• Difficult to quantify.

• However, in the European Guidelines for the Diagnosis and Treatment of PGP - there are four studies of good quality -> results show that the point prevalance of women suffering from PGP during pregnancy is close to 20%, and that the evidence for this is strong.

1. Structure

• Bones: Two hip bones (ilium, ischium, pubis), sacrum, coccyx, and pubic symphysis.

• Joints:

  • Sacroiliac Joints (SIJs) - transfer weight from spine to legs, limited mobility.

  • Pubic Symphysis - slight movement for flexibility, especially in pregnancy.

2. Ligaments

• Stabilise the pelvis.

  • Sacroiliac Ligaments (anterior, posterior, interosseous).

  • Pubic Ligaments - support the pubic symphysis.

  • Sacrotuberous and Sacrospinous Ligaments - prevent excessive movement.

3. Muscles

• Stabilisers.

  • Transversus Abdominis (TA), pelvic floor, glutes, and multifidus - critical for load transfer.

• Movers.

  • Hip flexors, adductors, and hamstrings.

4. Biomechanics

• Pelvis transfers load from the spine to legs.

• Pregnancy increases joint laxity (e.g., relaxin) and shifts the centre of gravity, affecting stability.

5. Nerves

• Pudendal Nerve - controls pelvic floor.

• Lumbosacral Plexus - links pelvis and legs.

• Mulit-factorial.

• Hormonal.

• Biomechanical.

• Inadequate Motor Control.

• Biopsychosocial Factors.

• Has a role in supporting, stabilising, and facilitating movement in the human body.

• Its functions are particularly crucial during activities such as walking, running, childbirth, and maintaining posture.

Load Transfer

• ASLR (Functional Pelvic Test)

  - 20cm lift -> ? pain provocation, comparing Lt and Rt sides.

• SLS

  - when standing on Rt leg, looking at the Lt leg (mainly the SIJ) to see if it becomes asymmetric.

Pain Provocation

• Posterior Pain Provocation Test.

• FABER Test.

• Long Dorsal Ligament Palpation.

• Symphysis Pubis Palpation (through towel)

Post Partum

• Gaenslens Test.

• FADIR Test.

• Reassure and educate.

• Correct dysfunction and restore symmetry.

• Improve motor control.

• Alter the load transfer pattern.

• Outlines key guidelines for the management of lymphoedema. Highlights include:

  • Definition and classification.

  • Diagnostic evaluation (clinical Ax, imaging, differential Dx).

  • Staging of lymphoedema.

  • Treatment strategeis.

  • Prevention and risk reduction.

  • Research and future directions.

• A type of Nuclear Medical Imaging testing.

• A small amount of dye-type tracer is injected into the skin or other tissues of an organ and transported by the draining lymphatic anastomoses and this locates your lymph nodes and provides a visual of the lymphatic drainage pattern.

• Helps to precisely locate the affected area.

• Sensitivity = 96%.

• Specificity = 100%.

• Encourage hydration - supports lymphatic function.

• Wear compression garments - prevents fluid accumulation and enhances lymphatic flow.

• Monitor signs of worsening lymphoedema.

• Protect the skin - avoid activities that could cause friction or trauma to the affected area.

• Focus on low-impact activities - swimming, walking, cycling.

• Gradual progression and avoid over exertion.

• Pinch test.

• Healthy skin - it rises quick and high.

• Lymphoedema effected skin - it rises slow and low.

• 6 weeks of radiation onto skin -> slow and low, skin is not very pinchable.

• Sensitivity = 92%.

• Specificity = 57%.

  -> Good at predicting patients who have lymphoedema, but not so good at excluding patients who do not have lymphoedema. Thus, it is useful in the examination of patients with suspected lymphoedema.

• At risk - individuals who have had a sentinel lymph node dissection or axillary lymph node dissection, but have no S&S.

• Subclinical / Stage 0 - no visible swelling, subtle symptoms -> prevent progression with early monitoring and intervention.

• Stage 1 - slight swelling, swelling is coming and going, self-surveillance in hopes of a timely call to physio.

• Stage 2 - nothing is changing, swelling is there all the time, persistent, pitting.

• Stage 3 - severe swelling, significant skin thickening, hyperpigmentation, increased skin folds, fat deposits -> focus on symptom relief.

• 1 - reversible.

• 2&3 - irreversible.

• Information, information, information and EARLY.

• Empower patients.

• Supple, healthy skin.

• Exercise & Movement.

• Compression.

• Soft Tissue Mobilisations.

• Manual Lymphatic Drainage.

• Hydration.

• Supple, healthy skin.

Circumference of limb - Myotape

• Can be carried out at home.

• Self-surveillance.

• Good inter-rater reliability.

• Inexpensive.

Pain - Numerical Pain Rating Scale

• Easy to use and understand.

• Good reliability and validity.

Function - ROM, grip strength dynamometry (UL), TUAG or 6MWT (LL)

• Standardised approach.

• Get a baseline.

• Can be used as a measure of progress and motivation.

Lymphoedema Quality of Life Questionnaire (LYMQOL)

• Disease specific.

• Assesses physical, emotional, practical, and social aspects.

• Provides detailed insights into patient quality of life.

• Downside = timely.

Hospital Anxiety and Depression Scale (HADS)

• Assesses anxiety and depression, which are common in lymphoedema patients.

• Quick and easy to administer.

• Downside = not specific to physical or functional impacts of lymphoedema.

• Depends on several factors, including the cause (primary or secondary lymphoedema), the stage at diagnosis, adherence to treatment, and the presence of complications.

• While being a chronic condition, effective management can significantly improve QoL and prevent its progression.

• 700 nodes in the body.

• 300 in abdomen.

• 150 in sides of neck.

• 28 in each axillae.

• 18 in each groin.

• Redirect via anastomoses.

  
  

• A preventable chronic inflammatory condition that affects the lymphatic system and is characterised by the accumulation of lymphatic fluid in the tissues.

• Primary - congenital (cause = unknown).

• Secondary - acquired (cause = infection, cancer, radiation therapy, surgery).

• Compression of local structures due to the swelling.

• Asymmetrical swelling.

• Usually not painful, but a dull ache may be experienced.

• Hyperkeratosis - where the skin becomes hardened and rough.

• Most swollen at the end of the day.

DVT

• Aymmetrical swelling and not lymphoedema -> ? Deep Vein Thrombosis (DVT) which can lead to Pulmonary Embolism (PE).

• DVT = red, swollen and painful.

• Dorsiflexion Test aka Homan's Sign - pain in calf upon dorsiflexion of the foot.

HF

• Symmetrical swelling -> > Heart Failure.

• Great resource for all things Lymphoedema.

• The body is split into four regions/quadrants.

• When one quadrant signals an issue, it receives assistance from the other quadrants through the anastomotic connections within the skin (superficial system).

• Flow direction is superficial to deep

• The understanding of complex paediatric pain is in its early days.

• Complex pain conditions are increasingly recognised in the paediatric population.

• Children with complex pain can become adults with complex pain (approx. 60%).

• Complex pain impacts on the life of the child and everyone related to the child.

• Compression socks for long haul flights.

• BELLALITE.

• 30-40 mm Hg of pressure on the limb.

• Provides graduated compression onto the skin, which encourages lymphatic drainage.

• Enhances the muscle pump effect.

• Ensure proper skin hygiene.

• Skin = microbiome for bacteria, infections,

• Is acidic with a pH of 5 in healthy skin -> acid mantle = buffer.

• Production of sweat and sebum supports the biome.

• Skin care is really important!

• Washing with suitable body wash (ph 5).

• For the elderly population - use EUCERIN, which has added urea.

• Meticulous skin care of the compromised system ++

• Reduction in swelling and tissue hardening.

• Improved limb mobility and function.

• Prevention of recurrent infections like cellulitis.

• Enhanced quality of life and independence.

• Better long-term management and control of the condition.

• A common side effect of lymphoedema.

• Chronic inflammation stretches and dries out the skin, cracking it -> bacteria enter through the cracks.

• Rx via antibiotics (oral - if caught early, IV - if caught late).

• If untreated, can lead to septicaemia.

• Promotes lymphatic flow, improves mobility, and reduces swelling.

• Moderate level of intensity walking // 150 mins per week.

• It is necessary to move to stimulate anastomotic connections within the lymphatic system.

• Moving our body tells our immune system to calm down and stop with the chronic inflammation.

• Aquatherapy.

• Tai Chi.

• The ideal temperature for water based exercising for people with lymphoedema is 94°F (34°C) degrees.

• It is preferable to exercise in a relaxed moderate manner, as strenuous exercise may also generate too much heat and increase lymphoedema.

• In water – hydrostatic pressure b/t 70 and 100 mm Hg.

• Good for leg lymphoedemas.

• Social aspect also.

• If immunosuppressed or have a cut – no pool activity.

• Form of prevention.

• Slow, purposeful movements.

• The new model of care is weighted towards screening, early detection & treatment of the earliest stages versus the old model being weighted towards treatment of the late stages.

• Emphasis is on screening and early Rx.

• To slow the swelling down.

• To stop it from progressing.
  OR

• To reverse it.

• To limit the chronic effects of lymphoedema on the skin, the tissues, the joints, the person’s independence and quality of life.

• To reduce the incidence of cellulitis infections.

• Education.

• Compression sleeves.

• Exercise.

• Manual Lymph Drainage/Self MLD.

• Multilayer bandaging.

• Exercise.

• Custom compression sleeves.

• MLD..

• Decongests the nodes and then the vessels (intact lymphatics).

• Redirects the lymph fluid away from
  damaged lymphatics to healthy
  neighbouring region’s nodes using the
  interconnecting anastomoses (damaged/missing lymphatics

• 4 strokes

  - Stationary circle.

  - Pump.

  - Rotary.

  - Scoop.

• Stationary circles and pump are easiest to learn.

• Key point to note in each stroke - If the skin becomes red ... lighten your touch. Red is an outcome for massage, this is a drainage technique.

• 2-3 L processed daily.

• Interstitial fluid enters the vessel to become lymph fluid.

• This transformation is crucial to maintain fluid balance.

• T, B & Natural Killer Cells.

• Are produced in the bone marrow and thymus and are the main type of cells found in the lymph.

• B cells make antibodies to fight foreign antigens.

• T cells + NK destroy cells with viruses or cancer.

• Children have around double the number of lymphocytes when compared with adults.

• "Pinch an inch"

• STMs mobilise scars & fibrosis to facilitate lymph flow as it redirects through the anastomoses.

• Assessing speed and height of affected tissue.

• Something to think about with lymphoedema.

  
  

• Stage I ulcers will heal with conservative treatment without any surgical intervention.

• Stage II ulcers needs debridement of the wound and split-thickness skin grafting.

• The most difficult to treat are the Stage III and IV ulcers, due to associated skin changes and reduced vascularity. These cases need debulking along with excision of the ulcer.

• Affects the largest organ of the body -> skin.

• Impact at a physical, psychological and social level.

• Thermal, chemical or electrical trauma.

• Destruction based on time, temperature and type, first aid.

• Impact on vulnerable individuals ++.

• Average of 7,500 euros per 1% of Total Body Surface Area.

• 1.5-2 square metres.

• 2-3 mm thick.

• In 1 square inch, there is:

  - 650 sweat glands.

  - 20 blood vessels.

  - 60,000 melanocytes.

  - 1,000 + nerve endings.

Epidermis

• Outermost, protective layer.

Dermis

• Support layer - growth and vital function, blood vessels lymph, sweat glands, hair follicles, nerve endings.

Hypodermis

• Loose, connective tissue, usually contains abundant fat.

Functions

• Absorption.

• Controls body temperature.

• Sensory organ.

• Protects against infection.

• Identity.

Thermal

• Heat sources - flames, hot liquids/objects, steam.

Electrical

• Electrical currents

• Entrance and exit wounds.

• High risk of nerve damage, cardiac arrhythmias, fractures.

  
  

Chemical

• Strong acids, alkalis, or other corrosives.

• Alkalis cause more severe injuries -> penetrate deeper.

Radiation

• Exposure to UV-light, x-rays, radioactive materials.

• Sunburn.

Friction

• Rubbing against a rough surface at high speed or pressure.

• Road rash or sports injuries.

• Depth.

• TBSA.

• Anatomical Site.

• Appearance - colour, blisters, moisture.

• Sensitivity and pliability.

• Co-morbidities.

Tools

• Rule of Nines - quick estimate of affected body area.

• Burn Depth Indicators - colour, moisture, sensitivity.

• Key factors - TBSA, anatomical site, inhalation injuries

• Example - how burns on hands are significant despite size

• Superficial Burn.

• Partial Thickness Burn - Superficial // Deep.

• Full Thickness Burn.

• Outer epidermis only.

• Red and painful.

• Blanching.

• No blisters.

• Heals in 2-5 days with no scarring.

• All epidermis and into upper layers of dermis.

• Blisters.

• Oedema.

• Erythema.

• Extremely painful.

• Wet appearance.

• Heals spontaneously in 5-21 days, minimal or no scarring.

• No grafting.

• All epidermis, severe damage to dermis.

• Painful but sensation varies.

• Blanching present, but diminished.

• Eschar.

• Healing possible - may heal spontaneously 3-5 weeks, but may scar excessively, therefore grafting likely.

• Complete skin layer destruction (epidermis and dermis).

• Initially pain free.

• Appears white / tan / mottles / black.

• Eschar.

• No blanching.

• Requires grafting.

• Complete destruction of tissue from epidermis to bone.

• Unpredictable prognosis and appearance.

• Extensive injury, surgery and amputation.

• Entrance and exit wounds.

Coagulation/necrosis

• Central portion

• Irreversible cell death.

• Prevent infection while awaiting wound closure.

Stasis/injury

• Intermediate region.

• Viable cells.

• Special care to avoid further damage.

Hyperaemia

• Outer portion.

• Minimal cell damage.

• Heals quickly.

• Maintain airway.

• Fluid resuscitation

  -Parkland Formula - 4 ml/kg/% TBSA.

  -Avoid under & over hydration.

• Analgesia.

• Sedation.

• Wound management.

• Surgery.

• Severe oedema -> vascular damage.

• Under hydration -> renal failure.

• Over hydration -> ARDS, CHF, pulmonary oedema.

• Acute respiratory tract damage.

• Severity depends on the chemical composition of the toxic gases/vapours, length of exposure, PMHx (COPD?)

• Carbon monoxide - has 200% higher affinity for Hb than oxygen.

Signs

• Hoarse voice.

• SOB.

• Tachypnoea.

• Stridor.

• Abnormal breath sounds.

• Facial burns, singed nasal hair, sooty sputum.

• Disorientation.

Points to Note

• Early intubation is key, if facial burns present.

• O2 therapy // mechanical ventilation.

• Physio

  - maintenance of airway.

  - removal of excess bronchial secretions.

  - improvement of gaseous exchange.

  - prevention/treatment of atelectasis.

  - maintenance of thoracic expansion and general mobility.

Escharotomy

• Surgical procedure performed to treat complications arising from circumferential full-thickness burns that restrict circulation, breathing, or other vital functions.

• Life-saving procedure in severe burns.

• Indications

  - Circulatory compromise.

  - Respiratory compromise.

  - Tissue perfusion risk.

Debridement

• Removal of dead, damaged, or infected tissue from a wound to promote healing and prevent infection.

• A critical step in wound management to prepare the area for healing or grafting.

• Removes necrotic tissue // eschar.

• Is needed in

  - Full thickness burns.

  - Infected burns.

  - Non-healing wounds.

• Early grafting is desirable.

Process

• Eschar tissue removed.

• Donor tissue harvested using a dermatome and may be meshed

• Graft applied.

• Check 3-5 days post-op.

• Sheet graft

  - areas where aesthetics and smooth texture are important.

• Mesh (perforated) graft

  - allows for expansion -> function is the priority.

  
  

• Full thickness skin graft

  - used for smaller wound areas (face, hands).

• Split thickness skin graft

  - preferred for larger wound areas (worse sensation, smoother, no hair).

Types of Grafts

• Autograft - skin taken from the patient’s own body (preferred to avoid rejection).

• Allograft - skin from another human donor (temporary solution).

• Xenograft - skin from animals (e.g., pigs; temporary).

• Synthetic Grafts - biologic or synthetic skin substitutes used when donor skin is unavailable.

Acute Phase

• 1-3 days.

Wound Care Phase

• Weeks-months.

  
  

Rehabilitation

• Weeks-years.

• Medics.

• Nursing.

• Anaesthetics/ICU.

• Clinical Nutrition.

• Microbiology.

• Physiotherapy.

• Occupational Therapy.

• Medical Social Worker.

• Psychologist.

• Speech and Language Therapist.

• Holistic, patient-centred care.

• Maintenance of airway.

• Oedema management.

• Maintain joint flexibility and soft tissue length.

• Splinting.

• Education.

• Support patient, family, carer etc.

Post graft

• Check operation note, liaise with team, consider whether the graft crosses the joint.

• Resp physio.

• Early mobilisation.

• Positioning.

• Oedema control.

• Splinting.

• AROM days 3-5 post op.

• Early scar management.

• Pressure garments.

• Restore ROM.

• Restore pre-morbid strength and CV function.

• Scar management.

• Education.

• Functional re-integration.

• Return to sport/work.

• Psychological impact of injury.

• Multiple surgeries.

• Pain.

• Co-morbidities.

• Geographical considerations.

• Replacement of normal tissue with metabolically highly active tissue lacking normal skin architecture comprising highly disorganised collagen.

• Replacement of normal elastic ground substance with Chondroitin Sulphate A.

• Involuntary contraction myofibroblasts.

• Increased vascularity - localised lymphoedema.

• Compaction of connective tissue by voluntary contraction of skeletal muscle.

• Keloid / hypertrophic / contracture.

• Massage.

• Laser.

• Pressure therapy.

• Silicone.

• Skin camouflage.

• Taping.

• Steroid injections.

• Mechanical mobilisations: LPG, lymphatouch.

• Stretching.

• Microneedling // acupuncture.

• Scar tissue remodels with low load sustained pressure resulting in realignment of collagen bundles and development of sarcomeres.

• Normal skin applies a pressure to structures beneath it. This is lost after a burn.

• Pressure garments aim to replace this pressure.

• Skin-tight pressure garments that allow for free movement.

• Aim to wear at night.

• Improves colour, thickness, pliability.

• Desensitises scar and reduces itch,

• Allows for free movement.

• + / - pressure garments.

• A skinfold is created in a treatment head with negative pressure; after which that skinfold can be manipulated in accordance with established defibrosis techniques.

• Non-invasive.

• Established in France 25 years ago by Louis Paul Guitay.

• Only available in UK.

Physiological Mechanism

• Drains tissue and prevent scar adherence, stimulates natural collagen and elastin formation, restores mobility.

• POSAS - Patient Observer Scar Assessment Scale.

• VSS - Vancouver Scar Scale.

• FAB(-CC) - Functional Assessment for Burns.

• DASH - Disability Arm Shoulder Hand.

• Clinical Photography.

• Cutometer/Mexameter/Tewameter.

• Generic: MSWT, 6MWT, TUAG, 5STS.

• Anxiety / Distress common post injury.

• Psychological impact often revealed long after skin heals – 2-3 years post-burn.

• Flashbacks / Sleep difficulties / Short term memory loss / Lack of energy / PTSD.

• Refer for appropriate psychological / psychiatric support.

• Guide in what to do AND what not to do in the acute care of a burn injury.

• Wrap the burn area too tight - swelling may lead to further burn injury.

• Pop any blisters - they prevent skin infection.

Rule of Nines

• Body is divided into approximately 9% or a multiple of 9% total surface area.

• Helps determine the severity of burns and guide fluid resuscitation and management.

Lund and Browder Chart

• More precise than the Rule of Nines.

• Useful in paediatrics - as it accounts for variations in body proportions with age.

Major Burns

• Adults > 15%.

• Children > 10%.

• Burns to the face, hands and genitalia are classified as 'major' burns despite the relatively small TBSA.

• Excellent resource that outlines the assessment, management and key considerations that must be made for physiotherapists when treating burn injuries.

• Disorganised fibres of excess collagen that stay within the boundaries of
  the wound.

• Elevated and hyper-vascular.

• Cause severe contractures if extending across the joint.

• Common in children and adolescents.

• Will often occur in burns post grafting.

• Scars mature in 2-3 years.

• Resource with information on scarring.

• Excessive amounts of collagen that no
  longer conform to the boundaries of
  the wound.

• Higher incidence in individuals with
  dark skin.

• Painful.

• Raised with a fungating appearance.

• Key information RE compression for the treatment of burns and scars

• Valuable, user-friendly tool for scar assessment -> combining clinical and patient-reported measures to ensure holistic evaluation.

• Observer Scale and Patient Scale.

• Scale of 1 (normal skin) to 1o (worst scar imaginable).

Observer Scale

• Vascularity.

• Pigmentation.

• Thickness.

• Relief.

• Pliability.

• Surface area.

Patient Scale

• Pain.

• Itchiness.

• Colour.

• Stiffness.

• Thickness.

• Irregularity.

• Highly sensitive, however specificity can vary.

• Moderately reliable.

• Resource for the immediate care while waiting to go to hospital or be seen by the local GP.

Symphysis Pubis

• SP widens (4-9 mm) due to relaxin from 8 weeks (usually only has just 2 mm of movement).

• Pelvis very sensitive to oestrogen.

• > 1 cm gap represents pubic instability

• > 2.5 cm ligamentous damage at SIJs.

• Worse with subsequent pregnancies.

Pelvis

• SIJ may become lax during pregnancy (laxity may increase 2-12 times).

• 75% have posterior posture, 25% have anterior (with the ilia rotating on the sacrum).

• 40 weeks of pregnancy -> lengthening of muscles occurs -> more difficult to contract.

Clinical Indicators

• Pain localisation.

• Aggravating activities.

Differential Diagnosis

• Distinguish from:

  - lumbar pain.

  - labral tears -> tend to become symptomatic during pregnancy.

  - other conditions.

• Principles are the same.

• Prioritise motor control and strength.

• Patients that regain their full baseline function appear to do better in subsequent births.

• "Pelvic Girdle Pain (PGP) is 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" - Vleeming A., et al (2008) - European Guidelines for the Diagnosis and Treatment of Pelvic Girdle Pain.

• Recently, healthcare physicians have been moving away from PGP to include LBP -> and coin it lumbo pelvic pain.

Posterior

• 75% women adopt a posterior posture.

• Characterised by a flattened back.

• ? counter nutated sacrum -> more mobile, short hip flexors, "anxious adductors", weak abductors = WADDLING GAIT (inactivity of glutes causing weakness).

Anterior

• 25% women adopt an anterior posture.

• Characterised by an anterior pelvic tilt

• ? lumbar disc prolapse.

• Bone or soft tissue infections (atypical: tuberculosis).

• Bone or soft tissue tumours.

• Cauda Equina syndrome.

• Lumbar disc prolapse.

• Obstetric complications: unstable pregnancy, abruption.

• DVT.

• UTI -> High grade LBP uni or bilaterally, normal movement.

• Keep the woman in the supine position for as brief a time as possible to minimise the effects of postural hypotension syndrome on mother and baby.

• Vena cava occluded in supine position for pregnant population -> position at 20-30* elevation, or side-lying

• Self-reported pain location.

• Pain increased with weight-bearing activities and turning in bed.

• NPRS.

• Validated Oswestry Disability Index (ODI).

• Pelvic Pain Questionnaire - Stuge et al (2012).

• Pain Catastrophising Scale.

• Laxity (both joint and muscle) is global during pregnancy, not just in the pelvic area.

• There is a significant relationship between asymmetrical stiffness and patients with Symphysis Pubis Dysfunction (SPD).

• Parity and previous modes of delivery.

• Previous LBP/pelvic trauma.

• Pain coping mechanisms / catastrophising behaviours.

• Presence of additional continence or sexual dysfunction disorders.

Muscle Energy Technique (MET)

• Contract and relax.

Mobilisations

• Respect the laxity as end range is reached more easily.

• GR I - for pain, low amplitude, not into resistance.

• GR II - for pain, large amplitude, not into resistance.

• GR III - for stiffness, large amplitude, into resistance.

• GR IV - for stiffness, small amplitude, at end of range.

Trigger Point Release/Dry needling/Muscle release

• Combined with Motor Control Exercises, they help restore balanced muscle activity and improve load transfer across the pelvis.

• They address secondary issues like muscle guarding or compensations resulting from joint dysfunctions.

Core Stabilising Exercises

• Transversus abdominus (TA) // pelvic floor // pelvic girdle musculature.

• Breathing exercises.

Functional Exercise

• Engaging TA on STS, turning in bed etc.

• Avoid single leg loading as appropriate.

Pilates/Yoga

• Brings a social aspect to exercise.

General Exercise

• 30 minutes daily.

• Monitor HR (difficult due to blunted HR).

• Monitor rate of perceived exertion, using the BORG scale.

• Hydration - critical for heat balance keep blood volume up.

• Energy cost - consider balance intensity vs duration.

• Prescription: 30 mins daily.

• CV and strength training with reasonable goals.

• This guideline serves as a comprehensive resource for healthcare providers, aiming to improve the quality of care for women experiencing PGP during and after pregnancy.

Comprehensive recommendations for managing PGP

• Definition & Prevalence.

• Aetiology.

• Epidemiology.

• Diagnostics.

• Treatment Strategies.

• Evidence-based recommendations for physical therapists managing PGP during pregnancy.

• Guidelines are aligned with the ICF Framework.

• Aims to standardise and improve the management of PGP in pregnant populations.

• 20% incidence of PGP during pregnancy.

• Most common time period for presentation is 14-30 weeks.

• In a 12 year follow up study in women who reported lumbo-pelvic pain severe enough to require sick leave while pregnant; 92% reported pain during a subsequent pregnancy and 86% had recurrent pain while not pregnant.

• Globally, 6% of children under the age of 5 were estimated to be overweight.

• 1 in every 4 primary school children in Ireland are overweight or obese.

• However, recent trends are showing a plateau - 21%.

• Children are becoming obese at a younger age -> likely to become obese adults.

  
  

Department of Health and Children (2015), Evans et al (2011), Barron et al (2009), Abarca-Gomez et al (2017), Bel-Serrat et al (2017), Singh et al (2008), Whitaker et al (1997).

• Direct (healthcare) costs.

• Indirect (absenteeism, productivity loss etc) costs.

  
  

• In 2019, it was estimated that 8.4% of the budget in western countries will be spent on the consequences of overweight in the next 30 years [OECD (2019)].

  
  

• There is a great international cost on physical inactivity -> increasing current levels of PA could significantly reduce the costs to society, but even maintaining current levels of PA can result in savings [WHO (2003), Martin et al (2001), Department of Health (2001)].

  
  

• Australia - Increasing PA by 30 mins per day saves 1.5 billion dollars a year in healthcare [Medibank (2007)].

Quality of Life Costs & Psychological Health

• Stigmatised -> less attractive, poor social function, low fitness, poor health, unhealthy eating.

• Obese children (girls > boys) experience greater psychological distress than non-obese children.

• Increased screen time.

• Environments and communities that are not supportive in shaping people's choices and preventing obesity.

• Decreased awareness.

• Modern conveniences.

• Food costs -> cheaper food, less healthy, super sizing.

Healthier Diet

• Limit saturated fat intake.

• Increase foot, vegetable, pulse, nut consumption.

• Review portion sizes.

• Limit sugar and salt intake.

PA (HSE Guidelines)

• See below.

Population-based obesity prevention

• Government policies and interventions.

• Population polices and iniatives.

• Community-based interventions.

Infants (< 1 y/o)

• Physically active several times a day in a variety of ways, particularly through interactive floor-based play.

• < 1 hour secured (e.g., prams/strollers, high chairs, or strapped on a caregiver’s back).

Children (1-2 y/o)

• Minimum 3 hours in a variety of physical activities at any intensity, spread throughout the day.

• < 1 hour secured (e.g., prams/strollers, high chairs, or strapped on a caregiver’s back) or sit for extended periods of time.

Children (3-4 y/o)

• Minimum 3 hours in a variety of physical activities at any intensity, of which at least 1 hour is moderate-to vigorous-intensity physical activity, spread throughout the day.

• < 1 hour secured (e.g., prams/strollers, high chairs, or strapped on a caregiver’s back) or sit for extended periods of time.

Children and adolescents (5-17 y/o)

• Minimum 1 hour per day moderate-to-vigorous intensity physical activity.

• Minimum 3 days a week muscle and bone strengthening activities.

• Certain disabilities (e.g. CP, MD) - a reduced level of physical activity may be adequate to attain significant health benefits, considering their higher energy cost of physical activity.

• "Overweight and obesity are defined as abnormal or excessive fat accumulation that may impair health" - WHO.

• Complex, multifactorial worldwide DISEASE.

• Most obesity is preventable.

BMI Chart

• Unit = kg/m^2.

• Overweight = BMI > 95th centile or >+1 SD from median.

• Obese = > 98th centile or >+2 SD from median.

• Linked with many cardiovascular, reproductive, respiratory and other co-morbidities [Obesity (2005), Nishida et al (2003)].

• SUFE [Manoff et al (2005), Bhatia et al (2006)].

• Genu Valgum [De Sa Pinto et al (2006)].

• Sub-optimal bone health [Goulding et al (2000)].

• Impaired flexibility, balance, muscle strength [De Sa Pinto et al (2006), O'Malley et al (2012), Goulding et al (2003), Hue et al (2007), Thivel et al (2016)].

• Blount's Disease / Tibia Varum [Montgomery et al (2010)]

Endocrine Gland Abnormalities

• Hypothyroidism

• Cushing's Syndrome

Genetic Conditions

• Turner's Syndrome

• Prader-Willi Syndrome

Depression

Meds

• Steroids, anti-HTN, seizure

• Usually the result of an energy imbalance between calories consumed and calories expended.

Diet

• Increased caloric intake, foods that are high in fat, large portion sizes.

Activity

• Reduced PA.

• Sedentary jobs and lifestyle.

Other

• Breast feeding [Arenz et al (2004), Armstrong et al (2002)].

• Environmental changes.

• Four strategic objectives and 20 policy actions^.

• To achieve a 15% relative reduction in physical inactivity by 2025.

Four objectives

• Create an active society.

• Create active environments.

• Create active people.

• Create active systems.

Global Action Plan on Physical Activity (GAPPA) 2018-2030

• Strategy to address the rising prevalence of overweight and obesity.

• The plan emphasises a multi-sectoral approach, recognising that obesity is a complex issue influenced by various factors, including environment, education, and socioeconomic status.

Ten Steps Forwards

• Interdependent steps including government level action, commercial sector, communications strategy, health services, resources and research.

• Outlines targets RE the topic.

• Overview of the implementation framework.

• Proposes methodology for tracking progress.

• School curriculum health promotion.

• Increased physical activity at school.

• Improved nutritional quality of food supplied in schools

• Environments and cultural practices that support children eating healthier foods and being active throughout each day.

• Support for teachers and other staff to implement health promotion strategies and activities.

• Parent support and home activities that encourage children to be more active, eat more nutritious foods and spend less time in screen based activities.

Waters E, de Silva-Sanigorski A, Burford BJ, Brown T, Campbell KJ, Gao Y, Armstrong R, Prosser L, Summerbell CD. Interventions for preventing obesity in children. Cochrane Database of Systematic Reviews 2011, Issue 12.

• Resource for assessing PA and sedentary time.

Links

• The 5 As of Obesity Management.

• A Word about BMI.

• Assessment section.

• Growth charts.

Assessment

• BMI.

• Physical Fitness (MSK screen).

• Activity Levels (IPAQ).

• Cardiorespiratory Fitness (6MWT, Chester step test).

• QoL.

• Sleep.

Education

• Whole family -> benefits of PA, risks of physical inactivity, need for lifestyle change.

Promote PA

• Individualise and tailor programmes -> activities need to match age, skill level and maturity.

• SMART goal setting.

• Motivation.

• Time and stress management.

• Exact same recommended PA Guidelines.

Additional Risk Factors

• Meds promoting weight gain

  - can limit independence with ADLs.

  - increased demands on carers.

  - makes rehab more difficult.

• Physical impairments.

• Poor sleep quality (spasm, pain, respiratory).

• ? limited opportunities for PA

• Offers comprehensive outpatient and emergency care services for children (AND physiotherapy).

• Advice on food safety and research into food safety.

• Nutritional advice for parents and professionals.

• Very active on media and social media.

• Encourages reduction of screen time and increase of activity time.

• Activity ideas and resources.

• Educational materials.

• Community programmes.

• Support for schools.

• Resource that covers a wide range of educational material on children's health.

• 'A child with amplified musculoskeletal pain has an amplified pain response, so the pain he or she experiences is much greater than one would expect.  Additionally, most of these children have disproportionate dysfunction’ .

  
  

  David D. Sherry

• Particular subgroup of chronic pain; characterised by symptoms such as burning, throbbing, stabbing or shooting pain and signs such as allodynia (pain from a stimulus which would not usually provoke pain) and hyperalgesia (increased perception of pain from a painful stimulus).

  
  

  Professor Jennifer Stinson. Children’s Pain Management Masterclass, RCSI, October 2016.

• Patient X, a 14 y/o, has persistent wrist pain (7/10 on NPRS) after a fall.

• Symptoms include - throbbing pain, allodynia, swelling, stiffness, anxiety about writing and school.

• Dx - Complex Regional Pain Syndrome (CPRS).

• Rx - Education, graded physiotherapy, cognitive based therapy for anxiety, school accommodation.

• Long term outcome (6/12) - pain reduced (3/10 on NPRS), regained mobility, resumed writing and school, improved mood.

• More common in females (65-80%).

• Most common in the early adolescent population (11-13 y/o).

• No social class distinction.

• Single or multiple physical symptoms.

• Unusual gait pattern/movement patterns.

• Inconsistencies in examination.

• Allodynia.

• Child may use medical terminology with ease.

• ‘La belle indifference’ – very self-conscious of what others think -> example: throwing a tantrum when asked to do something, not caring for what the physio thinks, ? spoiled.

• Incongruent affect - child not being fully truthful -> reports of 9/10 pain which is unlikely when observing the child.

• Pain minimally or unresponsive to medication.

• May have colour or temperature changes in affected limb.

• High intensity of pain – bedding may be intolerable.

• Interferes with ADLs, including school absence.

• Sleep disturbances.

• Fatigue.

• Poor endurance.

• Emotional disturbances - changes in mood, low mood, anxiety, depression.

• Investigations to rule out alternate diagnosis.

• Avoid over-investigation.

• Note inconsistencies.

• Needs to be led by orthopaedic/specialist team but huge role for physio in further explanations/clarification.

• Ideally these children are treated within a multimodal (pharmacology, psychology and physical interventions) model of care under the care of a pain specialist.

• Build Rapport – key to a successful outcome.

• Validate Symptoms.

• Every child experiences pain differently so the assessment needs to be child specific.

• Assessment includes both the history and the physical exam.

• The history is more important than the physical examination. The patient interview is most informative, as pain is subjective.

• The history encompasses the pain history, impact of the pain and biopsychosocial influences.

• Yellow Flags.

• Can be used to guide and diagnose Ax.

A - Attitudes

• Belief that pain is harmful or disabling resulting in fear-avoidance behaviour.

• Belief that all symptoms must be resolved before return to activity.

• Expecting increased symptoms with activity.

• Catastrophising.

• Belief that symptoms are uncontrollable.

• Passive attitude to rehabilitation.

B - Behaviour

• Using extended rest.

• Reduced activity level.

• Irregular participation/poor compliance with PA.

• Reports of extremely high intensity pain.

C - Compensation Issues

• Hx of claims due to other injuries.

D - Diagnosis and Treatment

• Experience of conflicting Dx

• Language that leads to catastrophising and fear.

• Dramatisation of symptoms.

• Lack of satisfaction with previous Rx for symptoms.

  
  

E - Emotions

• Fear of increased symptoms with activity.

• Depression.

• Anxiety and heightened awareness of body sensations.

• Feeling stressed.

• Social anxiety.

• Feeling useless.

F - Family & Friends

• Over-protective family -> encourages catastrophising.

• Lack of support.

S - School

• School changes, stress at school, school dissatisfaction, poor relationships with peers and teachers.

Kendall

• Less important than subjective with this patient cohort.

Observation

• General appearance.

• Posture.

• Gait.

• Colour changes.

• Use of crutches.

Musculoskeletal Exam

• (as tolerated)

• Secondary changes due to prolonged inactivity or abnormal posturing may be evident on objective examination.

• Fear of examination may increase pain and limit the exam -> a distraction may be helpful.

• MDT lead with large psychological input.

• Child and family need to be involved in developing and agreeing the treatment plan.

• Education +++.

• Goal Setting.

• Use of an Activity Diary.

• Validate, validate, validate their symptoms.

• Experience & positivity.

• Reassure.

• Function will improve before pain intensity diminishes.

• Sensitivity.

• Benefit of movement (‘Motion is Lotion’).

• Pacing - graded rehab approach.

• Patient responsibility - empower self-management.

• Be prepared for a prolonged course.

• A patient-centred manifesto outlining ten key rights to ensure high-quality cancer care across Europe.

1. Equal Access.

2. Information.

3. Quality, Expertise and Outcomes.

4. Specialised Interdisciplinary Care.

5. Shared Decision Making.

6. Research and Innovation.

7. Quality of Life.

8. Integrated, Supportive and Palliative Care.

9. Survivorship and Rehabilitation.

10. Reintegration.

Oncology

• Sarcomas

  - originates in the connective tissues of the body.

  - rare and diverse group of cancers that accounts for approximately 1% of all adult cancers and 15-20% of childhood cancers.

• Carcinomas

  - originates in the epithelial cells.

  - most common type of cancer in humans and can occur in almost any organ or tissue.

Haematology

• Blood disorders

  - diverse group of conditions affecting the components, production, or function of blood, including red blood cells, white blood cells, platelets, plasma, or the mechanisms of coagulation.

• Chemotherapy

  - Cytotoxic.

  - Uses drugs to kill or inhibit cancer cell growth.

  
  

• Radiation Therapy

  - Damages DNA in cancer cells to prevent replication.

  
  

• Hormone Therapy

  - Treats cancers driven by hormones (e.g., breast or prostate cancer).

  • Tamoxifen: Blocks oestrogen receptors in breast cancer.

  • Androgen Deprivation Therapy (ADT): Reduces testosterone levels in prostate cancer.

  - Affect hormonal signalling rather than directly killing cells.

  
  

• Targeted Therapy

  - Specific molecules are targeted.

  • Tyrosine Kinase Inhibitors (TKIs): Inhibit enzymes driving cancer growth.

  • Monoclonal Antibodies: Block cancer-promoting signals or deliver toxic agents directly to cancer cells.

  - Targeted therapies are less likely to affect normal cells.

  
  

• Immunotherapy

  - Stimulates the body's immune system to recognise and destroy cancer cells.

  • Checkpoint Inhibitors: Block proteins that prevent immune cells from attacking cancer.

  • CAR-T Cell Therapy: Genetically modifies a patient's T cells to target cancer.

  - Immunotherapies are not cytotoxic in the traditional sense but rely on immune-mediated mechanisms.

  
  

• Stem Cell Transplants

  - Replaces damaged bone marrow with healthy cells.

  - Not cytotoxic itself but often combined with high-dose chemotherapy or radiation.

• Surgery

  - Physically removes cancerous tissue.

  - Not cytotoxic but often part of a multimodal treatment strategy.

• Cytotoxic therapies also affect normal dividing cells, leading to side effects such as hair loss, nausea, and reduced immune function.

Prehabilitation

• Improve physical and functional status before treatment.

Acute-Care Treatment

• Mitigate side effects of treatments.

• Manage fatigue, pain, and functional impairments.

Rehabilitation

• Restore optimal physical function and reintegrate patients into daily life.

Cancer Survivorship

• Enhance long-term quality of life and prevent recurrence.

Palliative and End of Life Care

• Improve comfort, maintain dignity, and manage symptoms.

Psychosocial Support

• Address the emotional and psychological aspects of living with cancer.

-> Addressing impairments to enhance recovery and maximise QoL.

• The process of enhancing the functional and physiological capacity of an individual to enable them to withstand a stressful event.

• Promotes healthy behaviours in order to maximise resilience to treatment and improve long-term health.

• People are less vulnerable to the side effects of cancer treatment if they are as healthy as possible, physically and psychologically.

• It may, in some cases, allow people with cancer to access treatments that were not previously available to them.

• Prehabilitation can optimise cancer treatment by promoting health and well-being as part of a continuum of preventative, restorative, supportive and palliative rehabilitation interventions.

• Including exercise, nutrition and psychological support, should be integral to the care of all people with a

  cancer diagnosis.

• Interventions targeted at improving

  physical and/or mental health should start as early as possible and in advance of any cancer treatment

Principles and guidance for prehabilitation within the management and support of people with cancer - Macmillan Cancer Support

Poor physical fitness is associated with

• Increased all-cause mortality.

• Increased postoperative complications (Pre-operative exercise can reduce the risk of a developing a post-operative pulmonary complication by 67% - Cavalheri & Granger, 2017).

• Increased length of hospital stay and discharge destination.

• Increased hospital and healthcare costs.

Wilson et al. 2010; Robinson et al. 2013; Dronkers et al. 2013

Aerobic Exercise

• x3 per week.

• 30-60 minutes.

AND/OR

Resistance Exercise

• x2 per week.

• 2 sets / 8-15 reps.

Campbell et al, 2019

Optimise outcomes for cancer survivors;

• To prevent or minimise the impact of impairments.

• To reduce activity limitations.

• To maximise life participation.

Treatment is

• Preventative.

• Restorative.

• Supportive.

• Palliative.

Strong Evidence

• Reduced anxiety

  - No dose-response relationship.

  - Supervised sessions are preferable.

• Fewer depressive symptoms

  - Evidence supports a dose-response relationship.

  - Supervised sessions are preferable.

• Less fatigue

  - Intensity of exercise is NB - mod-intensity aerobic training x30 mins, x3 per week plus resistance training x2/3 per week.

• Better QoL.

• Improved perceived physical function.

Campbell et al, 2019

Moderate Evidence

• Sleep.

• Bone health.

Insufficient Evidence

• Cardiotoxicity.

• Chemotherapy-induced peripheral neuropathy.

• Cognitive function.

• Falls.

• Nausea.

• Pain.

• Sexual function.

Campbell et al, 2019

• Exercise principles remain the same, despite the different patient population. There are some specific considerations that must be made.

  - individualisation - based on baseline cardioresp fitness and/or muscular strength.

  - progressive overload - training stress is increased across the intervention.

  - recovery - appropriate rest between sessions to optimise physiological adaptation.

  - specificity - designed to induce improvements in the primary outcome.

FITT-VP Principle

• Frequency

• Intensity

• Type

• Time

• Volume

• Progression

Sasso et al, 2015

Intensity

• BORG Scale - RPE

• HR is not too useful as certain treatments (chemotherapy) affect resting HR.

Lines & Attachments

• Care needed not to disrupt same when exercising.

Prostate CA

• Potential risk of fracture.

Breast CA

• Ensure arm/shoulder issues are resolved before commencing any UL programme.

• Monitor for changes in symptoms or swelling.

• Women with lymphoedema should wear a compression bandage.

Colon CA

• Ostomy - caution RE contact sports or weight lifting.

• Avoid excessive intra-abdominal pressures.

Haematopoietic stem cell transplant

• Multiple myeloma patients should be treated if they have osteoporosis.

Gynaecological

• Swelling/inflammation of the LL or groin - ensure symptoms have resolved before starting LL exercise training.

• Monitor for changes.

Metastatic CA

• Bone health.

• Symptomatic vs Asymptomatic.

• Pain levels.

• Patient education.

Schmittz et al, 2010

• 6-20 scale to replicate the patient's HR (x10).

• Participants are asked to rate their exertion on the scale during the activity, taking into consideration feelings of physical stress and fatigue, disregarding any factor such as leg pain or breathlessness but focusing on the whole feeling of exertion.

• HR is not as useful as an outcome measure as it is affected by chemotherapeutics -> therefore making it less reliable.

Hb level < 8.0 g/dL

• Avoid high intensity activities that require significant O2 transport.

Absolute neutrophil count < 0.5 x 10^9 /L

• Avoid activities that may increase risk of bacterial infection (swimming).

Platelet count < 50 x 10^9 /L

• Avoid activities that increase risk of bleeding (contact sports).

Fever >38* C

• ? systemic infection - avoid high intensity activities.

Ataxia, dizziness, or peripheral neuropathy

• Avoid balance and coordination activities.

Severe cachexia (loss of >45% premorbid weight)

• Loss of muscle mass limits exercise to mild intensity.

Dyspnoea

• Exercise tolerance.

Bone pain

• Avoid high-impact activities.

Severe nausea

• Exercise tolerance.

Extreme fatigue

• Exercise tolerance.

• Symptoms include diminished endurance for standing, sitting, and walking.

• Pain or discomfort in any or all of the following places

  - over your pelvis, especially at the pubic bone at the front.

  - along your groin area.

  - below your tummy.

  - in your hips.

  - across one or both sides of your lower back or buttocks (bottom).

• Reports of difficulty transferring load from the LL and the trunk.

• Difficulty parting your legs (getting out of a car).

• Originally for Low Back Pain, but can be adapted to PGP.

• Assesses the impact of pain on daily activities and quality of life, offering a quantifiable measure to track changes over time.

• 10 sections, each with 6 statements that are scored 0-5.

• Higher scores indicate greater disability.

• Unlike generic tools (ODI), the PPQ is tailored for PPG.

• Captures PPG's multidimensional nature.

• Has 2 main sections

  1) Activity related questions

  2) Symptom related questions

  -> Addresses both functional limitations and pain perception = holistic view.

• High inter-rater and intra-rater reliability.

• ideal for monitoring changes over time.

• Useful in assessing the psychological aspect of PGP.

• Catastrophising can have a significant negative impact on recovery and disability levels.

• Developed by Sullivan et al, 1995

  - 13 items divided into 3 subscales - Rumination, Magnification, Helplessness.

  - Scored 0 (not at all) to 4 (all the time).

• Useful in combination with ODI and/or PPQ.

• Sensitivity = 87%

• Specificity = 94%

Laslett et al (2005)

• Sensitivity = Approx. 60%

• Specificity = Approx. 50%

• This means that the FABER test alone is not entirely recommended, however -> using the FABER in combination with other SIJ provocation tests (P4 test, Gaenslens test, long dorsal ligament palpation) enhances diagnostic accuracy.

• Vaginal bleeding.

• Dizzy/faint.

• Chest pain.

• Headache.

• Calf pain / swelling.

• Uterine contractions or decreased
  foetal movement.

• Vaginal fluid leak.

• If any of these occur, it is recommended that the patient stops exercising immediately.

• Supine position.

• Prolonged static standing (decreased cardiac output).

• Increased basal metabolic rate (heat production) above non-pregnant levels (increased maternal core temp above 1.5* C (early pregnancy).

• Avoid activities with high risk of falls.

Resources on

• Pregnancy care.

• Postnatal care.

• Newborn care.

• Women's health.

• Times, days of classes.

• Great resource for all things women's health.

• Educational videos on PGP.

• Great resource for PGP.

• Exercises with guidance.

• Tips and tricks to ease pain.

• Previous history of low back pain.

• Previous trauma to the pelvis.

• Heavy work.

• Smoking.

• Pluripara.

• Young age.

• Belief of a weak back.

• Increased weight during pregnancy.

• National Maternity Hospital Videos on moving in bed.

• Range of exercises with instructions for women who have PGP provided by the National Maternity Hospital.

• A wide range of educational material for PGP.

• Useful resource for those that are visual learners.

• An initiative by the Canadian science-media partnership that is a valuable resource for addressing paediatric pain.

• It aims to promote awareness, reducr the stigma around paediatric pain, and fosters effective pain management practices, ultimately improving the quality of life for children experiencing pain.

• Designed to help children and young people manage anxiety using Cognitive Behavioural Therapy (CBT) techniques.

• It offers tools such as breathing exercises, relaxation techniques, and thought-challenging activities to reduce anxiety symptoms.

• Electronic pain diary.

• Smartphone-based pain assessment.

• Designed for use in paediatric cancer by SickKids.

• While initially being designed for cancer-related pain, it is also a valuable tool for managing various types of complex paediatric pain.

• There is significant interplay between anxiety and pain perception in children.

• Incorporating the HSE's anxiety self-help strategies into a comprehensive pain management plan can be instrumental in addressing the multifaceted nature of complex paediatric pain.

• Pain as a biopsychosocial phenomenon may be summarised as ‘threat–attention–response’.

• Pain has an impact on sleep, mood, school attendance, and social interactions.

• Encourages identifying underlying conditions and evaluating sensory and motor function changes.

• Pain is often under-evaluated, especially in the youngest children and those who are cognitively impaired.

• Developmentally appropriate pain assessment tools.

• Supports a multidisciplinary approach, including pharmacological, psychological, and physical therapies.

• Stresses the need for educating healthcare providers, families, and children about pain management strategies.

• Recognition and alleviation of pain should be a priority when treating ill and injured children. This process should start at the triage, be monitored during their time in the ED and finish with ensuring adequate analgesia at, and if appropriate, beyond discharge.

• In treating pain, pay attention to the other factors distressing the child such as fear of the unfamiliar environment and people, parental distress, people in uniforms, needle avoidance, fear of injury severity etc.

• Also has recommendations for the timely administration of analgesia.

• Comprehensive, evidence-based recommendations for treating chronic pain.

• Recognises chronic pain as a complex interplay of biological, psychological, and social factors, necessitating a holistic treatment strategy.

• Encourages the use of physiotherapy.

• Recommends CBT.

• Suggests cautious use of medications.

• Emphasises involving both the child and family in the treatment process to ensure that care plans are tailored to the child's developmental stage and family dynamics.

• Detailed resource that talks through a lot of patient case studies and scenarios

• A comprehensive online resource.

• Key highlights are:

  - Understanding lymphoedema and the types of lymphoedema.

  - Symptoms and diagnosis.

  - Treatment options.

  - Prevention and risk reduction.

  - Additional resources for patients and family members to download.

• Overall this document gives the patient a sense of empowerment, provides professional resources that are accessible and gives guidance to carers.

• Around 15,000 people in Ireland are living with lymphoedema.

• Primary lymphoedema may affect around 1 in 6,000 people.

• Secondary lymphoedema affects

  - 2 in 10 people with breast cancer.

  - 5 in 10 people with vulval cancer.

  - 3 in 10 people with penile cancer.

Absolute

• Acute infections.

• Cardiac oedema.

• Acute DVT.

• Renal failure.

Relative

• Malignant disease.

Abdominal MLD

• Pregnancy.

• Diverticulitis, Crohn's Disease, Ulcerative Colitis.

• Aortic aneurysm.

• Intra-abdominal scar.

• Recent surgery.

• History of pelvic DVT.

• Unexplained abdominal pain.

• Reduce your risk of skin breaks by using insect repellent, sun screen and wearing protective clothing, such as a high collared shirt, long pants, boots, gardening gloves and oven gloves

• Try products that state they have a low pH.

• If we select products and practices that are compatible with the body’s own highly evolved mechanisms, we can boost our skin’s ability to defend itself from fungal and bacterial infections, including cellulitis.

• Tips and tricks on MLD.

• Great resource with detailed podcasts.

Information on

• Treatment modalities.

• Lymphatics and the system.

• Function of the lymphatics.

• Case studies.

• Pit stop educational resource on lymphoedema.

• Covers

  - Background and Context

  - Diagnostics

  - Treatment

• Gold standard Rx of lymphoedema.

• Two phases, 1) the therapist reduces the swelling and improves skincare, 2) maintenance of above by the patient while incorporating it into their daily lives.

Phase 1

• Manual lymph drainage or MLD

• Multi-layer, short-stretch bandaging.

• Drainage exercises.

• Meticulous skin and nail care.

• Compression garments,

• Patient education in self-care.

Phase 2

• Self-Manual Lymph Drainage (S-MLD).

• Lymphatic exercises e.g, a) at home, b) in the pool.

• Meticulous skin and nail care.

• Compression therapy e.g, a) self-bandaging, (b) compression garments, c) garments with velcro, d) pneumatic pumps.

• Serves as a valuable tool for comprehending lymphoedema, its origins, and its unique characteristics compared to other oedema forms.

• Useful resource for lay-understanding of burns.

• Article resource with lots of key information RE burns.

• Useful schematic for visualising the different burn degrees.

• Great resource for in depth information on burn injuries.

• Outlines how children and adults are different when it comes to burn injuries.

• Inhalation Injury information.

HPC

• Cause of burn.

• Location of where incident occurred.

• Nature of incident.

• Date and time of burn.

• Date and time of admission to burn service.

• Exposure to smoke or other respiratory irritants.

• Additional injuries.

• %TBSA, distribution, depth.

• Treatment at scene/first aid given.

• Treatment to date and details of surgical interventions.

• Current meds.

PMHx

• All PMHx.

• Any psychiatric history.

• Any learning disability.

• Cognition pre-admission.

• Level of physical function prior to admission.

• Drug Hx pre-admission.

• Allergies.

SHx

• Hand dominance.

• Smoking Hx.

• Alcohol Hx.

• Recreational drug Hx.

• Patient's accommodation status.

• Pre-burn level of support from family, friends and carers.

• Pre-burn level of mobility.

• Occupation.

• Hobbies.

• Language.

• Religion.

• Previous community input/other agencies.

BritishBurnAssociation - Standards of Physiotherapy and Occupational Therapy in the Management of Burn Injured Adults and Children 2022.

Risk Factors

• Depth of burn.

• Location of burn.

• Infection.

• Nutrition.

• Pain.

• Skin fragility - friction/shearing.

• PMHx.

• Patient compliance.

• Fluid balance.

• Heart/renal failure.

Assessment

• Area affected.

• Circumferential measurements.

• ROM limitation.

• Volume.

• Pain.

• Limb function.

• Skin condition.

Management

• Elevation and positioning.

• Exercises.

• Splinting.

• Massage.

• Pressure therapy.

• Stretches.

• Taping.

Outcome Measures

• Photography.

• Circumferential measurements.

• Figure of 8 (hand).

BritishBurnAssociation - Standards of Physiotherapy and Occupational Therapy in the Management of Burn Injured Adults and Children 2022.

Risk Factors

• Joint, facial involvement.

• Age.

• Long-term disabilities.

• PMHx.

• Hx of burns.

• Grafting.

• Exposed structures.

• Pain and anxiety.

Pre-Injury Considerations

• Mobility.

Management

• Positioning, splinting, mobility.

• Active/passive exercise, strengthening.

• Optimising CV Fitness.

• Education to patients and their family.

• Functional exercise.

• Proprioceptive neuromuscular training.

Outcome Measures

• Goniometry.

• Dynamometry.

• Oxford Grading Scale.

• Borg Scale.

• Endurance tests.

BritishBurnAssociation - Standards of Physiotherapy and Occupational Therapy in the Management of Burn Injured Adults and Children 2022.

RF

• Age.

• Limitations.

• PMHx.

• Environment.

• Family support.

Pre-Injury Function Considerations

• Mobility, transfers, ADLs, hand dominance, level of activity.

SHx

• Family support.

• Dependants.

• Occupation, hobbies and interests.

Management

• Transfers/mobility practice and progression.

• Social and family roles reintegration.

• Work/study reintegration.

• Discharge planning.

• Driving.

Outcome Measures

• CPAX - Chelsea Physical Assessment Scale.

• TUAG.

• Timed unsupported stand.

RF

• Depth and location of burn.

• Time to heal.

• Complications.

• Infection.

• Skin type, fragility.

• Scarring Hx.

• Age.

• PMHx.

• Patient compliance.

SHx

• Family/support network.

• Dependants.

• Occupation.

• Hobbies.

Management

• Pressure therapy.

• Silicone gels.

• Scar massage.

• Splinting.

• Positioning, stretching, exercise.

• Steroid injections.

• Taping, laser.

• Dermarolling, microneedling.

Outcome Measures

• POSAS - Patient Observer Scar Assessment Scale.

• Photography.

BritishBurnAssociation - Standards of Physiotherapy and Occupational Therapy in the Management of Burn Injured Adults and Children 2022.

RF

• Pre-existing mental health diagnoses.

• Self-inflicted burn injury.

• Assault by burn.

• Acute Stress Disorder/PTSD.

• Anxiety.

• Sleep pattern.

• Effects of pain.

• Body image and disfigurement.

Social Considerations

• Medico-legal capacity.

• Advanced care planning & EoL.

• Care of the family and peer support.

• Income.

• Housing arrangements.

• Safeguarding issues.

• Return to work.

Management

• Work re-integration programme.

• Promote re-engagement of social roles.

• Support family/friends in adapting to social role changes.

BritishBurnAssociation - Standards of Physiotherapy and Occupational Therapy in the Management of Burn Injured Adults and Children 2022.

Summary

• Examination of the effectiveness of taping as a prevention measure against hypertrophic scars.

• Analysation of the studies focusing on the application of timing, duration, and outcomes associated with taping.

Key Findings

• Taping reduces scar height, redness and pliability.

• Silicone tape hydrates the scar and modulates collagen production.

• Initiating taping soon after wound closure and continuining for several months yields the best results.

Limitations

• Small sample sizes.

• Heterogeneity in studies.

• Lack of consistent long-term follow up.

Implications for Practice

• Implement taping soon after wound closure.

• Education needed RE proper taping techniques and individualisation of taping strategies.

O'Reilly et al, 2021

Summary

• Evaluation of the effectiveness of the FAB-CC score - a tool designed to evaluate functional outcomes in burn patients.

• It's valuable in predicting discharge outcomes.

Key Findings

• The FAB-CC score demonstrated a significant correlation with discharge outcomes.

• Was able to differentiate scores between those that needed to stay for more rehab and those that were able to be discharged.

Limitations

• Smaller sample sizes limit the generalisability.

• Data only collected from one burn centre which may not represent care on a national basis.

Implications for Practice

• FAB-CC can aid clinicians in making informed decisions regarding discharge planning and the need for rehab.

• FAB-CC can help with making care more efficient.

• FAB-CC allows patients and families to form realistic expectations.

Smailes et al, 2021

• Medical and psychological impacts of childhood obesity.

• Emphasis on building a healthier lifestyle.

• Multi-targeted approach.

• Needs engagement from the family.

• What has caused the decline of physical literacy/activity.

• Ways/areas to resolve this.

• Addresses the escalating issue of childhood obesity and advocates for community-driven solutions. She emphasises the importance of small, collective actions in creating significant, positive changes in children's health.

• Emphasises the psychological impact and toll of obesity.

• Detailed podcast on scarring and burn injury anatomy, management, treatment, difficulty with same and outcomes.

• Talk on the psychological aspect of dealing with burns and scars.

• Visual of the anatomy behind burn injuries.

• Visual for the classification of burn injuries.

In 541 oncology patients over the age of 70...

• 319 (21%) had impaired functional status.

• 507 (94%) had impaired physical performance.

• 314 (58%) were impaired in both.

• It has been noted that there is both decreased physical performance as well as functional deficits with oncology patients.

• These deficits are modifiable.

• Yet, these oncology patients and oncology survivors are not receiving the physiotherapy care they need.

• THERE IS A GAP IN THE CARE of this patient cohort.

• Emphasis must be put on the integration of both rehabilitation and palliative services to address the comprehensive needs of patients throughout their cancer journey. 

• There should be a push for early incorporation of rehabilitation and palliative care to enhance patient outcomes, quality of life, and overall satisfaction with care.

Tools to screen for

• Frailty.

• Functional status.

• Gait/mobility.

• Cognition.

• Quality of Life.

• Distress.

• Longitudinal Research.

• PDF resource that aims to empower patients with knowledge and practical steps to enhance their recovery journey after breast surgery.

• Has components such as - post-operative care, lymphoedema prevention, exercise programmes and general advice.

• Great resource with lots of detail RE prehabilitation in oncology.

Outcome Measures used to

• Find a baseline.

• Assess throughout the programme.

• As a means of measuring progression and therefore provide motivation.

• Frailty - Clinical Frailty Scale.

• Strength - 30 sec STS.

• Fatigue - FACIT F.

• Aerobic Capacity - 6MWT.

• Important for patient goal setting.

• Guided classes for different patient populations -> how to join.

• Great resource as it brings a social aspect to exercise for this cohort of patients.

• Includes food and activity pyramids and planners

• Comprehensive recommendations.

Prevention

• Whole-system approach.

• Lifestyle education.

• Environment.

Assessment

• BMI.

• Holistic Ax.

• Risk factors.

Management

• MDT approach.

• Family and behavioural support.

Treatment

• Tier-based interventions.

• Medical, surgical.

• Long-term support and psychological health.

The Identification, Assessment and Management of Overweight and Obesity in Adults and Children (2014) - NICE

• This guideline emphasises early intervention and the importance of creating supportive environments to foster healthy behaviours in children and adolescents.

• Detailed guidance on multidisciplinary treatment and practical management approaches.

• More suited for clinicians directly managing childhood obesity.

Scottish Intercollegiate Guidelines Network (2010). Management of Obesity: a national clinical guideline.

• Talk about why it's so hard for a person living with obesity to lose weight.

• Great resource.

5 ways to address childhood obesity

• Promote healthy eating habits.

• Increase PA.

• Enhance health education.

• Create supportive environments.

• Implement community-based programmes.

• Vleeming A., et al (2008) - European Guidelines for the Diagnosis and Treatment of Pelvic Girdle Pain.

• American Physical Therapy Association Clinical Practice Guidelines - Pelvic girdle pain in the antepartum population.

• National Clinical Guideline (2012) - Management of Pelvic Girdle Pain in Pregnancy and Post-Partum.

• Liddle et al (2015) - Interventions for Preventing and Treating Low-Back and Pelvic Pain During Pregnancy: Cochrane Review.

• Van Benten et al (2014) - Recommendations for PTs on the Treatment of Lumbopelvic pain during Pregnancy: a Systematic Review.

Summary

• A Randomised Controlled Trial of the MEND programme as an intervention for childhood obesity.

• Sample size = 116, who were randomly assigned to an intervention group (MEND programme) and control group (typical care).

• Follow up at 6 and 12 months.

Key Findings

• Significant BMI reduction in the intervention group versus control group.

• Enhanced CV fitness in the intervention group.

• There were notable improvements in behaviour changes regarding diet and PA among those in the intervention group.

Limitations

• Short-term follow up.

• Generalisability concern that the findings may not be universally applicable.

Implications for Practice

• Demonstrates potential for community-based interventions.

• A holistic approach yields the best outcomes.

Sacher et al, 2010

Summary

• Evaluation of the impact of a family-centred programme on reducing childhood obesity.

• Sample size = 124 families to intervention group, 62 families to control group (no care -> remained on waitlist).

Key Findings

• BMI reduction in the intervention group.

• Improved health behaviours RE diet and PA.

• Active engagement of parents was linked with improved outcomes in their child's weight management.

Limitations

• Short term follow up.

• Lack of participant diversity.

Implications to Practice

• Encourage parental involvement.

• Family-oriented interventions are useful in addressing childhood obesity.

Brown et al, 2019

Summary

• SR and MA to evaluate the effectiveness of interdisciplinary interventions in managing chronic pain among children and adolescents.

• 28 studies.

• Assessing outcomes such as functional disability, pain, and psychological health.

Key Findings

• Significantly lower pain intensity scores were associated with people who received interdisciplinary interventions versus those who didn't. This was at one month, as well as 3 and 12 month follow ups.

• Improvements in anxiety, depression, catastrophising were noted in the intervention group that received interdisciplinary care.

  
  

Limitations

• There was heterogeneity noted across studies (outcome measures).

• Some analyses had limited sample sizes.

Implications to Practice

• Supports interdisciplinary approach.

• Need for standardised protocols and outcome measures for this cohort.

Liossi et al, 2019

Summary

• Systematic review examining RCTs assessing pain management interventions in children and adolescents with chronic pain.

• 58 RCTs.

  
  

Key Findings

• More RCTs focusing on non-pharmacological treatments.

• There was an underrepresentation of younger children and infants.

Limitations

• Limited sample sizes.

• High or unclear risk of bias.

• Variations in interventions, populations and outcomes - heterogeneity.

Implications for Practice

• ? Focus on integrating pharmacological and non-pharmacological interventions to enhance pain management.

• Future research to include the younger patient population.

Boulkedid et al, 2017

Summary

• Examines strategies for managing lymphoedema.

• 11 databases searched, with 16 articles reaching the inclusion criteria.

Key Findings

• Various techniques - compression therapy, skin care, exercise, manual lymphatic drainage - can be performed independently.

• Evidence suggests that these practices can help reduce lymphoedema symptoms and improve QoL.

Limitations

• Some studies lacked rigorous design -> affects the reliability of the findings.

• Small sample sizes in the studies makes it difficult to generalise the results to a broader lymphoedema patient population.

Implications for Practice

• Education is key.

• Self-management strategies must be tailored and personalised.

• Ensure regular follow-up and support.

Ridner et al, 2012

Summary

• Evaluation of qualitative and quantitative studies on health-related QoL in people with lymphoedema.

Key Findings

• There is a lack of professional understanding in the topic -> which leads to patients receiving insufficient information.

• There is a large psychological toll accompanied with lymphoedema - reports on feelings of embarrassment, social isolation etc.

• It hinders overall QoL and ability to perform ADLs.

Limitations

• Large amounts of heterogeneity.

• Selection bias noted in some studies.

Implications for Practice

• Need for CPD or enhanced education on the topic.

• Integration of psychological and social supports into treatment is key.

Morgan et al, 2005

Summary

• Evaluation of various treatments aimed at managing LBP and PGP.

• 34 RCTs, involving 5,121 pregnant women aged 16-45 y/o, between 12 to 38 weeks' gestation.

Key Findings

• There was low quality evidence suggesting that land-based exercises significantly reduced LBP.

• There was moderate quality evidence suggesting that 8 to 12 week exercise programme reduces the number of women reporting combined LBP and PGP.

• Land-based exercises reduced pain-related sick leave.

  
  

Limitations

• The quality of evidence is only low or moderate.

• There was clinical and statistical heterogeneity noted.

Implications for Practice

• Incorporate exercise - may reduce pregnancy-related LBP and PGP.

• Combining manual therapy, exercise and education may offer additional relief.

Liddle et al, 2015

Summary

• Evaluation of the effectiveness of various interventions for managing LPP in pregnant women.

• 11 RCTs, 1,257 pregnant women who experience LPP.

Key Findings

• There was moderate evidence suggesting that tailored exercise programmes reduce pain and improve functional outcomes.

• Limited evidence to suggest manual therapy can provide short-term pain relief.

• The combination of exercise and manual therapy yields the best outcomes.

Limitations

• Lack of blinding, small sample sizes.

• Heterogeneity of interventions

Implications for Practice

• Necessity for individualised and tailored programmes.

• Use of manual therapy as an adjunct to exercise.

• Holistic nature of care is key.

Van Benten et al, 2014.

Summary

• Focus is on exercise interventions immediately after primary cancer treatment.

• Emphasis on outcomes - physical function, QoL, fatigue, immune function, body composition.

• 10 studies.

• Approximately 80-90% adherence.

Key Findings

• Improved aerobic capacity, muscle strength and agility with exercise.

• Significant reductions in fatigue.

• Enhanced psychological well-being.

• Decrease in fat mass.

Limitations

• Only 4 of the 10 studies used randomisation.

• Lack of blinding in data collection.

• Heterogeneity when it came to timing of interventions and exercises used.

• Gaps in reporting null findings.

Implications for Practice

• Incorporate tailored aerobic and resistance exercise programmes in post-treatment care.

• Encourage MDT collaboration.

• Investigate long-term effects RE recurrence and survival rates.

Spence et al, 2010

Summary

• Examines the impact of prehab on long-term physical function, nutrition and patient-reported outcomes (SF-36, HADS) in oncology patients.

• 16 RCTs, total of 2,017 participants.

• 6 observational studies, 289 participants.

Key Findings

• Improvements in gait, cardiopulmonary function, urinary continence, lung function with prehab.

• Some studies reported enhancements in mood and reductions in anxiety and depression following prehab.

• Prehab and rehab combined demonstrated better benefits than just prehab alone at 30 days post treatment.

Limitations

• Heterogeneity of studies.

• Short-term focus, limited data on long-term effects.

Implications for Practice

• Implementing both prehab and rehab may offer synergistic effects, improving recovery and long-term health.

Faithfull et al, 2019

Learning about PGP allowed me to understand its multifactorial aetiology, being hormonal, psychosocial and biomechanical in nature. Studying how it can be assessed through load transfer strategies and treated with tailored motor control exercises allowed me to understand the necessity of restoring function while addressing the individual’s needs. I will prioritise patient education to empower individuals, helping them understand their condition and the reasoning behind treatment plans in future practice.

While collating resources and information on childhood obesity, the nature of how it affects patients, both their physical and psychological health really stood out to me. Reflecting on the economic burden of childhood obesity, physiotherapists can play a major role in preventative care and early intervention, not only to improve individual health outcomes, but also to alleviate the financial strain obesity imposes. Family-based interventions, such as the MEND programme highlight the role of holistic care. As a future physiotherapist, I will aim to develop engaging, age-appropriate physical activity programmes and promote preventative initiatives within communities. The importance of building a rapport with young patients and their families left an impression on me, especially among complex paediatric pain patients. Putting it into practice, I will aim to provide patient-centred care, with clear communication and education being at the forefront to support children to regain their function and enhance their self-efficacy.

Studying lymphoedema and exercise in oncology stressed my role as a physiotherapist and how I can improve a patient’s quality of life. This can be done by reducing fatigue, enhancing mobility, and addressing chronic-related symptoms. Gaining knowledge regarding tailored exercise programs and manual lymphatic drainage has prepared me for my pivotal role in the future as I contribute to the MDT, helping patients reach their goals. Burns, plastics and scars really opened up my eyes to the importance of early physiotherapy interventions. Scar mobilisation and compression therapy highlight the need to address physical and psychological outcomes. As a future clinician, I will ensure that patients feel supported throughout their entire rehabilitation journey.

Reflecting on these topics has deepened my appreciation for how much we, as physiotherapists, can help improve patients’ lives. This Padlet Portfolio will be an invaluable resource in my professional career, enabling me to provide evidence-based, tailored and individualised care to meet patient’s needs.

• Obesity (2005), Nishida et al (2003).

• Department of Health and Children (2015), Evans et al (2011), Barron et al (2009), Abarca-Gomez et al (2017), Bel-Serrat et al (2017), Singh et al (2008), Whitaker et al (1997).

• Manoff et al (2005), Bhatia et al (2006).

• De Sa Pinto et al (2006).

• Goulding et al (2000).

• De Sa Pinto et al (2006), O'Malley et al (2012), Goulding et al (2003), Hue et al (2007), Thivel et al (2016).

• Montgomery et al (2010).

• OECD (2019).

• WHO (2003), Martin et al (2001), Department of Health (2001).

• Medibank (2007).

• Arenz et al (2004), Armstrong et al (2002).

• PA Guidelines for Children - HSE Guidelines (2024).

• NICE Guidelines: Obesity: identification, assessment and management (2014).

• Scottish Intercollegiate Guidelines Network (2010). Management of Obesity: a national clinical guideline.

• Waters E, de Silva-Sanigorski A, Burford BJ, Brown T, Campbell KJ, Gao Y, Armstrong R, Prosser L, Summerbell CD. Interventions for preventing obesity in children. Cochrane Database of Systematic Reviews 2011, Issue 12.

• Sacher et al (2010), Randomised Controlled Trial of the MEND Programme: a family-based community intervention for childhood obesity.

• Brown et al (2019), Effectiveness of a Family-Based Childhood Obesity Intervention at the YMCA: A Randomised Controlled Trial.

• Professor Jennifer Stinson. Children’s Pain Management Masterclass, RCSI, October 2016.

• Kendall.

• Complex Pain on Children and Young People - Assessment. British Journal of Anaesthesia Education.

• Best Practices in Pain Assessment and Management for Children.

• The Royal College of Emergency Medicine Best Practice Guideline for the Management of Pain in Children (2017).

• Guidelines on the Management of Chronic Pain in Children - WHO.

• Liossi et al (2019), Effectiveness of interdisciplinary interventions in paediatric chronic pain management: a systematic review and subset meta-analysis.

• Boulkedid et al (2017), The Research Gap in Chronic Paediatric Pain: A Systematic Review of Randomised Controlled Trials.

• Sensitivity and Specificity of the Stemmer Sign for Lymphedema: A Clinical Lymphoscintigraphic Study - Goss et al 2019.

• The O'Reilly Centre - The Gold Standard Treatment for Lymphoedema.

• The O'Reilly Centre - Lymphoedema Loves Acqutherapy.

• Management of ulcers in lymphoedematous limbs - PubMed - Karnasula (2012).

• 2020 Consensus Document Treatment of Peripheral Lymphoedema - Lymphology.

• New PT-Focused Lymphedema Guideline Follows ‘Care Trajectory’ - American Physical Therapy Association (APTA) Clinical Practice Guidelines.

• Ridner et al (2012) - Self-Management of Lymphoedema - A Systematic Review of the Literature from 2004 to 2011.

• Pergolotti et al (2015) - The prevalence of potentially modifiable functional deficits and the subsequent use of occupational and physical therapy by older adults with cancer.

• Silver et al (2015) - Cancer rehabilitation and palliative care: critical components in the delivery of high-quality oncology services - Supportive Care in Cancer.

• Jensen-Battaglia (2022) - Association of Oncologist-Patient Communication With Functional Status and Physical Performance.

• Principles and guidance for prehabilitation within the management and support of people with cancer - Macmillan Cancer Support.

• Campbell et al, 2019.

• Schmittz et al (2010) - American College of Sports Medicine Roundtable on Exercise... Medicine & Science in Sports & Exercise.

• Spence et al (2010) - Exercise and Cancer Rehabilitation: A Systematic Review.

• Faithfull et al (2019) - Prehabilitation for adults diagnosed with cancer: A systematic review of long-term physical function, nutrition and patient-reported outcomes.

• Jeschke et al (2020) - Burn Injury.

• BritishBurnAssociation - Standards of Physiotherapy and Occupational Therapy in the Management of Burn Injured Adults and Children 2022.

• British Association of Plastic Reconstructive and Aesthetic Surgeons.

• The Royal Children's Hospital Melbourne.

• O'Reilly et al (2021) - Use of Tape for the Management of Hypertrophic Scar Development: A Comprehensive Review.

• Smailes et al (2021) - The Predictive Validity of the Functional Assessment for Burns — Critical Care (FAB-CC) score for discharge outcomes in major Burns.