HELP YOURSELF! TOP TEN TIPS

When you are injured, the level of incapacity can be overwhelming. Here are my top ten tips of things that you can do to help yourself:

  1. Go online – get your groceries & goods delivered and your banking & services online. Whilst you may not have had the time previously to set this up, it is so easy, and when you are injured, you are home all of the time for things to be delivered!
  2. Find nutritious prepared meals. When every movement is an agony and being on your feet is hard – find the meals that just need putting in the oven and taking out.
  3. If you are really struggling, ask someone for help. A lot of your friends will want to help, but be unsure what they can do. So call them up and ask if one or a group of them can help with cooking a few meals and freezing them, or coming in and stacking the dishwasher every couple of days, walking the dog, taking the kids to school, or whatever that task is.
  4. If you cannot bath or shower, can you get to the leisure centre? Most leisure centres have a shower block which does not involve any steps, and a shower with a seat. So if you can borrow a wheelchair, or get in there with your crutches, you can have a much safer shower than in your own bathroom (which probably has a ton of accessibility challenges). PS – if there are wounds that you really need to keep dry, clingfilm around the area does not work, as the water just goes behind it! You will need to get a large enough waterproof dressing. I found that our local independent pharmacy were really expert on wound dressing and management (so worth phoning around to find who can help you once you are out of hospital).
  5. Set up call-barring for nuisance calls. You will have your phone right next to you as you try to get the appointments that you need and talk with the experts on your injury, but nuisance calls are wearing!
  6. Can a family member do the medical appointments for you? One of the most debilitating things is that there are a ton of phone calls, documents and follow-up with the medical profession. When you are out of it on pain medication, this is close to beyond you! If someone can do this for you, it will be a huge help!
  7. Have a pad on hand and write lists and notes. When you are drifting in and out of shallow sleep, and have taken lots of painkillers, you really struggle to keep on top of things. So just write things down – including things that are worrying you, how you are going to talk with the Doctor tomorrow, things that need to get done etc.
  8. Get a sticker on the door to stop cold callers. You may be happy to struggle to the door for the thoughtful parcel or flowers from friends, but the cold caller is truly frustrating. You can get the sticker from your local police, Neighbourhood Watch or Trading Standards.
  9. Hairdressers etc will all come to you. Whilst you will have been used to rushing around and doing your chores on the run between other things, there are ways that almost everything can come to you.
  10. If you need more help than your friends and family can give, ask for help. Have a look at this website: https://www.nhs.uk/conditions/social-care-and-support-guide/ and talk with your GP and also Citizens Advice can help you.

I really hope that these make you feel less alone in facing the challenges associated with your injury. You will come through this and there are people and mechanisms there to help, if you can track them down.

Alex’s courage in talking about the loneliness of her head injury

If you have met Alex Danson MBE (gold medallist with the GB Hockey squad and since then the Captain of the England and GB Hockey teams), you will know her massive heart, her infectious smile and her complete passion for sport and team sport – and hockey especially.

It is so hard to see someone like Alex literally knocked out by the impact of concussion. But her courage in being searingly honest about how hard it is will be a lifeline to others who are injured. I also really hope that it will also be a lifeline to her with the massive outpouring of support for her on social media yesterday, and hopefully going forward in the coming weeks and months.

The most telling parts for me in her interview with The Times yesterday https://www.thetimes.co.uk/article/alex-danson-great-britain-hockey-captain-injury-post-0d09vm8bb were these lines:

“One of the hardest parts in all of this, aside from the physical trauma, has been losing my identity,” she wrote. “Going from leading my country, aspiring to qualify for the Tokyo Olympics to just trying to get through a day.

“Head injuries are serious, debilitating and lonely. When I have days when I feel well enough I will document some of my recovery. I’ve not been well enough to up to now and I’ve not been sure whether it’s something I wanted to do.”

They capture so brilliantly the complete stop that comes with an accident and injury, and the new mental framework that you have to build. And Alex’s commitment to make meaning out of this brutal, difficult and unfair injury by documenting her learnings and recovery to help others is totally inspirational.


Alex’s post on her Twitter feed @AlexDanson15 under the comment “It’s been a long 6 months….I’m thankful to say that I am on the road to recovery #mildtraumaticbraininjury”

Concussion is a very serious injury and many sports have now linked together to share the best knowledge. I am not an expert, but I would say that the Birmingham Sports Clinic is open to professional and amateur athletes over 16 years old, from all geographic areas. Instructions and how to get referred can be found here: https://www.uhb.nhs.uk/birmingham-sport-concussion-clinic.htm

Very best of luck for your recovery Alex. We are all rooting for you.

Imagining the Numskulls in the context of how bones heal

I don’t know whether you remember the Numskulls? This was a cartoon strip involving little people who lived inside the head of a person and did all of the hard work to make the person’s life function. 

I thought that they might be a helpful analogy for understanding why we really do need to give a broken bone the time to heal properly. So I created a couple of new characters:  

  • Mr(s) Preparation with a broom and all of the cleaning materials
  • Mr(s) Repair with a full tool-belt and DIY kit and team to help build the structure
  • Mr(s) Remodeller with the filler and sandpaper to make it fit in with the rest of the bone

Just like the healing of surgical cuts and tendons/ligaments/cartilage (covered in previous blogs) there are 3 phases, which I have added a little detail to below. Sadly all of this process goes a little slower when we are older (like most things!) – so worth adding a little extra time if you are older and ensuring that you pay even closer attention to the cues from your body.

  1. Reaction – with inflammation and initial tissue formation. The severed blood vessels in area of the break (or fracture – same thing) in the bone release blood into the area and this forms a clot very quickly (normally within a few hours). Then the first few days are characterised by a lot of inflammation as some of the body’s cells start to clear away the bone fragments and other damaged cells. In parallel, the new blood capillaries that have grown into the area bring the cells that start to build fibres to connect the bone and lay down the spongy bone structure.
  2. Repair – initially with a cartilage callus formation and then with bone: this stage starts after about 7-9 days and takes about 2 months to join the two ends together with a bony connection that has most of the bones original strength. During this time it hardens from being a fibrocartilaginous callus to a bony callus matrix, which evolves through two stages of bone hardening. This is often wider or thicker (so much so that you can feel this under the skin).
  3. Bone remodelling: The bony callus is remodelled over the next months (and often takes as long as 3-5 years) with the excess material on the outside and other locations being removed. There are also different layers of bone, so the remodelling gets back to the correct layering of these different types of bone – rather than the fast fix of the callus. Areas of well-healed breaks can remain uneven for years, but with 5-7% of bone mass being remodelled in the body each week, this will get fixed in time.

How is the fracture treated?

If you are lucky with your break, you have not got an infection in the fracture, and there is not the issue of the bone ends not coming together at all, or not coming together in the right way, or coming together too slowly.

These days it seems that many more people are having their fracture stabilised with surgical insertion of plates and screws (which generally stay in forever) and are being given a sling or protective boot, rather than the plaster-cast of old. The reasons for keeping away from the plaster-cast are often to maintain Range of Movement, but are not meant for you to keep doing your sport in the same way!

So what happens if you try to exercise with a broken bone?

Let’s go back to our friends the (new) Numskulls that I introduced at the start of this blog.

In those early days Mr(s) Preparation is out there working her socks off trying to clean everything up ready for Mr(s) Repair to get going. But if the area keeps getting moved, vibrated or jogged more bit of stuff keep falling off and Mr(s) Preparation keeps getting called back and getting in the way of Mr(s) Repair.

Likewise, Mr(s) Repair is trying to build out a new structure into the gap. This job takes weeks (like most building jobs!) and happens once the worst of the swelling and inflammation has passed. But if the area keeps getting moved, vibrated or jogged the bits fall off – meaning the work has to be done over and Mr(s) Preparation has to keep coming back and cleaning up again, rather than sitting down and having a cup of tea!

So activities like running and strong movement of the area lead to delay and having to repeat the healing

But there are a number of things that you can do to really help the healing:

  1. Good nutrition: the body needs a lot of nutrients to heal the bone, so ensuring that you have a good balanced diet with enough protein, and key vitamins (C and D) and minerals (Calcium, Iron, Magnesium and Phosphorus)
  2. Sleep well at night: a lot of healing happens in the deep sleep phases, so ensuring that you are getting your head down for a good uninterrupted 8 hours of sleep (or more if your body feels that it needs it) will be a big help.
  3. Avoid aspirin and ibuprofen, if you can: there can be a lot of pain, especially in the early inflammation stages, but the problem is that aspirin and ibuprofen delay the body’s natural healing process and therefore delay progress. So the sooner that you can stop taking them, the better. (There are some other medications that have impact – so worth checking with your Doctor, if you are taking any medication)
  4. Avoid smoking and limit alcohol intake
  5. Don’t feel tempted to test your broken bone whilst it is healing! Do keep it immobilised and work out how to take away risks in your day-to-day activities that could lead to a knock to the area. If you have been told that you must not be weight-bearing, then respect that and get shower chairs, scooting devices, crutches etc that enable you to do this all of the time (cycling gloves are brilliant for protecting your hands If you are on crutches).

So no sport at all?

You should review this with your medical team and coach. Depending on the fracture and the treatment, there may be some things that you can safely do that keep your strength and give you a cardiovascular workout whilst keeping the fracture immobilised. I have seen some really clever ideas that are safe and keep things going.

But if that is not possible? This is 6-8 weeks of your life. Add up how many weeks you have been alive (52 weeks per year!) – and this 6-8 weeks will be a very small percentage. Be kind to your body: let those Numskulls go their job without having to keep going back and repeating it, because you knocked down their hard work!

Good luck and keep smiling!

Jo Pavey’s ‘This Mum Runs’

One of the things about being injured and unable to move very much (without a lot of pain) is that I have read some great books. I wanted to share a few things that I took from reading Jo Pavey’s book that I think are really relevant for an injured athlete – but do buy the book, as it is a wonderful, human and inspiring read.

I remember really clearly the feeling of being in the crowd with my husband and two close friends and all screaming ourselves hoarse at Hampden Park stadium when Jo Pavey took bronze in the 2014 Commonwealth Games 5,000m and stopped the Kenyans taking a clean sweep of the medals. The race was incredibly exciting and inspiring – as this race report summarises https://www.bbc.co.uk/sport/commonwealth-games/28626133, but how Jo had come back to win this medal (and a Gold medal at the European Championships 2 weeks later) is even more inspiring.

Here are the top three things that I took away for injured athletes specifically:

  1. Having been British Champion in her late teens, Jo had six years in her 20’s of not being able to train and compete. She hung in through this – did not let it get her down and also qualified as a physiotherapist (which must have helped her to understand how to rehabilitate her injuries). Six years! And yet she came back to win major medals in her 40’s – to me that shows such true grit, resilience and mental strength.
  2. With her coach (and husband), Jo managed her annual, training block, weekly and daily training schedule and sessions based on what was possible and what her body responded best to. The fact that she could turn out amazing track performances in spikes, having done almost all of the training on much softer and more forgiving surfaces and in trainers says that peak performances are still possible when we do the right things for our bodies.
  3. After her stress fractures Jo threw away her orthotic supports in her shoes and concentrated on strength training to address the functional muscle, joint and bone issues.

I don’t under-estimate the incredible dedication and hard-work that lies behind the achievements. But if we could all soak up a little of the balance with which Jo has managed her way through the lows and the highs, this could help any injured athlete move forward.

Enjoy the book. It is great.

How do musculoskeletal injuries heal?

Following my blog on how the body heals from invasive surgery (http://www.injuredathlete.co.uk/how-do-you-heal-after-invasive-surgery/) , I thought that it would be useful to do the same for musculoskeletal issues, since these are common injuries for athletes. This is a really huge topic, and I have struggled to get down the most relevant parts into something that I think may be useful for injured athletes and coaches to understand what questions they will ask of the medical team treating them. I have not covered musculoskeletal diseases such as osteoarthritis, carpal tunnel syndrome, tendonitis etc (many of which qualify as a disability under Social Security, if the symptoms reach a certain level of severity), as these are much more complex and long-lasting.

The challenge of most of musculoskeletal injuries is that they generally involve tendons (which connect bones to muscles), ligaments (which connect bone to bone) and/or cartilage (the soft, gel-like tissue that provides cushioning and enables movement in joints). The white colour of these tissue types give a clue to the fact that they do not have their own blood supply. This means that they heal much more slowly than damaged skin or muscles (which have their own blood supply). The surgical view is that they do not regenerate and this is why often surgery is offered – mending torn tendons and ligaments and replacing ruptured ones.

You need to play an active role in healing musculoskeletal injuries

Whilst the fundamental phases of healing are the same as a cut or muscle tear, there are a couple of key differences that you need to act on:

  1. the pain signals through the healing phases are very different and you need to actively manage your way through this – at times managing the pain to protect the healing of the correct Range of Movement for your body. It seems counter-intuitive not to listen to the pain in your body, but this is the reason.
  2. you do need to actively rehabilitate the area through each of the 3 stages, as it is unlikely to heal correctly without your active focus and support: initially using the ‘POLICE’ protocol (see below) and then with range of movement for that joint and then specific strengthening of that area. When you are in a lot of pain, the constant health professional exhortations of ‘keep moving’ may not seem to be very helpful, but this is the reason why.
  3. this is a long-term game, and you can expect to need to focus on this for a period of 12 to 24 months. But for those who stay the course and do the right things, the results do come.

Stage 1 of musculoskeletal healing – Inflammation.

The swelling and redness may be hidden inside the joint, but the symptoms will be such that no time day or night is pain-free and you may be able to detect the heat coming from the joint, as well as the tenderness, pain and loss of range of movement. If rest or a change of position gives relief, then the healing has progressed to the repair stage. The inflammation stage generally lasts 3-5 days, but can last a lot longer and if you re-injure or re-inflame the same area, then you go back into this stage.

The point of this stage for the body is protecting the area with swelling whilst it lays the foundations for the healing – clearing out the damaged cells and starting to spin webs of protective tissue that bind the wound together and stop the flow of liquids through the area.

This is the stage that you really need to apply the ‘POLICE’ protocol. This has replaced the old ‘RICE’ protocol (see the table below). So that in the past, the recommendation was Rest, get an Ice pack on the area, use Compression and Elevate the limb. All of these are designed to reduce the inflammation and allow the body to get through this first stage. Interestingly, anti-inflammatory medications do reduce the inflammation, but interfere with the body’s natural management of inflammation – so as soon as you are out of the immediate pain it is best to stop taking these in order to encourage the cellular-level healing process to begin.

The new ‘POLICE’ protocol reflects the fact that the latest medical studies suggest that some movement is good, even at these early stages. So ‘Protect ‘the joint from the bad motion that has caused the injury (eg twisting), with support, splinting or bracing as needed. Then work to get ‘Optimum Loading’ – moving the joint through the range of movement in every-day activities, but not causing additional pain. This is why we see increasing numbers of people in protective boots and slings, instead of full plaster-casts. The view on ‘Icing’ has also developed – and the guidance is that you should not apply it for longer than 10 minutes and more than 3 times per day (as too much icing can also damage the tissues).

P = Protect
OL = Optimum Loading
R = Rest
I = Ice I = Ice
C = Compression C = Compression
E = Elevation E = Elevation

Stage 2 of musculoskeletal healing – Repair or Proliferation.

During this stage the body develops the new tissue, initially haphazardly and then starting to align these cells correctly. This stage usually starts from a week after the injury and lasts 6-12 weeks or longer. Pain usually comes and goes, according to the position or movement of the body. If pain or fear of pain inhibits movement in this stage, then the pattern with which the scar tissue is laid down can inhibit movement significantly and reduce your body’s ability to function. Failure to stretch and move at this time will lead to weak, but tight muscles that are intermittently painful and vulnerable to re-injury. Therefore you really need to consistently (and gently) put the body through a normal range of movement and the unhelpful cross-fibres will be broken and the useful fibres that support the usual range of movement will be strengthened.  If this repair stage does not lead to correct healing, the danger is that the body will start to develop workarounds and compensating movements, which can lead to aches and injuries elsewhere as the body moves into the third stage of healing with the wrong fundamental structure in the injury area.

Stage 3 of musculoskeletal healing – Remodelling or Maturation.

In this stage the tissues build their flexibility and strength, and this lasts at least 6 months and can be two years or more. Even now, you may get some pain with certain movements (especially when you take the movement to the end-zones of the Range of Movement – which you do need to do), or you may be pain-free. This is why usually from around 4-12 weeks after injury (depending on the injury: follow your surgeon’s or physio’s advice), you should be adding in some strength-based training – starting very gently and slowly building up to 3 sets of 10 repetitions (working to failure), with a day or two of rest between sessions for the body to recover and rebuild (in line with the progressive overload model of development) and obviously backing off if the level of pain increases.

If you do not keep rehabbing the area, there is a very strong probability of significantly reinjuring it because it is so far below strength. This is very challenging, as it is usually just one or two exercises that you need to do over and over again, gently progressing them. And before you have done this, it may well be too premature to go back to a repetitive loading activity like running, or even cycling. Many people do not have the patience to do this progressive strengthening over the period of 12-24 months that it takes, and this is one of the reasons why re-injury is common. Even with the correct rehab, the area often stays 20% weaker than before the injury.  Hence you will need to keep looking at your form to check that there are not compensation behaviours that will cause other injuries, and look at your activities to check that you are giving it the protection that it needs.

Why pain makes this all so much harder

The challenge for many people in chronic pain* is that the correct level of managing the inflammation, mobilising the joint to get the range of movement and strength building across the 3 phases is hard to do. The pain makes them avoid exercise and stretching required for correct healing. At times the level of incorrect healing in stage 2 can need significant manipulation (even under general anaesthetic) to break up the adhesion and re-stimulate inflammation. You then effectively start back at phase 1 of healing, and need to ensure that stretching (for Range of Movement) and exercise (to stimulate the limited blood supply to the area) then begin the process of rehabilitation.

As well as medications, guided corticosteroid injections into the area are common and can bring very significant short-term relief. You need to make the decision on these with your Orthopaedic Consultant. The only anecdote that I would pass on is one where an athlete had a number of injections into the tendon over a 2-year period, and the tendon did rupture. One of the questions was whether the perforations from the multiple injections had played a role.

* The definition of chronic pain varies, but it is long-term pain and most seem to define it as having lasted for over 3 months or over 6 months. I think that the key definition is having been in pain for that length of time, you get to the stage where you adapt your physical, mental and emotional approaches to life (whether consciously or unconsciously) as a consequence of the pain. As well as these external impacts on your life, the internal impacts of your body swimming in the chemicals associated with inflammation and the nerve pain patterns can also have significant impacts on your healing.

How do you heal after invasive surgery?

Just recently I had two athletes each bemoaning the fact that they were not successful in returning to training within 2 weeks of surgery. They had both had abdominal incisions and were having issues with the wound not sealing and a lot of pain in the surgical area.

So how soon can you start back to training?

I thought that it would be useful to understand the hard work that our bodies are doing in this time. The hard part of today’s ‘instant-everything’ world is that we are not giving ourselves a chance! But we can help ourselves by looking after the wound and the healing process.

The healing process is 4 stages – and last in total over a year and possibly two years!

The four stages of healing happen in an organised and sequential way – but they can progress better or worse, depending on factors associated with you (both as a patient and how you treat the wound). The second part of this blog will look at the factors for you to promote better healing.

Stage 1 seals the wound and is really quick!

The hemostasis phase closes the wound with a clot (usually in a matter of minutes/hours). Various components of the blood combine to create a mesh that forms a clot that adheres to the wound and closes it off. You need to protect that. There used to be a school of thought that you had to let the wound be open to air for the scab to harden properly, but the new hospital dressings allow it to do this without removing the dressing – so you will probably be advised by the hospital to keep the same dressing on for some time, in order to stop infection entering the area.

Stage 2 prepares the wound area for the growth of new tissue

The defensive/inflammatory phase focuses on destroying bacteria in the area and removing any debris, such that the wound area is all set for the growth of the new skin and tissue. White blood cells and microphages in the blood do this. It normally takes around 6 days and you can often see and/or feel swelling, redness of the skin, heat and pain. Obviously if the area keeps getting new infections into the area, then this period is extended. During this time it is absolutely critical to keep the scab dry – so you will need to find some good waterproof dressings or a different way of staying clean (wrapping cling-film over the area does not work!)

Stage 3 is the progressive filling and covering the wound, starting from the outside edges

The proliferative phase follows three distinct stages: 1) filling the wound, 2) contraction of the wound margins, and 3) covering the wound with new skin. You probably remember watching this as a child, as the new, pink skin forms from the shallowest and outside parts of the wound and eventually closes it up. It is a very clever process that remakes the blood vessels, tighten the open wound (often giving an uncomfortable feeling of tightness for a time) and then the skins cells work their way up from inside the body to form the boundary layer. This can all last anywhere from 4 to 24 days, and during this time dissolvable stitches on the surface should drop out. In order to protect the wound, it is still really important to keep the scan dry in order to protect it from damage, although to the latter end of the timeframe many nurses say that you can have a quick shower, but must keep away from baths and any kind of swimming pool/hot tubs etc until it is all completely sealed. Also across this time, a lot of nurses suggest gently putting Vaseline or moisturiser on the scab, in order to keep it flexible and stop it cracking and getting damaged.

Stage 4 is where the scar gains strength and flexibility

The maturation phase is where the tissues reorganise and remodel as they mature. During the proliferative phase the tissue gets laid down haphazardly, whereas the uninjured tissue is all lined up in a standard structure. Over the usual replacement of the layers of skin, this slowly gets addressed and as it does the way that the scar tissue moves stops being a big block and starts to move with the body and has strength. This phase can vary from 21 days to 2 years, and you can help it by gently massaging the wound and encouraging the tissue to realign. Also many nurses recommend rubbing in Bio Oil or a Vitamin E cream, which seems to visibly help the scar to fade in colour and settle back to flat with the skin.

So it all takes time

Back to our athletes – getting the wound to seal and be ready for the forces of movement in the area of the surgery is probably around 6 weeks, and within this time nurturing the area to maximise the healing will really help.

Things that you can do to encourage faster healing

There are many factors that mean that people heal differently. Some of these are inherent to you as the patient. Age has a direct effect on how fast we heal – as we get older, the skin is thinner and less elastic so we need to allow it more time. There are also factors associated with your body make-up in terms of how your body lays down the scar tissue, which you cannot change.

However, there are a number of things that you can look after.

  • What you eat is really important – You need to ensure that you are getting some good protein at each meal, and foods that are high in zinc, copper, vitamins A, B and C can also help the healing,
  • Good hydration really helps too, as this has a direct effect on the blood stream.
  • A good overnight sleep is key. The body’s repair mechanisms work hardest during the deep sleep cycle – so do make sure that you are getting your head down and getting a good quality 8 hour overnight sleep (or more if your body needs it)
  • Reducing inflammation – many people swear by arnica. Obviously the cream cannot be applied to open wounds, but I found major reduction in the bruising around where the cannula was inserted by using the cream on the adjacent skin areas. And you can buy oral arnica from homeopathic providers such as https://www.helios.co.uk/ and it generally does not have any interactions with other medication that you may be taking (although check with your own Doctor and/or surgeon)
  • Managing your weight – skin heals better when it has the blood supply into the tissue, which muscles give but fat does not. This helps the supply of all of the agents for the different phases of healing, as well as oxygenating the wound area.
  • Keeping the wound area dry and clean – this is so important for the right conditions for wound healing. This can be hard to do, but is a really significant factor. Try to get the right balance between waterproof dressings to stop external moisture and getting it open to the air if it is in an area of your body that stays damp and then covering it again.
  • Medication can slow healing down – some medications slow healing by impairing the inflammatory response, leading to a reduction in the collagen production which is key, especially in the 3rd and 4th stages. Treatments such as chemotherapy affect the new cells, so have a strong impact on healing, Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) that you may commonly take as over-the counter drugs can also slow down the process. Obviously you are likely to need medication after major surgery, but it will help if you can keep it to the minimum that you need and bear in mind that you may need to allow longer for your body to heal. 

So best of luck with your healing – do nurture your amazing body to do its thing! And after a major surgery taking a good month or 6 weeks off training that involves the juddering of impact, or the strain of strength training could be well worth it. It is also worth saying that there are other factors from surgery – for instance, anecdotally many Doctors say that it takes around 6 months for the body to completely recover from a general anaesthetic.

How do I know that I am going to a good physiotherapist?

This was a question that I Googled over and over again, and had some pretty scary experiences. In the absence of finding any answers online, here is my view:

A physiotherapist is there to help make you better, so their first rule has to be DO NO HARM!

So – if at any stage- you feel  a sense of a lack of trust, or you feel that they are not listening to you, or if the way that they are manipulating you is not respecting your body, then I would immediately ask them to stop, sit up, step down from the table and say why you think that the appointment needs to stop there. And if they do not make you feel comfortable by talking through the treatment plan that they have for you and how it will make you better, then simpl pay, leave and never go back! I wish that I had thought through in advance of a couple of appointments how I would respond if I was unhappy with the way that I was being treated and what I would do – as in the moment you can feel frozen and under pressure to just take whatever you are being given.

When I first got referred to a physiotherapist by the consultant after reviewing my scans, I asked people who had been before what made a good one. It’s frustrating – whilst we can each get a very detailed understanding of what it might be like to eat out at a given restaurant or stay at a certain hotel based on ratings and reviews sites or specialist guides, there is no such thing for physiotherapists (or any of the medical profession)! Many have a couple of google reviews – usually all 5 stars and not more than two. My hunch is that these are done by friends, as in order to get a good google listing you need a couple of reviews. I never found a useful or insightful one on physiotherapists.

What is the difference between a physiotherapist, an osteopath and a chiropractor?

Google search shows that this is a very common question, but there are not many simple answers.   My answer is that it is all a spectrum in the ‘manual therapy’ part – ie the hands-on part (as against giving you exercises and watching you). Some physios will only give you exercises, and this would be a potential marker of a poor physio for me – a huge proportion of injuries will not get better without some manual therapy assistance and will certainly need some hands-on testing to understand areas of tightness. But within the manual therapy spectrum, physios seem to focus more on the muscular (and also sometimes fascia) connections, with osteopaths and chiropractors both focusing more on the nervous system, spinal involvement/alignment and into ligaments/tendons connections. My own experience is that the osteopathy end of the spectrum is more gentle and helpful in pain relief and relaxing issues associated with excessive tightness. Whilst the chiropractic end of the spectrum is more active and associated with actively addressing issues to get to ongoing alignment, including retraining muscles, ligaments and tendons.

The interesting part is that orthopaedic surgeons and GPs will all tend to send you to a physiotherapist and never one of the others. My understanding for the reason behind this is that physios have more years of academic training than the others, and are therefore held in higher esteem by the more traditional part of the medical establishment. But you may find that your body responds much better to the touch and skills of a different practitioner.

What are the signs that I have found a good physiotherapist?

Here is my top 10 list:

  1. They really listen to you describe the symptoms and pain sites, and ask good questions.
  2. They do a full body screening set of tests of range of movement, movement patterns and pain in all parts of your body, even if these are not the site of the injury or problem. And then as your treatment progresses, they keep going back to these tests and monitoring progress.
  3. They listen to your feedback on pain levels, and if you say that you cannot take any more, they stop. Especially if it is your first time having acupuncture or dry-needling. These should create a strong relaxation of the muscle, but some people do have a reaction to it – so if the needles continue to hurt they should take all of the needles out.
  4. They explain their thinking on the problem and their treatment plan – and answer questions if you have them. And in the case of the physio that I respected the most, I went to see him 3 times before he was ready to share his view of this, because he was building a more detailed picture and evaluating it before rushing in. One of the most useful questions I found at this point was to ask what a standard case of a XXX injury would look like a this many weeks after, and then to compare how I fitted against that.
  5. They are prepared to talk with the surgeon to build a connected treatment plan, based on all of the scans and expert judgement. This makes such a difference, as they are able to have a different conversation from the one that you can have with the surgeon. Plus, if you end up having multiple surgical interventions, it gives you as the patient the confidence that going to further surgery is the right plan, and the surgeon really does have the full picture.
  6. They welcome feedback from you (and ideally help you to structure it in a way that gives them the information that they need in a simple way) about how the pain levels and progress on the exercises has been since the last appointment
  7. They give a really clear protocol of what they want from you. Genuine misunderstandings are so rife: ‘take it easy’ can mean anything from no hard running, through to nothing more than a gentle walk! Likewise sitting might be really bad. Having a detailed protocol agreed of how you will approach general life, as well as the exercises, is really important.
  8. They layer their exercises from the simplest and least weight-bearing form of the exercise, building the complexity when your body can handle it. The most frustrating times for me have been with 2 different physios after different surgeries, when they said “oops, I chose a set of exercises that were just too advanced for you. We’ll have to try something else”. These in each case put me in a situation of being unable to move at all for days in one case and weeks/months in the other
  9. They demo exercises and then watch and correct your form on the exercises so that you can be confident of doing a perfect rep when you get home, and spot when to stop when you lose perfect form – rather than when you are crying with pain.
  10. They are prepared to say when you do not need to see them too! There are points when you continuing with the strengthening exercises and giving it time will be enough – and a good physio will say this, rather than continue to take your money!

The no pain, no gain view of physiotherapy is really unhelpful

Everyone who I spoke to before seeing a physio had the view that physiotherapy has to be painful for it to work – that the manual manipulation has to hurt to release problems and that exercises have to hurt to work. I totally refute this. I think that there is really good evidence that when a body is swimming in the chemical markers associated with pain and everything is contracting and tightening from the electrical stimulus of pain then the problems are increasing, not decreasing. This is not to say that like in sports massage sometimes pressure can help a muscle release and there may be times where a physio will warn you that there could be a little discomfort – but this should only be very short-term.

I regret having gone to see those physiotherapists whose exercises and interventions increased my pain.

As an athlete, I would steer away from hospital physiotherapists

Initially, we thought that going to the hospital physiotherapists would be the best plan straight after surgery, because we thought that they would be deep experts because they saw lots of cases of this specific surgery (given that they are at the hospital) and because we assumed that just out of surgery all patients would be in pretty much the same situation. This was a bad call. The physios that I saw seemed to always be surprised at the level of muscle strength that I had (even though after a year of problems, I had lost 15 kg of muscle mass on the body composition scales). As a consequence they regularly chose exercises that were way too difficult and caused problems. And to compound the issue, they then seemed to bounce into another set of parallel exercises with slightly different approaches that also caused more pain and problems.

So do you have to go to know?

I think that there is a certain amount that you can do before meeting a physio – you can ask specific questions to previous clients who recommend them, you can phone and ask the clinic how the physio approaches things, and you can ask to talk through your case on the phone or via email before meeting them – in order to understand whether you and they think that they can help to make you better.

But at the end of the day, some of it will unfold as the diagnosis and treatment unfolds. Keep asking yourself (and them!) the questions. If you are not improving, then you need to understand whether your time and money would be better spent somewhere else.

And finally…

As an athlete you may have built a mentality of pushing through pain to finish a race (or even a training set). Physio exercises are not like that. If they are hurting (not the good and comfy ache of activation, but jagged and unpleasant pain), then stop and do not do them again before talking with the physio. You may be rating yourself as the failure (as I was), but actually pushing over multiple days to try to complete just one set when it is the wrong exercise can cause a lot of damage. Listen to your body first, and the physiotherapist second.

Best of luck with finding a partner who can help you rehabilitate your body and get you back to the movement and activities that you love. You deserve that. There are many people out there, and many apply just the same approach to everyone who comes through the door. If that one happens to help you to improve – brilliant. But if you have to keep going, knocking on lots of different doors to find the person with the approach that fixes you – it is not a failure and it does not mean that your condition cannot be fixed.  Listening to your body, testing and monitoring progress on the key measures and finding the right person or people will move you forward, one step at a time. Keep at finding the right person, just as you would keep at finding the right coach or the right training approach. You have the resilience to do this – even when you are at your lowest ebb.

Your basic bodycare toolkit

The other side of the opioids crisis

Following Andrew Gregory’s article in the Sunday Times on 24th February 2019:

https://www.thetimes.co.uk/article/britains-opioid-crisis-we-are-sleepwalking-towards-carnage-in-our-communities-7tjlzzq7x

And the British Medical Journal’s research that shows that between a third and a half of all UK adults live with chronic pain (defined as pain lasting more than 3 months), with a trend towards increasing prevalence with increasing age from 14% in 18–25 years old, to 62% in the over 75 age group. Hence the proportion of people suffering can be expected to increase, in line with an ageing population.

https://bmjopen.bmj.com/content/6/6/e010364.full

These made me feel the need to write to Andrew – and here is the text from my email:

Dear Andrew –

I felt the need to write to you after your articles on the opioid epidemic that you suggest is hitting the UK, as it has hit the USA. I agree with your concerns. But I think that the other half of the story is one that needs to be told too – our societies are simply are not managing chronic pain and the unintended consequences of not managing this are showing at the moment in opioids, but will move somewhere else if the solution is simply to cut down prescriptions. A friend who is a member of the Police Department in one of the northern states of the USA talks of the significant increase in the number of suicides that he now attends where people killed themselves because they could not find relief from the pain when they were no longer prescribed the painkillers.

Perhaps there is a follow-up feature with case studies of those in chronic pain who could be jeopardised by culling prescriptions and some case studies of the equally sad stories of those whose chronic pain was not addressed (which had outcomes equally, or perhaps even more sad than those featured in this week’s Sunday Times). The goal has to be for a real look at the challenges and potential solutions to this multi-faceted problem – as hopefully my comments below lay out.

My own experience is that I had an accident 15 months ago and have been in debilitating pain. I went from someone who was a keen marathon runner and representing Great Britain for my age group for Triathlon at World and European level to someone whimpering in pain, whilst lying on the floor. I freely admit that in my whole life what I thought was pain was really a little discomfort – for instance, taking ibuprofen for an ear infection, or massaging sore muscles after a marathon. And that is what is hard about pain – you can only know once you have experienced the jagged, searing, burning pains that make you think that your body will die of them (and sometimes lead to extended shuddering of the muscles, an inability to breathe properly and a racing heart-rate that implies that you are running a 10K race flat-out) and then when you realise that your body is not going to die of them, you  wonder if you would prefer that it did – as any quality of thought, life or enjoyment is out of the question. To those who simplistically suggest lighting an aromatherapy candle and practising breathing and mindfulness exercises, they are not talking of the pain that I talk of.

And so painkillers are what give you hope – after lying, shuddering for 16 hours on a bed in A&E counting up to 30 over and over and over, with a perspiration outline around you on the bed and then being told that it will be 5 weeks before you can see a spinal surgeon, it is painkillers that eke you through the sleepless hours, days and weeks to get to that appointment.

Or after surgeries, as you lie alone whilst the world merrily carries on and you try to get through just one hour at a time – sometimes not knowing whether that hour is a daytime hour or a night-time hour. Having sat with others in chronic pain, I know that people turn to alcohol and illegal drugs to escape their personal prison of agony. And sadly some people take their own lives as the ultimate escape. Taking away painkillers will only increase these other unofficial solutions. 

Through all of this the GP is the frontline. In the British medical system they are the lead contact who coordinates the rest of the treatment). The challenge is that with the pressure on the medical system, the waiting times for appointments are very long (even when you are in chronic pain) and the ageing population means that there are more people suffering. So what is the alternate option for the GP to prescribing painkillers? Who will take up the slack in the system to address the gap?

It is fair to say that the current approach with painkillers for chronic pain is a blunt tool. But if that tool is confiscated, what takes its place?

25th February 2019