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Students Conference - Pain can be ‘unlearned’

He was drawn to physiotherapy as a career by the prospect of treating sports injuries, he said, and has just finished a PhD in ‘Sports injuries in professional soccer and the effects of detraining’ at Liverpool John Moores University.

Tranmere Rovers fans are also fans of the football club’s physiotherapist, Les Parry, and can often be heard singing: ‘Who needs Mourinho, when we’ve got our physio’. [José Mourinho is one of the world’s top football managers]Les Parry, who was first appointed as Tranmere’s physio in 1991,took over as manager in December until the end of this season. He said that a physio’s main contribution as a manager is in dealing with the players.

He said: ‘As a physiotherapist you have to build up a relationship with them and that particular skill has come in handy since becoming a manager.’

Pain as a sensation is ‘multifactorial’, learned and can be altered through re-education, Professor Paul Watson, the UK’s first consultant physiotherapist, told a workshop on pain management.

People who hurt themselves become anxious and adopt strategies to avoid further pain, but brain scans show that pain management programmes can successfully re-educate them, he said. 

Stress and other psychosocial factors were very important in determining which people with chronic pain got better and who went on to develop severe disability, but clinicians’ assessments must be systematic to be effective, Prof Watson explained.

He added: ‘Our job is to reduce “catastrophising”, reduce fear and avoidance of physical activity and distorted cognitions, such as crumbling spine. And kick-start self management.

‘Remember, a psychological reaction to pain is normal. We are dealing with muscles and mistaken cognitions, not psychological problems. Most people don’t need to see a psychologist. Pain-related distress is your concern. Distress from other problems is not part of your job,’ Prof Watson told students.

Leadership ‘not just for heroes or charismatic charmers’

‘If I say “leader”, shout out some names,’ Karen Middleton, chief health professions’ officer for England (pictured right), told students. The names they shouted included Obama, Mandela and Jade Goody.

Obama was always the first name people suggest, she said, but leadership was not about being heroic and charismatic but nor was it synonymous with management or about sitting on the fence.

Leadership meant exciting people to achieve higher levels of performance and that needed authority, a strategy and followers. ‘It’s no good inspiring others but being unable to deliver, and no point in being a leader if you don’t have any followers,’ said Karen Middleton.

The biggest barrier to leadership was doing it on your own, she said. She advised students to join forces with other health professionals, to network and to consider working in the community.

And why was it important that physiotherapists have leadership skills? she asked. The answer was in order to develop NHS services for the benefit of patients. And it was vital that physios were much more systematic in identifying future leaders to enable the innovation necessary in order to anticipate and cope with changes in demographics and the nature of disease, she said. They would have to deal with the impact of the current economic situation and public expectations raised by access to the web.

‘We need to develop as practitioners and partners but we need to understand that your clinical skills alone will get you nowhere in terms of getting people to buy your services,’ she said.

Conference debated the view that leadership was a natural skill and could not be learned. Half the contributors agreed that was true, but said that leadership was a trait that was naturally embedded in physiotherapists; and many said it was possible to develop leaders by encouraging people to use their skills and gain confidence.

Shouting won’t work, students told

Motivating people to improve their health means working in partnership with them, giving positive reinforcement and expressing empathy rather than shouting, senior physiotherapist Billy McClean (left) told the conference.

Billy McClean, who works for the Leeds musculoskeletal and rehabilitation service, is involved in the Leeds Incapacity Employment Project, which is aimed at those who claim incapacity-related benefit as a result of musculoskeletal and/or mental health problems.

Contemplation, preparation and action were the three stages patients went through before seeking advice about their condition, he said. But once they arrived, avoid arguments and ‘finger-pointing’ language, recognise patients’ resistance and ask their view: ‘How ready are you to change and how confident are you that in six months’ time

you will have maintained these changes?’

Support self-efficacy and give positive reinforcement through eye contact and reflective listening, Billy McClean advised. And explore patients’ options, adjust their expectations and agree goals with them, he added.

Army physios help soldiers get their lives back

Life as an army physiotherapist means treating patients with sprained ankles as well as triple amputees, Captain Paul Thompson and Major Martin Colclough told the conference.

‘One of the most important things we do is to go on operations, working in field hospitals in Afghanistan, Captain Thompson said. ‘Soldiers come in from patrols having sprained their ankles or got a bad back and sometimes IED (improvised explosive device – roadside bomb) and shrapnel injuries, and we are out there trying to keep them at work.’

Seriously injured soldiers are flown back to hospital in Birmingham once their condition is stable, then sent for rehabilitation to Headley Court in Surrey, which specialises in working with amputees.

Said Captain Thompson: ‘Ordinary people have extraordinary experiences. Young people who are “normal” one minute, next minute have lost double and triple limbs and want to get back to doing as much as they can.’

Major Colclough, of the Army Physical Training Corps, described his work with the Battle Back Project at Headley Court, where he is commanding officer.

The project aims to help severely injured service personnel to ‘get their life back’ by using adventurous training and sport, he said.

People who have been through the courses have overcome their disabilities to compete in the Paralympics, climb mountains and swim the channel, but that is not the only measure of success.

‘If somebody learns a new life skill – to go for a holiday with their family or to cycle to work – that is a great result,’ said Major Colclough.

Flexibility is key to a bright future

The profession has some really important issues to face and top of the list is the employment situation, said CSP chief executive Phil Gray.

While the situation might be difficult now, it is much better than in 2006. The April 2009 CSP survey showed that at least 85 per cent of student physios had found jobs by November following graduation, compared with 23 per cent three years earlier, he said.  ‘This is a direct result of the CSP fighting on behalf of students with ministers and decision makers,’ Phil Gray said.

‘The future is looking better, but be flexible and don’t get fixed in the old patterns of thinking that the only job is in an acute hospital. Look at where the opportunities are in the public or private sector, acute or community,’ he told students. 

Try other treatments before acupuncture, conference hears

Acupuncture and electro-acupuncture are extra tools in the physiotherapist’s pain relief ‘box’ but they should exhaust other treatment techniques first, Ahmed Osman, senior physio at Gosport Memorial Hospital, told a workshop.

Suitable conditions for acupuncture included insomnia, neck and back pain, stress and infertility, he said. And it usually took 8 to 12 sessions with a few days’ gap between first and second appointments to relieve symptoms.

Acupuncture enhanced the production of endorphins, he added. Physiotherapists in the UK, who used the Western rather than the Chinese approach to acupuncture, explained it to patients in terms of mobilising the body’s natural

pain killers.  

Patient-centred or patient-led care?

Patient-centred care was centre-stage during a spirited debate that focused mainly on how far patients’ treatment should be driven by professionals’ expertise and grounded in academic training, rather than patients’ demand for care based on ‘want and limited knowledge’.

A study showed that 80 per cent of physios thought they gave patient-centred care, but only 20 per cent of patients thought they received it, the conference heard. Asked to define the concept, students thought patient-centred care meant treating the patient as an individual, empowering them, taking their environment and circumstances into account and involving them in their own rehabilitation.

One speaker said: ‘Patient-centred care is about not telling them what is best for them but using their goals to guide you. It is up to you as a physiotherapist to educate them and help them understand what is best for their condition.’

But one student asked whether, with 20 minutes’ treatment, physios should ‘mollycoddle’ patients with education or get on and treat them?

Another said communication was key, adding: ‘We have to remember there are people with chronic conditions who are learning as much as they can about their condition. They know their own bodies.’

Some students asked about collaboration between private and public sectors. The CSP, they heard, could facilitate relationships between private organisations and the NHS at a national level, but not locally, unless there was a specific issue that impacted on physios.

Meanwhile, some students raised concerns about dealing with patients’ ‘pushy’ families, and asked: ‘At what point do we say no?’

No physiotherapist could be an expert on every aspect of care and they should not dismiss patients’ ideas, but respect and work in partnership with them, was one answer.

But there was a huge difference between patient-centred and patient-led care, said one speaker. Physios should use their expertise, she said, and added: ‘If the patient wants something you are not trained to do or don’t believe there is evidence to support, don’t do it. That’s what professional autonomy is about.’

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