Physiotherapy Clinical Special by Patrick O Keane

Reflective Statement

patrickokeane — 2022-11-02 13:58:14 UTC

Physiotherapy involves many aspects of health promotion and rehabilitation but this module is particularly interesting as it involves a lot of aspects of physiotherapy that people would not even have heard of, or realise are a part of physiotherapy. Pelvic health, occupational health, and dermatology, etc., are among some of the topics that I knew very little about but the module 'Clinical Specialties' covers these topics in great detail which has furthered my education of physiotherapy and I feel I have a heightened awareness of the possible avenues of my future career.

I completed a 3-week placement in CHI Crumlin last year which had given me some insight into the area of paediatrics but as I was in the particular area of rheumatology my knowledge of other paediatric conditions was limited. Throughout this module, we discussed various other paediatric conditions that broadened my knowledge such as childhood obesity and paediatric intellectual disability which I will go into further detail in this padlet.

The topic of pelvic health is rarely addressed as it can be a sensitive topic but through this module and the research within this padlet, I have learned a great deal more and even understand the physiotherapy management of pelvic health. Especially that of my chosen subjects under that topic, incontinence, and pelvic girdle pain, both of which affect a lot of people but again are unknown or unspoken to the vast majority of people.

I had no idea physiotherapists played a role in dermatology and wound care so learning about how wounds heal and the different types of wounds was incredibly fascinating. I focused my subject on pressure sores as I did a 5-week placement in St Vincents University Hospital in neurology, in the area of stroke and care of the elderly. These people were all at high risk of pressure sores therefore it was reiterated to me multiple times how we must be mindful of the patients as we return them to their chairs or bed. Nurses would even report on the number of pressure sores found in a particular ward in the hospital as they were trying to minimise them as much as possible.

Occupational Health is a very interesting topic as it ranges from the manual handling side of cautioning people on the labour work they are doing to people in office jobs that tend to get back problems from spending too long sitting at a desk in a slumped position. Physiotherapy input is vital as it is unbelievable that so many people end up out of work due to unfortunate musculoskeletal problems.

Throughout my research on these topics, I have learned a great deal and I am inspired to continue learning in all of these areas of Dermatology, Pelvic Health, Occupational Health, and Paediatrics.
We never stop learning as a physiotherapist.

Wounds

patrickokeane — 2022-11-21 14:47:26 UTC

Definition: A wound can be described as any kind of breach in the integrity of the skin or underlying tissues

Wounds can be categorized by the following

Their depth
Open or closed
How they were caused
method by which they are expected to heal

Healing

patrickokeane — 2022-11-21 15:35:41 UTC

Definition: Healing is the process whereby destroyed or lost tissue is replaced by a viable tissue

Modes of Healing

Primary Intention (glue, suture, staples)
Secondary Intention (must heal from the bottom up as edges are left open)

Outcome

Complete regeneration
Scar tissue formation

Acute wounds (e.g. surgical wounds) can take 4-6 weeks to heal fully meanwhile chronic wounds (e.g. leg ulcer, infected wounds, or pressure ulcer) can take months to years to heal

3 stages of Wound Healing

Inflammation (pain, heat, redness, swelling)
Proliferation (angiogenesis, granulation, epithelialisation)
Maturation ( increase tensile strength, cellularity, vascularity)

Role of Physiotherapist with Pressure Ulcers

patrickokeane — 2022-11-21 15:59:28 UTC

Physiotherapists play a massive role in the management of wounds especially those of pressure ulcers as they can be very common for inpatients in hospitals and also for long-term wheelchair users. People are at risk of pressure ulcers in areas that have bony prominences in the body such as the greater trochanter, heel, elbows, and base of the spin.

Preventative measures must be taken by all healthcare staff with patients to reduce the prevalence of pressure ulcers. The HSE began a collaborative called Pressure Ulcers To Zero in 2014 and the primary aim of phase 1 which was to reduce pressure ulcers by 50% was achieved well and truly when they hit a reduction of 73% of avoidable pressure ulcers.

In the case of a pressure ulcer developing, our goals for physio with these particular wounds is

reduce any pressure on the ulcer
minimise contact the ulcer has with hard surfaces
decrease moisture of the ulcer
Keep it clean as much as possible (aseptic)

Pressure Ulcer Wounds

patrickokeane — 2022-11-21 17:02:10 UTC

The National Pressure Ulcer Advisory Panel (2016) defines a pressure ulcer as a "localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device, as a result of intense and/or prolonged pressure or pressure in combination with shear"

Pressure Ulcer To Zero

patrickokeane — 2022-11-21 17:05:55 UTC

Pressure Ulcers To Zero collaborative initiated by the HSE in 2014 and continued to this day

6 Stages of Pressure Ulcers

patrickokeane — 2022-12-06 11:30:57 UTC

Stage 1: intact skin with non-blanchable redness of a localised area usually over a bony prominence
partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister
full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed
full thickness tissue loss with exposed bone, tendon, or muscle

Unstageable: full-thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar (necrotic tissue)

Suspected deep tissue injury:
Purple or maroon localised area of discoloured intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear

Overweight and Obesity

patrickokeane — 2022-12-06 12:06:04 UTC

The World Health Organisation defines overweight and obesity as "abnormal or excessive fat accumulation that may impair health“.

According to the European Association for the Study of Obesity, overweight and obesity are the fifth leading risk for global deaths. At least 2.8 million adults die each year as a result of being overweight or obese.

In 2016, globally, 6% of preschool children (<5 years old) were estimated to be overweight.

1 in every 4 primary schoolchildren in

Ireland are overweight or obese. (Evans et al., 2011)

One of the major problems with childhood obesity is that all overweight children are more likely to become obese adults. This knock-on effect will later contribute to the statistic of overweight and obesity being the 5th leading risk for global deaths.

The statistics seem to be only increasing but this needs to change and can be changed as Obesity Is Preventable!

patrickokeane — 2022-12-06 12:18:55 UTC

Informative Video on Overweight and Obese Children in the UK

Complications of Childhood Obesity

patrickokeane — 2022-12-06 13:55:17 UTC

The complications of childhood obesity are endless and some are incredibly severe which will cause long-term problems for children if not addressed.

Obesity can cause changes in posture and other musculoskeletal issues that are detrimental to physical activity such as the list seen in the image above as well as...

Sub-optimal bone health
impaired balance
impaired flexibility
impaired muscle strength

Physical Activity Recommendations for Children and Young People

patrickokeane — 2022-12-06 14:04:25 UTC

Children and Young people should perform at least 60 minutes of activity daily as part of physical education, sport, free play, or transportation. This activity should be at a moderate to vigorous intensity. "Moderate intensity is defined as activity that increases breathing, sweating, and heart rate, and vigorous intensity substantially increases breathing, sweating, and heart rate". (ACSM guidelines, 2015)

In 2012 a global survey found that 80% of 13-15-year-olds had not achieved the recommended level. It was also found that boys tended to be more active than girls but inactivity increased with age (Hallal et al., 2012)

References

patrickokeane — 2022-12-06 14:22:48 UTC

Hallal PC, Andersen LB, Bull FC, Guthold R, Haskell W, Ekelund U. Global physical activity levels: surveillance progress, pitfalls and prospects. The Lancet 2012, 380(9838); 247-257

American College of Sports Medicine (2015) “Physical Activity in Children and Adolescents.” : ACSM’s Consumer Information Committee.

Department of Health and Children. Healthy Ireland Survey (2015)

(2016) Childhood Obesity in the UK. Available at: https://www.youtube.com/watch?v=5Km1fFLX6T8&ab_channel=JoeLeaf (Accessed: December 2, 2022).

References

patrickokeane — 2022-12-06 14:26:51 UTC

Mervis, J.S. and Phillips, T.J., 2019. Pressure ulcers: Pathophysiology, epidemiology, risk factors, and presentation. Journal of the American Academy of Dermatology, 81(4), pp.881-890.

Smith, H.A., Moore, Z. and Tan, M.H., 2019. Cohort study to determine the risk of pressure ulcers and developing a care bundle within a paediatric intensive care unit setting. Intensive and Critical Care Nursing, 53, pp.68-72.

Rafter, M. and Meagher, H. (2014) “Pressure Ulcer To Zero.” Dublin: HSE.

Role of Physiotherapist

patrickokeane — 2022-12-06 14:46:14 UTC

As physiotherapists, we need to be advising all parents that their child needs to remain active and communicate to them the guidelines on daily and weekly physical activity. Although it may not be part of our job to mention the appropriate food intake, we can mention the World Health Organisation's recommendations to reduce and prevent childhood obesity which are to

Increase consumption of fruit and vegetables, as well as legumes, whole grains, and nuts
Limit energy intake from total fats and shift fat consumption away from saturated fats to unsaturated fats
Limit the intake of sugars

Education is one of the biggest parts a physiotherapist plays when it comes to obesity, whether it's in children or adults. We need to talk about the importance and

health benefits of physical activity and the risks of not

being physically active

We want to promote any physical activity we can. It is important to inform parents that there is some kind of physical activity for all. They need to be exerting themselves somehow with physical activity, whether it's a sport after school or even encouraging children to go out to play with their friends. A lot of children these days are more obsessed with spending time in front of a screen and this might need to be reduced or limited to promote further physical activity.

patrickokeane — 2022-12-06 15:09:03 UTC

Occupational Health (OH): the relationship between work and health.

OH specialists/ (physiotherapists) aim to enhance a worker’s health status, increase the productivity of a
workforce, and improve business performance and the
economy."(Nicholsan et al.2017)
5% of all sickness absences will become long-term (ie. it will be> 4 weeks) and this accounts for almost half of the
total working days lost each year. (Black et al. 2020)
The longer a person is absent from work, the greater the chance that s/he will not return to work.

A write-up about Health in the Workplace

patrickokeane — 2022-12-06 15:16:07 UTC

The likelihood of falling out of work increases as the duration of Long Term Sickness Absence (LTSA) increases.

The proportion of those that stayed in work following their LTSA decreased as the duration of their LTSA increased. People whose LTSA spell lasted for 1 year or more, were 8 times more likely to leave work following their LTSA than those with a 4-week duration

Evidence about Effectiveness of Occupational Health Interventions

patrickokeane — 2022-12-06 15:34:06 UTC

Van Niekerk et al. 2012 found moderate evidence from 5 studies to support the use of ergonomic interventions-adjustable sit to stand desks to reduce neck or back pain.
Cullen et al. 2018 discovered that "Move to Remain at Work Interventions" can minimise lost time associated
with MSK injuries and pain related conditions and can
improve work function

Ergonomics Principles

patrickokeane — 2022-12-07 12:11:02 UTC

Ergonomics is the study of people's work efficiency in their work environment. Trying to achieve the optimum worker-

task relationship

Work with joints in mid-range
Provide the option for repeated force to be exerted by arms or legs
Muscle force should be exerted by the largest muscles available
Work at or below heart level
Provide adequate rest breaks

Using these principles, the risk of injury is hopefully reduced and productivity is increased

Role of Physiotherapist in Occupational Health

patrickokeane — 2022-12-07 12:34:32 UTC

Carry out DSE (VDU) workstation assessments and training to minimise the risk of musculoskeletal disorders
Carry out moving and handling assessments and training
Are active in the management of occupational injury particularly musculoskeletal disorders
Carry out Functional Capacity Evaluations

References

patrickokeane — 2022-12-07 12:47:55 UTC

Bevan, S., 2015. Economic impact of musculoskeletal disorders (MSDs) on work in Europe. Best Practice & Research Clinical Rheumatology, 29(3), pp.356-373.

Chartered Physiotherapists in Occupational Health and Ergonomics

https://www.hsa.ie/eng/publications_and_forms/publications/corporate/esri_report_2019.pdf

Van Niekerk, S.M., Fisher, D. and Louw, Q.A., 2017. Standing desks in schools: what are the effects? A summary of reviews. Occupational Health Southern Africa, 23(6), pp.8-14.

Cullen, K.L., Irvin, E., Collie, A., Clay, F., Gensby, U., Jennings, P.A., Hogg-Johnson, S., Kristman, V., Laberge, M., McKenzie, D. and Newnam, S., 2018. Effectiveness of workplace interventions in return-to-work for musculoskeletal, pain-related and mental health conditions: an update of the evidence and messages for practitioners. Journal of occupational rehabilitation, 28(1), pp.1-15.

Departemtn of Health and Socail Care, . and Department for Work and Pensions , . (2019) “Health in the workplace – patterns of sickness absence, employer support and employment retention.” .

Intellectual Disability

patrickokeane — 2022-12-07 12:58:33 UTC

Definition: Greater than average difficulty in learning.

Considered when intellectual functioning is significantly below average (IQ <70)
Significant deficits exist in adaptive skills
Present from childhood

Deficits in Intellectual Function

Reasoning
Problem Solving
Planning
Abstract thinking
Judgement
Academic Learning
Learning from experience

Diagnosis of Intellectual Disability (Lecture by Ciara Sheridan)

patrickokeane — 2022-12-07 13:52:51 UTC

Antenatal screening
First 1-2 years of life
Delayed development of motor skills e.g. sitting, standing, walking, talking
Lower levels of interest in the environment and others
Slower reaction to visual and auditory stimulation
Others at school age (more common with mild ID – language, learning, academic, behaviour)
Comprehensive medical and family history, physical examination and developmental assessment
Outrule – hearing/vision deficit, seizure activity, neurological deficit
Educational psychology assessment

Importance of Making an Intellectual Disability Diagnosis

Plan social and educational intervention as early as possible
Help child /adult reach full potential
Correct identification of needs → appropriate intervention
Establish a prognosis for the child’s future
Support for parents and families
Genetic counseling for parents
Late diagnosis is always better than no diagnosiss

References

patrickokeane — 2022-12-07 14:12:49 UTC

Patel, D.R., Cabral, M.D., Ho, A. and Merrick, J., 2020. A clinical primer on intellectual disability. Translational pediatrics, 9(Suppl 1), p.S23.

(2020) What is intellectual disability? University of Cape Town. Available at: https://www.youtube.com/watch?v=oliZ3CE66To&ab_channel=UCTCILT (Accessed: December 1, 2022).

Epidemiology & Aetiology

patrickokeane — 2022-12-07 15:01:03 UTC

According to Patel et al., (2020) between 1-3% of the global population is estimated to have some degree of intellectual disability.
The ratio of males to females is around 2:1
Prenatal risk of intellectual disability is alcohol/ substance abuse by the mother, bleeding during pregnancy, injury the to mother, or smoking.
Perinatal risks are extreme prematurity, low birth weight, and brain injury.
If a child is diagnosed with a severe intellectual disability, the subsequent child's recurrence risk is between 3-9%
IQ is only an estimation of intellectual functioning and is not always correct when diagnosing a disability. But based on studies an IQ of 50 or less is considered a severe intellectual disability. An IQ of above 50 is considered a mild intellectual disability
"The most common identified conditions in persons with severe intellectual disability include chromosomal abnormalities, genetic syndromes, congenital brain malformations, neurodegenerative diseases, congenital central nervous system infections, inborn errors of metabolism, maternal disease during pregnancy, in utero exposure to toxins, and birth injury". (Patel et al., 2020)

Information Video on Intellectual Disability

patrickokeane — 2022-12-07 16:20:51 UTC

The University of Cape Town talks about Intellectual Disability from the causes, needs, characteristics, conceptual intelligence, and social communication.

A very informative video that can assist in our understanding of Intellectual Disability.

Pelvic Girdle Pain

patrickokeane — 2022-12-08 14:22:30 UTC

“Pelvic Girdle Pain (PGP) is defined by pain experienced between the posterior iliac crest and the gluteal fold, particularly in the vicinity of the sacroiliac joints(SIJ). The pain may radiate into the posterior thigh in conjunction with/or separately into the symphysis"

The cause may be related to pregnancy, trauma, arthritis, and/or
osteoarthritis.
(Vleeming et al.2008)

References

patrickokeane — 2022-12-08 14:22:50 UTC

Vleeming, A., Albert, H.B., Östgaard, H.C., Sturesson, B. and Stuge, B., 2008. European guidelines for the diagnosis and treatment of pelvic girdle pain. European Spine Journal, 17(6), pp.794-819.

Albert, H., Godskesen, M. and Westergaard, J., 2000. Evaluation of clinical tests used in classification procedures in pregnancy-related pelvic joint pain. European Spine Journal, 9(2), pp.161-166.

Risk factors for Pelvic Girdle Pain

patrickokeane — 2022-12-08 14:31:57 UTC

Increased BMI
Smoking
History of trauma to the pelvis
History of Low Back Pain
Orthopaedic dysfunctions

Risk Factors for Persistent Pelvic Girdle Pain

History of low back pain
BMI more than 25 pre-pregnancy
Pelvic girdle pain in pregnancy
Depression in pregnancy
Heavy workload during pregnancy

Pelvic Girdle Pain Diagnosis

patrickokeane — 2022-12-08 14:52:22 UTC

P4 (posterior pain provocation test)
FABER test
Long Dorsal Ligament Palpation
Palpation symphysis pubis

Post Partum:

Gaenslens test
FADIR test

Functional Tests

Active straight leg raise
Modified Trendelenberg test

Short Podcast Episode about Pelvic Girdle Pain

patrickokeane — 2022-12-08 14:57:38 UTC

Physiotherapy intervention

patrickokeane — 2022-12-08 15:23:42 UTC

Reassure and educate
Correct the dysfunction: Restore symmetry
Improve motor control
Alter the load transfer pattern

Clinicians should consider the application of a support belt in the antepartum population with PGP.

The American College of Obstetrics and Gynecologists
(ACOG) and the Canadian Clinical Practice Guidelines
(CPGs) have recommended exercise for health benefits
because of the low risk and minimal adverse effects for
the antepartum population.

Urinary Incontinence

patrickokeane — 2022-12-09 10:01:53 UTC

Urinary incontinence (Overactive bladder OAB) is defined as the "involuntary leakage of urine that has a multifactorial etiology" (Soysal et al., 2022)

Stress Incontinence: due to increased abdominal pressure under stress (weak pelvic floor muscles)

Urge Incontinence: due to involuntary contraction of the bladder muscles

Overflow Incontinence: due to blockage of the urethra

Neurogenic Incontinence: due to disturbed function of the nervous system

Faecal Incontinence

patrickokeane — 2022-12-09 10:05:20 UTC

Faecal incontinence is defined by the unintentional loss of solid or liquid stool. Stool leaks out of the rectum with or without the person's knowledge. (Bharucha et al., 2022)

The term anal incontinence is used if any of these situations occur:

Stool leaks out when passing gas
Stool leaks out due to exerting oneself during physical activity
Feeling like you need to use the bathroom but not being able to make it to the bathroom on time
Stool is seen in the underwear after a normal bowel movement
Complete loss of bowel control

References

patrickokeane — 2022-12-09 10:05:42 UTC

Bharucha, A.E., Knowles, C.H., Mack, I., Malcolm, A., Oblizajek, N., Rao, S., Scott, S.M., Shin, A. and Enck, P., 2022. Faecal incontinence in adults. Nature Reviews Disease Primers, 8(1), pp.1-21.

Soysal, P., Smith, L., Bracchitta, L.M., Pizzol, D. and Verdejo-Bravo, C., 2022. Managing Urinary Incontinence. In The Role of Family Physicians in Older People Care (pp. 199-219). Springer, Cham.

Norton, P. and Brubaker, L., 2006. Urinary incontinence in women. The Lancet, 367(9504), pp.57-67.

(2019) Urinary incontinence - causes, symptoms, diagnosis, treatment, pathology. Osmosis. Available at: https://www.youtube.com/watch?v=vsLBApSlPMo&ab_channel=Osmosis (Accessed: November 29, 2022).

Urinary Incontinence Educational Video

patrickokeane — 2022-12-09 10:16:15 UTC

Youtube creator Osmosis created this 7-minute video which is very informative about the causes, symptoms, diagnosis, treatment, and pathology.

Prevalence and Risk Factors

patrickokeane — 2022-12-09 10:20:40 UTC

1 in 3 women suffer a pelvic floor issue
More than 200 million people worldwide live with incontinence
Only 1 in 5 women seek treatment for urinary incontinence after waiting for an average of 6.5 years to do so

Risk Factors

Gender
Age
Obesity
Chronic Cough
Genetics
Brain/ Spinal Cord Injury
Menopause

Physiotherapy Management for People with Incontinence

patrickokeane — 2022-12-09 11:38:35 UTC

Advice and Education- Reassurance!
Health Promotion
Bladder retraining
Exercise Training
Myomed
Electrotherapy

Pelvic Floor Training

Sit/ Stand or Lie in a comfortable position with knees slightly apart
Breathe in normally to prepare
As you breathe out, squeeze and lift the front and back passage towards your pubic bone/ bellybutton
You should feel your lower abdominal muscles engage too
Hold for 4/5 seconds or 3 breaths (in and out)
Release completely
Repeat 8-10 times beginning with twice daily and progressing to thrice daily when possible
Aim to progress to doing it when active too e.g. standing, walking, going upstairs.

Bladder Training

Attempt to resist the urge to go to the bathroom for a few minutes if you are going more often than 2 hours.
Do NOT go to the bathroom just in case!

Health Promotion

Avoid smoking
Exercise regularly
Avoid heavy lifting
Avoid strenuously activity
Avoid being overweight

Physiotherapy Outcome Measures

patrickokeane — 2022-12-09 11:42:33 UTC

Patient-Focused Goal e.g. Run 5k, retrun to gym
Nos of pads used 24 hours
PERFECT –Power, endurance, reps, fast, every, contraction, timed - Are they improving?
SF 36 Quality of Life Questionnaire