z8MiyUno/s1600/Thoma_Loneliness.jpg" height="256" width="320" /></a></b><span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Cambria; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB; mso-hansi-theme-font: minor-latin;"> </span></h3>
<h3>
<span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Cambria; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB; mso-hansi-theme-font: minor-latin;">Because it is EASY to be a naysayer in the tiny
World of evidence based medicine (EBM) or practice (EBP). We seem to be beset by
a veritable queue of them, some aspiring desperately to be the next <a href="http://edzardernst.com/" target="_blank"><span style="mso-bidi-font-family: Cambria;">EdzardErnst</span></a> (he made a career out of it … and still does!) within their
own ‘specialist’ domain. </span></h3>
<h3>
<span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Cambria; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB; mso-hansi-theme-font: minor-latin;"> </span></h3>
<br />
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<br />
<br />
<span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Cambria; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB; mso-hansi-theme-font: minor-latin;">Physiotherapy (PT) has not escaped this trend. There is an
increasing army of bloggers (he said from his blog … such irony!) and
Twitterati, who now peddle their view of the World. They utilise the latest evidence, to back
up their statements and often negative rants about WHAT DOESN’T work in PT (Yawn! If you haven't seen one, don't go looking for one ... you could end up writing a blog!). </span></div>
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<span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Cambria; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB; mso-hansi-theme-font: minor-latin;">They pre-empt criticism, by cleverly suggesting that anyone who
disagrees <span style="mso-spacerun: yes;"> </span>with their interpretation of
the the evidence, is either ‘unscientific’, a ‘fool’ or perhaps a ‘</span><span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: minor-latin;">curmudgeon’, thereby
discouraging discourse or opposing views from the outset.</span></div>
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<b style="mso-bidi-font-weight: normal;"><span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: minor-latin;">…and so what?<span style="mso-spacerun: yes;">
</span>I hear you ask! </span></b></div>
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<span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: minor-latin;">PT has
come a long way in the last decade or two, in terms of its use of the evidence
base, to drive treatment interventions and mould out-dated thinking and
practice. As each day goes by we find more and more studies, which guide the
way we treat and rehabilitate our cases. </span></div>
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<span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: minor-latin;">Of course, it can be very puzzling
and even soul destroying for clinicians to find that a mode of treatment which
they believed was ‘effective’, is suddenly found by the latest study to have
little or ‘no effect’ ...BUT that's life, it makes us stronger! </span></h3>
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<span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: minor-latin;">A good example is the
recent publication in the <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2814%2960457-8/fulltext" target="_blank">Lancet</a>,
which suggested in its ‘Interpretation’ section … “We have shown that simple
advice is equally as effective as a more intense and comprehensive
physiotherapy exercise programme.”</span></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiAWAcUOMEHVmDvlhq-ijeYUnRh9cU3YJSEAbxjH5Ha9DLd6j_nIMOrQ9glBrnVk7DWwYTvYrGsF_n0g64imwC-pDocKZaST2nNEkwfOFVzoxgKyAKtqBWWjaJfC-knceXNv8vqtFTmABA/s1600/Screenshot+2014-04-23+14.22.59.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiAWAcUOMEHVmDvlhq-ijeYUnRh9cU3YJSEAbxjH5Ha9DLd6j_nIMOrQ9glBrnVk7DWwYTvYrGsF_n0g64imwC-pDocKZaST2nNEkwfOFVzoxgKyAKtqBWWjaJfC-knceXNv8vqtFTmABA/s1600/Screenshot+2014-04-23+14.22.59.png" height="300" width="640" /></a></div>
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</h3>
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<span lang="EN-US" style="font-family: Cambria; mso-ansi-language: EN-US; mso-ascii-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: minor-latin; mso-no-proof: yes;"></span><span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: minor-latin;"></span></h3>
<h3>
</h3>
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<span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: minor-latin;"> </span></h3>
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<span style="color: #0b5394;"><span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: minor-latin;">This type of conclusion ...
naturally comes as a body blow to clinicians, many of whom have an inherent
faith in the belief that their interventions are doing good. </span></span></h3>
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<span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: minor-latin;"> </span></h3>
<div class="separator" style="clear: both; text-align: center;">
</div>
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<br /></div>
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<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg5Gkcdh5Va2ns4W2eos_7qt02_4FqU9vV-Qy7T3Wdr3Knxg0SrZ1w2xsmV1ltJ87HPRiR-rn6Xixsj8YRv4mQZjQlOfb3PgORYBXMjLZDU-4CVZH7rSVQmxVWj3T_XHgDDHzFvsoQ6hDw/s1600/Black+dog.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg5Gkcdh5Va2ns4W2eos_7qt02_4FqU9vV-Qy7T3Wdr3Knxg0SrZ1w2xsmV1ltJ87HPRiR-rn6Xixsj8YRv4mQZjQlOfb3PgORYBXMjLZDU-4CVZH7rSVQmxVWj3T_XHgDDHzFvsoQ6hDw/s1600/Black+dog.jpg" /></a></div>
<br />
<br />
<span style="font-family: Cambria;">So just when you were feeling a little vulnerable ... </span><b style="mso-bidi-font-weight: normal;"><span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: minor-latin;">ENTER THE NAYSAYER!</span></b><span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: minor-latin;"> … Usually a confident and
bold academic type, who with all the guile of <a href="http://www.independent.co.uk/news/people/jeremy-clarkson-and-his-black-dog-didier-dogba-unsurprisingly-manage-to-offend-another-group-of-people-9273173.html" target="_blank">Jeremy Clarkson in a dog naming competition </a></span></div>
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<span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: minor-latin;">...explains gleefully in a detailed blog, that, ‘actually folks you got it all wrong’ ... which of course
he/she knew all along … and which is now ‘evidenced’ by the latest trial!</span></div>
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<br /></div>
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<br />
<b><span style="font-family: Cambria;">Brilliantly done and incredibly EASY … BUT
WHAT IS THE POINT? </span></b></div>
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<b style="mso-bidi-font-weight: normal;"><span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: minor-latin;">Answer … There isn’t one! </span></b></div>
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<span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: minor-latin;">… Though they WILL say, they
are disseminating information … updating us all on the latest evidence. </span></div>
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<span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: minor-latin;">Errr maybe …
OR it could be argued, gleefully exercising blatant ‘told you so’ promotion of their own Worldview.</span><span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Cambria; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB; mso-hansi-theme-font: minor-latin;"> </span></h3>
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<span style="font-family: Cambria;">Naysayers seldom offer a pragmatic alternative ...</span></h3>
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<span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Cambria; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB; mso-hansi-theme-font: minor-latin;">Academics have the luxury of being able to access,
read and analyse the latest research and some do that brilliantly, as do many
clinicians. As a result there is a plethora of blogs, which are designed to be genuinely
helpful to clinicians and academics alike, and give thoughtful interpretations of contemporary evidence,
which can be translated into practice. The <a href="http://thesportsphysio.wordpress.com/" target="_blank"><span style="mso-bidi-font-family: Cambria;">sportsphysio</span></a> is one excellent example, <a href="http://rogerkerry.wordpress.com/" target="_blank"><span style="mso-bidi-font-family: Cambria;">rogerkerry.wordpress</span></a>
is another.</span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEifEfU47gxj7nAOGVHMpTsNUh7yRr3JlQfk-wongR89n4YObBqdj-JErM1PBK4JfhT4hhxnyphgrr1OJfyUdRgMpQfSjHy6LmcMf8yMiLKlWEQXRJc8SCnymKDGr2N_5wZpfuQmNRs4jdA/s1600/Edzard_ernst.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEifEfU47gxj7nAOGVHMpTsNUh7yRr3JlQfk-wongR89n4YObBqdj-JErM1PBK4JfhT4hhxnyphgrr1OJfyUdRgMpQfSjHy6LmcMf8yMiLKlWEQXRJc8SCnymKDGr2N_5wZpfuQmNRs4jdA/s1600/Edzard_ernst.jpg" height="268" width="320" /></a><span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Cambria; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB; mso-hansi-theme-font: minor-latin;">Thankfully, as the <a href="http://www.urbandictionary.com/define.php?term=naysayer" target="_blank"><span style="mso-bidi-font-family: Cambria;">Urban Dictionary</span></a> helpfully
suggests, naysayers are, “<b>Not to be confused with non-naysayers </b>… who fight
against the negativity brought forth by naysayers, make the best of a situation
and are not afraid to call out a naysayer on the spot.” </span></div>
<div class="MsoNormal" style="line-height: 115%; margin-bottom: 10.0pt;">
<span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Cambria; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB; mso-hansi-theme-font: minor-latin;">My personal advice to busy clinicians is to seek
out the pragmatic NON-NAYSAYERS (like those mentioned above and <a href="http://physiotalk.co.uk/2014/04/16/an-msk-who-to-follow-for-twitter-from-peter_gettings/" target="_blank">here</a>). Those who have the ability to construct rather than deconstruct their own profession, whilst at the same time, embracing the concepts of contemporary science and evidence based clinical practice. </span><br />
<br />
<b><span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Cambria; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB; mso-hansi-theme-font: minor-latin;"><span style="color: #cc0000;">Change is required, but not via the medium of lofty negativity.</span> </span></b></div>
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<span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Cambria; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB; mso-hansi-theme-font: minor-latin;">On the subject of whiplash injury</span></h3>
<div class="MsoNormal" style="line-height: 115%; margin-bottom: 10.0pt;">
<span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Cambria; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB; mso-hansi-theme-font: minor-latin;">This is NOT a trivial subject … The emerging science is welcome, it is clear
that PT’s will need to look carefully at current practice in the light of contemporary studies relating to Whiplash Associated Disorder. </span><br />
<br />
<span style="font-family: Cambria;">Prof Michelle Sterling
herself, suggested a <b>PT role in assessment, sub-grouping, early recognition of <a href="http://www.ncbi.nlm.nih.gov/pubmed/23707284" target="_blank"><span style="mso-bidi-font-family: Cambria;">PTSD</span></a> and triage </b>(for early cognitive behavioural therapy) may well be sequelae of the groups latest findings. </span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhsCSogtdDcPxZs7n4dW7gMmbjBflg4ag8GgExX6Ra7oaAfn4CfifpWHsWh50dLaetGC5_-E6Mf_LIK4j8CuMnW01Xej189PQHFMOS5fhlZ1A2Fb8Bu3z2J6HuhAeYPQY6qJWe-nyf_cps/s1600/IIHS_Hyundai_Tucson_crash_test.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhsCSogtdDcPxZs7n4dW7gMmbjBflg4ag8GgExX6Ra7oaAfn4CfifpWHsWh50dLaetGC5_-E6Mf_LIK4j8CuMnW01Xej189PQHFMOS5fhlZ1A2Fb8Bu3z2J6HuhAeYPQY6qJWe-nyf_cps/s1600/IIHS_Hyundai_Tucson_crash_test.jpg" height="208" width="320" /></a><span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Cambria; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB; mso-hansi-theme-font: minor-latin;">Using
Michaleff et al’s study as an example, DON’T FORGET ... it only looked at one
particular ‘pragmatic exercise programme’ ... devised by 'experts' YES, but was it the right type of rehab, applied at the right time? </span></div>
<div class="MsoNormal" style="line-height: 115%; margin-bottom: 10.0pt;">
<span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Cambria; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB; mso-hansi-theme-font: minor-latin;">In other words, in the same way that
the emerging research has guided our thinking on best practice in ACL rehab for example,
it may well guide us further in the field of WAD. </span></div>
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<span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Cambria; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB; mso-hansi-theme-font: minor-latin;"><br /></span></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhAeBvsjEcBlqdxZNjHLTWpO9cyfR8JzWqETuku6Iyz1B-EVhrf5ianrN_MqDbYcPtLFqjuD1UFl56p2r76G5jaBKfR1SkKAz8n5k5dGJeMgPeN3qnb_9zlC40IX75LGAIyYIwBYiSDEHU/s1600/Screenshot+2014-04-23+11.28.31.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhAeBvsjEcBlqdxZNjHLTWpO9cyfR8JzWqETuku6Iyz1B-EVhrf5ianrN_MqDbYcPtLFqjuD1UFl56p2r76G5jaBKfR1SkKAz8n5k5dGJeMgPeN3qnb_9zlC40IX75LGAIyYIwBYiSDEHU/s1600/Screenshot+2014-04-23+11.28.31.png" height="294" width="640" /></a></div>
<div class="MsoNormal" style="line-height: 115%; margin-bottom: 10.0pt;">
<br /></div>
<div class="MsoNormal" style="line-height: 115%; margin-bottom: 10pt;">
<span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Cambria; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB; mso-hansi-theme-font: minor-latin;"><b>DO NOTE</b> (because the naysayers may have missed it ...) the final paragraph in another <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2814%2960130-6/fulltext?rss=yes" target="_blank"><span style="mso-bidi-font-family: Cambria;">Lancet Article relating to WAD and exercise</span></a>… </span></div>
<h2 class="MsoNormal" style="line-height: 115%; margin-bottom: 10pt;">
<span style="font-family: Cambria;"> </span><span style="color: #0b5394;"><b><i><span style="font-family: Calibri;">“… </span></i><span style="mso-bidi-font-weight: normal;"><i style="mso-bidi-font-style: normal;"><span style="font-family: Calibri; mso-ascii-theme-font: major-latin; mso-fareast-font-family: "Times New Roman"; mso-hansi-theme-font: major-latin;">These findings should NOT be interpreted as
encouragement to abandon exercise therapy in these patients: ... the question is
HOW & WHEN to exercise people with chronic whiplash-associated disorders.”
(upper case, for non-naysayer emphasis)</span></i></span></b></span><span style="font-family: "Calibri","sans-serif"; font-size: 11.0pt; line-height: 115%; mso-ascii-theme-font: minor-latin; mso-bidi-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;"> </span></h2>
<div class="MsoNormal" style="line-height: 115%; margin-bottom: 10pt;">
<span style="font-family: "Calibri","sans-serif"; font-size: 11pt; line-height: 115%;">Academics might dwell for a moment on this statement from <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2814%2960130-6/fulltext?rss=yes" target="_blank">Nijs and Hickman 2014 ...</a> </span><br />
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starting to integrate cognitive behavioural therapy as part of pain management
modules ... Future physiotherapists might have the necessary attitudes, beliefs,
and skills to apply specific cognitive behavioural therapy rules <b>during
exercise therapy for chronic pain patients, including those with
whiplash-associated disorders.</b>"</span></div>
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<br />
<div style="line-height: 115%;">
<span style="font-family: "Calibri","sans-serif"; font-size: 11pt; line-height: 115%;">FINALLY clinicians, ask yourself
honestly … (with or without CBT) when was the last time you REALLY applied resistance to cervical
spine musculature during neck <a href="http://www.ncbi.nlm.nih.gov/pubmed/24561636" target="_blank">rehabilitation</a>? ...and more
importantly, would it make any difference to outcomes?</span><br />
<br />
<span style="font-family: "Calibri","sans-serif"; font-size: 11.0pt; line-height: 115%; mso-ascii-theme-font: minor-latin; mso-bidi-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;">The jury, on those particular
questions will remain out for some time. <b> </b></span></div>
<div style="line-height: 115%;">
<br />
<span style="font-family: "Calibri","sans-serif"; font-size: 11pt; line-height: 115%;"><b>REMEMBER pendulums swing!</b></span><b><span style="font-family: "Calibri","sans-serif"; font-size: 11pt; line-height: 115%;"><span style="color: #cc0000;"> </span></span></b><br />
<br />
<b><span style="font-family: "Calibri","sans-serif"; font-size: 11pt; line-height: 115%;"><span style="color: #cc0000;">For a guide on useful BLOGS and
'Physio Twitterati' ... Here is the helpful</span> <a href="http://physiotalk.co.uk/2014/04/16/an-msk-who-to-follow-for-twitter-from-peter_gettings/" target="_blank">physiotalk </a></span></b><span style="font-family: "Calibri","sans-serif"; font-size: 11.0pt; line-height: 115%; mso-ascii-theme-font: minor-latin; mso-bidi-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;"><a href="http://physiotalk.co.uk/2014/04/16/an-msk-who-to-follow-for-twitter-from-peter_gettings/" target="_blank"><b>BLOG</b></a></span></div>
</div>
<span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Cambria; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB; mso-hansi-theme-font: minor-latin;"></span><br />
<div align="center" class="MsoListParagraphCxSpFirst" style="line-height: 115%; margin-bottom: 10.0pt; mso-add-space: auto; text-align: center;">
<b><span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Cambria; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB; mso-hansi-theme-font: minor-latin;">- BEWARE THE NAYSAYERS -</span></b><br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEieicEjqr-Zei9owg5WwaXWhccOeDsz8jE8sZccxNTme1JtNgEZqKuW2U096_t0bflSGZ4S9vCb8xLIDsznjfDR5nFlZrnXjOabzfyPATpG2_htet9_0rXk4n3avAaauCUxVWE24R0DmXQ/s1600/Naysayers+II.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEieicEjqr-Zei9owg5WwaXWhccOeDsz8jE8sZccxNTme1JtNgEZqKuW2U096_t0bflSGZ4S9vCb8xLIDsznjfDR5nFlZrnXjOabzfyPATpG2_htet9_0rXk4n3avAaauCUxVWE24R0DmXQ/s1600/Naysayers+II.jpg" height="302" width="320" /></a></div>
</div>
<div class="MsoListParagraphCxSpLast" style="line-height: 115%; margin-bottom: 10.0pt; mso-add-space: auto;">
<i style="mso-bidi-font-style: normal;"><span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Cambria; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB; mso-hansi-theme-font: minor-latin;"><a href="http://funnyasduck.net/" target="_blank">http://funnyasduck.net/ </a></span></i><br />
<br />
<i><span style="font-family: Cambria;">This article
was written by a curmudgeonly, argumentative NON-NAYSAYER, entirely for the purposes of pleasure and self promotion (..ha, ha!). </span></i></div>
<div class="MsoNormal" style="line-height: 115%; margin-bottom: 10.0pt;">
<br />
<div style="color: #990000;">
<b><i style="mso-bidi-font-style: normal;"><span style="font-family: Cambria; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Cambria; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB; mso-hansi-theme-font: minor-latin;">Any association of this article with any particular blog ... or any person living or dead, is entirely constructed via the imagination of the reader.</span></i></b></div>
<br />
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<b><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">Author</span></b></div>
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<br /></div>
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<span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">Alan J Taylor - is
a medico-legal expert witness, in the field of clinical negligence related to
manual therapy and stroke or other haemodynamic events.</span></div>
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<br /></div>
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<span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">He has worked as a
lecturer in Physiotherapy and Sports Rehabilitation & Exercise Science at
the University of Nottingham since 2010.</span></div>
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<br /></div>
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<span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">He worked full-time
as a clinician until joining the UoN and maintains a clinical case load via his
Consultancy, which regularly takes him to to some of the UK's leading sports
clubs. He deals with a variety of pain and performance related cases, many with
a haemodynamic bias. </span></div>
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<br /></div>
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<span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><a href="https://twitter.com/TaylorAlanJ"><span style="color: blue;">https://twitter.com/TaylorAlanJ</span></a></span></div>
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<br /></div>
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<b><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">References</span></b></div>
<div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: 45.8pt 91.6pt 137.4pt 183.2pt 229.0pt 274.8pt 320.6pt 366.4pt 412.2pt 458.0pt 503.8pt 549.6pt 595.4pt 641.2pt 687.0pt 732.8pt;">
<span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">Geary K, Green BS,
Delahunt E (2014). Effects of Neck Strength Training on Isometric Neck Strength
in Rugby Union Players. <i style="mso-bidi-font-style: normal;">Clin J Sport Med</i>.
Feb 24. PMID: <a href="http://www.ncbi.nlm.nih.gov/pubmed/24561636"><span style="color: blue;">24561636 </span></a> </span></div>
<div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
<span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">Michaleff ZA, Maher CG, Lin CW, Rebbeck T, Jull G, Latimer J, Connelly
L, & Sterling M (2014). Comprehensive physiotherapy exercise programme or
advice for chronic whiplash (PROMISE): a pragmatic randomised controlled trial.
<i>Lancet</i> PMID: <a href="http://www.ncbi.nlm.nih.gov/pubmed/24703832"><span style="color: blue;">24703832</span></a></span></div>
<div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: 45.8pt 91.6pt 137.4pt 183.2pt 229.0pt 274.8pt 320.6pt 366.4pt 412.2pt 458.0pt 503.8pt 549.6pt 595.4pt 641.2pt 687.0pt 732.8pt;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: 45.8pt 91.6pt 137.4pt 183.2pt 229.0pt 274.8pt 320.6pt 366.4pt 412.2pt 458.0pt 503.8pt 549.6pt 595.4pt 641.2pt 687.0pt 732.8pt;">
<span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">Nijs J, Ickmans
K.Lancet (2014). Chronic whiplash-associated disorders: to exercise or
not? Lancet PMID: <a href="http://www.ncbi.nlm.nih.gov/pubmed/24703833"><span style="color: blue;">24703833</span></a> </span></div>
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Clinical Reasoning Sessionshttp://www.blogger.com/profile/09852524904111114134noreply@blogger.com0tag:blogger.com,1999:blog-6560398305209426117.post-80344902963549471602014-01-07T06:19:00.000-08:002018-02-20T07:51:54.251-08:00Understanding cervical arterial dysfunction (CAD) for clinicians<!--[if gte mso 9]><xml>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjEEXdkw9tcKHmAXm5GtIJQVvQmd4PIPg8I67_NGKwHZHYd9vBsp8hhU4J8Ih5SLjM5e9Li_cVuCVvIYNDucJUuY1Lat0SHDMnIs3oniGAty1hWziAmdMJFsDko40TkViUTjTb-YR3wMg0/s1600/Haemodynamics+of+the+mind.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjEEXdkw9tcKHmAXm5GtIJQVvQmd4PIPg8I67_NGKwHZHYd9vBsp8hhU4J8Ih5SLjM5e9Li_cVuCVvIYNDucJUuY1Lat0SHDMnIs3oniGAty1hWziAmdMJFsDko40TkViUTjTb-YR3wMg0/s1600/Haemodynamics+of+the+mind.png" width="110" /></a><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"> </span></div>
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The publication of the
succinctly titled;</div>
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<br /></div>
<div class="MsoNormal" style="font-family: Verdana,sans-serif; line-height: normal; margin-bottom: 0.0001pt;">
<i style="mso-bidi-font-style: normal;">‘International
framework for examination of the cervical region for potential of Cervical
Arterial Dysfunction prior to Orthopaedic Manual Therapy intervention’</i>
(Rushton, et al 2013)</div>
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<br /></div>
<div class="MsoNormal" style="font-family: Verdana,sans-serif; line-height: normal; margin-bottom: 0.0001pt;">
... has highlighted the need for manual therapy clinicians to
be cognisant with<b> <i style="mso-bidi-font-style: normal;">cervical arterial
dysfunction (CAD)</i></b>. </div>
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<br /></div>
<div class="MsoNormal" style="font-family: Verdana,sans-serif; line-height: normal; margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="font-family: Verdana,sans-serif; line-height: normal; margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="font-family: Verdana,sans-serif; line-height: normal; margin-bottom: 0.0001pt;">
<b><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">BUT what is that? … and what does it
mean to clinicians?</span></b></div>
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<br /></div>
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<br /></div>
<div class="MsoNormal" style="font-family: Verdana,sans-serif; line-height: normal; margin-bottom: 0.0001pt;">
<b>Let
us start ... by dealing with what it is NOT</b></div>
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgrvf6dbJHdPfYbKP5K1NpxPtvFyMv8Ge68Cb2LHkv7SQcPhYIY4sVDXNHGZ0EA5A_I6IrHMP0tZonAiyrVsiVwBQmKeTds_ukuUsDj0njlASMbQWgkICWaIfsOUAr5llB0pN2vudlh0tQ/s1600/Dissection.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="260" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgrvf6dbJHdPfYbKP5K1NpxPtvFyMv8Ge68Cb2LHkv7SQcPhYIY4sVDXNHGZ0EA5A_I6IrHMP0tZonAiyrVsiVwBQmKeTds_ukuUsDj0njlASMbQWgkICWaIfsOUAr5llB0pN2vudlh0tQ/s1600/Dissection.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: "verdana" , sans-serif;">Dissection of an artery</span></td></tr>
</tbody></table>
<ol>
<li><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;"><span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"></span></span></span> <span style="font-family: "verdana" , sans-serif;">Cervical arterial dysfunction is NOT cervical
arterial dissection! That may seem obvious to some, but both acronyms are now
in common usage and therefore some confusion may arise. The term </span><i style="font-family: Verdana,sans-serif;">dissection</i><span style="font-family: "verdana" , sans-serif;"> is specific to dissection
events (see image) and therefore narrow. Cervical arterial </span><i style="font-family: Verdana,sans-serif;">dysfunction </i><span style="font-family: "verdana" , sans-serif;">is a broader term which is all-encompassing of a range of
pathologies which may affect the cervico-cranial vasculature. </span></li>
<li style="font-family: Verdana,sans-serif;"><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">CAD is NOT vertebro-basilar insufficiency
(VBI). However, it does incorporate it - as one of the component parts of a wider
system based approach to thinking about haemodynamics and ischaemia </span></li>
<li style="font-family: Verdana,sans-serif;"><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;"><span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"></span></span></span><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">Above all, CAD is NOT (in isolation) dissection of the
vertebral artery. That would simply be a continuation of the narrow thought process
which lead us to believe that a single test i.e. the vertebral artery test,
could somehow allow us to decide whether cervical manipulation was ‘safe’ or
not! That outdated concept has thankfully been de-bunked once and for all, as
we move closer to science based practice.</span></li>
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<b style="mso-bidi-font-weight: normal;"><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">So what is cervical arterial dysfunction
then…?</span></b><br />
<br />
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<i><span style="font-family: "verdana" , "sans-serif"; font-size: 12.0pt;">CAD is a consideration of ALL of the potential arterial
dysfunctions, which may present to, or ensue from a manual therapy
intervention.</span></i></div>
</div>
<div class="MsoListParagraphCxSpMiddle" style="font-family: Verdana,sans-serif; line-height: normal; margin: 0cm 0cm 0.0001pt;">
<span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">CAD
is simply a way of thinking about an age old problem in a different way, and
more importantly asking ourselves different questions about this familiar
problem – linked to RISK and cervical spine management. The emphasis has moved
firmly away from just ‘manipulation’, into a consideration of movement per se.
This clearly widens the thinking into a consideration of ASSESSMENT (which
incorporates movement) as well as intervention, which may incorporate ANY form
of manual therapy or exercise prescription. This is then combined with a consideration of ALL of the potential structures and vascular 'dysfunctions'. Thinking is no longer constrained by one structure or pathology.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="font-family: Verdana,sans-serif; line-height: normal; margin: 0cm 0cm 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="font-family: Verdana,sans-serif; line-height: normal; margin: 0cm 0cm 0.0001pt;">
<b style="mso-bidi-font-weight: normal;"><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">So why the shift from VBI and
vertebral artery dissection …?</span></b></div>
<div class="MsoListParagraphCxSpMiddle" style="font-family: Verdana,sans-serif; line-height: normal; margin: 0cm 0cm 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="font-family: Verdana,sans-serif; line-height: normal; margin: 0cm 0cm 0.0001pt;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjsZkMLY5rgxJ_fy76QCEue3w4rME6Uz2vdkafaZ9abKH-Da2qOA0OP79pEBOGefzPaNJCbrLPQGb9DvXb2d8LmtkQD-tSMr6_6IYIPDBdY4VOQ0WrBNuQST4c_jr5EGtrwhYJoatJLdrU/s1600/Endo_dysfunction_Athero.PNG" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjsZkMLY5rgxJ_fy76QCEue3w4rME6Uz2vdkafaZ9abKH-Da2qOA0OP79pEBOGefzPaNJCbrLPQGb9DvXb2d8LmtkQD-tSMr6_6IYIPDBdY4VOQ0WrBNuQST4c_jr5EGtrwhYJoatJLdrU/s1600/Endo_dysfunction_Athero.PNG" width="291" /></a><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">Well
first of all, there is a lot more to the cervical vasculature than the vertebro-basilar
system and there is a lot more to the range of pathologies than just dissection.
Dissection or damage to the intimal wall of a vessel is a commonly cited
vascular ‘injury’ thought to be associated with cervical spine manipulation in
particular. However, an understanding of the basic science of haemodynamics
allows us to incorporate many more conditions and pathologies into the paradigm. </span></div>
<div class="MsoListParagraphCxSpMiddle" style="font-family: Verdana,sans-serif; line-height: normal; margin: 0cm 0cm 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="font-family: Verdana,sans-serif; line-height: normal; margin: 0cm 0cm 0.0001pt;">
There are a range of reasons why blood vessels may be compromised in the
cervico-cranial region, from pre-existing underlying anatomical anomalies, vasospasm,
atherosclerotic disease, through to arteritis (i.e. temporal). All of these may lead
in different ways, to potential ischaemia which may manifest and a variety of
ways, ranging from PAIN, through to blindness, stroke or at worst death.</div>
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<span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"> </span><b style="mso-bidi-font-weight: normal;"><span style="color: black; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">Some direction for clinicians:</span></b></div>
<ul><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgbgqkOuquv6bDassRvnRfFoZ-ofvzj6DO3fKXOMlamhC7bQmbOgC8v4uKYiMR64wyEYK_CX_F0kayShwbXtMeW9TUAhV23MxeNWB0-izkcUcYXRzTLxeZR7hisblj_l-i67hYry115pw4/s1600/Vesalius_Fabrica_p190.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgbgqkOuquv6bDassRvnRfFoZ-ofvzj6DO3fKXOMlamhC7bQmbOgC8v4uKYiMR64wyEYK_CX_F0kayShwbXtMeW9TUAhV23MxeNWB0-izkcUcYXRzTLxeZR7hisblj_l-i67hYry115pw4/s1600/Vesalius_Fabrica_p190.jpg" width="182" /></a>
<li><span style="color: black;"><span style="mso-list: Ignore;"><span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"></span></span></span><span style="color: black; font-family: "verdana" , sans-serif;">Develop an understanding that
there is more to cervical spine risk assessment than a consideration of ‘VBI’
or dissection of the vertebral artery.</span></li>
<li style="font-family: Verdana,sans-serif;"><span style="color: black;"><span style="mso-list: Ignore;"><span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"></span></span></span><span style="color: black; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">Consider a ‘systems based’ approach,
incorporating the whole cervical vascular system, including the carotid vasculature
(and branches) and the whole range of potential pathologies (NOT just
dissection).</span></li>
<li style="font-family: Verdana,sans-serif;"><span style="color: black;"><span style="mso-list: Ignore;"><span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"></span></span></span><span style="color: black; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">Develop awareness, that whilst
commonly cited vascular risk factors have not been shown to be associated with
dissection pathologies, they <b style="mso-bidi-font-weight: normal;">are strongly
correlated</b> with atherosclerosis, hypertension and stroke … This is ‘system
based thinking’.</span></li>
<li style="font-family: Verdana,sans-serif;"><span style="color: black;"><span style="mso-list: Ignore;"><span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"></span></span></span><span style="color: black; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">Develop increased awareness that
neck pain and headache may be the early signs of pre-existing vascular
dysfunction.</span></li>
<li style="font-family: Verdana,sans-serif;"><span style="color: black;"><span style="mso-list: Ignore;"><span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"></span></span></span><span style="color: black; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">Develop an index of suspicion for
cervico-cranial vascular pathology, particularly in cases of acute trauma or non-resolving/worsening
conditions.</span></li>
<li style="font-family: Verdana,sans-serif;"><span style="color: black;"></span><span style="color: black; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">Enhance subjective/objective
examination by including vascular risk factors such as hypertension, and
procedures such as blood pressure, cranial nerve testing and eye examination.</span></li>
<li style="font-family: Verdana,sans-serif;"><span style="color: black;"><span style="mso-list: Ignore;"><span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"></span></span></span><span style="color: black; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">Consider carefully the ORDER of
your examination in the presence of potential vascular ‘red flags’. </span></li>
<li style="font-family: Verdana,sans-serif;"><span style="color: black;"><span style="mso-list: Ignore;"><span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"></span></span></span><span style="color: black; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">Expand manual therapy teaching and
practice to include haemodynamic principals and their relationship to movement,
handling, anatomy and biomechanics.</span></li>
</ul>
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<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgOyjKQYlT1HvZDD36zZ1_sF8nd62HcSq-bnYmJP5bl88f2JdgWqZv7JKkKLEmNdVFYqWhs7bXvJqgFGB1A8eMcDKwjANIlT_C3whRcHu1wKQOy9Wke0ZE9bqDOQgNaU0ttP6do5cIi07A/s1600/Diplodocus_by_Hay_1910.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="126" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgOyjKQYlT1HvZDD36zZ1_sF8nd62HcSq-bnYmJP5bl88f2JdgWqZv7JKkKLEmNdVFYqWhs7bXvJqgFGB1A8eMcDKwjANIlT_C3whRcHu1wKQOy9Wke0ZE9bqDOQgNaU0ttP6do5cIi07A/s1600/Diplodocus_by_Hay_1910.jpg" width="200" /></a></div>
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<span style="color: black;">Despite all this … when all is said and done, the 64m dollar
question still seems to be</span><b style="mso-bidi-font-weight: normal;"><span style="color: black; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"> … Should clinicians perform a ‘vertebral artery
test’?</span></b></div>
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<b style="mso-bidi-font-weight: normal;"><span style="color: black; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">Answer</span></b><span style="color: black; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"> … there is little to support it's use as a stand alone test. Its sensitivity and
specificity are very poor <b>AND</b> its clinical utility is of little value. It has been argued that it should be retained from a 'medico-legal' perspective, but that contention would most likely be destroyed by any half competent barrister. </span></div>
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<b style="mso-bidi-font-weight: normal;"><span style="color: black; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">Note</span></b><span style="color: black; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"> - that cranial nerve and blood
pressure testing are additional objective measures to incorporate into the physical examination. Both feature prominently in the IFOMPT framework.</span></div>
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<br /></div>
<div class="MsoNormal" style="font-family: Verdana,sans-serif; line-height: normal; margin-bottom: 0.0001pt;">
<span style="color: black; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">See:</span><br />
<span style="color: black;"><span style="mso-spacerun: yes;"><a href="http://alteredhaemodynamics.blogspot.co.uk/2013/10/cranial-nerve-testing-cervical-spine.html" target="_blank">Cranial nerve testing</a></span><a href="http://alteredhaemodynamics.blogspot.co.uk/2013/10/cranial-nerve-testing-cervical-spine.html"></a></span></div>
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<a href="http://alteredhaemodynamics.blogspot.co.uk/2013/12/5-good-reasons-for-manual-therapists-to.html" target="_blank">Blood pressure testing</a></div>
<div class="MsoNormal" style="font-family: Verdana,sans-serif; line-height: normal; margin-bottom: 0.0001pt;">
<span style="color: black; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormal" style="font-family: Verdana,sans-serif; line-height: normal; margin-bottom: 0.0001pt;">
<span style="color: black; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">For a more detailed
description of this paradigm change see:</span></div>
<div class="MsoNormal" style="font-family: Verdana,sans-serif; line-height: normal;">
<span style="mso-bidi-font-family: Calibri; mso-bidi-font-weight: bold; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB; mso-font-kerning: 18.0pt;">A ‘system based’
approach to risk assessment of the cervical spine prior to manual therapy (Taylor
& Kerry 2010) </span><span style="color: black; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><a href="http://www.sciencedirect.com/science/article/pii/S1746068910000532">http://www.sciencedirect.com/science/article/pii/S1746068910000532</a></span><span style="mso-bidi-font-family: Calibri; mso-bidi-font-weight: bold; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB; mso-font-kerning: 18.0pt;"></span></div>
<div class="MsoNormal" style="font-family: Verdana,sans-serif; line-height: normal; margin-bottom: 0.0001pt;">
<br />
‘International framework for examination
of the cervical region for potential of Cervical Arterial Dysfunction prior to
Orthopaedic Manual Therapy intervention’ (Rushton, et al 2013)<span style="color: black;"></span></div>
<div class="MsoNormal" style="font-family: Verdana,sans-serif; line-height: normal; margin-bottom: 0.0001pt;">
<span style="color: black; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><a href="http://www.sciencedirect.com/science/article/pii/S1356689X13001926">http://www.sciencedirect.com/science/article/pii/S1356689X13001926</a></span><br />
<br />
<span style="color: black;"><a href="https://twitter.com/TaylorAlanJ" target="_blank">Follow on Alan J Taylor on Twitter</a> </span><br />
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgMV1KZQb2APT3FJ1KeZb28aBelsdfo-AqhjVb98Dkt_LSotl1DM4dEO4eIcBh4zzXpJoSJsKHacZMCyPEvCYR886qSvm3368QKQya7md1CsKhY92_2162oZ3ry7YruczWnD70Pn4CriwQ/s1600/Gray562.png" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="303" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgMV1KZQb2APT3FJ1KeZb28aBelsdfo-AqhjVb98Dkt_LSotl1DM4dEO4eIcBh4zzXpJoSJsKHacZMCyPEvCYR886qSvm3368QKQya7md1CsKhY92_2162oZ3ry7YruczWnD70Pn4CriwQ/s1600/Gray562.png" width="400" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Haemodynamics - A 'system based approach'</td></tr>
</tbody></table>
</div>
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Clinical Reasoning Sessionshttp://www.blogger.com/profile/09852524904111114134noreply@blogger.com0tag:blogger.com,1999:blog-6560398305209426117.post-73880005978783282372013-12-19T04:20:00.001-08:002013-12-19T09:07:54.469-08:00Twitter in Physiotherapy education: Exciting prospect or lame duck?<!--[if gte mso 9]><xml>
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<span style="font-family: Verdana,sans-serif;">Reflections on TWEED13 @University of Nottingham</span></h3>
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The University of Nottingham’s ‘Twitter in Education
Conference’ TWEED13 took place on December 16th 2013. The mini-conference raised a number of interesting issues and potential
directions for the future. </div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgF0VO6obA44yuWsHtp8yGS3QmgksIf_wfFEg5I_YSJTl2yzGzyzCbHKoynIlExxfmm6bt89-QiAKIzn0Q4gwpZnVP-PfK8miq7XfuSdmZf5TToKYWT4QjHkoxJUHwKIbwDNexVb07btDU/s1600/University.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="213" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgF0VO6obA44yuWsHtp8yGS3QmgksIf_wfFEg5I_YSJTl2yzGzyzCbHKoynIlExxfmm6bt89-QiAKIzn0Q4gwpZnVP-PfK8miq7XfuSdmZf5TToKYWT4QjHkoxJUHwKIbwDNexVb07btDU/s320/University.jpg" width="320" /></a></div>
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Roger Kerry <a href="https://twitter.com/RogerKerry1">@RogerKerry1</a> (Division of Health Sciences) and Natasa
Lackovic <a href="https://twitter.com/natasa_wonders">@natasa_wonders </a>(Learning Sciences Research Institute) presented their experiences of attempting
to engage 43 Physiotherapy (PT) students in a Twitter based project to promote
engagement with the evidence based practice (EBP2) module.</div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEghyyK0oNBnvNI2O4OLMQ2NOiVd9GNjUg6GjG-zryvAwA7nT7trcXv-jGQGNQSNFhEj5eqzrJfHrXBgjOQkIli04GupH8ey4gh9i3r-C7VZVlWRdy1liiSbHdJ9yJhCKg0EonZImuFGFO0/s1600/Graph+1.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="238" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEghyyK0oNBnvNI2O4OLMQ2NOiVd9GNjUg6GjG-zryvAwA7nT7trcXv-jGQGNQSNFhEj5eqzrJfHrXBgjOQkIli04GupH8ey4gh9i3r-C7VZVlWRdy1liiSbHdJ9yJhCKg0EonZImuFGFO0/s320/Graph+1.jpg" width="320" /></a></div>
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In short … Despite the news that recent research from <a data-scribe="element:mention" href="https://twitter.com/pewinternet">@<b>pewinternet</b></a>
shows Twitter's influence has doubled amongst (US) teens. <b>Nottingham’s PT
students did NOT engage!</b><br />
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This may come as a surprise to some and a no brainer
to others.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgzdesmZKP-iLyki7NQW4UJXucP_crbUzXtcXlvEZ7fGZ_fhPdynQlHxU9qvpzGeqxMkbtctloc2UIKn-KkfulnwapypqY98amk5ayHvTRjFByxVyxYEE6VtRszdfmJAKffgauPUYqmtgE/s1600/2013-12-16+13.58.07.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="239" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgzdesmZKP-iLyki7NQW4UJXucP_crbUzXtcXlvEZ7fGZ_fhPdynQlHxU9qvpzGeqxMkbtctloc2UIKn-KkfulnwapypqY98amk5ayHvTRjFByxVyxYEE6VtRszdfmJAKffgauPUYqmtgE/s320/2013-12-16+13.58.07.jpg" width="320" /></a></div>
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So why not? ... I hear you asking. </h3>
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Whilst is well known that
students spend many hours on social media platforms; it seems they are spending
the bulk of it on Facebook and only a small proportion of it on Twitter. </div>
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As it turned out that only 12/43 students in the Nottingham cohort
actually were Twitter users prior to the study. Subsequently, next to no local students
took up the cudgels. However, there did seem to some take up of the #EBP2
hashtag from other academics and interested parties and PT students other
Universities.</div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgHUjGaPesFVyi13oQI2IytKnlwARcNf0nbI9aitXt-sBaeT-gbZP2XoLy7Jab53zr_vScOkGb_aa3ZqRx_aUIwFN8OZUrQtkLhJZHl2wMbhVf6dmJsfk3ODeaCphNO6B8R0vSjj8eqP1Y/s1600/Theatre.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgHUjGaPesFVyi13oQI2IytKnlwARcNf0nbI9aitXt-sBaeT-gbZP2XoLy7Jab53zr_vScOkGb_aa3ZqRx_aUIwFN8OZUrQtkLhJZHl2wMbhVf6dmJsfk3ODeaCphNO6B8R0vSjj8eqP1Y/s320/Theatre.jpg" width="305" /></a></div>
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<b>So what does this tell us? … and what are the directions for
the future?</b> Well it seemed in this one small study that students simply didn’t
‘get it’. The conference perhaps provoked more questions than answers. Such as;</div>
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<i>‘Should lecturers be
incorporating this technology into lectures to illustrate its worth?’</i></div>
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<i>‘Is the whole thing simply distracting anyway… and would we
be better without it?’</i></div>
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<b style="mso-bidi-font-weight: normal;">So what are the
barriers to Twitter use in education?</b></h3>
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<b> </b></h3>
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<i>“I would never use Twitter for learning” (UoN student)</i></div>
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<i>“I don’t want to follow lecturers … They might look at what
I post” (UoN student)</i></div>
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<i>Twitter novices "fear of saying something inadequate /
embarrassment" </i></div>
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<i>Twitter is perceived by students to be "not for
students"</i></div>
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<i>‘I have encouraged some colleagues onto Twitter for CPD but
they are resolute lurkers.’</i></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiS7jmj_nbhUFYkgrV4u_omtgegQdMhhdAA91jVAn_mytkCzfT7_W1uQybqPj063XD3M2G9BlqD8DwlhL_x7cCaZ4n-pXQhzN8g_GMQxQ4_RMFWfCklJSKfBnVDx3HXfqANOUy9q55vqds/s1600/Ambulance.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiS7jmj_nbhUFYkgrV4u_omtgegQdMhhdAA91jVAn_mytkCzfT7_W1uQybqPj063XD3M2G9BlqD8DwlhL_x7cCaZ4n-pXQhzN8g_GMQxQ4_RMFWfCklJSKfBnVDx3HXfqANOUy9q55vqds/s320/Ambulance.jpg" width="249" /></a></div>
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<b style="mso-bidi-font-weight: normal;"> </b></h3>
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<b>Potential tweepy solutions</b></h3>
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<b> </b> </h3>
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<b>Provide social media training/induction?</b> … to highlight how and why they might want to use social media avenues
for their studies.</div>
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<b>Use a ‘professional’
Twitter pseudonym</b> … a tactic commonly used in business, music and education. It is not
uncommon for individuals to have multiple ‘profile/personalities’ on social
media. This eliminates the student’s <span style="mso-spacerun: yes;"> </span>worry of lecturers ‘seeing their silly tweets’.</div>
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<b>Encourage ‘lurkers’</b> … It is often possible to learn a great
deal from the posts, debates and discussions of more confident engagers without
EVER entering into the conversation.</div>
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<b>Use of twitter for providing student feedback</b> (via the private message facility - 140 characters) …
The beauty of this, is that it HAS to be short and to the point … a useful
writing skill at every level for students and academics alike.</div>
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Overview</h3>
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#Tweed13 provided an outcome which was perhaps different from
my own personal expectations. However, that in itself was entirely thought provoking. The mini-conference provoked (cyber and real) discussion and gave us some useful pointers for future directions in an emerging field within University education. </div>
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Far from being a lame duck, this small study perhaps just illustrated we may have to be a little more inventive with regard to our own approach to innovation. I can't wait to get back on the lake again!</div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiOxZCLYT3B2qmJTTC1skeEbFwEAvCaCHQY9yFDg4955ZNa4URz29YhgS-EhCszqzLJWjJ9-dMGJsa_R0jxtgQrxKiWzvqmvGmotUR8T8cDtXU3tRhg8xgVSyHvMPkT7TPAs5YPJ8h_NR0/s1600/Lake.PNG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="208" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiOxZCLYT3B2qmJTTC1skeEbFwEAvCaCHQY9yFDg4955ZNa4URz29YhgS-EhCszqzLJWjJ9-dMGJsa_R0jxtgQrxKiWzvqmvGmotUR8T8cDtXU3tRhg8xgVSyHvMPkT7TPAs5YPJ8h_NR0/s320/Lake.PNG" width="320" /></a></div>
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Watch this space tweepies!</div>
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The author <a href="https://twitter.com/TaylorAlanJ">@TaylorAlanJ </a>uses Twitter in education in a variety of ways.</div>
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Tweepy resources </h3>
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<b style="mso-bidi-font-weight: normal;"> </b> </div>
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<a href="http://journals.heacademy.ac.uk/doi/abs/10.11120/ened.2013.00015?prevSearch=Twitter+lectures&searchHistoryKey=">http://journals.heacademy.ac.uk/doi/abs/10.11120/ened.2013.00015?prevSearch=Twitter+lectures&searchHistoryKey=</a></div>
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Clinical Reasoning Sessionshttp://www.blogger.com/profile/09852524904111114134noreply@blogger.com1tag:blogger.com,1999:blog-6560398305209426117.post-22053972259749895742013-12-05T09:53:00.000-08:002015-02-19T00:58:07.929-08:00 5 good reasons for manual therapists to take blood pressure<div class="separator" style="clear: both; text-align: center;">
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhOqGbphwNFPNsHJTbVi7BWKywFhts10-PbKZitSTuZc1onG_U5eBN-OdFcRNypkD8NKbrued-g-5EaxuB151t40GF8AZZYEPK_XgPzSGKh8XK6RiOuvF_LpOZGGUwIdBf3Ub4-Se4V3ww/s1600/BloodPressure2.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhOqGbphwNFPNsHJTbVi7BWKywFhts10-PbKZitSTuZc1onG_U5eBN-OdFcRNypkD8NKbrued-g-5EaxuB151t40GF8AZZYEPK_XgPzSGKh8XK6RiOuvF_LpOZGGUwIdBf3Ub4-Se4V3ww/s320/BloodPressure2.jpg" height="320" width="224" /></a><b><span id="goog_2004132407"></span><span id="goog_2004132408"></span>1. Risk assessment</b> – The International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) produced a seminal consensus document for cervical spine risk assessment (Rushton et al, 2012). The accompanying paper available here <a href="http://www.sciencedirect.com/science/article/pii/S1356689X13001926">http://www.sciencedirect.com/science/article/pii/S1356689X13001926</a><br />
details a core shift in thinking about vascular risk and manual therapy. One of its key recommendations is that manual therapists consider incorporating blood pressure testing into their toolkit for risk assessment prior to treatment. <br />
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The concept of haemodynamic awareness is not limited to the cervical spine. It is known that simple therapeutic exercise can have haemodynamic implications throughout the body. There are systemic vascular responses to a range of therapeutic interventions such as lumbar mobility exercises in healthy subjects (Al-Obaidi et al, 2001). It is currently unknown what the responses might be in individuals with underlying pathology such as abdominal aortic aneurysm or atherosclerotic plaque. Clinicians have a duty to make appropriate risk assessment prior assessment, manual therapies or exercise prescription. The assessment of blood pressure may be a component of this process for some patients.<br />
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<b>2. Health Check?</b> - In the UK, high blood pressure is one of the most important preventable causes of premature ill health and death. It is identified as a major risk factor for stroke, heart attack, heart failure, chronic kidney disease and cognitive decline. It has also been identified as a focus of the NHS ‘Health Check’ drive, (<a href="http://www.healthcheck.nhs.uk/">http://www.healthcheck.nhs.uk/</a>).<br />
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Patients visit physiotherapy departments for a variety of musculoskeletal (MSK) complaints which may be associated with other health issues or co-morbidities. Physiotherapists should be cognisant with a patient’s blood pressure status from a health assessment perspective (Taylor and Kerry 2013). It is known that some conditions of vascular origin may mimic MSK conditions i.e. abdominal aortic aneurysm, impending stroke (Kurihara 2007). <br />
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In the United States this concept is well recognised and the American Physical Therapy Association produced a Guide to Physical Therapist Practice (2001) which made the recommendation that patient examination should begin with a history and systems review which includes “anatomical and physiological status of the cardiovascular/pulmonary system, integumentary, musculoskeletal and neuromuscular systems”. The guidance went on to say, “Heart rate and BP are measured to assess aerobic function and circulation, these measures can assist the physical therapist in identifying cardiovascular or pulmonary problems that might affect prognosis and intervention or require referral to another practitioner.” <br />
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It is an unfortunate reality however, that many clinicians do not see the relevance to their practice, which poses the question of whether they are cognisant of their unique role and opportunity, to play a part in the health and wellbeing of their patient population. <a href="http://www.csp.org.uk/frontline/article/second-opinion-exercise-life">http://www.csp.org.uk/frontline/article/second-opinion-exercise-life</a><br />
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<b>3. Clinical Reasoning</b> – Vascular tissue contains nociceptors and may be source of local PAIN… Manual therapists treat PAIN and should be cognisant of that within their clinical reasoning.<br />
It is well recognised that vascular tissue and mechanisms of cervical arterial dysfunction (CAD) may give rise to pain in the cranio-cervical region (Taylor and Kerry 2005). It is perhaps less well known that vascular tissue can be the source of pain syndromes throughout the body, ranging from the obvious – abdominal aortic aneurysm (low back pain), through to the less obvious (or less well known) distal limb pain/numbness as a result of popliteal artery entrapment syndrome (PAES). PAIN may be local due to a nociceptor response in the tunica adventitia due to underlying pathology (arterial dissection, atherosclerosis, aneurysm) or distal due to ischaemia (which may be movement or exercise induced).<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh0QcZhIWXfQY3lvIuUn8oybRWgucgb6X5UPHmXEHnSzjoFOj-ADK0kReFDnokXvNJjUYEh-u9XZeIQx6UKA5ezxLEhL_QYXBV9cBwUfFq4ikDK99VNLYQO0lBxHSYcASKJV6PEI18Xz0M/s1600/Blood+vessels.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh0QcZhIWXfQY3lvIuUn8oybRWgucgb6X5UPHmXEHnSzjoFOj-ADK0kReFDnokXvNJjUYEh-u9XZeIQx6UKA5ezxLEhL_QYXBV9cBwUfFq4ikDK99VNLYQO0lBxHSYcASKJV6PEI18Xz0M/s1600/Blood+vessels.jpg" /></a></div>
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<b>4. Medico-Legal</b> – Enough has been written in the manual therapy literature for a healthy evidence base to underpin both practice and clinical reasoning. The job of an expert witness is to assess whether a practitioner is acting according with contemporary evidence and in the way that a reasonable body of similar professionals would. Certainly in the cervical spine, the 2012 IFOMPT cervical spine risk assessment document provides clinicians with the current best evidence level and guides assessment, decision making and practice.<br />
<a href="http://nvmt.fysionet.nl/ifompt/ifompt-examination-cervical-spine-doc-september-2012-definitive.pdf">http://nvmt.fysionet.nl/ifompt/ifompt-examination-cervical-spine-doc-september-2012-definitive.pdf</a><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhsO1bki2LRyBm9C_WO5bzi9wB3ShpWzjmErMnnvLirnx1Ra0zNyrubuIK9wqMO4keCkY2_-RnT3K9CnEXfqP-IVFcfeRO3hT86LMYGrISUnlSqcq2HC-pwmPSeuSKwD_IP4KwrM5X-xDI/s1600/Hieronymus_Brunschwig_Liber_de_arte_Distillandi_306_AQ12_%25281%2529.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhsO1bki2LRyBm9C_WO5bzi9wB3ShpWzjmErMnnvLirnx1Ra0zNyrubuIK9wqMO4keCkY2_-RnT3K9CnEXfqP-IVFcfeRO3hT86LMYGrISUnlSqcq2HC-pwmPSeuSKwD_IP4KwrM5X-xDI/s320/Hieronymus_Brunschwig_Liber_de_arte_Distillandi_306_AQ12_%25281%2529.jpg" height="320" width="213" /></a>Elsewhere, from an anatomical perspective, there is an increasing body of literature relating to ‘altered haemodynamics’ throughout the body. What may surprise clinicians is that this work relates to a wide range of groups or profiles, from elite athletes (Bender et al, 2012) through to elderly diabetics with atherosclerosis (Chin 2014). As manual therapists are in the business of manipulating, mobilising, moving and prescribing movement based exercises there is a need to be aware of haemodynamic theory and the relevance to active and passive interventions. <br />
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Working as an expert witness in the field of clinical negligence and altered haemodynamics has raised my own awareness of the need for therapists in a range of specialties, to give consideration to BP. Furthermore, it seems and that adverse events are NOT confined to manipulation and may occur after examination or exercise prescription. This is a sobering thought and one which clinicians would be wise to cognisant of.<br />
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<b><br />5. Cos you know it makes sense!</b> - I haven’t got time for all these extra tests is the common cry. Well IFOMPT have cleverly suggested that you should find time! Perhaps consider re-ordering your routine physical testing. In other words, if you have an index of suspicion of CAD following the patient interview, then it may be prudent (for all of the above reasons) to consider a cursory BP check. It actually takes about two minutes of your time. BUT may save you hours!<br />
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Oh, and BP measurement is increasingly being performed by fitness instructors and Sports Rehabilitators... Don't get left behind!<br />
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... and if the results surprise you... What then ???<br />
<a href="http://www.nice.org.uk/nicemedia/live/13561/56015/56015.pdf">http://www.nice.org.uk/nicemedia/live/13561/56015/56015.pdf</a> will help to guide your clinical reasoning. The answers are often not clear cut and should be considered on a case by case basis, when ALL of the relevant imformation has been gathered. For case by case examples see ... <a href="http://www.ncbi.nlm.nih.gov/pubmed/23021565">http://www.ncbi.nlm.nih.gov/pubmed/23021565 </a><br />
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KEY ADVICE - Read the salient points in the IFOMPT document ...<br />
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DON'T RELY on one single test to make your decision (i.e. just the blood pressure values ... Unless they are dangerously high -<b> >180/110 </b>see<b> NICE Clinical Guideline 127</b> ...<br />
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For values below that threshold ... consider the whole patient presentation and the range of potential pathologies, as described in the IFOMPT document. Specific case studies can be found at <a href="http://www.physiospot.com/research/vascular-profiling-should-manual-therapists-take-blood-pressure/">http://www.physiospot.com/research/vascular-profiling-should-manual-therapists-take-blood-pressure/ </a><br />
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For more information on blood pressure measurements go to: <a href="http://www.cpptjournal.org/pdfs/members/fulltext/2011/june/blood_pressure.pdf">http://www.cpptjournal.org/pdfs/members/fulltext/2011/june/blood_pressure.pdf</a> <br />
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Author</h3>
Alan J Taylor - is a medico-legal expert witness, in the field of clinical negligence related to manual therapy and stroke or other haemodynamic events.<br />
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He has worked as a lecturer in Physiotherapy and Sports Rehabilitation & Exercise Science at the University of Nottingham since 2010.<br />
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He worked full-time as a clinician until joining the UoN and maintains a clinical case load via his Consultancy, which regularly takes him to to some of the UK's leading sports clubs. He deals with a variety of pain and performance related cases, many with a haemodynamic bias. <br />
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<a href="https://twitter.com/TaylorAlanJ">https://twitter.com/TaylorAlanJ</a><br />
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<b>References</b><br />
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Al-Obaidi S, Anthony J, Dean E, Al-Shuwai N (2001) Cardiovascular responses to repetitive McKenzie lumbar spine exercises Phys Ther. 81(9):1524-33.<br />
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Bender MH, Schep G, Bouts SW, Backx FJ, Moll FL (2012) Endurance athletes with intermittent claudication caused by iliac artery stenosis treated by endarterectomy with vein patch--short- and mid-term results. Eur J Vasc Endovasc Surg. 43(4):472-7. doi: 10.1016/j.ejvs.2012.01.004. Epub 2012 Jan 20.<br />
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Chin JA, Sumpio BE (2014) Diabetes mellitus and peripheral vascular disease:<br />
diagnosis and management. Clin Podiatr Med Surg. 31(1):11-26. doi: 10.1016/j.cpm.2013.09.001. Epub 2013 Nov 7. PubMed PMID: 24296015.<br />
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Guide to physical therapy practice. 2nd ed. Alexandria, Va: American Physical Therapy Association; 2001. P. 28.<br />
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Kurihara, T. (2007). Headache, neck pain, and stroke as characteristic manifestations of the cerebral artery dissection. Intern Med 46(6): 257-258.<br />
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<a href="http://www.ncbi.nlm.nih.gov/pubmed/23021565" target="_blank">Taylor AJ, Kerry R (2013) Vascular profiling: should manual therapists take blood pressure? Man Ther. 18(4):351-3. doi: 10.1016/j.math.2012.08.001. Epub 2012 Sep 25.</a><br />
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Taylor AJ, Kerry R (2005) Neck pain and headache as a result of internal carotid artery dissection: implications for manual therapists. Man Ther. 10(1):73-7.<br />
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<a href="http://nvmt.fysionet.nl/ifompt/ifompt-examination-cervical-spine-doc-september-2012-definitive.pdf">http://nvmt.fysionet.nl/ifompt/ifompt-examination-cervical-spine-doc-september-2012-definitive.pdf</a><br />
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<br />Clinical Reasoning Sessionshttp://www.blogger.com/profile/09852524904111114134noreply@blogger.com3tag:blogger.com,1999:blog-6560398305209426117.post-50453386706131355412013-10-09T01:31:00.000-07:002016-01-14T06:41:10.863-08:00Cranial nerve testing & cervical spine risk assessment – A ‘no brainer’!<style>
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<div class="MsoNormal">
<br /></div>
<h2>
<b>Straw poll anyone...?</b></h2>
<br />
<div class="MsoNormal">
Hands up manual therapists ... if you would perform a neurological examination
(upper limb/lower limb/UMN), if a patient’s subjective history indicated that
you should………..<br />
GOOD, that’s pretty much 100% of you then?</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Hands up ... if you would perform a <span style="text-transform: uppercase;">cranial
nerve examination</span> if a patient’s subjective history indicated that you
should…. Mmmm, I suspect that result is well below 100% (amongst
physiotherapists for sure...!)</div>
<div class="MsoNormal">
<br /></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiOVv2z1LIbeVS279IzJZCGzwADTtBLfXRxprwQuOYg9oTzP2Fz6GGm3hOLXKNMMNVIhHbIAVjqS7IcYCl3GPfDm2fEJhWsH2I-ngLknea5MUS_Zr2pECcvYHfcZzc0DHR_0mEtLj2NsZU/s1600/12-cranial-nerves-poster.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="313" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiOVv2z1LIbeVS279IzJZCGzwADTtBLfXRxprwQuOYg9oTzP2Fz6GGm3hOLXKNMMNVIhHbIAVjqS7IcYCl3GPfDm2fEJhWsH2I-ngLknea5MUS_Zr2pECcvYHfcZzc0DHR_0mEtLj2NsZU/s400/12-cranial-nerves-poster.jpg" width="400" /></a></div>
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-ansi-language: EN-GB; mso-bidi-language: AR-SA; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><a href="http://www.medical-artist.com/cranial-nerves.html">http://www.medical-artist.com/cranial-nerves.html</a></span><br />
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-ansi-language: EN-GB; mso-bidi-language: AR-SA; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">Medical illustrations of the cranial
nerves by Joanna Culley of <a href="http://medical-artist.com/">Medical-Artist.com</a></span><br />
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
For decades, manual therapists worldwide, have talked about
the importance of the D’s (dizziness, drop attacks, diplopia, dysarthria and dysphagia)
and N’s (numbness, nausea and nystagmus) when taking a subjective history in
patients’ suspected of having ‘vertebrobasilar insufficiency’ (VBI). </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
In the same way
physiotherapists in the UK, were traditionally taught to perform a thorough
neurological examination in upper and lower limbs, in cases of suspected
neurology or upper motor neurone dysfunction.
</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
So why did we never really get to grips with cranial nerve
examination in suspected cervico-cranial neurology? There’s no point in looking
back really (though a few educationalists might shift awkwardly in their seats), the plain stark fact is that we have been missing a trick! The D’s
and N’s we diligently worried so much about, were simply subjective
manifestations of cranial nerve dysfunctions linked to brain ischaemia. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Frankly, it is that simple. A well-performed CN examination
may provide key information to assist in the clinical reasoning, risk
assessment and triage process. That is why it appears as a prominent part of
the <i style="mso-bidi-font-style: normal;">2012 IFOMPT </i><i>International Framework for Examination of the Cervical Region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy Intervention ... </i>A somewhat long winded name, for what is essentially a cervical spine risk assessment document<i>.</i><br />
<br />
<a href="http://tinyurl.com/bpkj2xw"><b><span style="mso-fareast-font-family: "Times New Roman";">http://tinyurl.com/bpkj2xw</span></b></a></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgv_yrLCgJrjXpeDlGmzkMtTocQJI3JTJfBXmdS_36PqwEvmotuZH3KZw8GcBuFk557ov8L8GxsR8yOT2doLTIa-hrWNY6PcN-D6pZp4lUz9TOaJX3ClqgCp0cQxqb9EwCnAqSaiv1WJlI/s1600/Screen+shot+2013-10-09+at+09.10.19.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="222" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgv_yrLCgJrjXpeDlGmzkMtTocQJI3JTJfBXmdS_36PqwEvmotuZH3KZw8GcBuFk557ov8L8GxsR8yOT2doLTIa-hrWNY6PcN-D6pZp4lUz9TOaJX3ClqgCp0cQxqb9EwCnAqSaiv1WJlI/s400/Screen+shot+2013-10-09+at+09.10.19.png" width="400" /></a></div>
<div class="MsoNormal">
<b><span style="mso-fareast-font-family: "Times New Roman";"> </span></b><b><span style="mso-fareast-font-family: "Times New Roman";"> </span></b></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="mso-bidi-font-weight: bold; mso-fareast-font-family: "Times New Roman";">The IFOMPT document was achieved via protracted
International consensus and represents the best level of evidence we currently
have. Therapists would be wise to avail themselves of the key recommendations
for practice contained in the document. Some key points are mentioned below, BUT …
<b>the author advises reference to the complete document for balance. </b></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<h3>
<b><span style="mso-fareast-font-family: "Times New Roman";">Implications
for practice</span></b></h3>
</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="mso-fareast-font-family: "Times New Roman";">There
are serious conditions, which may mimic musculoskeletal (MSK) dysfunction in
the early stages of their pathological progression.</span></div>
<div class="MsoListParagraphCxSpFirst" style="mso-list: l1 level1 lfo1; text-indent: -18.0pt;">
<span style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="color: #073763;"><span style="background-color: white;"><span style="mso-fareast-font-family: "Times New Roman";">Cervical arterial dysfunction</span></span></span></div>
<div class="MsoListParagraphCxSpLast" style="mso-list: l1 level1 lfo1; text-indent: -18.0pt;">
<span style="color: #073763;"><span style="background-color: white;"><span style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="mso-fareast-font-family: "Times New Roman";">Upper cervical instability</span></span></span></div>
<div class="MsoNormal">
<br />
<span style="mso-fareast-font-family: "Times New Roman";">This
basically means that manual therapists need to possess the tools by which they
can make informed decisions about risk, from a subjective and objective
perspective.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="mso-fareast-font-family: "Times New Roman";">A
comprehensive list of risk factors and differential diagnosis table is
contained within the IFOMPT document (pp 13-14). There are also some useful
case histories which help to put this into perspective (pp 15-16)</span></div>
<div class="MsoNormal">
<span style="mso-fareast-font-family: "Times New Roman";"> </span><b style="mso-bidi-font-weight: normal;"><span style="mso-fareast-font-family: "Times New Roman";"> </span></b>
</div>
<div class="MsoNormal">
<h3>
<b style="mso-bidi-font-weight: normal;"><span style="mso-fareast-font-family: "Times New Roman";">Clinical decision-making</span></b>
</h3>
</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="mso-fareast-font-family: "Times New Roman";">Some
important points are made with regard to decision making for the physical
examination are also highlighted.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i style="mso-bidi-font-style: normal;"><span style="mso-fareast-font-family: "Times New Roman";">“Based upon the evaluation
and interpretation of the data from the patient history, the physical therapist
needs to decide:</span></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i style="mso-bidi-font-style: normal;"><span style="font-family: Symbol; mso-ascii-font-family: "Times New Roman"; mso-char-type: symbol; mso-fareast-font-family: "Times New Roman"; mso-hansi-font-family: "Times New Roman"; mso-symbol-font-family: Symbol;"><span style="mso-char-type: symbol; mso-symbol-font-family: Symbol;">·</span></span></i><i style="mso-bidi-font-style: normal;"><span style="mso-fareast-font-family: "Times New Roman";">Are there any precautions to orthopaedic
manual therapy OMT?</span></i></div>
<div class="MsoNormal">
<i style="mso-bidi-font-style: normal;"><span style="font-family: Symbol; mso-ascii-font-family: "Times New Roman"; mso-char-type: symbol; mso-fareast-font-family: "Times New Roman"; mso-hansi-font-family: "Times New Roman"; mso-symbol-font-family: Symbol;"><span style="mso-char-type: symbol; mso-symbol-font-family: Symbol;">·</span></span></i><i style="mso-bidi-font-style: normal;"><span style="mso-fareast-font-family: "Times New Roman";">Are there any
contraindications to OMT?</span></i></div>
<div class="MsoNormal">
<i style="mso-bidi-font-style: normal;"><span style="font-family: Symbol; mso-ascii-font-family: "Times New Roman"; mso-char-type: symbol; mso-fareast-font-family: "Times New Roman"; mso-hansi-font-family: "Times New Roman"; mso-symbol-font-family: Symbol;"><span style="mso-char-type: symbol; mso-symbol-font-family: Symbol;">·</span></span></i><i style="mso-bidi-font-style: normal;"><span style="mso-fareast-font-family: "Times New Roman";">What physical tests need to
be included in the physical examination?” (IFOMPT 2012)</span></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="mso-fareast-font-family: "Times New Roman";">The
above are generally normal practice for most experienced manual therapists.
However, the following two items, frankly should be normal practice also, but
are explicit in the document.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Symbol; mso-ascii-font-family: "Times New Roman"; mso-char-type: symbol; mso-fareast-font-family: "Times New Roman"; mso-hansi-font-family: "Times New Roman"; mso-symbol-font-family: Symbol;"><span style="mso-char-type: symbol; mso-symbol-font-family: Symbol;">"·</span></span><i style="mso-bidi-font-style: normal;"><span style="mso-fareast-font-family: "Times New Roman";">What is the
priority for these physical tests for this specific patient? What is the order
of testing and to which tests should be completed at the first visit?</span></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i style="mso-bidi-font-style: normal;"><span style="font-family: Symbol; mso-ascii-font-family: "Times New Roman"; mso-char-type: symbol; mso-fareast-font-family: "Times New Roman"; mso-hansi-font-family: "Times New Roman"; mso-symbol-font-family: Symbol;"><span style="mso-char-type: symbol; mso-symbol-font-family: Symbol;">·</span></span></i><i style="mso-bidi-font-style: normal;"><span style="mso-fareast-font-family: "Times New Roman";">Do the physical tests need to
be adapted for this specific patient?</span></i><span style="mso-fareast-font-family: "Times New Roman";">" <i style="mso-bidi-font-style: normal;">(adapted from IFOMPT
2012)</i></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<h3>
<b style="mso-bidi-font-weight: normal;"><span style="mso-fareast-font-family: "Times New Roman";">Implications for clinicians</span></b></h3>
</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="mso-fareast-font-family: "Times New Roman";">Well
simply, there is an International guidance document, which suggests you need to
think carefully about HOW TO PROCEED with your physical examination. The
clinician may be wise not to launch into a ‘routine examination’ and this has
obvious medico-legal implications.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="separator" style="clear: both; text-align: center;">
</div>
<div class="MsoNormal">
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhsb6JrRi8gAQuAEn4Wpv9jOHpZ6B9lqVamvfjkHT4hpLTUEbpaZ8BOvNjXUK3XWzW9yPiYkUgL8i7xP-FxaZlkFoA983_EshZ8WX035b90jgpzaF7CO0tQtRalQYuHBSgAAHf7OZOvRDQ/s1600/GreekReduction.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhsb6JrRi8gAQuAEn4Wpv9jOHpZ6B9lqVamvfjkHT4hpLTUEbpaZ8BOvNjXUK3XWzW9yPiYkUgL8i7xP-FxaZlkFoA983_EshZ8WX035b90jgpzaF7CO0tQtRalQYuHBSgAAHf7OZOvRDQ/s320/GreekReduction.jpg" width="302" /></a></div>
<br /></div>
<div class="MsoNormal">
<h3>
<b style="mso-bidi-font-weight: normal;"><span style="mso-fareast-font-family: "Times New Roman";">What does that mean practically?</span></b>
</h3>
</div>
<div class="MsoNormal">
<span style="mso-fareast-font-family: "Times New Roman";">Essentially,
that clinicians should, from a detailed subjective history and sound clinical
reasoning, be able to adapt their clinical examination (and order of)
accordingly. This may, based on the findings of the subjective history include
a consideration of upper cervical instability, high or unstable blood pressure
and cervical arterial dysfunction. </span><br />
<br />
<span style="mso-fareast-font-family: "Times New Roman";">A series of possible actions are described
in full, in the IFOMPT document (pp 18-21)</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="mso-fareast-font-family: "Times New Roman";">I
will draw your attention to the specific sections on <i style="mso-bidi-font-style: normal;">cranial nerve examination</i> and blood pressure testing (which I cover
in a separate blog), which may form part of the physical examination.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh1VW3wwIwx32RxnYlIP51A4Lsz0Nk_eH8lLme6nBJcTFnr75netN6fVseiKfdLFfKIZi-RE0K55SJ1zIXMBPlcGbEz-9TOoWPifeDtcp3rVCjD64ZzRPqH7F7dvxkStfxLy-nLH1FbgiY/s1600/Screen+shot+2013-10-09+at+09.17.18.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="285" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh1VW3wwIwx32RxnYlIP51A4Lsz0Nk_eH8lLme6nBJcTFnr75netN6fVseiKfdLFfKIZi-RE0K55SJ1zIXMBPlcGbEz-9TOoWPifeDtcp3rVCjD64ZzRPqH7F7dvxkStfxLy-nLH1FbgiY/s400/Screen+shot+2013-10-09+at+09.17.18.png" width="400" /></a></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<h3>
<span style="color: #073763;"><span style="background-color: white;"><b style="mso-bidi-font-weight: normal;"><span style="mso-fareast-font-family: "Times New Roman";">Clinical pearls</span></b></span></span></h3>
<h3>
<span style="color: #073763;">
<b style="mso-bidi-font-weight: normal;"><span style="mso-fareast-font-family: "Times New Roman";"> </span></b></span></h3>
</div>
<div class="MsoListParagraphCxSpFirst" style="mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<span style="color: #073763;"><b style="mso-bidi-font-weight: normal;"><span style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span style="mso-fareast-font-family: "Times New Roman";">Cranial nerve testing is an
essential part of physical examination in the presence of neurovascular signs and symptoms in
the cranio-cervical region</span></b></span></div>
<div class="MsoListParagraphCxSpFirst" style="mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<span style="color: #073763;"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<span style="color: #073763;"><b style="mso-bidi-font-weight: normal;"><span style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span style="mso-fareast-font-family: "Times New Roman";">Physical examination involves
movement and that alone may cause neurovascular compromise</span></b></span></div>
<div class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<span style="color: #073763;"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<span style="color: #073763;"><b style="mso-bidi-font-weight: normal;"><span style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span style="mso-fareast-font-family: "Times New Roman";">Remember, this is no longer
just about the vertebral artery – USE SYSTEM BASED THINKING</span></b></span></div>
<div class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<span style="color: #073763;"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<span style="color: #073763;"><b style="mso-bidi-font-weight: normal;"><span style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span style="mso-fareast-font-family: "Times New Roman";">Cases of arterial compromise
have been documented (usually as medico-legal cases) linked to EXAMINATION
only! </span></b></span></div>
<div class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<span style="color: #073763;"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<span style="color: #073763;"><b style="mso-bidi-font-weight: normal;"><span style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span style="mso-fareast-font-family: "Times New Roman";">Remember, this is no longer
just about just arterial dissection</span></b></span></div>
<div class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<span style="color: #073763;"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<span style="color: #073763;"><b style="mso-bidi-font-weight: normal;"><span style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">6.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span style="mso-fareast-font-family: "Times New Roman";">Clinicians should be aware of
the range of arterial pathologies and their potential links to movement based
therapies NOT JUST MANIPULATION!</span></b></span></div>
<div class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<span style="color: #073763;"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<span style="color: #073763;"><b style="mso-bidi-font-weight: normal;"><span style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">7.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span style="mso-fareast-font-family: "Times New Roman";">GOOD NEWS …Physiotherapists
are currently World leaders in guiding practitioners toward safe, evidence based
practice and risk assessment in the cervical spine </span></b></span></div>
<div class="MsoListParagraphCxSpLast">
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<span style="color: #073763;"><b style="mso-bidi-font-weight: normal;"><span style="mso-fareast-font-family: "Times New Roman";">It is in your interest as a
clinician (at every level) to be familiar with IFOMPT 2012</span></b></span><br />
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<b style="mso-bidi-font-weight: normal;"><span style="mso-fareast-font-family: "Times New Roman";">References</span></b></div>
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International Framework for Examination of the Cervical Region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy Intervention (2012) <a href="http://www.ifompt.com/site/ifompt/files/pdf/Standards%20Committee/Standards%20Committee%20Documents//IFOMPT%20Examination%20cervical%20spine%20doc%20September%202012%20definitive.pdf">http://www.ifompt.com/site/ifompt/files/pdf/Standards%20Committee/Standards%20Committee%20Documents//IFOMPT%20Examination%20cervical%20spine%20doc%20September%202012%20definitive.pdf</a></div>
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Taylor AJ, Kerry R (2010) A systems based approach to risk assessement of the cervical spine prior to manual therapy. International Journal of Osteopathic Medicine 13(3):85-93 </div>
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Kerry R, Taylor AJ (2009) Cervical arterial dysfunction: knowledge and reasoning for manual physical therapists. Journal of Orthopaedic and Sports Physical Therapy 39(5):378-387<br />
<br />
<h3>
Education </h3>
<a href="https://www.youtube.com/watch?v=8IlDew4QK1w&feature=em-subs_digest" target="_blank">Anatomy Video </a><a class="yt-uix-sessionlink g-hovercard spf-link " data-sessionlink="itct=CC8Q4TkiEwismILVhKnKAhVQvhYKHd_WBAQo-B0" data-ytid="UCesNt4_Z-Pm41RzpAClfVcg" href="https://www.youtube.com/channel/UCesNt4_Z-Pm41RzpAClfVcg">(Armando Hasudungan)</a><br />
<br />
<br />
<a href="http://armandoh.org/video/cranial-nerves-functions-and-disorders/" target="_blank">Cranial Nerves - functions and disorders </a><a class="yt-uix-sessionlink g-hovercard spf-link " data-sessionlink="itct=CC8Q4TkiEwismILVhKnKAhVQvhYKHd_WBAQo-B0" data-ytid="UCesNt4_Z-Pm41RzpAClfVcg" href="https://www.youtube.com/channel/UCesNt4_Z-Pm41RzpAClfVcg"> </a><br />
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Cranial nerves - <a href="http://prezi.com/l-chg-rsdkf5/cranial-nerves/">http://prezi.com/l-chg-rsdkf5/cranial-nerves/</a><br />
<br />
Physiotherapy UK Congress 2013 - <a href="http://prezi.com/yv9w6ixyjbrn/cervical-spine-risk-assessment-rehabilitation-guidance-for-safe-effective-clinical-practice/">http://prezi.com/yv9w6ixyjbrn/cervical-spine-risk-assessment-rehabilitation-guidance-for-safe-effective-clinical-practice/</a><br />
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One minute medical school - <a href="http://www.youtube.com/watch?v=Hs0yMBmQi5E&noredirect=1" target="_blank">Cranial Nerves </a><br />
<br />
<a href="http://www.youtube.com/watch?v=HkaUYEEWnzw" target="_blank">Cranial Nerve OSCE examination </a><br />
<br />
<a href="http://www.youtube.com/watch?v=eLzkgPkgkEo" target="_blank">Two minute CN Examination </a><br />
<br />
<h3>
Author</h3>
Alan J Taylor - is a medico-legal expert witness, in the field of clinical negligence related to manual therapy and stroke.<br />
<br />
He works as an Assistant Professor in Physiotherapy and Sports Rehabilitation & Exercise Science at the University of Nottingham. <br />
<br />
<a href="https://twitter.com/TaylorAlanJ">https://twitter.com/TaylorAlanJ</a><br />
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Clinical Reasoning Sessionshttp://www.blogger.com/profile/09852524904111114134noreply@blogger.com0tag:blogger.com,1999:blog-6560398305209426117.post-71744780081055569662013-04-16T11:03:00.000-07:002017-03-09T09:16:37.506-08:00Andrew Marr's "exercise induced stroke" ...What have we to learn?<h2>
<span style="font-family: "verdana" , sans-serif;"><b>Andrew Marr; a case of exercise induced stroke?</b></span></h2>
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<span style="font-family: "verdana" , sans-serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh7-NIliGLXgm8LP8EFW22vwjGXoWFzdcpfbDG5p5WjICwApd7TRlgc1SLSrbmhWJL1pugxzEiAV95_EZUCHqVu86QhLZgvqEsk4iJ0smUsu1GKqCm-Omg5gl-2MAxglJdas_Dj98JsG7w/s1600/Marr.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh7-NIliGLXgm8LP8EFW22vwjGXoWFzdcpfbDG5p5WjICwApd7TRlgc1SLSrbmhWJL1pugxzEiAV95_EZUCHqVu86QhLZgvqEsk4iJ0smUsu1GKqCm-Omg5gl-2MAxglJdas_Dj98JsG7w/s1600/Marr.jpg" /></a></span></div>
<span style="font-family: "verdana" , sans-serif;"><br /></span>
<span style="font-family: "verdana" , sans-serif;">Well-known political commentator Andrew Marr, recently told the story of his sudden stroke. It seems that Marr was of the belief that his stroke was ‘exercise induced’ … alarming news indeed, so alarming that the topic made the Jeremy Vine show on Radio 2! So how did he come to that conclusion I hear you ask? Marr explained that he had suffered two 'mini-strokes' – or transient ischaemic attacks – the year before, but that he "hadn't noticed" (presumably revealed by subsequent scans). He went on to make the suggestion that his stroke was triggered by a vigorous rowing machine exercise bout, that he was undergoing in response to newspaper reports relating to the benefit of high intensity training (HIT).........</span><br />
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<h4>
<span style="font-family: "verdana" , sans-serif;">
Carotid artery dissection </span></h4>
<span style="font-family: "verdana" , sans-serif;">So what happened? Well all we can say, is that Marr reported how he felt the symptoms of his stroke (“blinding head ache and flashes of light”) following the exercise where he said he "gave it everything I had" in the belief that this would benefit his health. He described how he had “torn the carotid artery, which takes the blood supply to the brain”. In other words he had suffered an arterial dissection with embolisation. He woke the next morning with what was essentially an ischaemic stroke........</span><br />
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<h4>
<span style="font-family: "verdana" , sans-serif;">
NHS response</span></h4>
<span style="font-family: "verdana" , sans-serif;">There has been much commentary since the interview and the NHS have been quick to respond and reassure patients in a factual way. <a href="http://www.nhs.uk/news/2013/04April/Pages/Is-exercise-to-blame-for-Andrew-Marrs-stroke.aspx" target="_blank">Is-exercise-to-blame-for-Andrew-Marrs-stroke?</a></span><br />
<br />
<span style="font-family: "verdana" , sans-serif;">.......... Indeed, some ‘experts’ have made the suggestion that there may not have been a link between the two events. Marr had explained some of his life style risk factors such as his high-pressure job, previous smoking and a history of being overweight. So it is of course plausible that his carotid arteries were already showing signs of atherosclerotic pathology. Was there a link? Well it is impossible to say for sure, but stroke sufferers commonly report headache, neck pain and visual disturbances as their primary symptoms and this is well documented in the literature........ </span><br />
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<h4>
<span style="font-family: "verdana" , sans-serif;">
IFOMPT guidance on risk </span></h4>
<span style="font-family: "verdana" , sans-serif;">The significance of this event to physiotherapists is multifactorial. As prescribers of exercise we have to have an understanding of what happened and be able to risk assess and advise patients accordingly. It illustrates also that we must consider the holistic health of patients too as part of a risk assessment strategy and this is supported by the recent <a href="http://www.ifompt.org/site/ifompt/files/pdf/Standards%20Committee/Standards%20Committee%20Documents//IFOMPT%20Examination%20cervical%20spine%20doc%20September%202012%20definitive.pdf" target="_blank">IFOMPT cervical spine document. </a></span> <br />
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<span style="font-family: "verdana" , sans-serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhcZjc3X8u6mAto0h7fRdEO4YkK4gG-KsLDpOM0cDLmQqvagLMvDA4Njmt41_0pkF0FOmVoOkyhGCtxwPoYbHx2TyMzDS3wXxIVpRNgI7eRiWJXQeLQEEwTHcxhJg_TkyIS5BAn041xBnw/s1600/Carotid.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhcZjc3X8u6mAto0h7fRdEO4YkK4gG-KsLDpOM0cDLmQqvagLMvDA4Njmt41_0pkF0FOmVoOkyhGCtxwPoYbHx2TyMzDS3wXxIVpRNgI7eRiWJXQeLQEEwTHcxhJg_TkyIS5BAn041xBnw/s1600/Carotid.jpg" /></a></span></h4>
<h4>
</h4>
<h4>
<span style="font-family: "verdana" , sans-serif;">
Cranial nerve examination?</span></h4>
<span style="font-family: "verdana" , sans-serif;">Indeed it is feasible for such a patient (pre-ischaemia) to walk into a physiotherapy out patient department seeking treatment for their “head ache” (Marr had a window between the onset of his symptoms and his eventual stroke). <span style="font-family: "verdana" , sans-serif;">O</span>nly careful consideration of their <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3311823/" target="_blank">symptoms</a> and physical examination, to include blood pressure and cranial nerve testing, may reveal the true nature of the underlying pathology. </span><br />
<br />
<span style="font-family: "verdana" , sans-serif;">Remember the acronym FAST (face, arms, speech, time – full details on the NHS website) and don’t forget to include the <a href="https://prezi.com/l-chg-rsdkf5/cranial-nerves/" target="_blank">cranial nerves</a> in your examination<b>.<span style="font-weight: normal;"><a href="http://prezi.com/l-chg-rsdkf5/cranial-nerves/"> </a></span></b></span><br />
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<h4>
<span style="font-family: "verdana" , sans-serif;"><b><span style="font-weight: normal;">So, is HIT harmful?</span></b></span></h4>
<span style="font-family: "verdana" , sans-serif;"><b><span style="font-weight: normal;">Well the jury remains out on that one, though the balance of evidence suggests not<b>. </b></span></b>W<b><span style="font-weight: normal;">hilst </span></b><span style="font-weight: normal;">it would be bad science to</span><b><span style="font-weight: normal;"> use a single case study to</span></b><span style="font-weight: normal;"> promote</span><b><span style="font-weight: normal;"> a knee jerk reaction, Marr’s experience certainly raises the debate and once again raises the spectre of heterogeneity. </span></b></span><br />
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<br />
<h4>
<span style="font-family: "verdana" , sans-serif;"><b><span style="font-weight: normal;">The key message</span></b></span></h4>
<span style="font-family: "verdana" , sans-serif;"><b><span style="font-weight: normal;"><br /></span></b></span>
<span style="font-family: "verdana" , sans-serif;"><b><span style="font-weight: normal;">If those commentators are right; and this was simply a stroke that was 'waiting to happen'. Then you truly never know, </span></b><b><span style="font-weight: normal;">quite </span></b><b><span style="font-weight: normal;">who or what might be lying on your treatment table ... Happy risk assessment! </span></b></span><br />
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<span style="font-family: "verdana" , sans-serif;"><b><span style="font-weight: normal;">
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<h4>
<span style="font-family: "verdana" , sans-serif;"><span style="font-weight: normal;">T</span><span style="font-weight: normal;">he author </span><b><span style="font-weight: normal;"> </span></b></span></h4>
<span style="font-family: "verdana" , sans-serif;"><b><span style="font-weight: normal;">..... has written over 20 peer reviewed papers relating to blood flow issues related to manual therapy, his work has been cited in the IFOMPT International Framework for Examination of the Cervical Region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy Intervention</span></b></span><br />
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<br />
<h4>
<a href="http://prezi.com/t0rqjvwrkio_/altered-haemodynamics-taylor-aj-kerry-r-2013/" target="_blank"><span style="font-family: "verdana" , sans-serif;"><b><span style="font-weight: normal;">Altered haemodynamics</span></b></span></a></h4>
<span style="font-family: "verdana" , sans-serif;"><b><span style="font-weight: normal;">Follow <a href="https://twitter.com/TaylorAlanJ">on twitter@TaylorAlanJ </a></span></b></span>Clinical Reasoning Sessionshttp://www.blogger.com/profile/09852524904111114134noreply@blogger.com1tag:blogger.com,1999:blog-6560398305209426117.post-16736975429369646982012-06-11T12:34:00.001-07:002012-06-12T02:04:29.658-07:00BMJ, Manipulating the manipulators!<div style="font-family: Arial,Helvetica,sans-serif;">
<h2>
<span style="font-size: large;">BMJ Manipulating the manipulators!</span></h2>
<span style="font-size: x-small;">
</span><br />
<span style="font-size: large;">
What fun the BMJ are having. Take three authors will little or no track
record in the field, get them to review a few 'Cherry picked' papers,
write a non-peer reviewed opinion/debate article (<a href="http://www.bmj.com/content/344/bmj.e3679">http://www.bmj.com/content/344/bmj.e3679</a>) add a press release (<a href="http://www.bmj.com/press-releases/2012/06/07/should-spinal-manipulation-neck-pain-be-abandoned">http://www.bmj.com/press-releases/2012/06/07/should-spinal-manipulation-neck-pain-be-abandoned</a>) and light the touch paper! </span><br />
<br />
<span style="font-size: large;">Enter the
'Daily Mail' (<a href="http://www.dailymail.co.uk/health/article-2156179/Letting-chiropractor-crack-neck-ease-pain-trigger-stroke.html">http://www.dailymail.co.uk/health/article-2156179/Letting-chiropractor-crack-neck-ease-pain-trigger-stroke.html</a>), fan the flames and watch the manipulators eat themselves.
Nice . . . Or is it? </span></div>
<div style="font-family: Arial,Helvetica,sans-serif;">
<span style="font-size: large;"><br /></span></div>
<div style="font-family: Arial,Helvetica,sans-serif;">
<span style="font-size: large;">We learnt a lot in Physiotherapy about the
haemodynamics of the cervical spine and risk assessment over the last
decade or so. We had seen the limitations of our own 'bad science', the
vertebral artery test and IFOMPT will this year provide guidance to
those who treat the cervical spine in a well thought out attempt to
limit risk. <br />
<br />
Wand et al (2012) have been manipulated themselves, and whilst they clearly
enjoy the spotlight (#abandonneckmanipulation on Twitter "woohoo") their argument
is weak and badly thought out (see the considered respondents on the BMJ site) and furthermore is harmful to the
profession. My last two (expert witness) medico-legal cases involving stroke post manual
therapy, were in fact not manipulation cases, but rather ASSESSMENT CASES
. . . Oh, I hear the wolves call, perhaps we should call a halt to
assessment and movement too? Then we truly can stick to handing out leaflets (<a href="http://rogerkerry.posterous.com/should-cervical-manipulations-be-abandoned">http://rogerkerry.posterous.com/should-cervical-manipulations-be-abandoned</a>). <br />
<br />
So unwittingly we (as a profession) fall into the trap set by the BMJ, we antagonise the
Chiropractors/osteopaths and call our own profession into question. We
have more to learn about haemodynamics and risk in the cervical spine I
have no doubt . . . but </span><span style="font-size: large;">is</span><span style="font-size: large;"> this the way to operate in what is already a
challenging and hostile environment? There really is no strong scientific case for calling a
halt to manipulative therapy, any more there is many components of conventional medicine. You can read the debate yourself and I
would invite you to make up your own mind.<br />
<br />
In the mean time take the opportunity to vote on the BMJ website . . .
Have your say, they did . . . in the most manipulative way.</span></div>
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<div style="font-family: Arial,Helvetica,sans-serif;">
1. Kerry R, Taylor AJ, Mitchell, JM, McCarthy C. Cervical arterial
dysfunction and manual therapy: A critical literature review to inform
professional practice. Manual Therapy 2008;13: 278-288<br />
2. Bowler N, Shamley D, Davies R. The effect of a simulated manipulation
position on internal carotid and vertebral artery blood flow in healthy
individuals. Manual Therapy 2011; 16: 87-93<br />
3. Kerry R, Taylor AJ. Cervical arterial dysfunction: knowledge and
reasoning for manual physical therapists. Journal of Orthopaedic and
Sports Physical Therapy 2009; 39:378-387<br />
4. Vogel S, Mars T, Keeping S et al 2012 Clinical Risk Osteopathy and
Management (CROaM) project: national cross-sectional survey. BSO,
London.<br />
5. Carnes D, Mars TS, Mullinger B, Froud R, Underwood M. Adverse events
and manual therapy: A systematic review. Manual Therapy 2010;15:
355-363<br />
6. Taylor AJ, Kerry R. A systems based approach to risk assessment of
the cervical spine prior to manual therapy. International Journal of
Osteopathic Medicine 2010;13:85-93</div>Clinical Reasoning Sessionshttp://www.blogger.com/profile/09852524904111114134noreply@blogger.com1tag:blogger.com,1999:blog-6560398305209426117.post-46927799995436401432012-02-16T06:03:00.000-08:002012-02-16T08:12:33.490-08:00Government hit from behind on whiplash injury claims<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span><br />
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<b><span style="font-family: 'Trebuchet MS', sans-serif;">David Cameron out of touch with
contemporary evidence say University of Nottingham academics!<o:p></o:p></span></b></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;"><span style="letter-spacing: -0.6pt;">David Cameron’s pledge to cut car whiplash claims</span> has been challenged by University of
Nottingham academics and physiotherapists Roger Kerry and Alan Taylor. Backed
by leading USA researcher James Elliott, they have called into question the
Government’s <span class="ft"><span style="color: #222222;">exposé </span></span>of
the whiplash injury industry in the UK. <o:p></o:p></span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;">Whilst accepting the
critique of the unethical and corrupt practices within the ‘whiplash injury
industry’ and a justified call for an end to so called referral fees. Kerry,
Taylor and Elliott who have written extensively on neck issues and teach
evidenced based practice in whiplash injury, have called into question the
second layer of the broadside. Here there
is a suggestion that “all whiplash injuries are artificially contrived”,
therein casting doubt on the medical legitimacy of the diagnosis at all levels.
They contend that challenging the current argument<a href="http://www.blogger.com/blogger.g?blogID=6560398305209426117" name="_GoBack"></a> is not
difficult. The suggestion for instance, that ‘whiplash Injury’ is not a
clinical entity is both ill informed, irresponsible and not up to date with
contemporary research on the subject. They are able to draw attention to high
quality objective evidence from internationally recognised MRI studies demonstrating
changes in neck muscle properties in people who have suffered whiplash (e.g.
Elliott et al 2010, Spine). Furthermore, they highlight trial and
experimental evidence has demonstrated that chronic whiplash associated
disorder (WAD) can be reliably indentified. WAD is thus, for some a very real
physical problem. <o:p></o:p></span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;">The Government’s
diatribe unfortunately, calls into question the genuineness of all whiplash
injury claims. This notion has, according to some, been supported further by recent
media reports of a Physiotherapist winning a so called “landmark case” proving
that ‘whiplash injury’ doesn’t exist (Daily Mail Jan 29<sup>th</sup> 2012).
These reports do of course champion the proposals, but are a predictable,
inaccurate spin of the facts of the quoted case, i.e. Robinson Vs Hussain, which
was not technically a ’whiplash injury’ case (in fact the exact opposite of
such).<o:p></o:p></span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;">For many involved
in front line care delivery, the unfortunate part of this politicised rhetoric is
that the proposed actions could easily lead to an irretraceable stigmatisation
of the percentage patients who genuinely suffer following road traffic
accidents. If wholesale changes to the industry are undertaken, there is
genuine fear that evidence-based health interventions will be withdrawn for
patients who have genuine, demonstrable WAD. It is important that before politically
fuelled knee-jerk reforms are made, that dialogue takes place between MPs and
health care practitioners such as Chartered Physiotherapists, who have been at
the forefront of clinical practice and research in this area.<o:p></o:p></span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;">Government
rhetoric may well be designed to galvanise public opinion and has clearly been
taken up with typical emotional aplomb by tabloids such as the ‘Daily Mail’. However,
it only serves to generalise and then stigmatise those patients who have
genuine complaints affecting their day-to-day function. Such patients may now,
in the light of this important new research, be identified by appropriate
evidence based scientific tests, which the Government appear to have
conveniently overlooked. <o:p></o:p></span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;">Roger Kerry
(University of Nottingham, UK)<o:p></o:p></span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;">Alan J Taylor
(University of Nottingham, UK)<o:p></o:p></span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;">James M Elliott
(Northwestern University, USA)<o:p></o:p></span><br />
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<span style="font-family: 'Trebuchet MS', sans-serif;">References;</span></div>
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<pre><span style="font-size: 11pt;"><span style="font-family: 'Trebuchet MS', sans-serif;">Elliott J, Jull G, Noteboom JT, Darnell R, Galloway G, Gibbon WW. (2006) Fatty infiltration in the cervical extensor muscles in persistent whiplash-associated disorders: a magnetic resonance imaging analysis. Spine;31(22): pp 847-55<o:p></o:p></span></span></pre>
<pre><span style="font-size: 11pt;"><o:p><span style="font-family: 'Trebuchet MS', sans-serif;"> </span></o:p></span></pre>
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<span style="font-family: 'Trebuchet MS', sans-serif;">Elliott JM, O'Leary S, Sterling M, Hendrikz J,
Pedler A, Jull G. (2010) Magnetic resonance imaging findings of fatty
infiltrate in the cervical flexors in chronic whiplash. Spine;35(9): pp 948-54</span><o:p></o:p><br />
<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span><br />
<span style="font-family: 'Trebuchet MS', sans-serif;"><a href="http://feeds.myptsd.me/are-there-implications-for-morphological-changes-in-neck-muscles-following-whiplash-injury/">http://feeds.myptsd.me/are-there-implications-for-morphological-changes-in-neck-muscles-following-whiplash-injury/</a></span><br />
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<a href="http://www.nottingham.ac.uk/physiotherapy/index.aspx" style="font-family: Verdana, sans-serif;"><span style="color: #4f81bd;">http://www.nottingham.ac.uk/physiotherapy/index.aspx</span></a><br />
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<span style="font-family: Helvetica, sans-serif; font-size: 10pt;"><a href="https://twitter.com/#!/TaylorAlanJ">https://twitter.com/#!/TaylorAlanJ</a><o:p></o:p></span></div>
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</div>Clinical Reasoning Sessionshttp://www.blogger.com/profile/09852524904111114134noreply@blogger.com5