PAIN MANAGEMENT - Physiotherapy Association of British ...
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
A P U B L I C AT I ON FO R THE P HYSIO T H ERAPY CO M M UN I T Y O F B C
PAIN MANAGEMENT
Read more pg 4 – Kids in Pain
IN THIS ISSUE Winter 18/19
06 / Virtual Physiotherapy for Rural BC
10 / Shock Wave Therapy
bcphysio.org 19 / Physiotherapy in Indigenous Communities
21 / 100 and Going Strong
100% Pure Ingredients
Natural Pain Relief Solution
Pre & Post Manual Therapy Water based formula is gentle on
the skin for therapist and patient.
to reduce muscle tension,
reduce inflammation and
Natural Magnesium Sulfate
promote flexibility reduce muscle tension
Organic Arnica Montana
Non irritating
reduce inflammation
Mild fragrance
No NSAIDs, Pure Essentials Oils
No harmful side effects increase circulation
epsomgel.ca PRODUCT OF CANADA
Winter 18/19
WHAT’S INSIDE PRESIDENT’S MESSAGE
02 / CEO Message This is my last message to you as PABC President. It has been
03 / Knowledge Services Update a privilege to work with such a dedicated group of healthcare
professionals across the province, highlighting the value and
06 / PABC Education Updates
role of physiotherapy. I have enjoyed my time in this role
22 / Membership News and look forward to contributing as a general member in
24 / Student Corner Patrick Jadan, the coming year when our new President, Alex Scott will be
PABC President guiding us forward.
26 / UBC Update
New Northern Director
I would like to formally thank Nikolina Nikolic for her time spent serving as a Board
Director representing Northern BC. Nikolina will be moving to Cranbrook and has
Cover: PABC’s Kristie Norquay, Golden BC thus vacated her position on the board. I am pleased to announce Angela Pace
Photo: Lois of Lolo & Noa Photography from Kitimat will be stepping into the role of Northern Director and will complete
the remainder of the term until our AGM in April 2019. Angela is currently the
CONTRIBUTORS Rehabilitation Services Manager at Kitimat General Hospital and co-owner of
Paceyourself Physiotherapy in Kitimat. We are looking forward to having Angela
Casey Legault, Ashley Carmody, Amy
contribute to a wide variety of board discussions.
Edwards, Kristie Norquay, Jocelyn
Chandler, Natasha Wilch, Georg Branch Presidents Forum Meetings
Reuter, Nathan Hers, Patrick Jaden,
Christine Bradstock, Tori Etheridge, The Branch President’s Forum (BPF), a meeting of all provincial association
Terri McKellar, Ramsey Ezzat, Caroline presidents, was recently held in Montreal, just prior to the start of CPA Congress.
Mombourquette, Bryce Kelly, Karen I attended representing PABC, and had several productive discussions about
Sauve, Sue Murphy, Jollean Willington issues that were common to all provinces. These included: vacancies in public
health, better representation from all areas of Canada on the CPA Board of
BOARD OF DIRECTORS Directors, election of a new chair for the BPF, extended health benefit changes,
Patrick Jadan President and the ability of physiotherapists to communicate the diagnosis of a concussion.
Dr. Alex Scott Greater Vancouver/ Consortium Meeting
Sunshine Coast Director
Chiara Singh Greater Vancouver/
Christine, Dr. Alex Scott and myself met with members from both UBC and
Sunshine Coast Director CPTBC in mid November at our quarterly consortium meeting. We discussed
Joanna Sleik Kootenay Director
many important issues that affect all three pillars of our profession. We brought
the concerns of our members forward regarding the RCA while respecting the
Brad Jawl Vancouver Island Director
College’s mandate to ensure the safety of the general public through regulation of
Angela Pace Northern BC Director physiotherapists.
Kevin Bos Okanagan Director
Governance Committee Meeting
Janet Lundie South Fraser Director
Roland Fletcher Fraser Valley Director Several other senior PABC volunteers and I had a teleconference in November
for the inaugural meeting of our newly created Governance Committee. Together,
Amy Edwards
Student Director, MPT1 we formulated a strategy to have a very organized and proactive approach to
Cassandra Legault
recruitment and succession planning for both our Board of Directors and all of
Student Director, MPT2 the many important sub-committees of PABC. Part of the work of the Governance
Dr. Tommy Gerschman
Committee will be evident at our upcoming April Practice Forum, where we will be
MD External Director providing exciting opportunities to get involved with PABC!
Christine Bradstock CEO Thank you again to all the PABC, Board and Committee members for your support
and I wish you all the best through the coming year!
Member of
Patrick co-owns Thrive Now Physiotherapy, with two locations in the Cowichan
Valley. Patrick has spent the past 8 years volunteering with PABC, and has
served on the Board of Directors since 2014.
PA BC D I RECT I O N S / 1
DIRECTIONS CEO FEBRUARY 2019 MESSAGE
As we enter year two of our Volunteer Opportunities Available are:
strategic plan, we are well
The Business Affairs Committee (BAC) is a group of private
positioned to fulfill the plan on
practice physios that advise matters like: what resources to
time and on budget.
put on the website; how to help members navigate WSBC
Planning for the changeover at and ICBC matters.
the AGM, I would like to remind
The Public Practice Advisory Committee (PPAC) is a group
you that PABC, as a member
of public practice physios that advise on matters like:
driven organization, relies on
advocating for and supporting working in public practice.
volunteer members to oversee the
organization and help to fulfill the The Rural and Remote Advisory Committee (R&R) is a group
Christine Bradstock, strategic plan. A huge thank you to of physios that practice in rural and remote settings and has
PABC CEO all our volunteers! a focus on recruitment and retention, among other issues.
We will see changes to the Board and Committees this The Professional Development Advisory Committee
coming year. If you have any interest please contact (PDAC) is a group of physios that advise on PABC run
Patrick or myself. education courses. They work closely with our Knowledge
Service Team: Nathan Hers, Education Manager; Terri
Board and Committee volunteer McKellar, Knowledge Services Manager and Alison Hoens,
members at PABC: Knowledge Broker.
PABC Board of Directors The Forum Planning Committee – This group has
representatives from PABC, the College and UBC. They
Each year, there are positions that are up for election
help to plan the Forum and especially the speakers.
Notices for nominations for PBAC Board of Directors
(BoD) positions were sent out in February. If there is The Awards Committee – This committee collects
more than one nomination for a Board position, an nominations for PABC awards and determines the winners
election will be held. of the awards.
Patrick Jadan will be stepping down as President after
Other Standing Committees positions appointed by
our AGM, April 2019. It has been a tremendous pleasure
the Board include:
working with Patrick, an authentic leader who understands
the physiotherapy community and the values of PABC. He The Finance Committee – The Finance Committee oversee
will be missed at the Board table! the PABC Budget.
I am delighted that Dr. Alex Scott will take over as The Governance Committee – The Governance
President. Alex brings a wealth of knowledge and Committee promotes volunteering on the Board and the
leadership that will help guide us as we move forward. Committees.
All BoD members that are leaving will be celebrated at the CEO Review Committee – This committee does the
AGM on April 27th. performance review on the CEO.
PABC Standing Committees PABC Adhoc Committees
Each year we have positions available on a variety of PABC currently has one Adhoc Committee with a total of
committees. PABC Standing Committees act at the 10 volunteers. Adhoc Committees are short term or single
pleasure of the PABC BoD. The PABC BoD provides subject focused committees that also act at the pleasure
guidance to each committee on their area of focus and of the BoD.
the committee, as a group of knowledgeable physios, The Scope of Practice Committee (SOP) is looking at the
advises the BoD. If any of these opportunities sounds Physiotherapy Scope of Practice – what can we do, what
appealing to you please contact me. are we doing, what do we want to do and why?
PABC has nine Standing Committees with 93 volunteers As you can see, we have lots of committees and lots of
on these committees. wonderful volunteers! Thank you to all of our volunteers!!!
We are always happy to hear from you so please do
continue to contact us with questions and suggestions.
2 / Winter 18/1 9
UPDATES FROM KNOWLEDGE SERVICES
A brief review of 2018
The Knowledge Centre has been a busy place this year. A big thanks to all of you who have reached
out with library requests. You have all helped me learn about what information is important for
physiotherapists! Looking into 2019 you can expect to see big changes in the Knowledge Centre as
we redesign and restructure the layout and resources for a more streamlined user experience.
Terri McKellar, Requests for library services have continued to grow and requests for article retrievals continue to be
MLIS, BN, BA the most common service request. Your fascinating questions have kept me on my toes! The most
PABC Knowledge common requests have been to find the latest evidence for treatments, information and resources on
Services Manager rare conditions, and obtaining evidence to support expanding services within health care facilities.
Your most popular topics have included shockwave therapy, ultrasound therapy, evidence for PRP/prolotherapy/cortisone/
ozone injections, exercising during and after cancer treatment, treatment for osteoarthritis (various joints), and cannabis.
How to stay on top of the latest research
There are a few ways to keep current with research. You can watch for the monthly Knowledge Services Update, which has
links to current research articles that reflect the research queries your peers have submitted to the library. These can also
be found in “Physio Finds” on the website. You can also review “hot-topic searches” (also on the website) to review the
latest research on a topic of interest. If there is a search you would like to see added to the hot topic list, send me a note at
librarian@bcphysio.org. I look forward to hearing about your research interests!
COMMITTEE NOTES
PPAC BAC PDAC Rural and Remote
• Increased communication • We welcome two new • Met in November to plan • Met with MLA’s to discuss
and collaboration for members: Allison Kraby our 2020 course schedule. hiring and retaining
recruitment and retention. and Christina Conrad. challenges and ensure
• Discussed education for
physiotherapy is included
• Compiled a list of key • An audit of all the private the 2019 Forum – post-
on Health Authorities’
contacts in each health practice resources on forum courses as well as
primary care teams.
authority (HA) & currently the website has been presentations.
compiling information completed. Stay tuned for • Discussions are underway
• Met with UBC CPD to
about recruitment and updates! to increase training seats
discuss collaboration on
retention initiatives across by opening a PT campus
• Currently selecting the distributed courses – more
the province to share with at UNBC led by Hilary
new chair, who will be to come here!
key contacts in each HA. Crowley and the Prince
in place for our next
George group.
• Developing a toolkit meeting at the Forum in
to recruit PTs to public April. Ramsey Ezzat will • We welcome two new
practice focused on have chaired his last BAC members: Allison Kraby
students who have not meeting in January 2019. and Christina Conrad.
yet entered physiotherapy
programs (ie. high school,
undergraduate students).
PA BC D I RECT I O N S / 3
F E AT URE EDI TO R IA L
F E AT URE
Chris Perrey and Dr Tommy
KIDS IN PAIN Gerschman, Fortius Sport
and Health
A common generalization regarding children and youth who get injured and experience pain,
Jollean Willington, is that they get over it quickly and move on easily. Sports physiotherapist Chris Perrey and
PABC Communications Pediatric Rheumatologist Dr. Tommy Gerschman, who both work with young people at Fortius
Manager Sport Health, and share a different perspective. Both health practitioners work as members
of interdisciplinary healthcare teams and see children generally between four to 18 years old.
Most of the youth arrive at the clinic with a pain component, whether with an acute injury or
due to issues such as chronic back, neck, knee or ankle pain.
The youth in pain that Chris and Dr.Gerschman see have wide-ranging causes of pain related to
changing biomechanical realities. These issues directly impact how they move, and there is a
need for improved movement strategies. For some kids going through their adolescent growth
spurt, it could mean that they need to relearn certain skills, such as running, to better work with
legs or torsos that are suddenly longer.
Another consideration when working with children in pain is that their bones are still developing
and maturing, and are not yet as strong as adult bones. “We see certain patterns of disease, pain
or injury that are related to how mature the bones are. A lot of the effects we see, be it knee pain
or heel pain, sometimes relate to where bones are at in their maturity. Some injury patterns are
also associated with that. I think it is part of my job and Chris’ also to try and educate kids and their
families, that yes, kids can get pain. We can try to work with them and make that pain reduced or
hopefully gone. Really, the bottom line is to keep the kids active,” says Dr. Gerschman.
Chris says increased load and volume also impact youth activity. “I think from a physio
perspective, with the kid’s population we tend to see one or two things. Something that is
biomechanically driven, which may mean movement patterns, or even strength, as they are
growing into their new bodies. Or they are doing more things than they are capable of doing
at that point. Or it’s load related, fitting into a number of categories. So, they’re loading in
more and more activities with multiple training sessions per week, or they are going through a
growth spurt,” reflects Chris.
4 / Winter 18/1 9
Teamwork is very important, and youth will often see a When talking about identifying pain in children and youth,
doctor first who determines the needs of patients. “I think Dr. Gerschman says their experiences often translate from
physios have been working hard so the general population their family. “If a parent has an approach that, ‘I jump on
understands the role of physios and what they can help every little ache and pain’, then the child will do the same.
with, and that you don’t need a referral to see a physio,” Pain can be a symbol of something for us to stand up and
points out Dr. Gerschman. “For the physios I work closely pay attention to, but there are times when pain is expected.
with, which is a tremendous benefit, we’ll often get an email Pain is not something that is necessarily a danger signal that
saying ‘I’ve been working with this child, but something is something bad is going on,” clarifies Dr. Gerschman.
not fitting right’.” Dr. Gerschman carries out an assessment, Understanding people’s conceptualization of pain is an
makes a provisional diagnosis, and very often will important consideration, and talking about pain and how
recommend various allied health professionals. “Certainly, patients approach pain is key for the team. “Particularly in
we are lucky here at Fortius, to be working so closely with youth, pain language is sometimes a little bit different. They
each other and know each other’s strengths and interests,” don’t have the same conceptualization of pain as adults.
says Dr. Gerschman. They’ll often come in with phrases that we just don’t hear in
Once a patient has been recommended to physiotherapy, adults, or they find it difficult to describe their pain. An adult
Chris carries out a full assessment including knows sharp versus dull versus lancinating, whereas children
biomechanical, load and strength assessments. “At find those terms quite difficult. Sometimes, this is their first
that point we’ll usually have a chat after the first time time experiencing long-standing pain,” explains Chris.
we’ve seen them, in terms of what we find as physios, Chris points out that in order to treat pain, the cause needs
what we’ve given as recommendations and then where to be understood. “One of the hard things for us all to work
all of us fit in, medical, physio and whether we include out is what the drivers are for the pain. If we don’t nail down
anybody else, such as hydrotherapy, Pilates or massage the pain drivers, we don’t successfully treat the patients.
therapists,” says Chris. Once a clear path has been The role between all of us is to work out what the driver is,
agreed upon, the team meets only as necessary to review be it biomechanical, strength, growth or load,” says Chris.
files that may have changed slightly. Both Chris and Dr. Gerschman agree that solutions rely on
There could be several factors to consider if the treatment the biopsychosocial model, where there is a biomechanical
plan is not going well. “Sometimes we’ll need additional component but it’s complicated by the rest of life. “Kids
imaging, be it x-ray, MRI, bone scans, and certainly I help can be massively under stress at school or home or in
arrange that,” says Dr. Gerschman adding, “Sometimes, sports, and that can definitely play into their pain cycle.
additional medications or therapies can supplement It’s pointless giving exercises if we’re not dealing with
the work being done with the physiotherapist.” Other their driver being stress from the team, or lack of sleep,”
considerations are sleep quality, life stresses, nutrition and highlights Chris.
diet, and of course compliance with the treatment plan. Success with youth pain treatment means returning them
Chris has a lot of experience treating youth in pain. “I use to their activities with pain under control, but there are
largely active rehabilitation and therapy. Passive for me considerations in that process. “Ultimately we want to see
is something that achieves a short-term goal. If someone the child succeed in the sport they love to participate in.
isn’t moving well, certain muscles, joints or fascia, then But really, more importantly, is that they maintain an active
we facilitate that so we can get on to the active rehab lifestyle for the rest of their life. That they aren’t going to
component,” says Chris. As a physician, Dr. Gerschman get burned out and say ‘I never want to play hockey again’.
has seen incidents where a young patient has taken part Helping them avoid that type of outcome is part of the
in physiotherapy treatments without any great progress. conversation as well,” says Dr. Gerschman. He adds there
“I think where a lot of families get frustrated tends to be is often a mental component to getting youth back to their
when they’ve had a lot of passive therapy, and it doesn’t activities, which can be overlooked, when patients realize
go beyond that. I think there is a role for passive therapy they might not know how to return to their sport.
in the early and acute phase, and for short term goals, Building confidence in their sport and movement helps
to reduce pain or swelling. But probably within a few young people with that transition. While the work is
weeks at least, it needs to shift to an active program,” challenging, Chris asks, “Who would want to sit at a desk
recommends Gerschman. when you can work and help change people’s lives?”
PA BC D I RECT I O N S / 5
VIRTUAL PHYSIOTHERAPY FOR RURAL BC
When Natasha Wilch began her physiotherapy career, she divided her time between public
Jollean Willington, and private practice with a focus on neurology. Moving to Nanaimo, she discovered a lack of
PABC Communications services for the population requiring neurological treatments and she opened her own clinic,
Manager Symphony Rehabilitation. She quickly discovered that many of her patients were traveling
far distances to have treatments with her. Wilch also belongs to a national online fitness
community called Healthy Role Models, answering general physiotherapy questions. Through
this group, she has clients in locations such as Haida Gwaii and the Northwest Territories who
do not have immediate access to healthcare services and suffer with conditions such as basic
tendonitis and shoulder impingement.
“It became glaringly obvious to me that physiotherapy has so much that we can offer, with
education that we can provide people, and exercise instruction, giving them power back to
take control of their health,” recalls Wilch. “There were all of these people who suffered from
acute issues which, if they were corrected earlier, would not be turning into chronic conditions
just because they had no one to connect with who could help them. And to me that was not
OK,” she says.
This remote and regional need for physiotherapy services, and her passion for patient well-being,
led Natasha to start delivering services by way of telehealth in 2017 as part of her clinic services.
“I used the program that integrated with my EMR (electronic medical record) system, which
allows that necessary encrypted, secure connection with people. If it came up that someone
needed something, I was able to help support them through telehealth,” Natasha recounts. Her
practice has evolved with an emphasis on being user/patient friendly. “The definite downfall
with telehealth is that they don’t know what it is, or understand how it can work. And that is
6 / Winter 18/1 9
what we are still facing in trying to build the telehealth course the most serious cases get dealt with first. That
realm and trying to get the word out,” she says. means you could wait a year or longer until you see
someone if your problem is more minor,” explains Janelle.
Lori Holt is a physiotherapy telehealth patient who lives in
Haida Gwaii and has worked with Natasha for two years. For Janelle, there are many benefits to accessing
Lori’s rural location means there are inherent challenges physiotherapy with Natasha via telehealth. “I think the
to accessing primary healthcare, with the most important biggest value is being able to recognize the problem with
being consistent internet quality and the lack of physical my shoulder, that I over extend it. So now, when I work
contact with her physio to help point out issues. “The out I am very aware of the issue and focus hard on making
ability to get feed back and continuous support via email, sure I don’t do that to cause another injury, as well as not
with me being so remote, and the idea to get a physio over exerting myself by using too much weight. If I can’t
appointment is amazing, as it is very difficult where I live. keep a proper form then it’s too heavy!” says Janelle.
Options are limited and costly. The workout program is “Telehealth is very much a partnership between the
easy and very user friendly. It is truly a great option for client and me, and it is an active form of rehab. So, for
this area and I have recommended this to others as the the people who like passive rehab, this is definitely not
options available are pretty impressive for telehealth from appropriate, because I can’t passively do anything to them
Natasha and her team,” adds Lori. through a screen,” Natasha clarifies.
Another client of Natasha’s is Janelle Mulligan, who “My goal and dream is to be able to service Canada
lives in Norman Wells, Northwest Territories. Janelle through partnerships with other physical therapists in
accessed physiotherapy through telehealth with Natasha other provinces. Ultimately, the aim is that everybody
for six months. “Where I live there is a physiotherapist has access to healthcare, regardless of where they live.
that comes in every couple of months, but the wait list And telehealth eliminates that barrier and improves their
is usually pretty long and done on a triage system, so of quality of health,” shares Natasha.
Natasha Wilch & patient Janelle Mulligan
PA BC D I RECT I O N S / 7
UPDATES FROM PABC EDUCATION
Working in musculoskeletal practice, it’s easy to forget the scope
of issues we are dealing with. Low back pain is a leading cause
of disability in Canada, with 1 in 5 Canadians suffering from high
intensity low back pain over a 6-month period.1 In Ontario alone,
over a year-long period, 22.3% of people saw a physician for
musculoskeletal issues; that’s 2.8 million people!2 So the natural
question is what physiotherapists can do to help these people in
pain? While we have a number of tools in our toolbelt, is there one
Education Manager that we should bring out a bit more often than the rest?
Nathan Hers,
There are a few reasons why I think there’s a general answer to
PABC Registered
that question. The answer is not a newly minted manual therapy
Physiotherapist
technique, nor is it ACT, ART, or PNF. In fact, it’s humble, well
BKin, MPT
known, and called EXERCISE. A recent systematic review of
treatments for common musculoskeletal pain sites such as neck, back, hip, knee and multi-site
pain, found that exercise had the strongest recommendation, greater than other modalities
such as manual therapy or oral pharmacological management.3 Bottom line, we are very
confident that exercise is a highly influential and effective treatment that physiotherapists are
well positioned to administer. While there are issues with these reviews and they can’t inform
all of our practice, they can inform about what our power tool might be.
To zoom in on a specific treatment area let’s look at a review of lumbar spine pain comparing
active versus passive care. A massive review of lumbar spine treatment in the US, of over
750,000 individuals, looked at whether people received “adherent” versus “non-adherent”
care.4 Adherent care was defined as having 75% of treatment being active, either “exercise
therapy” or “neuromuscular re-education”. The authors found that patients who received
adherent (active) care had a significantly lower rate of advanced imaging, spinal injections,
lumbar surgery, and had lower medication costs over the subsequent 2 years.
There’s no use in having this “Power Tool” if patients don’t understand
why we’re using it. Exercise can be uncomfortable. It’s hard work, and
it’s sometimes painful. We need strategies to motivate patients to
engage and adhere to their exercise prescriptions.
Importantly, this review is not saying that we can’t or shouldn’t use manual techniques or therapeutic
modalities. Indeed, the authors state that manual therapy in the first two weeks of care is part of
clinical practice guidelines based on positive effects with early manual therapy in acute low back
pain.5 I would suggest the thesis is that exercise shouldn’t get left out, and that it should usually
make up a large portion of a treatment session.
There’s no use in having this “Power Tool” if patients don’t understand why we’re using it. Exercise
can be uncomfortable. It’s hard work, and it’s sometimes painful. We need strategies to motivate
patients to engage and adhere to their exercise prescriptions.
8 / Winter 18/1 9Patients prefer individualized exercises that are tailored to their particularly in the lumbar spine.9 Exercise is not a panacea
normal activities.6 This review of patient feedback emphasized for pain, and we will need to consider all things that are
demonstrating exercises, observing their performance, and sensitizing the patient in front of us to have optimal outcomes.
giving feedback based on technique. Patients seem to have In chronic low back pain there is some promising evidence
a bias against cookie-cutter approaches, which is echoed in that combining exercise, or a graded-exposure approach with
lower back pain treatment guidelines.7 I’m not saying that ‘Explain Pain’ education, leads to better outcomes in pain and
perfect technique is necessary for an exercise to be effective – function.10
rather, technical tips and instruction seem to increase patient
There are some guidelines below11 that have been suggested
buy-in and enthusiasm.
for chronic presentations that I think are helpful to keep in
Keep it fun! Our exercise programs should match the intensity mind when treating patients. These guidelines offer a starting
and type to the patient in front of us, but also introduce point when implementing our exercise programs.
variability and a good bit of fun to the process. It’s often the • Understanding contemporary pain biology and ‘explaining pain’
case that many different types of exercise will achieve similar are key competencies required for biopsychosocial treatment
benefits. For instance, with low back pain treatment, core
• Frequently reassure patients that it is safe to move/pace-up
stabilization, moderate-intensity aerobic exercise, strength
despite their symptoms
programs and flexibility programs, lead to a similar magnitude
• Exercise prescription should be time, as opposed to pain,
of benefit.8 That leaves us in a position to pick what exercise
contingent to using a tolerable/not tolerable dichotomy
resonates with our patients. If there’s an exercise that the
patient finds meaningful or fun, their adherence will increase, • Having ready-made responses to flare-ups can reduce severity
and they will realize the benefits. • Exercise should be individualized, enjoyable, meaningful, and
related to patient goals.
• Many patients with CMP will respond to lower exercise dosage
than recommended for healthy individuals (i.e. graded low to
If there’s an exercise that the patient finds moderate intensity).
meaningful or fun, their adherence will • Closely observe and monitor exercise, then provide feedback &
increase, and they will realize the benefits. correct poor technique
• Encourage patients to self-monitor exercise (diaries, activity
trackers, etc.)
While the review on musculoskeletal pain mentioned above • Place emphasis on developing/restoring movement confidence
found moderate to large effect sizes with exercise, other and quality
reviews have found smaller effect sizes on pain and disability,
References:
1.
assidy, J. et al. (1998). The Saskatchewan health and back pain
C about exercise for nonspecific chronic low back pain?: A systematic
survey. The prevalence of low back pain and related disability in review of qualitative studies. The Clinical Journal of Pain
Saskatchewan adults. Spine 7.
ICE. (2016). Low back pain and sciatica in over 16s: assessment
N
2.
acKay, C. et al. (2010). Health care utilization for
M and management. Retrieved from https://www.nice.org.uk/
musculoskeletal disorders. Arthritis Care & Research guidance/ng59
3.
abatunde, O. et al. (2017). Effective treatment options for
B 8.
aragiotto, B. et al. (2016) Motor control exercise for chronic
S
musculoskeletal pain in primary care: A systematic overview of non-specific low-back pain. Cochrane Library.
current evidence. PLOS One 9.
Searle, A. et al. (2015). Exercise interventions for the treatment of
4.
hilds, J. et al. (2015). Implications of early and guideline
C chronic low back pain: a systematic review and meta-analysis of
adherent physical therapy for low back pain on utilization and randomised controlled trials. Clinical Rehabilitation
cost. BMC Health Services Research 10.
ires, D. et al. (2015). Aquatic exercise and pain
P
5.
hilds, J. et al. (2004). A clinical prediction rule to identify
C neurophysiology education versus aquatic exercise alone for
patients with low back pain most likely to benefit from spinal patients with chronic low back pain: a randomized controlled
manipulation: a validation study. Annals of Internal Medicine trial. Clinical Rehabilitation.
6.
Slade, S. et al. (2014). What are patient beliefs and perceptions 11.
ooth, J. et al. (2017). Exercise for chronic musculoskeletal pain:
B
A biopsychosocial approach. Musculoskeletal Care
PA BC D I RECT I O N S / 9SHOCK WAVE THERAPY IN CLINICS
With much discussion
Jollean Willington, regarding active and passive
PABC Communications treatments, extracorporeal
Manager shock wave therapy (ESWT)
has been an area of curiosity
for many of our PABC members. This is a modality that
utilizes kinetic energy, created by compressed air which
is transferred to a shockwave transmitter and targeted
to the tissue of the patient. This creates a mechanical
vibration of the tissue and is aimed at promoting
regeneration and triggering the reparative process of
the bone, tendon and soft tissue. Proposed effects of
ESWT are to encourage blood vessel formation, the
reversal of chronic inflammation, the stimulation of
collagen production, the dissolution of calcified fibroblast
and the dispersion of pain mediator. Currently, there is
a lot of discussion around how effective ESWT is and
if this passive modality should be used for patients
experiencing pain.
Curtis Wong, a physiotherapist and a co-owner of Treloar
Physiotherapy clinic in Kitsilano, has done his homework
and believes there is a place for ESWT. “We’ve had this in
the clinic for over two years. We’ve had good success with
our clients, particularly with tendinopathy conditions such
as Achilles tendinopathy and wrist extensor tendinopathy.
We also use shockwave for other conditions such as rotator
cuff calcification and plantar fasciitis,” explains Curtis.
When Curtis initially heard of this new type of
electrotherapy he was intrigued. “It was a new way to help
our clients reach optimal recovery, so was very exciting. We
looked into it with an open mind and decided to invest
in one as there was quality evidence in relevant literature
supporting its use. Now, having had it for a couple of years
and seeing the benefits, I have become an advocate for
the use of shockwave with many of my clients,” says Curtis.
Curtis Wong, Treloar Clinic
Most of Treloar’s clients who could benefit from this
modality will use this device for anywhere from five to 10
sessions over the course of a couple of months. This is
done in combination with exercise and manual therapy as
Now, having had it for a couple of years
ESWT is shown to be most effective as part of a multimodal
approach to treatment. and seeing the benefits, I have become
Richard Tarnow is a patient at Treloar and has been using an advocate for the use of shockwave
shockwave as part of his treatment plan. “I had an injury with many of my clients,” says Curtis.
and was desperate for something to be done.
1 0 / Winter 18/ 1 9Through Curtis sharing knowledge of this new treatment, I His experience shows similarities with that of the Treloar
was definitely willing to try something different. I’ve had team. “We have been using pulsed pressure radial SWT
nothing but success with this,” says Richard. “We had since 2010. We reserve the use of SWT for conditions
started with the exercises. Then Curtis introduced me to that have been reported in the literature that have used
this new therapy. But I was skeptical because this is all new, low energy, radial SWT or are considered degenerative
but excited too because I needed to have this injury taken and have failed to respond to conservative treatment. It
care of. So, with this new treatment and my exercises, other includes a well-designed tendon loading program. Our
forms of pain management, and my foam roller, this has treatments are five weekly applications, with a short-
helped me recover from my injury.” term follow-up six weeks later, for a three-month total.
We apply an outcome measure to our SWT treatment,
Richard notes that during the treatment, he feels a tingly
upper extremity functional index / UEFI, lower extremity
sensation on the area of pain, but that no pain is caused
functional scale / LEFS, to track our success. For the
by the treatment. Initial treatment plans are determined
first few years, we kept a database to compare our
by using the machine research data, which worked out
outcomes to the literature. Our experience closely
to 2000 shocks delivered with adjustments to the pulse
matched the research for success in improving pain and
duration and frequency. “You are always reassessing to
function for selected conditions, which included calcific
decide whether shockwave should still be a part of the
shoulder tendinosis, lateral elbow tendinopathy, Achilles
treatment plan,” explains Curtis. “With Richard, we were
tendinopathy, insertional and mid-substance, and plantar
using shockwave on his lateral epicondyle, so we would
fasciitis,” Michael explains.
continually reassess his wrist extension strength, tolerance
of his eccentric loading program, as well as his subjective “Patient selection and appropriate timing in a tissue
reports of functioning at his work and his activity of healing recovery model is important when considering
competitive golfing.” SWT. The literature does not support the use of SWT in
the early stages of tendon disorder. SWT also does not
replace a thoughtful biomechanical assessment, activity
modification, and a progressive tendon loading program,”
“[...] I was skeptical because this is all new, Michael points out. “When used as part of a multi-modal
but excited too because I needed to have approach to treating tendinopathies, SWT may improve
outcomes. In the PABC Knowledge Broker projects
this injury taken care of. So, with this new
Achilles Tendinopathy and Lateral Elbow Tendinopathy
treatment and my exercises, other forms of Toolkits, SWT was included in the treatment algorithm as
pain management, and my foam roller, this a modality to be considered as an adjunct to therapeutic
has helped me recover from my injury.” exercise. The effect of SWT is likely a mechanical
repair stimulus at a cellular level, with other neural
accommodation producing local desensitization.”
Shock wave machines can be costly investments, but there In the treatment of tendinopathies, SWT could be
are other factors to be considered when choosing the considered once a client has failed to respond to other
right machine. Curtis said that while he and his colleagues conventional treatment options. Michael summarizes,
trialed several different machines, factors like ergonomics “Pulsed Pressure Radial SWT is a much more affordable
and comfort during treatment, from both the therapist and form of extra-corporeal SWT, and is becoming more
client perspectives, were key. The Treloar team chose a available in physiotherapy practice. Although there are
radial machine rather than the focused shock wave. conflicting and controversial reports in the literature on the
effectiveness of SWT, following a treatment algorithm such
Michael Yates, from the Dale Charles and Sports Clinic as used in the Achilles and LET Tendinopathy Toolkits can
Physiotherapy in Penticton, says they were the only clinics lead to better treatment planning, decision making and
in the Thompson-Okanagan using Shock Wave Therapy ultimately better outcomes when considering modalities
(SWT) for a while, but now a number of clinics offer it. such as SWT.”
PA BC D I RECT I O NS / 11What’s Changing?
We’re making changes to increase care for
your patients injured in a crash.
This means:
• double the money for care and recovery
• more money per treatment
• more types of treatments covered
• reduced user fees.
icbc.com/partners/health-services
2019 EDUCATION CALENDAR
EDIT: Nov. 28 2018
The PABC Education Manager and the Professional Sat, Feb 23 - Sun, 24th 2019, New Westminister
Development Advisory Committee (PDAC) have been Hypopressive™ - Low Pressure Fitness Level 1 Certification
working diligently over the past year to organize the with Trista Zinn and Tamara Rial. Registration is now open
professional development calendar for 2019. This coming
year has some exciting course offerings that cover a broad Sat, April 6 - Sun, April 7 2019, Port Moody
range of topics. In addition to the post-forum courses, we A Step Above Prosthetic Training with Shirlene Campbell
will be offering twelve courses in 2019, covering a variety of at Eagle Ridge Hospital. Registration is now open.
topics including multisensory integration, vestibular training,
Sat, May 4 - Sun, May 5 2019, West Kelowna
balance disorders, and wound care.
A 2 Day Introduction To Vestibular Rehabilitation- A
We are also very excited to offer more courses to diverse Comprehensive Approach. Registration is now open.
regions outside of the Vancouver area, and look forward to
expanding our reach even further in 2020. Utilizing distributed Sat May 25 - Sun, May 26 2019, Vancouver and
learning technology, we will be able to offer courses to Distributed Locations
physiotherapists unable to attend courses in urban areas. Evidence-Based Balance Disorder Assessment and Treatment
with Fay Horak in Vancouver and distributed locations
If you would like to recommend a topic or speaker that
throughout BC. See the PABC website for further details.
you and your peers would like to attend, please email
education@bcphysio.org.
1 2 / Winter 18/ 1 9THE IMPORTANCE OF CONNECTION
WHEN TREATING CHRONIC PAIN
Working with individuals When providing education, consider how your language
Tori Etheridge (Arca) who have persistent pain, for can impact their beliefs and understanding of their pain.
BKin, MPT. Certified many practitioners, can seem Ask yourself if what you are saying could lead to more or
Vestibular Therapist demanding and overwhelming. less fear of movement. Use your current knowledge of
There is a large range in pain to help their story make sense to them. This should
presentation of persistent pain, and sometimes, these be a two-way conversation, not just a regurgitation
individuals’ needs are not able to be met in a typical of “explain pain” (Explain Pain, Butler and Moseley).
fast-paced clinic environment. In their constant pursuit Consider discussing the heightened sensitivity of the
for answers, these patients can also feel as though they nervous system, dysfunctional modulators of pain, sensory
are lost in a sea of healthcare professionals, and may not hypersensitivity, protective responses and other social and
gain any further understanding of how to manage their psychological factors that can influence pain.
pain. Paradoxically, the information they do receive could
compromise their self-confidence leading to patterns of
avoidance, isolation and withdrawal. Having an open mind
A person in pain shares, “I think the
to explore the complexities of their pain experience is
essential. Below are a few things to consider when working biggest struggle I faced when seeking
with patients with persistent pain. medical care was the lack of engagement
Taking the time with these patients to explore their history, and understanding by the care providers.
thoughts and beliefs can often lead the therapist down a I often felt dismissed and judged as to
good path to help the patient. Rather than listening only
for a potential diagnosis, consider listening to be able to
what my issues and symptoms were and
understand their pain and to understand the impact their how I was functioning with them. On
pain has had on their life. Use this opportunity to provide several occasions I felt as though the
validation of their experience and build a therapeutic
care provider thought my issues were
alliance. Their story is key for understanding how they got
where they are. Listen carefully and ask questions through non-existent and I was making it all up”.
a biopsychosocial focus. Ask open-ended questions that
require them to reflect and explain what their understanding
is of their pain, tailoring the questions to the person sitting Be honest, and discuss expectations and realistic timelines
in front of you. It is here you can gain knowledge about their for change. Patients are vulnerable to falling into a
beliefs, expectations, fears and other factors which may dependent role where they rely on you to manage their
have a role in maintaining their pain. Some questions that pain. We should be facilitators in their care. Work to
can be helpful to ask those with persistent pain are: empower your patients to take control and give them the
tools they need to manage their pain. Avoid promoting
• What have you been told is going on with you?
passive treatments that lack clinical research to support
• How do you feel about what you have been told? their efficacy. These individuals should be encouraged
• What do you think is going on? to actively participate in self management and have
ownership over their rehabilitation. Teach them how to
• What else is going on in your life?
advocate for themselves, how to educate others about
• What is something that you would like to do again that their pain, and be honest with their healthcare providers.
you have stopped because of your pain?
Provide opportunities to experience pain reduction in the
• Do you think it is safe for you to participate in exercise? clinic; calming strategies such as relaxation, breathing and
• Is there anything else you would like to tell me about your visualization can positively influence pain. Movement and
current situation or pain? manual therapies can provide novel inputs to modulate
PA BC D I RECT I O NS / 13pain and reinforce the benefits of activity. Teaching We need to teach them how to find a balance between patients how to recognise protective responses and how the extremes of inactivity and over activity. to change them can be powerful and give a sense of During physiotherapy sessions, frustrations and emotions control. For example, are they holding their breath, tensing often come out, and this should not scare us. Some up, bracing or moving awkwardly? These strategies can may shy away from conversations around this, but if you reinforce that our nervous system can change. don’t ask questions, who will? To quote Peter O’Sullivan, Build confidence to move. Help patients build the Professor of Musculoskeletal Physiotherapy at Curtain confidence to load the tissues and coach them to manage University in Perth, Australia, “We need to treat the the protective buffer of their nervous system. Encourage emotional consequences of their disability that arise when them to move and educate how hurt does not always they can no longer do the things in life that give them mean new harm. Encourage them to move mindfully and meaning”. We need to be comfortable asking about slowly as they attempt new exercises, versus with high depression, anxiety, PTSD, trauma and other emotions. caution. Educate about the difference of challenging the Explaining the role of emotions in chronic pain and linking pain versus pushing through the pain and ignoring it. the mind and body are key. We need to open the door, Discuss flare ups and teach them pacing strategies to help and if you find your patient needs more advanced skills, avoid them. Explain how pain will increase slightly when then we refer on appropriately. they go to move, but that this is safe and expected. A special thank you to the Pain Science Division (PSD) Executive Team and a few PSD members for their feedback on this article. 1 4 / Winter 18/ 1 9
FORUM KEYNOTE SPEAKER:
INTERVIEW WITH DR. TASHA STANTON
Our Education Manager, Nathan Hers recently interviewed together in the brain. If you think about bending forward,
Dr. Tasha Stanton, a researcher from the Body in Mind you will have input from proprioceptors, input from tactile
research group. Dr. Stanton, an Associate Professor at receptors in your skin, vestibular input from your head
the University of South Australia, conducts research into bending forward, and visual input of how far you moved.
pain and perception and won the 2016 Rising Star Award All these different sensory signals can become paired with
from the Australian Pain Society. Dr. Stanton is keynoting nociceptive signals (i.e., the danger message that occurs
our 2019 Physio Forum and will be discussing pain with tissue damage, extreme temperatures, or mechanical
neuroscience and physiotherapy practice. This interview changes) and thus, your resultant experience of pain. These
has been edited for length and clarity pairings can become so strong that pain can be evoked
even when only a few of those inputs are present (i.e., pain
Nathan: Let’s start with a 10,000-foot view. For a clinician
by slightly bending forward). But alternatively, changing
where this is their first exposure, could you explain what
those inputs, even a small change, can have a large impact
pain neuroscience is?
on the pain experience. That is, the way that movement has
Tasha: Sure. In a nutshell, pain neuroscience explores how been coded and represented in the brain has included all
pain works and importantly, why we hurt. Pain neuroscience those inputs (multisensory), so if you take away or alter one
aims to understand the complexity of pain – particularly of them, it inherently changes the experience.
understanding what sorts of things shape our experience
of pain – and this is what intrigues me. This is important
because then we might be able to modify or change
our experience of pain. It’s interesting, most of us have
experienced pain’s complexity ourselves. Think of a paper
cut that hurts a ridiculous amount – this is a tiny injury but
it can be so painful. Or if you have ever noticed a bruise
on your leg and couldn’t recall how you got it? You’ve
experienced tissue damage but you’ve not experienced
pain - otherwise you’d remember getting the bruise.
In the last decade or so, pain neuroscience has shown us
that there are varied and vast contributors to our pain and
it’s our brain’s job to consider everything that’s going on in Nathan: Last question. Do you have any burning clinical
our body, mind, and lives and use that information to decide questions right now that are keeping you up at night?
whether we need protecting at that given moment. And
Tasha: That’s a good question. I am intrigued by the
that understanding, that pain is there to protect us, is key
people that have shockingly “bad” x-rays or MRIs, but
because it then makes sense why we might experience more
have no pain. I would like to systematically test how their
pain when we have other indicators of danger around us.
systems are working – is it that their inhibitory systems work
Nathan: One area you focus on is the field of multi- incredibly well and their facilitatory systems don’t and this
sensory integration. How would you describe that in the allows them to block any nociceptive signals? Or is it that
context of pain perception? their systems are completely normal and indistinguishable
Tasha: Basically, multisensory integration refers to how from someone with a completely clear MRI, thus supporting
input from different sensory sources is combined together. that in that person, there is unlikely to be a nociceptive
Multisensory integration allows us to experience the feeling signal being generated? And does this change if we show
that our body is our own, and allows us to know what’s them the terrible MRI findings? It is well known that there is
going on with our body at any given moment. So, where it a disconnect between tissue damage and pain experienced,
becomes really interesting is we’re starting to understand but we don’t always know exactly why that disconnect
that these sensory inputs can be paired together and coded occurs. I’m really interested in digging into the “why”.
PA BC D I RECT I O NS / 152019 BC EDUCATION FORUM, EXPO & GALA Register Now! April 27 & 28, 2019 Westin Bayshore Hotel, Vancouver Keynote Speaker: Dr. Tasha Stanton, Body in Mind Research Group Join your physio colleagues for a day of professional development, networking, and fun! This year we are offering educational sessions on a variety of topics, a larger wellness expo, the UBC Buddy Program and awards that recognize physiotherapists who have excelled in their practice. New This Year – Post Forum Courses on April 28th *Register for post forum courses and get the entire Saturday package free! • Pain and the Brain: using language, sensorimotor treatment, and virtual reality to target the brain in chronic pain with Dr. Tasha Stanton from Body in Mind Research Group • Clinical Management of the Fitness Athlete with Dr. Zach Long – The Barbell Physio • Concussion Management Workshop with Shannon McGuire, PT • Putting Evidence into Practice: Wound Healing using High Volt Pulse Current (HVPC/Estim) and Ultrasound with Nancy Cho, PT • Getting Online with Telerehabilitation in British Columbia with Dr. Trevor Russell and Jeremy McAllister, PT 1 6 / Winter 18/ 1 9
AWARDS GALA & BROADWAY NIGHTS!
This is included in your Saturday registration fee!
We are excited to announce that this year’s reception will feature entertainment
from some classic Broadway favourites: Rent, Wicked, Grease and more! Get
ready for an engaging night filled with awards, libations, prizes and live music.
There are Student Volunteer positions available. Students can volunteer and
receive free Saturday registration!
Contact: events@bcphysio.org
Register now and reserve your hotel room for the weekend.
Rural and Remote funding opportunities are available to attend the Physio Forum.
Visit https://bcphysio.org for details and application.
For discounted accommodation rates visit our website or contact
events@bcphysio.org.
PA BC D I RECT I O NS / 17LEGAL WORD PRACTICAL seems intoxicated by cannabis or another substance,
and to follow any relevant procedures in place at your
EFFECTS OF CANNABIS place of work. Accurate documentation will be important
if a patient later claims that they did not consent to a
LEGALIZATION treatment due to certain levels of intoxication.
In making the decision to treat, you should put the
Cannabis is legal and question of consent at the forefront of your mind. Even if
Georg Reuter many physiotherapists are the patient seems capable of consenting, it is also worth
Partner, Richards considering the nature of the activities being undertaken
understandably wondering
Buell Sutton
how this will affect their in the course of a physiotherapy session. Under the Act,
practice. The general answer is: not as much as you may true consent can only be given if the patient is adequately
think. The legalization of cannabis should not cause notified of the risks associated with certain forms of
clinics to significantly alter any policies and procedures treatment. Therefore, knowledge of the impacts of certain
in place. Instead, legalization serves as a good reminder levels of intoxication on, for example, motor coordination
of the general issues that arise regarding patients and and judgment, will ensure the patient is provided with all
intoxicating substances. the necessary information to make an informed decision.
The Effects of Cannabis and Treatment Tips to Address these Issues:
Studies on the effects of cannabis are continually 1. Implement mandatory education and training on the
developing and it would be worthwhile to keep up to risks of cannabis use and physiotherapy exercises.
date on developments as further studies are conducted. 2. Implement mandatory education and training on
As a starting point, the Occupational and Environmental recognition of cannabis impairment and develop
Medical Association of Canada issued a recent position policies and procedures for obtaining consent and
statement that recognizes the following: responding to emergency situations.
• “Cannabis use is associated with short-term impairment 3. Include in your intake form whether or not the patient
of memory, motor coordination and judgement, driving has consumed any impairing substances, including
and risk of injury”; cannabis. This may provide a baseline from which one
can further assess the patient’s ability to consent to
• “The extent and duration of impairment from cannabis is
treatment and to partake in treatment.
uncertain, and may differ between different people, but
it can last for up to 24 hours after cannabis use”; 4. H
ave good resources on hand and develop and
maintain good relationships with physicians and nurse
• “The presence of cannabis results in an increased risk of
practitioners who can provide information on cannabis
road traffic accidents, likely more than doubling the crash
use, its effects, and its relationship to pain management.
risk”; and
• “Aside from intoxication, cannabis is considered to References:
be addictive and associated with the potential for 1
osition Statement on the Implications of Cannabis Use for
P
the development of cannabis use disorder as well as Safety-Sensitive Work, September 24, 2018; found at: https://
cannabis withdrawal”. oemac.org/wp-content/uploads/2018/09/Position-Statement-on-
the-Implications-of-cannabis-use.pdf
It also remains clear that physiotherapists are not able to 2
hysical Therapist Regulations to the Health Professions Act, B.C.
P
prescribe, and should not recommend, cannabis for pain Reg. 288.2008, Section 6.
management. 3
Health Care (Consent) and Care Facility (Admission) Act , RSBC
Patient Consent, Safety, and Intoxication 1996 c 181, Section 5.
The Health Care (Consent) and Care Facility (Admission) Grateful acknowledgment for the assistance of my
Act prescribes that a patient must provide consent to colleague, Rhys Volkenant, who provided invaluable
treatment. Under s. 7 of this Act, consent is generally assistance in researching and preparing this article. Georg
measured based on the adult’s ability to understand the Reuter is a partner at RICHARDS BUELL SUTTON LLP
information given to him or her. and the practice leader for the Employment and Human
Rights Group. He has over 25 years of experience in the
To ensure that you comply with the Act, it is important
to adequately document interactions any patient that areas of employment and human rights law.
1 8 / Winter 18/ 1 9You can also read
